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Presentation on history of pellagra and hookworm in the early 20th century in the United States of America. Contrasts the medical and social science models understanding disease causation. Compares the work of Dr. Joseph Goldberger and the Rockefeller Sanitary Commission for the Eradication of Hookworm Disease.
Citation preview
Pellagra and Hookworm
Prepared by Dennis A Bertram
2013This PowerPoint slide set has audio narration and provided
text Download to access
Learning Objectives
bull Upon completion you will be better able to Distinguish between biomedical and
public health causative models of disease
Apply the ecological model to analyzing public health challenges
Pellagra (pəlᾱʹgrə) ndash niacin (vitamin B3) or tryptophan deficiency disease
Pellagra Clinical features
CDC
weakness lethargy insomnia weight loss
rough reddened and scaly skin
painful mouth sores
appetite loss indigestion diarrhea
headache vertigo general aches muscle tremors mental illness
death
1906-1911 25000 cases
40 case fatality rate
1913 50000 or more cases with 11000 in Mississippi
Treatment
Cesare Lombroso
(1836-1909)
Promoted arsenic based treatment
Claimed cause was spoiled corn
Thompson-McFadden Commission
J H McFadden
Col Robert M Thompson
Barn fly
Dr Walter Wyman Surgeon General
Pellagra a ldquonational calamityrdquo
1911 appointed pellagra commission
Joseph Goldberger
(1874-1929) CDC
Appointed in charge of PHS pellagra program 1914
Spartanburg South Carolina (1909)
In June 1914 the Public Health Service opened a temporary pellagra hospital and laboratory in Spartanburg
Orphans Asylum Mobile Alabama (1934)
Visited asylums and orphanages
Dined with staff saw what they and residents ate
Poor Southernerrsquos diet the 3 Mrsquos of fatback (meat) cornbread (meal) molasses ndash cheap easy to keep easy to cook filling tasty
Wife of sharecropper removing fatback from hook (1938)
Pellagra cannot be communicablebull Mississippi State Lunatic Asylum
October 1 1909ndashJuly 1 1913
bull 98 pellagra deaths
bull Georgia State Sanitarium
996 patients admitted in 1910
bull 32 cases of pellagra within one year
bull No cases among employees
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Learning Objectives
bull Upon completion you will be better able to Distinguish between biomedical and
public health causative models of disease
Apply the ecological model to analyzing public health challenges
Pellagra (pəlᾱʹgrə) ndash niacin (vitamin B3) or tryptophan deficiency disease
Pellagra Clinical features
CDC
weakness lethargy insomnia weight loss
rough reddened and scaly skin
painful mouth sores
appetite loss indigestion diarrhea
headache vertigo general aches muscle tremors mental illness
death
1906-1911 25000 cases
40 case fatality rate
1913 50000 or more cases with 11000 in Mississippi
Treatment
Cesare Lombroso
(1836-1909)
Promoted arsenic based treatment
Claimed cause was spoiled corn
Thompson-McFadden Commission
J H McFadden
Col Robert M Thompson
Barn fly
Dr Walter Wyman Surgeon General
Pellagra a ldquonational calamityrdquo
1911 appointed pellagra commission
Joseph Goldberger
(1874-1929) CDC
Appointed in charge of PHS pellagra program 1914
Spartanburg South Carolina (1909)
In June 1914 the Public Health Service opened a temporary pellagra hospital and laboratory in Spartanburg
Orphans Asylum Mobile Alabama (1934)
Visited asylums and orphanages
Dined with staff saw what they and residents ate
Poor Southernerrsquos diet the 3 Mrsquos of fatback (meat) cornbread (meal) molasses ndash cheap easy to keep easy to cook filling tasty
Wife of sharecropper removing fatback from hook (1938)
Pellagra cannot be communicablebull Mississippi State Lunatic Asylum
October 1 1909ndashJuly 1 1913
bull 98 pellagra deaths
bull Georgia State Sanitarium
996 patients admitted in 1910
bull 32 cases of pellagra within one year
bull No cases among employees
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Pellagra (pəlᾱʹgrə) ndash niacin (vitamin B3) or tryptophan deficiency disease
Pellagra Clinical features
CDC
weakness lethargy insomnia weight loss
rough reddened and scaly skin
painful mouth sores
appetite loss indigestion diarrhea
headache vertigo general aches muscle tremors mental illness
death
1906-1911 25000 cases
40 case fatality rate
1913 50000 or more cases with 11000 in Mississippi
Treatment
Cesare Lombroso
(1836-1909)
Promoted arsenic based treatment
Claimed cause was spoiled corn
Thompson-McFadden Commission
J H McFadden
Col Robert M Thompson
Barn fly
Dr Walter Wyman Surgeon General
Pellagra a ldquonational calamityrdquo
1911 appointed pellagra commission
Joseph Goldberger
(1874-1929) CDC
Appointed in charge of PHS pellagra program 1914
Spartanburg South Carolina (1909)
In June 1914 the Public Health Service opened a temporary pellagra hospital and laboratory in Spartanburg
Orphans Asylum Mobile Alabama (1934)
Visited asylums and orphanages
Dined with staff saw what they and residents ate
