Pellagra and Hookworm - Public Health History

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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.

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  • Using the historical examples of pellagra and hookworm, after viewing this presentation you should be Better able to distinguish between biomedical and public health causative models of disease and injury, andBe better able to apply the ecological model as a guide for analyzing public health problems
  • What is pellagra?Pellagra is a vitamin deficiency disease most commonly caused by a chronic lack of niacin (vitamin B3) in the diet or its precursor tryptophan.
  • The privately endowed Thompson-McFadden Commission of the New York Post-Graduate Medical School and Hospital set up headquarters in Spartanburg, South Carolina and began its studies of pellagra in 1912. The Commission concluded that pellagra was an infectious disease with contaminated food the possible source but the contamination was transmitted by an insect vector thought to be the barn fly.The Pellagra Commission of the State of Illinois in 1911 came to similar conclusions, namely, that pellagra was an infectious diseaseand a diet deficient in animal protein could be a predisposing factor in contracting the infection. ----------------------------------------Title: J.H. McFadden and wife Creator(s): Bain News Service, publisher Date Created/Published: [between ca. 1910 and ca. 1915] Medium: 1 negative : glass ; 5 x 7 in. or smaller. Reproduction Number: LC-DIG-ggbain-18486 (digital file from original negative) Rights Advisory: No known restrictions on publication.Call Number: LC-B2- 3388-11ba [P&P] Repository: Library of Congress Prints and Photographs Division Washington, D.C. 20540 USA http://hdl.loc.gov/loc.pnp/pp.print -------------------------------------Title: Col. R.M. Thompson Creator(s): Bain News Service, publisher Date Created/Published: 1914 July 3 (date created or published later by Bain) Medium: 1 negative : glass ; 5 x 7 in. or smaller. Summary: Photograph shows Robert Means Thompson (1849-1930) who served as a United States Navy officer, businessman, and a president of the American Olympic Association. (Source: Flickr Commons project, 2011) Reproduction Number: LC-DIG-ggbain-16460 (digital file from original negative) Rights Advisory: No known restrictions on publication.Call Number: LC-B2- 3133-12 [P&P] Repository: Library of Congress Prints and Photographs Division Washington, D.C. 20540 USA http://hdl.loc.gov/loc.pnp/pp.print Barn fly picture: http://www.gutenberg.org/files/18050/18050-h/18050-h.htm U. S. DEPARTMENT OF AGRICULTURE FARMERS' BULLETIN No. 1408 The HOUSE FLY AND HOW TO SUPPRESS IT
  • Mill families bought fresh meats from fresh-meat markets and milk, butter, and eggs were bought from nearby farms.-----------------------------------------Title: Meat market, Plain City, Ohio Creator(s): Shahn, Ben, 1898-1969, photographer Date Created/Published: 1938 Aug. Medium: 1 negative : nitrate ; 35 mm. Reproduction Number: LC-DIG-fsa-8a18026 (digital file from original) LC-USF33-006487-M2 (b&w film nitrate neg.) Rights Advisory: No known restrictions. For information, see U.S. Farm Security Administration/Office of War Information Black & White Photographs(http://www.loc.gov/rr/print/res/071_fsab.html)Call Number: LC-USF33- 006487-M2 [P&P] Other Number: F 637 Repository: Library of Congress Prints and Photographs Division Washington, DC 20540 USA http://hdl.loc.gov/loc.pnp/pp.print
  • In the village with no pellagra cases, a fresh-meat market had been open seven days a week the year round for several years, and another market a mile away took orders and delivered fresh meat to mill workers’ households. On the other hand, the village with the high pellagra rate had not had a fresh-meat market since February of the year and a mile or so away a market was selling fresh meat for cash only and had but a few regular customers. The nearest other market accessible to the village with the high pellagra rate was 13 miles away in the city of Spartanburg.---------------------------Title: Meat market, Plain City, Ohio Creator(s): Shahn, Ben, 1898-1969, photographer Date Created/Published: 1938 Aug. Medium: 1 negative : nitrate ; 35 mm. Reproduction Number: LC-DIG-fsa-8a18026 (digital file from original) LC-USF33-006487-M2 (b&w film nitrate neg.) Rights Advisory: No known restrictions. For information, see U.S. Farm Security Administration/Office of War Information Black & White Photographs(http://www.loc.gov/rr/print/res/071_fsab.html)Call Number: LC-USF33- 006487-M2 [P&P] Other Number: F 637 Repository: Library of Congress Prints and Photographs Division Washington, DC 20540 USA http://hdl.loc.gov/loc.pnp/pp.print
  • The Rockefeller Sanitary Commission for the Eradication of Hookworm Disease, the “New” Public Health
  • The Sanitary Commission worked through state health departments, and provided funds to hire staff for these often poorly funded and understaffed departments and to build or improve the state health laboratory. Staffing included a state director of sanitation, full-time inspectors who were licensed physicians, microscopists, and laboratory technicians.
