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One Doctor's Fight to End an American Epidemic
Goldberger's War chronicles one of the U.S. Public Health Service's most renowned heroes--an immigrant Jew who trained as a doctor at Bellevue, became an early recruit to the federal government's health service, and ended an American plague. And he did so by defying conventional wisdom, experimenting on humans, and telling the South precisely what it didn't want to hear.
In this fine work, Alan Kraut shows why Dr. Goldberger's life became, quite literally, the stuff of Action Comic storyboards. On the front lines of the legendary public-health battles of the early 20th-century, he fought the epidemics that were then routinely sweeping the nation--typhoid, yellow fever, and the measels. After successfully confronting (and often contracting) the infectious diseases of his day, in 1914 he was assigned the mystery of pellagra, a disease whose cause and cure had eluded the world for centuries and was then afflicting tens of thousands of Americans every year, particularly in the emerging "New South." Dispatched to find a medical solution to what prevailing wisdom assumed was another infectious disease, Goldberger discovered its cause in a dietary deficiency and spent years conducting experiments (some on himself and family) to prove he was right. But finding the cause was just half the fight; its cure required nothing less than challenging the economy, culture, and politics of the entire South.
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Alan M. Kraut is a professor of history at American University. His most recent book, Silent Travelers: Germs, Genes, and the Immigrant Menace, won the Theodore Salutous Memorial Book Award. He lives in Bethesda, Maryland.
Goldberger's War opens in 1916, as Joseph Goldberger injects his wife with blood taken from patients with advanced pellagra. As the vignette suggests, historian Alan Kraut's engaging biography is about a bold medical investigator, an inexplicable disease, human experimentation, and an unusual marriage. (Figure) In 1874 Joseph Goldberger and his family left Hungary for New York City. His father ran a grocery store on the Lower East Side, and the son studied medicine at Bellevue Hospital's Medical College, graduating in 1895. Goldberger's limited means and his identity as a Jewish immigrant led to his rejection by the U.S. Navy Medical Corps, which he tried to join at the start of the Spanish-American War. In 1899 Goldberger entered the Public Health Service, in which he spent the rest of his professional life, attracted by both the regular government salary and the opportunities for scientific investigation in the laboratory and in the field. While holding his first position, as a quarantine officer, he was introduced by a fellow physician to Mary Humphreys Farrar of New Orleans. Her father, a wealthy Episcopalian lawyer, conducted an investigation of the Goldberger family before reluctantly agreeing to the marriage of Joseph and Mary in 1906. The young couple struggled to create a happy, mixed-faith family. For Joseph, Kraut argues, the Public Health Service's Hygienic Laboratory "would become his temple," but for Mary, his constant traveling left her too often as the sole parent of four rambunctious children. And his work could be dangerous: Goldberger contracted yellow fever in 1902, dengue fever in 1907, and typhus in 1910. To Mary he admitted "a certain pride in my `battle' scars . . . received in the line of duty for my country." In the early 20th century, the Public Health Service offered its officers an exciting new job as physician-investigators on "search and destroy" missions, calming a hysterical public, confronting the skeptical with technological expertise, and saving the day with scientifically sound solutions. The work was not always so simple, however, as Goldberger discovered when he began to argue that pellagra -- a major health problem in the South with an associated mortality rate of around one in three -- was caused not by a germ but by a nutritional deficiency. Drawing on histories by Elizabeth W. Etheridge and Daphne A. Roe, as well as on letters between Goldberger and his wife, Goldberger's published work, and an interview with Goldberger's son, Joseph Herman Goldberger, Kraut traces Goldberger's efforts to convince the medical profession and the public of his theory. At that time, the germ theory had made environmental explanations sound old-fashioned and unscientific. White Southerners, angry at this attack on their region and on the "three-m" diet of the rural poor (meat, meal, and molasses), retorted that pellagra was a "germ" disease, thus one that could easily be fixed by some kind of sanitary measure. Black physicians, conscious that deficiency diseases were frequently blamed on ignorant, lazy, and thriftless black persons, also argued that pellagra was "communicable," that perhaps, like yellow fever, it was spread by insects. Impressed by suspicious evidence that pellagra appeared in state institutions among inmates but never among their keepers, Goldberger tried to undermine theories of bacterial infection by organizing "filth parties," during which he, his wife, and 14 volunteers took pellagra "pills" and were injected with pellagra-contaminated blood. I wish Kraut had speculated further and explored Goldberger's attraction to an explanation for pellagra based on nutrition. Certainly his sharp eyes, trained to detect diseases caused by germs and insects, could "sweep away" other explanations. Or perhaps Goldberger's assumption that milk and other "animal proteins" were the solution may have reflected the effect of the powerful advertising campaigns conducted by the dairy industry in the popular and medical press (to counter the many times milk was blamed for outbreaks of typhoid fever and tuberculosis) -- a kind of early 20th-century version of "Got Milk?" A more troubling side of Goldberger's efforts to prove that pellagra could be explained by diet, not germs, was his experimentation for over a decade on human subjects who were in orphanages, prisons, and asylums. Kraut admits that the mentally ill black women at the Georgia state asylum who were Goldberger's subjects from 1915 to 1926 "had little choice about whether they would participate," but he has restricted what should have been an extensive bioethical discussion of these experiments to a brief footnote. For Goldberger, the solution to pellagra was a political morass that defeated him. The detailed epidemiologic study of seven mill towns in South Carolina that he conducted with statistician Edgar Sydenstricker, also in the Public Health Service, showed the complex social and economic factors that underlay the Southern agricultural economy and shaped what people ate and why they got sick. By the mid-1920s, although Goldberger acknowledged that "the problem of pellagra is in the main a problem of poverty," he concluded that bold structural solutions such as food cooperatives and community dairies would not "conform to local conditions" and retreated to the relative serenity of the laboratory to try to find a specific "pellagra-preventive." Mary Goldberger lobbied Congress to establish the National Institute of Health. In 1927, when a massive pellagra outbreak threatened after floods on the Mississippi River, the Red Cross, advised by Goldberger, developed a "moderate" solution -- education about nutrition and handouts of canned vegetables, brewer's yeast, and even some cows. Nominated five times for the Nobel Prize, Goldberger died in 1929 amid odd rumors that the cause of his death was not kidney cancer but pellagra. His wife received a $125-a-month pension thanks to a special congressional bill that recognized the value of Goldberger's work. In the 1930s niacin deficiency was identified as the specific cause of pellagra, although the Southern Medical Association continued to honor researchers who demonstrated the pellagra "virus." The disease ceased to be an important American health problem as a result of the expanded use of home refrigerators, made possible by the New Deal's electrification programs, and the government-mandated vitamin enrichment of bread and flour that was introduced during World War II. In this century, however, pellagra continues to threaten communities in the Third World whose food supply is disrupted by civil war. "Goldberger's war never really ends," Kraut concludes. "We just send in fresh troops." In this engrossing story of an American medical hero whose work and life illustrate the intertwining of medical, social, and political history, Kraut shows us that the research and practice of physicians can help to explain how people become sick, but that especially for diseases for which there are no vaccines, prevention and treatment must involve a conscious reorganization of the ways people live and of the social and economic factors that shape their choices. Naomi Rogers, Ph.D.
Copyright © 2004 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
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