Poor Southernerrsquos diet the 3 Mrsquos of fatback (meat) cornbread (meal) molasses ndash cheap easy to keep easy to cook filling tasty
Wife of sharecropper removing fatback from hook (1938)
Pellagra cannot be communicablebull Mississippi State Lunatic Asylum
October 1 1909ndashJuly 1 1913
bull 98 pellagra deaths
bull Georgia State Sanitarium
996 patients admitted in 1910
bull 32 cases of pellagra within one year
bull No cases among employees
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Pellagra Clinical features
CDC
weakness lethargy insomnia weight loss
rough reddened and scaly skin
painful mouth sores
appetite loss indigestion diarrhea
headache vertigo general aches muscle tremors mental illness
death
1906-1911 25000 cases
40 case fatality rate
1913 50000 or more cases with 11000 in Mississippi
Treatment
Cesare Lombroso
(1836-1909)
Promoted arsenic based treatment
Claimed cause was spoiled corn
Thompson-McFadden Commission
J H McFadden
Col Robert M Thompson
Barn fly
Dr Walter Wyman Surgeon General
Pellagra a ldquonational calamityrdquo
1911 appointed pellagra commission
Joseph Goldberger
(1874-1929) CDC
Appointed in charge of PHS pellagra program 1914
Spartanburg South Carolina (1909)
In June 1914 the Public Health Service opened a temporary pellagra hospital and laboratory in Spartanburg
Orphans Asylum Mobile Alabama (1934)
Visited asylums and orphanages
Dined with staff saw what they and residents ate
Poor Southernerrsquos diet the 3 Mrsquos of fatback (meat) cornbread (meal) molasses ndash cheap easy to keep easy to cook filling tasty
Wife of sharecropper removing fatback from hook (1938)
Pellagra cannot be communicablebull Mississippi State Lunatic Asylum
October 1 1909ndashJuly 1 1913
bull 98 pellagra deaths
bull Georgia State Sanitarium
996 patients admitted in 1910
bull 32 cases of pellagra within one year
bull No cases among employees
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
1906-1911 25000 cases
40 case fatality rate
1913 50000 or more cases with 11000 in Mississippi
Treatment
Cesare Lombroso
(1836-1909)
Promoted arsenic based treatment
Claimed cause was spoiled corn
Thompson-McFadden Commission
J H McFadden
Col Robert M Thompson
Barn fly
Dr Walter Wyman Surgeon General
Pellagra a ldquonational calamityrdquo
1911 appointed pellagra commission
Joseph Goldberger
(1874-1929) CDC
Appointed in charge of PHS pellagra program 1914
Spartanburg South Carolina (1909)
In June 1914 the Public Health Service opened a temporary pellagra hospital and laboratory in Spartanburg
Orphans Asylum Mobile Alabama (1934)
Visited asylums and orphanages
Dined with staff saw what they and residents ate
Poor Southernerrsquos diet the 3 Mrsquos of fatback (meat) cornbread (meal) molasses ndash cheap easy to keep easy to cook filling tasty
Wife of sharecropper removing fatback from hook (1938)
Pellagra cannot be communicablebull Mississippi State Lunatic Asylum
October 1 1909ndashJuly 1 1913
bull 98 pellagra deaths
bull Georgia State Sanitarium
996 patients admitted in 1910
bull 32 cases of pellagra within one year
bull No cases among employees
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Treatment
Cesare Lombroso
(1836-1909)
Promoted arsenic based treatment
Claimed cause was spoiled corn
Thompson-McFadden Commission
J H McFadden
Col Robert M Thompson
Barn fly
Dr Walter Wyman Surgeon General
Pellagra a ldquonational calamityrdquo
1911 appointed pellagra commission
Joseph Goldberger
(1874-1929) CDC
Appointed in charge of PHS pellagra program 1914
Spartanburg South Carolina (1909)
In June 1914 the Public Health Service opened a temporary pellagra hospital and laboratory in Spartanburg
Orphans Asylum Mobile Alabama (1934)
Visited asylums and orphanages
Dined with staff saw what they and residents ate
Poor Southernerrsquos diet the 3 Mrsquos of fatback (meat) cornbread (meal) molasses ndash cheap easy to keep easy to cook filling tasty
Wife of sharecropper removing fatback from hook (1938)
Pellagra cannot be communicablebull Mississippi State Lunatic Asylum
October 1 1909ndashJuly 1 1913
bull 98 pellagra deaths
bull Georgia State Sanitarium
996 patients admitted in 1910
bull 32 cases of pellagra within one year
bull No cases among employees
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Thompson-McFadden Commission
J H McFadden
Col Robert M Thompson
Barn fly
Dr Walter Wyman Surgeon General
Pellagra a ldquonational calamityrdquo
1911 appointed pellagra commission
Joseph Goldberger
(1874-1929) CDC
Appointed in charge of PHS pellagra program 1914
Spartanburg South Carolina (1909)
In June 1914 the Public Health Service opened a temporary pellagra hospital and laboratory in Spartanburg
Orphans Asylum Mobile Alabama (1934)
Visited asylums and orphanages
Dined with staff saw what they and residents ate
Poor Southernerrsquos diet the 3 Mrsquos of fatback (meat) cornbread (meal) molasses ndash cheap easy to keep easy to cook filling tasty
Wife of sharecropper removing fatback from hook (1938)
Pellagra cannot be communicablebull Mississippi State Lunatic Asylum
