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Pellagra in the American South

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Pellagra in the American South The Rise and Fall of Pellagra in the American South Karen Clay* Ethan Schmick† Werner Troesken‡ This draft: August 2016 Abstract No other nutrition-related disease in American history caused as many deaths as pellagra. The by-product of insufficient niacin consumption, pellagra reached epidemic proportions in the American South, killing roughly 7,000 Southerners annually at its peak in 1928. We document the rise and fall of pellagra in the American South and present three main findings. First, pellagra resulted, in part, from Southern agriculture’s heavy emphasis on cotton, which displaced local food production and effectively raised the price of niacin consumption. Evidence for this proposition derives in part from the arrival of the boll weevil. Although the boll weevil reduced Southern incomes and cotton production, it was also associated with increases in local food production and sharp reductions in pellagra. Second, pellagra was largely eliminated through voluntary fortification of cereal-grain products starting in 1937 and a series of state fortification laws passed in the 1940s. These laws, for the first time in Southern history, broke the strong positive correlation between cotton production and pellagra. Third, exposure to early-life interventions that reduced cotton production and/or increased niacin consumption were associated with improved stature and wages. These findings have important implications for our understanding of the economic history of the American South and economic development in general. * Contact: Karen Clay, Associate Professor of Economics and Public Policy, Carnegie Mellon University, Heinz College, 5000 Forbes Avenue, Pittsburgh, PA 15213. Email: [email protected] † Contact: Ethan Schmick, University of Pittsburgh, Department of Economics, 4901 Wesley W. Posvar Hall, 230 South Bouquet, Pittsburgh, PA 15260. Email: [email protected] ‡ Contact: Werner Troesken, Professor of Economics, University of Pittsburgh, Department of Economics, 4901 Wesley W. Posvar Hall, 230 South Bouquet, Pittsburgh, PA 15260. Email: [email protected] 1 1. Introduction While virtually unheard of in the United States today, no other nutrition-related disease in American history has caused as many deaths as pellagra. The by-product of insufficient niacin consumption, pellagra reached epidemic proportions in the American South during the first half of the twentieth century, killing roughly 7,000 Southerners annually at its peak in 1928 (Bollet 1992).1 Put another way, at its peak in 1933, malaria killed around 4,500 Southerners annually, or only two-thirds the number of people killed by pellagra at its peak.2 If one looks at the incidence of pellagra, the data are even more striking. According to one estimate, the case fatality rate for pellagra was only around 3% (Goldberger 1928). Thus, it is possible that in 1928 there were approximately 230,000 cases of pellagra in the United States, which is equivalent to the population of Atlanta at the time. In places where pellagra was endemic, it was estimated that around 20 percent of all households had at least one person sick with the disease (Goldberger 1928). While pellagra was not as pervasive as hookworm, which infected around one- third of the Southern population, it is important to remember that pellagra is an extreme indicator: one need not have developed a full-blown case of pellagra to have been poorly nourished, and the high incidence of pellagra is suggestive of widespread malnutrition in the South (Etheridge 1972, Youmans 1964). Although there is a small literature on pellagra in the American South, that literature is mostly qualitative and has not been subjected to formal hypothesis testing. As a result, our understanding of the origins and effects of pellagra is incomplete and predicated on a limited evidentiary base. In this paper we document the rise and fall of pellagra in the Southern United States by conducting a series of falsification exercises to test the central predictions of the existing historical literature. Additionally, we extend the literature by offering and testing new hypotheses on the long-term effects of early- 1 The Mortality Statistics of the United States report 6,824 deaths from pellagra in the year 1928. 2 The Mortality Statistics of the United States report 4,678 deaths from malaria in the year 1933. This number is likely overstated since in several years it is reported that the term malaria “is used somewhat loosely in some sections of the country” and that this “undoubtedly has much to do with some of the higher rates recorded” (Mortality Statistics of the United States 1924; pg. 25). 