  • The physician inspectors assessed the geographic distribution and degree of hookworm infection; inspected schools and instructed teachers; enlisted local physicians to provide treatment of persons infected with hookworm; identified sanitary conditions that could contribute to the spread of hookworm, especially the presence and conditionof privies; enlisted the cooperation of the press to publicize events and publish information about hookworm; and informed the public through lectures and demonstra­tions about hookworm disease, the importance of being tested and treated, and sanitation especially as applied to privies.
  • People would bring their stool samples in tin boxes to the dispensaries and the microscopist would examine the samples while the people heard testimonials and the physician inspector would give a lecture on hookworm, sanitation and the need to wear shoes. There were exhibits describing how hookworm disease was spread and showing pictures of sanitary houses and privies. Those found infected with hookworm were given thymol with instructions on how to use it once they were home and to follow up with their local physicians. 440,000 persons received at least one dose of thymol via these dispensaries.-----------------------------------------pictures are from Rockefeller publication
  • The Commission’s reports presented vignettes and photos of persons before and after treatment.----------------------------pictures are from Rockefeller publication
  • of entire families cured-----------------------------------pictures are from Rockefeller publication
  • And of school children cured of hookworm.-------------------------pictures are from Rockefeller publication
  • By 1926 the Rockefeller Foundation International Health Board declared that hookworm disease had almost disappeared from the United States
  • Charles Stiles, however, strongly disagreed pointing out that as late as 1930 his own survey of grade school children in the South found that 25% were infected with hookworm. Other studies conducted in the 1930s supported Stiles’ view that the number of persons infected had decreased but it was still high and the geographic area affected had remained the same.------------------------------Title: Dr. C.W. Stiles Creator(s): Bain News Service, publisher Date Created/Published: [between ca. 1910 and ca. 1915] Medium: 1 negative : glass ; 5 x 7 in. or smaller. Reproduction Number: LC-DIG-ggbain-19316 (digital file from original negative) Rights Advisory: No known restrictions on publication.Call Number: LC-B2- 3516-1 [P&P] Repository: Library of Congress Prints and Photographs Division Washington, D.C. 20540 USA http://hdl.loc.gov/loc.pnp/pp.print
  • What lessons can be drawn from the histories of pellagra and hookworm?The histories of pellagra and hookworm reflect two differing views for addressing public health challenges. ------------------------------------------Title: [Classroom interior with students and blackboard] Related Names: Detroit Publishing Co. , publisher Date Created/Published: [between 1910 and 1930] Medium: 1 negative : glass ; 5 x 7 in. Reproduction Number: LC-D419-18 (b&w glass neg.) Call Number: LC-D419-18 <P&P> [P&P] Repository: Library of Congress Prints and Photographs Division Washington, D.C. 20540 USA
  • The key to social reform was individual enlightenment through education, not governmental legislationThe economic system was assumed to be largely beneficent with the market rightly dispensing justiceSocial reformers and like-minded politicians were seen as misguided
  • Gates and Rockefeller saw the cause and cure of hookworm to be essentially a matter of educating individuals to change and adopt appropriate, hygienic behaviors including building sanitary privies. It was a matter of individual responsibility. The Sanitary Commission provided the direction. The campaign had a distinctly evangelical overtone, in the Baptist minister Frederick Gates’ own words, “the evils of society are not fundamentally economic but are physical and moral.” From such a perspective efforts to eradicate a disease such as hookworm need not involve much in the way of political, economic, social, cultural or institutional change. There was no need for public health professionals to involve themselves in social reforms.
