Pellagra, however, is far from dead in the developing world and is often seen in the midst of chaotic situations. For example, the disease surfaced a few years ago in Malawi, when thousands of Mozambicans fled the civil conflict in their own country to seek refuge there. Once in Malawi, they lived in refugee camps or nearby villages, where - between July and October 1989 - 1,169 cases of pellagra were diagnosed among refugees living in 11 sites. From February 1 through October 30,1990, another 17,878 cases were reported among a population of 285,942 refugees; in other words, over 6 percent were afflicted. But the rate of affliction varied from one location to another, ranging from 0.5 percent to 13.2 percent. Moreover, females were more than seven times as likely to be afflicted as males; young children, however, were substantially less affected than adults, as has generally been the case during outbreaks of pellagra. The disease was also less common among those who lived in integrated villages rather than in camps (Editorial 1991).
French epidemiologists working for Medectns
Sans Frontieres, who investigated the epidemic, found that those refugees who escaped pellagra were more likely to have gardens, have a daily supply of peanuts (an important niacin-containing staple of the region), or have the ability to mill maize. At the time of the epidemic, peanut distribution had been disrupted, and the maize sent in by donor nations was neither vitamin-enriched nor even ground into meal. Thus, those who developed pellagra were totally dependent on the maize ration, and the greater vulnerability of women was explained by the tendency of males to appropriate nuts, meats, and fish (foods high in niacin as well as tryptophan, its precursor) for themselves.
Clearly, the appearance of a major epidemic of pellagra toward the end of the twentieth century - when the means of preventing the disease have been known for more than 50 years - suggests a substantial error in judgment by supposedly compassionate nations.
Lessons to Be Learned
At the risk of belaboring points that have already been made, by way of conclusion it seems worthwhile briefly to revisit some past notions about pellagra. The first of these is that pellagra was the fault of the afflicted, rather than of those who maintained the existing inequalities of the social system. The second (not all that different from the first) was that the eating habits of pellagrins were the consequence of an unwillingness to change their lifestyles.
Some social critics of the past did better than the scientists in understanding pellagra. French novelist Edmond About (1858), for example, clearly indicated his grasp of the social causes of the disease when he had one of his characters remark that pellagra would continue to exist in the marshy southwestern area of his country (the Landes region) until the nature of the environment changed. His succinct prediction,
Tant que Lande sera lande,
La pellagre te demande
(As long as the Landes remains a moor,
There pellagra will claim the poor),
Suggests that pellagra was the fault of the society in which it raged rather than that of the peasant who suffered the deprivations of such a society.
In rural areas of the southern United States, the sharecroppers’ “bad habit” of eating an unvaried diet of cornmeal with occasional fatback and molasses - the “three Ms”: maize, molasses, and meat (but only the fatback type of meat) - was understood to increase their nutritional risk of pellagra. In urban environments, the “bad” food habits of alcoholics were thought to explain their pellagra susceptibility. Lost in this tendency to blame the victim was the fact that sharecroppers ate a deficient diet because they had little or no access to food other than the “three
Ms.” Similarly, pellagra susceptibility in “down-and-out” alcoholics can be explained by society’s inability to accept alcoholism as a disease and the consequent belief that alcoholics should not receive adequate nutritional assistance because this would only encourage them to continue in their lifestyle.
In the case of refugee camps, not only were the refugees viewed as an inferior social group, but (as with the alcoholics who were the urban pellagrins of the 1920s and 1930s) they were fed with indifference by donor nations without any effort to improve their health and quality of life. Even today, nations that send food to those living in such camps assume little responsibility for providing an adequate diet for the recipients. Rather, they continue to ship food - like maize - that is unfamiliar to the consumers and is grossly deficient in nutrients.
Certainly, past - often elitist - views of pellagra as the fault of the pellagrin are no longer acceptable today. Moreover, instead of claiming the conquest of endemic pellagra as a scientific triumph, we might ask why pellagra came about in the first place and why it persisted for so long. Finally, we should ask why, even after the means of pellagra prevention are fully understood, there are still serious outbreaks of the disease in various parts of the world.
Daphne A. Roe Stephen V. Beck
to Dr. Charles C. Dickinson, III, for his help with the quotation from the work of Edmond About.
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World History