2 life exposure to high pellagra environments. Our results do not call for a wholesale revision of the prevailing understanding of pellagra in the American South, but they do bring to the fore economic and nutritional mechanisms that have important implications for our understanding of the American South in particular, and cash crop economies in the developing world more generally. We focus on three sets of questions. First, what were the origins of pellagra, and why was it so pronounced in the American South? Existing historical accounts suggest the disease stemmed from the Southern production of cotton. According to the standard logic, cotton displaced local food production and drove poor Southern farmers and mill workers to consume milled Midwestern corn, which was relatively cheap but was also devoid of niacin (Park et al. 2000, Goldberger et al. 1920, Rajakumar 2000). Second, pellagra rates plummeted during the mid-twentieth century. What drove this sharp decline? Existing historical accounts attribute the eradication of pellagra to a series of state laws passed during the 1940s mandating breads and grains be fortified with niacin and other nutrients (Humphreys 2009, Park et al. 2000). Third, we ask a question that the existing qualitative literature has left unaddressed: what were the effects of pellagra, and nutritionally deficiencies more generally, on the long-term welfare of Southerners? We begin our analysis by searching for systematic evidence that cotton production displaced local food production, which in turn limited the availability of nutritionally-rich locally-sourced foods and discouraged adequate consumption of nutrients, such as niacin. Consistent with the prevailing historical understanding, we find that in times and places of high cotton production, pellagra rates were also higher. One might wonder if these estimates conflate changes in income with changes in food availability: perhaps years of high cotton production were also years of low income, and it was the reduction in income, not the reduction in local food production, that drove the increase in pellagra. Two pieces of evidence, however, suggest this is not the case. First, the positive correlation between cotton production and pellagra survives the inclusion of controls for changes in farm revenue generated per acre of cotton. Second, the arrival of the boll weevil during the early 1900s reduced both income and cotton production, 3 and yet was associated with increased food production and reduced pellagra rates. Moreover, when cotton production rebounded after the boll weevil, pellagra rates returned to their pre-boll-weevil levels. After exploring the relationship between cotton production and pellagra, we search for evidence on the forces behind the decline in pellagra rates during mid- twentieth century. The raw data reveal two sharp drops in the pellagra death rate. The first break occurs during the early 1930s, at the peak of the Great Depression. The second sharp drop in the pellagra death rate is permanent and takes place during the late 1930s and 1940s. Because this drop happens at around the same time that state and federal governments introduced laws encouraging and mandating that breads and grains be enriched with niacin, historical observers have long attributed a causal connection between the laws and the reduction in pellagra. Using a panel of state-level data and a standard difference-in-differences set up, we exploit the interstate variation in the timing of niacin-fortification laws to identify their effects on pellagra and other nutrition-related diseases. Consistent with the prevailing historical literature, the results suggest fortification laws significantly reduced the mortality associated with pellagra and low niacin consumption more generally. In the final part of our analysis, we look at the long-term effects of early life exposure to high pellagra (low-niacin consumption) environments. Building on work in an earlier section of the paper and using a difference-in-differences estimation strategy, we first study how the arrival of the boll weevil, and the subsequent increase in local food production, affected the heights (a now common barometer of early-life health and nutrition) of World-War II army recruits. The results suggest that the arrival of the boll weevil gave rise to taller, healthier soldiers, despite the reductions in farm income likely associated with the arrival of the boll weevil. The results are, moreover, most pronounced in counties producing high levels of cotton and in states with high pre-boll weevil pellagra rates. Following Neimish (2015), we also explore how early-life exposure to state-level niacin-fortification laws affected wages in the long-term. We find that fortification increased wages by approximately 2% amongst Southerners born after a 4 state passed a fortification law. The results are, again, larger for states that had higher levels of pre-fortification pellagra. Taken together, our results contribute to the following literatures. The first, and probably the most important contribution, is to our understanding of the economic history of the American South. The American South has long lagged behind the North in economic performance, and only after World War II did incomes begin to converge. Until 1940, income per capita in the South was 45 to 60 percent of the U.S. average; by 1980, that deficit had been reduced to 80 to 95 percent (Wright 1987). Standard explanations for these patterns fall into one of three categories.
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