  • The history of pellagra illustrates an alternate view. By searching beyond the immediate cause of pellagra, a dietary deficiency, Goldberger and his colleagues embodied an approach informed by the social sciences emerging at the end of the 19th and beginning of the 20th centuries. This social medicine conceptualized the existence of larger social forces such as income, religion, economics, and social inequality, generated by society and acting on individuals and communities. Social problems were the consequences of the confluence of these forces and the cure is to be found in modifying these forces. The approach emphasizes social responsibility and espouses social justice.
  • Goldberger saw the cause and cure of pellagra to be institutional.Goldberger concluded that the cause was one of lack of adequate household food supplies due to economic factors and the means of production affecting family income, agricultural practices and market conditions.Pellagra was not the result of irresponsibility of individuals or families, or of uninformed choices.The cure, therefore, was a matter of social responsibility to increase family income and improve food availability ------------------------------
  • So, what became of pellagra and hookworm in the Southern States? The Sanitary Commission did not eradicate hookworm, and Goldberger could bring attention to factors affecting pellagra but he could not modify those factors.
  • Relying on individuals to build sanitary privies, adopt more hygienic behaviors, purchase shoes, plant gardens, keep cows, and learn about providing themselves with better diets; and providing support during hard times, such as distributing yeast or providing food during emergencies, are clearly useful but limited approaches; efforts to control disease and illness need the support of a sound underlying economic system. Advances in science, especially nutrition, and fundamental changes in the southern economy significantly diminished pellagra, hookworm and similar consequences of poverty. As Goldberger had predicted in the case of pellagra, in time, it was a fundamental change in the economics of the South that spelled the end of pellagra; and the same was true for hookworm.
  • Pellagra and Hookworm - Public Health History

    1. 1. Pellagra andHookwormPrepared by Dennis A. Bertram2013This PowerPoint slide set has audio narration and provided text.Download to access.
    2. 2. Learning Objectives• Upon completion, you will be betterable toDistinguish between biomedical andpublic health causative models of diseaseApply the ecological model to analyzingpublic health challenges
    3. 3. Pellagra (pə●lᾱʹgrə) – niacin(vitamin B3) or tryptophandeficiency disease
    4. 4. Pellagra: Clinical featuresCDCweakness, lethargy,insomnia, weight lossrough, reddened, andscaly skinpainful mouth soresappetite loss,indigestion, diarrheaheadache, vertigo,general aches, muscletremors, mental illnessdeath
    5. 5. 1906-1911: 25,000 cases40% case fatality rate1913: 50,000 or more cases,with 11,000 in Mississippi
    6. 6. TreatmentCesareLombroso(1836-1909)Promotedarsenic basedtreatmentClaimed causewas spoiled corn
    7. 7. Thompson-McFadden CommissionJ. H. McFaddenCol. Robert M. ThompsonBarn fly
    8. 8. Dr. Walter Wyman,Surgeon GeneralPellagra, a “nationalcalamity”?1911 appointedpellagracommission
    9. 9. JosephGoldberger(1874-1929) CDCAppointed incharge of PHSpellagra program,1914
    10. 10. Spartanburg, South Carolina (1909)In June 1914, the Public HealthService opened a temporary pellagrahospital and laboratory in Spartanburg
    11. 11. Orphans Asylum, Mobile, Alabama (1934)Visited asylums and orphanagesDined with staff, saw what they and residentsate
    12. 12. Poor Southerner’s diet: the 3 M’s of fatback (meat),cornbread (meal), molasses – cheap, easy to keep,easy to cook, filling, tasty.Wife of sharecropper removing fatback from hook (1938)
    13. 13. Pellagra cannot be communicable• Mississippi State Lunatic AsylumOctober 1, 1909–July 1, 1913• 98 pellagra deaths• Georgia State Sanitarium996 patients admitted in 1910• 32 cases of pellagra within one year• No cases among employees
    14. 14. An orphanage study (Jackson, MS)1914 studyAge # of Orphans Pellagra cases< 6 years 25 26-12 years 120 65> 12 years 66 1Total 211 68