October 1 1909ndashJuly 1 1913
bull 98 pellagra deaths
bull Georgia State Sanitarium
996 patients admitted in 1910
bull 32 cases of pellagra within one year
bull No cases among employees
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Thompson-McFadden Commission
J H McFadden
Col Robert M Thompson
Barn fly
Dr Walter Wyman Surgeon General
Pellagra a ldquonational calamityrdquo
1911 appointed pellagra commission
Joseph Goldberger
(1874-1929) CDC
Appointed in charge of PHS pellagra program 1914
Spartanburg South Carolina (1909)
In June 1914 the Public Health Service opened a temporary pellagra hospital and laboratory in Spartanburg
Orphans Asylum Mobile Alabama (1934)
Visited asylums and orphanages
Dined with staff saw what they and residents ate
Poor Southernerrsquos diet the 3 Mrsquos of fatback (meat) cornbread (meal) molasses ndash cheap easy to keep easy to cook filling tasty
Wife of sharecropper removing fatback from hook (1938)
Pellagra cannot be communicablebull Mississippi State Lunatic Asylum
October 1 1909ndashJuly 1 1913
bull 98 pellagra deaths
bull Georgia State Sanitarium
996 patients admitted in 1910
bull 32 cases of pellagra within one year
bull No cases among employees
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Dr Walter Wyman Surgeon General
Pellagra a ldquonational calamityrdquo
1911 appointed pellagra commission
Joseph Goldberger
(1874-1929) CDC
Appointed in charge of PHS pellagra program 1914
Spartanburg South Carolina (1909)
In June 1914 the Public Health Service opened a temporary pellagra hospital and laboratory in Spartanburg
Orphans Asylum Mobile Alabama (1934)
Visited asylums and orphanages
Dined with staff saw what they and residents ate
Poor Southernerrsquos diet the 3 Mrsquos of fatback (meat) cornbread (meal) molasses ndash cheap easy to keep easy to cook filling tasty
Wife of sharecropper removing fatback from hook (1938)
Pellagra cannot be communicablebull Mississippi State Lunatic Asylum
October 1 1909ndashJuly 1 1913
bull 98 pellagra deaths
bull Georgia State Sanitarium
996 patients admitted in 1910
bull 32 cases of pellagra within one year
bull No cases among employees
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Joseph Goldberger
(1874-1929) CDC
Appointed in charge of PHS pellagra program 1914
Spartanburg South Carolina (1909)
In June 1914 the Public Health Service opened a temporary pellagra hospital and laboratory in Spartanburg
Orphans Asylum Mobile Alabama (1934)
Visited asylums and orphanages
Dined with staff saw what they and residents ate
Poor Southernerrsquos diet the 3 Mrsquos of fatback (meat) cornbread (meal) molasses ndash cheap easy to keep easy to cook filling tasty
Wife of sharecropper removing fatback from hook (1938)
Pellagra cannot be communicablebull Mississippi State Lunatic Asylum
October 1 1909ndashJuly 1 1913
bull 98 pellagra deaths
bull Georgia State Sanitarium
996 patients admitted in 1910
bull 32 cases of pellagra within one year
bull No cases among employees
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Spartanburg South Carolina (1909)
In June 1914 the Public Health Service opened a temporary pellagra hospital and laboratory in Spartanburg
Orphans Asylum Mobile Alabama (1934)
Visited asylums and orphanages
Dined with staff saw what they and residents ate
Poor Southernerrsquos diet the 3 Mrsquos of fatback (meat) cornbread (meal) molasses ndash cheap easy to keep easy to cook filling tasty
Wife of sharecropper removing fatback from hook (1938)
Pellagra cannot be communicablebull Mississippi State Lunatic Asylum
October 1 1909ndashJuly 1 1913
bull 98 pellagra deaths
bull Georgia State Sanitarium
996 patients admitted in 1910
bull 32 cases of pellagra within one year
bull No cases among employees
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Orphans Asylum Mobile Alabama (1934)
Visited asylums and orphanages
Dined with staff saw what they and residents ate
Poor Southernerrsquos diet the 3 Mrsquos of fatback (meat) cornbread (meal) molasses ndash cheap easy to keep easy to cook filling tasty
Wife of sharecropper removing fatback from hook (1938)
Pellagra cannot be communicablebull Mississippi State Lunatic Asylum
October 1 1909ndashJuly 1 1913
bull 98 pellagra deaths
bull Georgia State Sanitarium
996 patients admitted in 1910
bull 32 cases of pellagra within one year
bull No cases among employees
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Poor Southernerrsquos diet the 3 Mrsquos of fatback (meat) cornbread (meal) molasses ndash cheap easy to keep easy to cook filling tasty
Wife of sharecropper removing fatback from hook (1938)
Pellagra cannot be communicablebull Mississippi State Lunatic Asylum
October 1 1909ndashJuly 1 1913
bull 98 pellagra deaths
bull Georgia State Sanitarium
996 patients admitted in 1910
bull 32 cases of pellagra within one year
bull No cases among employees
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Pellagra cannot be communicablebull Mississippi State Lunatic Asylum
October 1 1909ndashJuly 1 1913
