The health of a country is probably the most important part of its national security. Anyone who doesn't understand that is either too stupid or too greedy to be in the United States Congress -- and apparently too many of our legislators fit in one or the other category.
In general, what we call "public health" is the art and science of protecting and improving community health by various means. We already have government agencies, federal, state, and local, concerned with public health.
Public health is part of our national health care. So here's a story about public health, rich and poor, and national health care.
In the early part of the 20th century we were a rapidly growing country, industrializing at a frantic pace, with hardly any public health because few people realized that public health was important for national security. Among many scourges, we had one scourge that afflicted poor rural people, particularly in the South in places like South Carolina and Alabama.
The Italians in Europe called the scourge "rough skin" -- pelle agra. It was common all over Europe in poor villages, a puzzle for physicians.
The affliction apparently first appeared in Europe in 1735, and the evidence is that superstitious villagers in the eighteenth century quickly concluded the condition was caused by vampires.
The disease had a predictable course. Over four or five years, the pellagrin (an individual with pellagra) would progress through the "four Ds"-- dermatitis, dementia, diarrhea, and death. Of course, once dementia occurred, the pellagrins were treated like other demented individuals -- secluded by their families or incarcerated in pauper houses or insane asylums until they died.
Pellagra has always been a disease of poverty, a complicated disease whose simple prevention would not be evident for two hundred years after it first appeared in Europe. It's a sterling example of how ignorance can wreck the lives of large numbers of people.
So what was it and how did it originate?
During the seventeenth century, when the Europeans established contact with the New World, one consequence was the introduction of corn into European agriculture. The hardy corn plant rapidly became more economical for the poorer classes than the rye and wheat that had been the staples of the poor for centuries. Corn was already the staple in the Americas, where it was treated with lime by the native Americans in the process of making corn meal. The Europeans bypassed the lime treatment. They did not know that as a result the corn meal they produced did not release the chemical niacin, a chemical nutrient essential to the body and especially to the nervous system (we call niacin vitamin B3). Niacin was first prepared as a chemical in 1873, but at that time nothing was known about its nutritive value.
Corn meal produced without lime (alkali) treatment leaves the niacin in corn meal biologically unavailable as a nutrient, and if the corn meal is the main source of food the consequence is niacin deficiency and slow destruction of the brain and nervous system. Pellagra became endemic in Europe, and then endemic in the American South, where corn meal was the major food source in the poor population. An approximate total of 7000 deaths a year from pellagra occurred across fifteen American Southern states. Other states had a similar incidence, but they apparently refused to report cases of pellagra. It's estimated that in the early part of the 20th century America had three million cases of pellagra and 100,000 deaths from the disease.
In the early part of the 20th century in America, pellagra was as much a mystery as it had been in the eighteenth century. A faulty diet was suspected, but at that time the idea was only a speculation. The disease was a particular affliction in insane asylums -- not only in the South but also in the North. Why insane asylums? No one knew.
Enlightenment arrived in 1914 when someone was astute enough to put two and two together and get four -- without any experiments. On June 26, 1914, a short note appeared in the journal Public Health Reports. The author was the man in charge of pellagra investigations at the United States Public Health Service. The modest first sentence of the note is a classic in medical science:
"The writer desires to invite attention to certain observations recorded in the literature of pellagra the significance of which appears entirely to have escaped attention."
And the "certain observations" were what? In the three short pages of the note, the author pointed out that in no insane asylums anywhere, in or out of the United States, where pellagra was endemic, did nurses or attendants ever get the disease. In Italy, for example, in a large hospital for pellagra patients near Venice, a place that always had 300 to 500 pellagra patients cared for by nurses and attendants, no employee had ever developed the disease while at the institution.
At that time, most people in the medical community believed that pellagra was an infectious disease associated with an inherited degenerative susceptibility. The author of the short 1914 report concluded that the medical community was wrong. He concluded that pellagra was not an infectious disease, and was most likely caused by unhealthy diets of patients. Nurses and attendants always had either better diets or opportunity to supplement the institutional diets--and that was why they did not contract pellagra.
The author also pointed out that pellagra was common among the rural poor but not common among the urban poor, and the explanation for this was probably that the urban poor had more varied diets than the rural poor.
Concerning diet as a cause of pellagra, the author stated as follows:
"With regard to the question of just what in the dietary is responsible, the writer has no opinion to express. From a study of certain institutional dietaries, however, he has gained the impression that vegetables and cereals form a much greater proportion in them than they do in the dietaries of well-to-do people; that is, people who are not, as a class, subject to pellagra. The writer is satisfied that the consumption of corn or corn products is not essential to the production of pellagra, but this does not mean that corn, the best of corn, or corn products, however nutritious and however high in caloric value they may be, are not objectionable when forming of themselves or in combination with other cereals and with vegetables, a large part of the diet of the individual."
The author's concluding remarks were as modest as his opening statement:
"In view of the great uncertainty that exists as to the true cause of pellagra, it may not be amiss to suggest that pending the final solution of this problem it may be well to attempt to prevent the disease by improving the dietary of those among whom it seems most prevalent. In this direction I would urge the reduction in cereals, vegetables, and canned foods that enter to so large an extent into the dietary of many of the people in the South and an increase in the fresh animal food component, such as fresh meats, eggs, and milk. It may be of interest to add that intensive studies along the lines so strongly suggested by the observations above considered are being prosecuted by several groups of workers of the United States Public Health Service."
Intensive studies, indeed. Immediately after his report was published in 1914, the author began experiments with volunteers--experimental groups on restricted diets based heavily on corn meal, and control groups on ordinary unrestricted diets. He demonstrated that corn-based diets greatly increased the risk of pellagra. It took a while to convince the medical community and the managers of hospitals and insane asylums, but by the 1920s everyone understood the reality of the dietary cause of pellagra.
The author of the 1914 report was Joseph Goldberger (1874-1929), a physician and epidemiologist, born in Hungary, emigrated to America with his parents when he was nine years old, the family settling in the Lower East Side in Manhattan. Goldberger attended the City College of New York, switched from engineering to medicine, and graduated from Bellevue Medical College at the age of twenty-one. Goldberger was nominated for a Nobel Prize five times during his lifetime, but the prize was never awarded to him.
No private interest solved the pellagra problem of the American South. Rich people did not get afflicted with pellagra and they had little interest in it. People whose roots are in places like South Carolina and Alabama need to ask themselves how many of their grandparents and great grandparents had their lives saved by the United States Public Health Service in the early part of the 20th century.
A public health service is not just a convenience, it's a vital part of the national security of a country. What we call "public health" is just part of national health -- and national health will always also be part of national security.
How many lives would we save, and how much would our health and productivity improve, if we had at least the beginning of an efficient and accessible national health service?
We do not farm out our national security to private interests. The reason is simple: history demonstrates that private interests will usually give their bank accounts priority over any other concern.
Does anyone really believe executives in the health insurance industry and health care industries will ever sacrifice profits for the sake of national health? They will not do that. Their record is clear that they will not do that. They simply do not think in those terms. Private health care interests cannot be entrusted with our basic national security. We can use them as the equivalents of contractors for certain parts of the job but not for all of the job. We cannot keep all of our health care in the hands of mercenaries. Putting all of our national security in private hands is simply too dangerous. It's a reality -- and we do need reality in our lives.