    15. 15. An orphanage study (Jackson, MS)Age Cases DietYoungest < 6 8 % Principally milkMiddle-sized6-12 54 % General diet of grits (cornproduct) and gravy,biscuits, corn bread,molasses and boiledgreens; practically no milk,no cheese and lean meatonce per weekWorkers >12 2 % General diet plus milk,cheese and meat
    16. 16. Experimental Studies• Two orphanages, Jackson, MS• Two wards, Georgia State Sanitarium• Both begun in 1914• Diet:– Included fresh animal protein foods (milk, meat,and, at the orphanages, eggs) and morelegumes• All administrative routine and hygienic andsanitary conditions unaltered
    17. 17. Human experimentsDietary groups NRecurrence ordeveloped diseaseOrphanagesPellagrins 172 1Nonpellagrins 168 0AsylumPellagrins 72 0Pellagrins, nospecial diet32 15
    18. 18. Experimental StudiesRankin farm, Mississippi StatePenitentiary, Jackson, MS, 1915Cases ofpellagraPellagra diet 11 volunteers 6 (perhaps 7)Controls RemainingfarmpopulationNone
    19. 19. Experimental Studies• Experimental subjects: 16volunteers• Material obtained from 17 pellagrapatients administered tovolunteers:– blood, nasopharyngeal secretions,epidermal scales from pellagrousskin lesions, urine and feces
    20. 20. Satisfies biomedical model:Diet  Pellagra
    21. 21. Sparta Cotton Mill, Spartanburg, S.C., 1909Arkwright Cotton Mill, Spartanburg, S.C., 1909Wylie Mill, Chester, S.C., 1908
    22. 22. Arkwright Mills, Spartanburg, SC, 1912Beaumont Cotton Mill,Spartanburg, SC, 1912Relatively isolatedvillagesPopulations ~500-800Almost exclusivelymill employees andfamiliesMostly white
    23. 23. Cotton mill studies05101520253035J F M A M J J A S O N DMonth (1916)%ofcases
    24. 24. Pellagra not associated with:SanitationHousehold corn supplyDietary carbohydratesNo evidence that is was aninfectious diseaseCotton mill studies
    25. 25. Cotton mill studiesCompared to nonpellagroushouseholds, pellagrous households hadLarger supply offoods low in niacinand tryptophanGrits (cornproduct), cannedcorn, potatoes, jellies andjams, salt porkSmaller supply offoods high in niacinand tryptophanCheese, milk, stringbeans, fresh meat
    26. 26. Pellagra associated with:A difference in dietof quantity,not of kindCotton mill studies
    27. 27. Cotton mill studiesFamily incomemeasureNumber offamiliesFamilies with > 1cases of pellagra> $ 14.00 64 1 (1.5%)$ 10.00 – 13.99 144 3 (2.1%)$ 8.00 – 9.99 139 8 (5.8%)$ 6.00 – 7.99 183 21 (11.5%)< $6.00 217 28 (12.9 %)As income increased, the proportion of affectedfamilies in the income category decreased.
    28. 28. Cotton mill studiesFamily incomemeasureFreshmeatCuredleanmeat Butter Eggs> $ 14.00 100 100 100 100$ 10.00 – 13.99 68 53 117 97$ 8.00 – 9.99 64 45 47 75$ 6.00 – 7.99 45 38 63 64< $6.00 40 23 63 56The smaller the income, the smaller werefamily supplies for many types of foods high inniacin or precursor tryptophan.
    29. 29. Building a social sciencemodel:Income Diet Pellagra
    30. 30. Cotton mill studiesVillagePellagrarate*A 26B 19C 65D 11E 21F 0G 25Differences in pellagra ratesamong villages were notexplained by differences in:General environmentOrigin/type of populationCharacter of workLiving habitsSanitary conditionsFamily incomePurchasing powerSusceptible ages* Per thousand
    31. 31. Cotton mill studiesVillagePellagrarate*A 26B 19C 65D 11E 21F 0G 25* Per thousandCompared food availabilityand local markets for twoextreme cases
    32. 32. Cotton mill studiesBoth villages had similarly stocked company stores andnearby grocery stores.Buying canned goods at a company store (1940)
    33. 33. Cotton mill studies
    34. 34. Village with nopellagra casesVillage with highpellagra rateFresh meat marketopen dailyNo fresh meatmarket
    35. 35. Cotton mill studiesNumber ofpurchasesNo pellagravillageHigh pellagrarate villageNone 31 % 66 %1 11 % 26 %2-4 36 % 9 %> 5 22 % 0 %Percent of households purchasing fresh meataccording to number of purchases madeduring period May 16-30, 1916(in households with family incomes less than theaverage of the two mill villages)
    36. 36. Cotton mill studiesArticlepurchasedNo pellagravillageHigh pellagrarate villageFresh milk 51 % 4.5 %Butter 49 % 1.5 %Eggs 40 % 1.5 %Percent of households purchasing articleduring period May 16-30, 1916, from nearbyfarms
    37. 37. Cotton mill studiesVillage with no pellagra surrounded bydiversified farmingFarm near Summerton, South Carolina (1939)