bull 98 pellagra deaths
bull Georgia State Sanitarium
996 patients admitted in 1910
bull 32 cases of pellagra within one year
bull No cases among employees
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
An orphanage study (Jackson MS)
1914 study
Age of Orphans
Pellagra cases
lt 6 years 25 26-12 years
120 65
gt 12 years
66 1
Total 211 68
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
An orphanage study (Jackson MS)
Age
Cases
Diet
Youngest lt 6 8 Principally milk
Middle-sized
6-12 54 General diet of grits (corn product) and gravy biscuits corn bread molasses and boiled greens practically no milk no cheese and lean meat once per week
Workers gt12 2 General diet plus milk cheese and meat
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Experimental Studiesbull Two orphanages Jackson MSbull Two wards Georgia State Sanitariumbull Both begun in 1914bull Diet
ndash Included fresh animal protein foods (milk meat and at the orphanages eggs) and more legumes
bull All administrative routine and hygienic and sanitary conditions unaltered
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Human experiments
Dietary groups
NRecurrence or
developed disease
Orphanages
Pellagrins 172 1
Nonpellagrins 168 0
Asylum
Pellagrins 72 0
Pellagrins no
special diet
32 15
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Experimental StudiesRankin farm Mississippi State Penitentiary Jackson MS 1915
Cases of pellagra
Pellagra diet 11 volunteers 6 (perhaps 7)
Controls Remaining farm population
None
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Experimental Studiesbull Experimental subjects 16
volunteersbull Material obtained from 17
pellagra patients administered to volunteers ndashblood nasopharyngeal
secretions epidermal scales from pellagrous skin lesions urine and feces
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Satisfies biomedical model
Diet Pellagra
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Sparta Cotton Mill Spartanburg SC 1909
Arkwright Cotton Mill Spartanburg SC 1909
Wylie Mill Chester SC 1908
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Arkwright Mills Spartanburg SC 1912
Beaumont Cotton Mill Spartanburg SC 1912
Relatively isolated villagesPopulations ~500-800Almost exclusively mill employees and familiesMostly white
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cotton mill studies
J F M A M J J A S O N D0
5
10
15
20
25
30
35
Month (1916)
o
f cases
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Pellagra not associated with Sanitation Household corn supply Dietary carbohydrates
No evidence that is was an infectious disease
Cotton mill studies
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cotton mill studiesCompared to nonpellagrous households pellagrous households had
Larger supply of foods low in niacin and tryptophan
Grits (corn product) canned corn potatoes jellies and jams salt pork
Smaller supply of foods high in niacin and tryptophan
Cheese milk string beans fresh meat
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Pellagra associated with
A difference in diet
of quantity
not of kind
Cotton mill studies
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cotton mill studies
Family income measure
Number of families
Families with gt 1 cases of pellagra
gt $ 1400 64 1 (15)
$ 1000 ndash 1399 144 3 (21)
$ 800 ndash 999 139 8 (58)
$ 600 ndash 799 183 21 (115)
lt $600 217 28 (129 )
As income increased the proportion of affected families in the income category decreased
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cotton mill studies
Family income measure
Fresh meat
Cured lean meat Butter Eggs
gt $ 1400 100 100 100 100
$ 1000 ndash 1399 68 53 117 97
$ 800 ndash 999 64 45 47 75
$ 600 ndash 799 45 38 63 64
lt $600 40 23 63 56
The smaller the income the smaller were family supplies for many types of foods high in niacin or precursor tryptophan
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Building a social science model
Income Diet Pellagra
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Differences in pellagra rates among villages were not explained by differences in
General environment Origintype of population Character of work Living habits Sanitary conditions Family income Purchasing power Susceptible ages
Per thousand
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cotton mill studies
VillagePellagra rate
A 26
B 19
C 65
D 11
E 21
F 0
G 25
Per thousand
Compared food availability and local markets for two extreme cases
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cotton mill studiesBoth villages had similarly stocked company stores and nearby grocery stores
Buying canned goods at a company store (1940)
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cotton mill studies
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Village with no pellagra cases
Village with high pellagra rate
Fresh meat market open daily
No fresh meat market
CLOSE
D
OPEN
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cotton mill studies
