The Red Death: The Pellagra Epidemic in the Early 20th Century American South

A victim of Pellagra

A victim of Pellagra

Mysterious diseases have plagued humanity throughout our history. In ancient days, there was little that could be done to explain, let alone stop, the ravages of epidemics. Such scourges as small pox, cholera, and the bubonic plague killed huge numbers of people and disappeared as quickly as they came, leaving ancient cultures reeling in their wake.

In the 20th century, mankind  began to get a better handle on the causes of disease. Even so, a mysterious disease ravaged the American South. Its symptoms were horrific and debilitating: red, peeling skin, diarrhea, mental problems up to and including dementia, and ultimately in many cases, death. The disease was pellagra, a disease caused by niacin deficiency, and it roared through the South throughout the first half of the twentieth century, killing upwards of 100,000 people before it was finally stopped.


A mystery disease

Pellagra was first described in Spain by Gasper Casal y Julian in 1735. The disease was mainly seen in Southern Europe and the Mediterranean during the 18th and 19th century. In particular, the disease was studied in Italy and Spain. Gaetano Strambio in particular studied the disease extensively. He proved that pellagra was more than only a skin disease. He was the first to connect pellagra to diet, claiming the cause was spoiled bread and polenta.  Another Italian physician, Cesare Lobroso, determined in 1869 that pellagra was caused by a poison present in spoiled corn, initiating the connection between corn and pellagra that would continue into the mid twentieth century.

When the disease appeared for the first time in American in 1902, it left doctors baffled. Experts were divided from the beginning of the outbreak—some suspected spoiled corn was the culprit, in keeping with Lobroso’s determination almost fifty years earlier, while others thought the disease was spread by insects or contaminated water. The one point of agreement was that pellagra was most prevalent among the poor. Early studies suggested that the disease was spread by some as yet unknown pathogen. In 1914, the US Public Health Service dispatched Dr. Joseph Goldberger, who had success fighting previous epidemics, to South Carolina to study the pellagra plague. His findings would cause a political tumult that would delay the needed methods to stop the disease for years.


Dr. Joseph Goldberger

Dr. Joseph Goldberger

The Three M’s

Dr. Goldberger examined institutions such as prisons and asylums were pellagra raged unchecked. He found that, while patients and inmates at these institutions often suffered from pellagra, their nurses and guards did so only rarely. If pellagra were infectious, this should not be the case. Dr. Goldberger concluded that the difference between the inmates and their caretakers lay in their diet. While guards and nurses had access to a greater variety of food, their charges’ diets primarily consisted of cornmeal, molasses, and small bits of fatty pork back. This was similar to the traditional diet of the Southern poor, called the three M’s: meal, molasses, and meat.

Extrapolating his results to the broader population, Dr. Goldberger realized that the traditional Southern diet itself was the cause of the epidemic, particularly among poor populations who did not have access to wider variety of foods. This revelation caused a ruckus among Southerners, especially the political class. The post Reconstruction South was still sensitive over its defeat in the Civil War, and saying that the cause of the horrific disease ravaging its population was due to economic factors was seen as a slight against Southern pride and the idea that the South would rise again to its former greatness.

Dr. Goldberg struggled against this blowback at first, but he found that the forces who favored the infectious theory of pellagra’s spread were too intransigent to be convinced. He devoted himself to figuring out what specific deficiency was behind the disease. He died of renal cancer in 1929 before finding that which he sought. The final revelation came in 1937, when it was found that niacin deficiency, among others, was the cause of pellagra. The subsequent enrichment of flour with niacin and other b vitamins virtually eliminated pellagra in the United States.


The law of unintended consequences

The question remains: what caused the pellagra epidemic to occur so suddenly in the early 20th century? There were likely multiple causes. It is a given that the poor Southern diet mixed with a reluctance to admit that the cultural touchstone were both factors in extending the epidemic. However, the diet was nothing new in the South, and while it is not entirely known how widespread pellagra was before 1902, there is no evidence of it being to epidemic proportions before the 20th century.

Looking to another, similar disease can shed some light on the beginning of the epidemic. Beriberi, a deficiency of the nutrient thiamin, became epidemic in the Far East in the 1880s, shortly after a new method for milling rice was developed.  Similarly, a new method of milling corn was developed around 1900. Called degermination, it removed the germ of the corn, resulting in a product that was more stable but lacking in many of the nutrients present in corn milled the traditional way. This explained then why pellagra was more common in institutions, where corn meal was the primary food source. It also explained why the disease was more common in mill workers, who ate corn meal shipped from the Midwest that had undergone the degermination process. It was less common among rural farmers, who ate corn prepared in traditional stone mills.

So, then it was a confluence of factors that brought about the pellagra epidemic. Cultural bias, technological innovation, and long standing tradition conspired to produce an epidemic that sickened millions and killed around 100,000. Largely forgotten today, the southern pellagra epidemic is a case study in both the importance of good science and the strength of tradition in the study of disease.



Bollet, Alfred Jay. “Politics and Pellagra: The Epidemic of Pellagra in the U.S in the Early Twentieth Century.” The Yale Journal of Biology and Medicine 65 (1992) 211-221. Retrieved from:

“History of Pellagra.” UAB Libraries. Reynolds-Finley Historical Library. Retrieved January 15, 2016. Retrieved from:

Tuttle, Grace. “A Mysterious Epidemic: Pellagra in South Carolina.” August 5, 2014. South Carolina Digital Newspaper Program. January 15, 2016.