    38. 38. Cotton mill studiesHigh pellagra village surrounded by cottonfieldsPicking cotton, Summerton, South Carolina (1939)
    39. 39. Cotton mill studiesFarmers near high pellagra rate village soldtheir products in Inman and Spartanburg, notin the village.Spartanburg, South Carolina, 1909
    40. 40. Cotton mill studies• Village with no pellagra had bettersupply of foods high in niacin ortryptophan• Differences between the twovillages in food supply weresimilar to differences in foodsupply between non-pellagrousand pellagrous households
    41. 41. Social science modelType of localfarmingMill wages Food availablefrom farmsFamilyincomeMarketforcesPricesFood availablelocally for saleHouseholdfood supplyPellagraincidenceCharacterof diet
    42. 42. Social science modelType of localfarmingMill wages Food availablefrom farmsFamilyincomeMarketforcesPricesFood availablelocally for saleHouseholdfood supplyPellagraincidenceCharacterof diet
    43. 43. Social science modelType of localfarmingMill wages Food availablefrom farmsFamilyincomeMarketforcesPricesFood availablelocally for saleHouseholdfood supplyPellagraincidenceCharacterof diet
    44. 44. Social science modelType of localfarmingMill wages FoodavailableFamilyincomeMarketforcesPricesLocal foodavailableHouseholdfood supplyPellagraincidenceCharacterof diet
    45. 45. Goldberger recommended: improve incomesand improve available suitable food supply(e.g., crop diversification, cow ownership)Milking cows, Clarendon County, South Carolina (1939)
    46. 46. “The Nation’s Billion Dollar Crop” (1915)Single-crop system in the south
    47. 47. Sharecropping• Financing tenant farmer•Landowner provides cashadvances•Credit given at company store orother store for supplies•Farmer mortgaged crop tocompany store for supplies
    48. 48. Sharecropping• Income of tenant farmer•From sale of cottonseed and thecotton lint clinging to the seedafter deduction of any cashadvances or settling credit ormortgage
    49. 49. Sharecropping• Farmer’s household subsisted onpellagra producing diet (salt porkor fatback, corn meal, molassesplus some wheat flour, rice anddried beans)
    50. 50. SharecroppingFamily picking cotton (1916)Landlords discouraged gardens and cows
    51. 51. Reception
    52. 52. Newspaper articlesBulletins left at countrystoresPersuade state healthdepartments to provideeducation
    53. 53. Picking cotton, Mississippi Delta (1939)“Pellagra – 100,000 victims threatened in U.S.cotton belt” – NY Times, 1921
    54. 54. 1900 – 1940>100,000 deaths from pellagra~ half African-American> 2/3 women
    55. 55. The Rockefeller SanitaryCommission for theEradication of HookwormDiseaseThe “New” Public Health
    56. 56. Charles Wardell Stiles(1867-1941)Charles Wardell Stiles
    57. 57. Charles Wardell StilesWalter Wyman(1848-1911)Charles Wardell Stiles(1867-1941)
    58. 58. Charles Wardell Stiles• Preached sanitation and lectured onhookworm prevention and treatmentthroughout the South
    59. 59. Commission on Country Life (1908)• Appointed byPresident TheodoreRoosevelt• Investigate theeconomic, socialand sanitary con-ditions of countrylife• Sanitarian: CharlesW. Stiles
    60. 60. Rockefeller General Education Board• Address publiceducation in theSouthDr. Wallace Buttrick(1853-1926)
    61. 61. John D. Rockefeller(1839-1937)Frederick T. Gates(1853-1929)
    62. 62. • 1909 - 1915: Rockefeller SanitaryCommission for the Eradication ofHookworm Disease• Modeled after the Institute forMedical Research and the GeneralEducation Board• The “new” public health
    63. 63. General Education Board• Worked through local institutions– Supported Southern teachers’ colleges– Indirect lobbying locally for primary andsecondary schools by fundingprofessorships at Southern UniversitiesHampton Normal andAgricultural Institute,Hampton, Virginia
    64. 64. Staffing• State director of sanitation• Corps of full-time licensedphysician inspectors, microscopists,and laboratory techniciansSanitary Commission
    65. 65. Sanitary Commission• Assessed geographic distribution ofhookworm and degree of infection• Inspected schools, instructed teachers• Enlisted cooperation of physicians• Assessed contributory sanitaryconditions• Cooperated with the press• Informed the public
    66. 66. Sanitary Commission
    67. 67. 440,000 doses ofthymol dispensed