Number of purchases
No pellagra village
High pellagra
rate village
None 31 66
1 11 26
2-4 36 9
gt 5 22 0
Percent of households purchasing fresh meat according to number of purchases made during period May 16-30 1916
(in households with family incomes less than the average of the two mill villages)
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cotton mill studies
Article purchased
No pellagra village
High pellagra rate village
Fresh milk
51 45
Butter 49 15
Eggs 40 15
Percent of households purchasing article during period May 16-30 1916 from nearby farms
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cotton mill studiesVillage with no pellagra surrounded by diversified farming
Farm near Summerton South Carolina (1939)
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cotton mill studiesHigh pellagra village surrounded by cotton fields
Picking cotton Summerton South Carolina (1939)
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cotton mill studies
Farmers near high pellagra rate village sold their products in Inman and Spartanburg not in the village
Spartanburg South Carolina 1909
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cotton mill studiesbull Village with no pellagra had
better supply of foods high in niacin or tryptophan
bull Differences between the two villages in food supply were similar to differences in food supply between non-pellagrous and pellagrous households
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Social science modelType of local farming
Mill wages
Food available from farms
Family income
Market forces
Prices
Food available locally for sale
Household food supply
Pellagra incidenc
e
Character of diet
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Social science modelType of local farming
Mill wages
Food available
Family income
Market forces
Prices
Local food available
Household food supply
Pellagra incidenc
e
Character of diet
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Goldberger recommended improve incomes and improve available suitable food supply (eg crop diversification cow ownership)
Milking cows Clarendon County South Carolina (1939)
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
ldquoThe Nationrsquos Billion Dollar Croprdquo (1915)
Single-crop system in the south
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Sharecroppingbull Financing tenant farmer
bull Landowner provides cash advances
bull Credit given at company store or other store for supplies
bull Farmer mortgaged crop to company store for supplies
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Sharecroppingbull Income of tenant farmer
bull From sale of cottonseed and the cotton lint clinging to the seed after deduction of any cash advances or settling credit or mortgage
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Sharecropping
bull Farmerrsquos household subsisted on pellagra producing diet (salt pork or fatback corn meal molasses plus some wheat flour rice and dried beans)
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Sharecropping
Family picking cotton (1916)
Landlords discouraged gardens and cows
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Reception
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Newspaper articles
Bulletins left at country stores
Persuade state health departments to provide education
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Picking cotton Mississippi Delta (1939)
ldquoPellagra ndash 100000 victims threatened in US cotton beltrdquo ndash NY Times 1921
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
1900 ndash 1940 gt100000 deaths from pellagra
~ half African-American
gt 23 women
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
The Rockefeller Sanitary Commission for the
Eradication of Hookworm Disease
The ldquoNewrdquo Public Health
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Charles Wardell Stiles
(1867-1941)
Charles Wardell Stiles
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Charles Wardell Stiles
Walter Wyman (1848-1911)
Charles Wardell Stiles (1867-1941)
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Charles Wardell Stilesbull Preached sanitation and lectured on
hookworm prevention and treatment throughout the South
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Commission on Country Life (1908)bull Appointed by
President Theodore Roosevelt
bull Investigate the economic social and sanitary con-ditions of country life
bull Sanitarian Charles W Stiles
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Rockefeller General Education Board
bull Address public education in the South
Dr Wallace Buttrick
(1853-1926)
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
John D Rockefeller(1839-1937)
Frederick T Gates
(1853-1929)
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
bull 1909 - 1915 Rockefeller
Sanitary Commission for the Eradication of Hookworm Disease
bull Modeled after the Institute for Medical Research and the General Education Board
bull The ldquonewrdquo public health