    68. 68. • Documented extent of the problem– 39% of examined children (age 6-18)were infected– 50% of households had no privy• 694,494 Southerners given at least onedose of thymol• Ordinances requiring sanitary privies atpublic schools• Medical schools increased instruction• Physicians treated patients• Health departmentSanitary Commission
    69. 69. Sanitary Commission
    70. 70. Sanitary Commission
    71. 71. Sanitary Commission
    72. 72. Sanitary CommissionIncreases in school enrollment, regularschool attendance, and literacyBleakley, Hoyt. Disease and development:Evidence from hookworm eradication in theAmerican South. The Quarterly Journal ofEconomics, 122(1):73-117, 2007
    73. 73. Sanitary Commission“At the present time it is fair to saythat hookworm disease has almostdisappeared from the United States. . .”Rockefeller FoundationInternational Health BoardAnnual Report for 1926
    74. 74. Sanitary CommissionCharles WardellStiles(1867-1941)
    75. 75. Lessons?
    76. 76. Germ Theory and the New Public Health• Disease caused by germs• Focus on individual behavior andindividual responsibility• Personal hygiene and educationcombats disease• Consistent with middle class values• Limited responsibilities for healthdepartments
    77. 77. Germ Theory and the New Public Health• Individual enlightenment key to socialreform• Through education rather than legislation• Economy assumed to be largely beneficent• Espouse market justice• Social reformers and like-minded politiciansmisguided
    78. 78. • Gates and Rockefeller– Cause and cure of hookwormmatter of individual change andeducation– “. . . the evils of society are notfundamentally economic but arephysical and moral.”
    79. 79. Pellagra and Social Medicine• Conceptualize larger social forces(e.g., income, religion, ethnicity,institutions, social inequality)generated by society which act onindividuals and communities• Cause and cure both social/institutional• Approach: social responsibility• Espouse social justice
    80. 80. Pellagra and Social MedicineCause and cure are institutional– Characteristics of economy affectingfamily income, single crop farming(esp. cotton), and local/regionalmarket conditions– Not result of individual or familyuninformed choices– Cure matter of social responsibility
    81. 81. Which position to choose? The newpublic health or social medicine?
    82. 82. NOTES: Adapted from Dahlgren and Whitehead, 1991.The dotted lines denote interaction effects betweenand among the various levels of health determinants(Worthman, 1999).Over the life spanThe Ecological Model
    83. 83. NOTES: Adapted from Dahlgren and Whitehead, 1991.The dotted lines denote interaction effects betweenand among the various levels of health determinants(Worthman, 1999).Over the life spanThe Ecological ModelBroad social, economic,cultural, health andenvironmental conditionsand policies that operate atthe global, national, stateand local levels
    84. 84. NOTES: Adapted from Dahlgren and Whitehead, 1991.The dotted lines denote interaction effects betweenand among the various levels of health determinants(Worthman, 1999).Over the life spanThe Ecological ModelEmployment status andoccupational factorsSocioeconomic statusThe natural and builtenvironmentsPublic health servicesHealth care services
    85. 85. NOTES: Adapted from Dahlgren and Whitehead, 1991.The dotted lines denote interaction effects betweenand among the various levels of health determinants(Worthman, 1999).Over the life spanThe Ecological ModelSocial, family andcommunity networks
    86. 86. NOTES: Adapted from Dahlgren and Whitehead, 1991.The dotted lines denote interaction effects betweenand among the various levels of health determinants(Worthman, 1999).Over the life spanThe Ecological ModelIndividual behavior
    87. 87. NOTES: Adapted from Dahlgren and Whitehead, 1991.The dotted lines denote interaction effects betweenand among the various levels of health determinants(Worthman, 1999).Over the life spanThe Ecological ModelInnate traits such as sex,age, race and biologicalfactors, and the biologicalcharacteristics of particulardiseases and injuries affecthealth
    88. 88. NOTES: Adapted from Dahlgren and Whitehead, 1991.The dotted lines denote interaction effects betweenand among the various levels of health determinants(Worthman, 1999).Over the life spanThe Ecological Model
    89. 89. What became of pellagra andhookworm in the South?
    90. 90. John Thomas and daughter working in their homevegetable garden, Georgia (1939)Southern States’ Relief
    91. 91. Nutrition exhibit, Farm Security Administration (1941)National campaign to improve nutrition
    92. 92. Increase in truck farmingPacking tomatoes from truck farms, Mississippi (1936)
    93. 93. Charlie McGuires children in their new wagon,Alabama (Farm Security Administration) (1939)
    94. 94. Putting up a fence at a community garden (1941)
    95. 95. Farm SecurityAdministrationexhibit (1939)
    96. 96. Farm Security Administration (1941)
    97. 97. Farm Security Administration (1941)
    98. 98. Farm Security Administration (1941)
    99. 99. New Deal brought food and other helpFactory financed by Federal Emergency ReliefAdministration. Produced starch from sweet potatoes.Laurel, Mississippi (1936)
    100. 100. Civilian Conservation CorpsCivilian Conservation Corps workers, Prince GeorgesCounty, Maryland (1935)
    101. 101. Rural electrification hastened refrigerationElectrical switchyard, Wilson Dam, Alabama(Tennessee Valley Authority) (1942)
    102. 102. More cold storage lockers appearedSelecting turkeys at cold storage plant, Brownwood,Texas (1939)
    103. 103. Science of nutrition comes into its ownWartime food demonstration (1943)
    104. 104. Textile strikesPickets at textile mill, Greensboro, GA (1941)
    105. 105. Dallas, Texas, exhibit (1936)Rural poverty labeled un-American
    106. 106. World War II prosperityU.S.S. California hit, Pearl Harbor (1941)
    107. 107. Camp Lejeune, North Carolina (1943)
    108. 108. Food production improved
    109. 109. Cattle on cottonplantation,Mississippi (1940)Peach orchard,Georgia (1939)Agriculture changed in the South
    110. 110. Greenbelt, Maryland (1942)Supermarkets in rural areas
    111. 111. South became more urbanizedDowntown Atlanta, Georgia (1938)
    112. 112. Postscript
    113. 113. END
    114. 114. “Pellagra and Hookworm”Prepared by:Dennis A. BertramUniversity at Buffalo School of Public Health and Health ProfessionsBuffalo, NY 14214USA
    115. 115. Image SourcesCenters for Disease Control and Prevention Public Health Image Libraryhttp://phil.cdc.gov/phil/home.asphttp://rmc.library.cornell.edu/bailey/commission/commission_5.htmlHendrick, Burton J. The Life and Letters of Walter H. Page.http://www.gutenberg.org/files/17017/17017-h/17017-h.htmLibrary of Congress Prints and Photographs Division, Washington, D.C.20540 http://www.loc.gov/pictures/National Library of Medicine, Images from the History of Medicinehttp://ihm.nlm.nih.gov/luna/servlet/view/allThe Rockefeller Sanitary Commission for the Eradication of HookwormDisease, Annual ReportsU.S. Department of Agriculture Farmers’ Bulletin No. 1408 The House Flyand How to Suppress It. Washington, D. C. Issued April, 1925; revisedNovember, 1926http://www.gutenberg.org/files/18050/18050-h/18050-h.htm
    116. 116. Bibliography Bleakley, Hoyt. Disease and development: Evidence from hookworm eradication in theAmerican South. The Quarterly Journal of Economics, 122(1):73-117, 2007. Budetti, Peter P. Market justice and US health care. Journal of the American MedicalAssociation, 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 theNew South. Harvard University Press: Cambridge, Massachusetts, 1981. Goldberger on Pellagra. Edited by Milton Terris. Louisiana State University Press: BatonRouge, Louisiana, 1964. Kunitz, Stephen J. The Health of Populations. Oxford University Press: New York, NewYork, 2007. Marks, Harry M. Epidemiologists explain pellagra: gender, race and political economy inthe work of Edgar Sydenstricker. Journal of the History of Medicine, 58:34-55, 2003. Stiles, Charles Wardell. Is it fair to say that hookworm disease has almost disappearedfrom the United States? Science, 77(1992):237-239, 1933.

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