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
General Education Boardbull Worked through local institutions
ndash Supported Southern teachersrsquo colleges
ndash Indirect lobbying locally for primary and secondary schools by funding professorships at Southern Universities
Hampton Normal and Agricultural Institute
Hampton Virginia
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Staffingbull State director of sanitationbull Corps of full-time licensed
physician inspectors microscopists and laboratory technicians
Sanitary Commission
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Sanitary Commission
bull Assessed geographic distribution of hookworm and degree of infection
bull Inspected schools instructed teachers
bull Enlisted cooperation of physiciansbull Assessed contributory sanitary
conditionsbull Cooperated with the pressbull Informed the public
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Sanitary Commission
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
440000 doses of thymol dispensed
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
bull Documented extent of the problemndash 39 of examined children (age 6-
18) were infectedndash 50 of households had no privy
bull 694494 Southerners given at least one dose of thymol
bull Ordinances requiring sanitary privies at public schools
bull Medical schools increased instructionbull Physicians treated patientsbull Health department
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Sanitary Commission
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Sanitary Commission
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Sanitary Commission
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Sanitary Commission
Increases in school enrollment regular school attendance and literacy
Bleakley Hoyt Disease and development Evidence from hookworm eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Sanitary Commission
ldquoAt the present time it is fair to say that hookworm disease has almost disappeared from the United States rdquo
Rockefeller Foundation
International Health Board Annual Report for 1926
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Sanitary Commission
Charles Wardell Stiles
(1867-1941)
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Lessons
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Germ Theory and the New Public Healthbull Disease caused by germsbull Focus on individual behavior and
individual responsibilitybull Personal hygiene and education
combats diseasebull Consistent with middle class
valuesbull Limited responsibilities for health
departments
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Germ Theory and the New Public Healthbull Individual enlightenment key to social
reform
bull Through education rather than legislation
bull Economy assumed to be largely beneficent
bull Espouse market justice
bull Social reformers and like-minded politicians misguided
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
bull Gates and RockefellerndashCause and cure of hookworm
matter of individual change and education
ndashldquo the evils of society are not fundamentally economic but are physical and moralrdquo
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Pellagra and Social Medicinebull Conceptualize larger social forces
(eg income religion ethnicity institutions social inequality) generated by society which act on individuals and communities
bull Cause and cure both socialinstitutional
bull Approach social responsibility
bull Espouse social justice
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Pellagra and Social Medicine
Cause and cure are institutionalndashCharacteristics of economy
affecting family income single crop farming (esp cotton) and localregional market conditions
ndashNot result of individual or family uninformed choices
ndashCure matter of social responsibility
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Which position to choose The new public health or social
medicine
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Broad social economic cultural health and environmental conditions and policies that operate at the global national state and local levels
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Employment status and occupational factors Socioeconomic statusThe natural and built environmentsPublic health servicesHealth care services
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Social family and community networks
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Individual behavior
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
Innate traits such as sex age race and biological factors and the biological characteristics of particular diseases and injuries affect health
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
NOTES Adapted from Dahlgren and Whitehead 1991 The dotted lines denote interaction effects between and among the various levels of health determinants (Worthman 1999)
Over the life span
The Ecological Model
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
What became of pellagra and hookworm in the
South
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
John Thomas and daughter working in their home vegetable garden Georgia (1939)
Southern Statesrsquo Relief
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Nutrition exhibit Farm Security Administration (1941)
National campaign to improve nutrition
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Increase in truck farming
Packing tomatoes from truck farms Mississippi (1936)
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Charlie McGuires children in their new wagon Alabama (Farm Security Administration) (1939)
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Putting up a fence at a community garden (1941)
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Farm Security Administration exhibit (1939)
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Farm Security Administration (1941)
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Farm Security Administration (1941)
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Farm Security Administration (1941)
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
New Deal brought food and other help
Factory financed by Federal Emergency Relief Administration Produced starch from sweet potatoes Laurel Mississippi (1936)
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Civilian Conservation Corps
Civilian Conservation Corps workers Prince Georges County Maryland (1935)
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Rural electrification hastened refrigeration
Electrical switchyard Wilson Dam Alabama (Tennessee Valley Authority) (1942)
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
More cold storage lockers appeared
Selecting turkeys at cold storage plant Brownwood Texas (1939)
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Science of nutrition comes into its own
Wartime food demonstration (1943)
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Textile strikes
Pickets at textile mill Greensboro GA (1941)
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Dallas Texas exhibit (1936)
Rural poverty labeled un-American
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
World War II prosperity
USS California hit Pearl Harbor (1941)
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Camp Lejeune North Carolina (1943)
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Food production improved
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Cattle on cotton plantation Mississippi (1940)
Peach orchard Georgia (1939)
Agriculture changed in the South
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Greenbelt Maryland (1942)
Supermarkets in rural areas
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
South became more urbanized
Downtown Atlanta Georgia (1938)
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Postscript
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
END
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
ldquoPellagra and Hookwormrdquo
Prepared by
Dennis A BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo NY 14214USA
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Image SourcesCenters for Disease Control and Prevention Public Health Image Library httpphilcdcgovphilhomeasp
httprmclibrarycornelledubaileycommissioncommission_5html Hendrick Burton J The Life and Letters of Walter H Page httpwwwgutenbergorgfiles1701717017-h17017-hhtm
Library of Congress Prints and Photographs Division Washington DC 20540 httpwwwlocgovpictures
National Library of Medicine Images from the History of Medicinehttpihmnlmnihgovlunaservletviewall
The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease Annual Reports
US Department of Agriculture Farmersrsquo Bulletin No 1408 The House Fly and How to Suppress It Washington D C Issued April 1925 revised November 1926httpwwwgutenbergorgfiles1805018050-h18050-hhtm
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
Bibliography Bleakley Hoyt Disease and development Evidence from hookworm
eradication in the American South The Quarterly Journal of Economics 122(1)73-117 2007
Budetti Peter P Market justice and US health care Journal of the American Medical Association 299(1)92-94 2008
Etheridge Elizabeth W The Butterfly Caste Greenwood Publishing Company Westport Connecticut 1972
Ettling John The Germ of Laziness Rockefeller Philanthropy and Public Health in the New South Harvard University Press Cambridge Massachusetts 1981
Goldberger on Pellagra Edited by Milton Terris Louisiana State University Press Baton Rouge Louisiana 1964
Kunitz Stephen J The Health of Populations Oxford University Press New York New York 2007
Marks Harry M Epidemiologists explain pellagra gender race and political economy in the work of Edgar Sydenstricker Journal of the History of Medicine 5834-55 2003
Stiles Charles Wardell Is it fair to say that hookworm disease has almost disappeared from the United States Science 77(1992)237-239 1933
