There is a stereotype of poor southern Americans being lazy and dumb. This characterization began popping up in art and literature after the Civil War ended. In the South, these people that seemed to have a deep aversion to work and knowledge were known as “dirt eaters” because many of them also ate dirt. Other symptoms of these people were yellow skin, dry, dull hair, lackluster fish eyes, bloated stomachs, and intense melancholy. Many of the children were undersized and underdeveloped, many of the teenagers looked like they were only six or eight years old while some of the adults could pass off as tweens. Southerners would call this affliction “the lazy sickness” or “the big lazy.” Most of the medicine that was prescribed was just alcohol and many became dependent on it and were turned into alcoholics as well.
In 1902, Dr. Charles W. Stiles, a zoologist from New York City that had been educated in Europe, was tasked by the Department of Agriculture to visit the south and educate the farmers down there on how to keep their animals healthy. While in the South treating animals, Stiles was taken aback by these “dirt eaters” and how unhealthy they all looked. Stiles was sure that this wasn’t just a cultural trait of the South, but something must actually be making these people sick. Some of the symptoms reminded him of a parasite known as a hookworm that he had studied back in Europe, however the hookworm had never been identified in America before.
Hookworms enjoy loamy soil and feces along with a humid climate. If an animal or human steps on a hookworm larvae that is hiding out in the soil, the larvae will burrow through the skin like a corkscrew. Once this happens, the host will develop an itchy sore on their foot that is known as “ground itch.” Once the larvae is inside the body, the will make their way into the bloodstream which they will ride all the way into the lungs. This will cause the host to have an irritating, dry cough. When the host coughs hard enough, the larvae will get expelled into the windpipe where they get swallowed back down into the esophagus and then travel in the digestive system until they reach the small intestine. Once in the small intestine, the larvae grows into an adult, where it then uses it’s fangs to latch onto the inner lining of the small intestine and start sucking out blood like a leech and keep growing larger. While the worm is there, the host will feel extremely exhausted and seem like they’re in a deep haze which could come across as being dimwitted. While still sucking on blood off of the host, a female hookworm can lay up to anywhere between 5,000 eggs and 25,000 eggs in a single day, which is then passed through the host’s body with their stool onto the ground, where the eggs hatch into larvae and hope something steps on them so they can start the whole process over again.
The worms can live up to five years inside of host, and in some extreme cases, 20 years. A worm sucks about 1/100th of a teaspoon of blood a day and while that seems small, it would only take 25 worms to create an iron deficiency for a child or a pregnant woman. If a person was already malnourished and not getting their daily dose of iron, the effects could be severe. Iron is critical in child development. It helps girls start to menstruate and boys hit their growth spurts. It also immensely important for brain function and development, so if you have a severe deficiency as a child, you could have irreversible cognitive and intellectual defects. Iron deficiency will also make you very tired and want to do nothing but sleep and feel a need to eat dirt in order to get your iron.
Southerners in low socio-economic classes often went without wearing shoes until they were in their teens. Many of them also did not have a proper outhouse so they also often did their business outdoors. Along with that, some poorer farmers used night soil, which is human excrement, to fertilize their gardens. So many children had plenty of chances of their bare feet to come into contact with hookworms.
Stiles was sure that the hookworm was the cause for the South’s symptoms. In his spare time, Stiles started to collect samples, which meant he was collecting people’s poop and checking it for worms. It didn’t take long for Stiles to find them. While visiting a family farm in Florida, Dr. Stiles noticed that both parents and all five children seemed to be afflicted with hookworm symptoms. Stiles also noticed fifteen children’s graves behind the house. When Stiles asked the local doctor what had killed all of the children, the doctor replied “I don’t know what you’d call it, but if you can tell me what is killing that girl there (while pointing at a little girl who was tiny, malnourished, and eating dirt) I’ll tell you what was the matter with the others.”
Once he had collected enough samples that were filled with hookworms, Stiles went to the doctors in the South to tell them about his findings and sharing with them the simple treatment. However, the doctors told Stiles that he was a zoologist, not a doctor, and he should just stick with animals. The idea that a large proportion of southerners were infected with a parasite that lived in feces was horrifying and they didn’t want the South to be associated with that. They also took offense that a yankee was telling them that they were dumb and lazy, but with an explanation, saying to Stiles “Where was the hookworm when it took three yankees to take out one rebel boy in the war?”
Not making any progress in the South, Stiles returned north to attend the 1902 Pan-American Sanitary Congress, where he spoke to several others about his hypothesis of the hookworms in the south. The next morning, the a New York newspaper published an article that stated that the “germ of laziness” had been discovered.
Other newspapers and magazines printed that same phrase and word of the hookworms in the South began to spread. Many Southerners were upset and felt that they were being ridiculed by Northerners, but some were open to the idea. One Southern daily newspaper wrote “We have known the poor whites for generations, and no one has ever explained their condition satisfactorily. Here is a man who claims that he has found the cause of their worthlessness and inefficiency. Now, in all fairness, do not let us go off the handle as some of our esteemed contemporaries have done, but let us hear him out. Perhaps he is a fool. Perhaps he is an Ananias. But perhaps, he is neither. It is just possible that he knows what he is talking about. In justice to the poor whites, let us hear what he has to say.”
News of the hookworms finally made way to John D. Rockefeller who had been actively searching for the right philanthropy project to spend his money on. Rockefeller didn’t want to spend money on income inequality, but he was interested in investing in healthcare. He also figured that if he could get Southerners healthy, they would be more productive in the work environment and would be a better investment for the future. It was estimated that hookworms could have been costing the state of South Carolina around $30 million a year with the majority of that number coming from the loss of people being able to work.
In 1909, Rockefeller created the Rockefeller Sanitary Commission for the Eradication of Hookworm Disease and donated $1 million to help it get started. Wickliffe Rose was chosen to run the newly created organization. He was a professor of philosophy in Nashville, so even though he didn’t have a medical degree, he was a southerner and that was a good first step. Rose’s first course of action was to send doctors that had just graduated from medical school to visit towns all across the South. A few weeks before the doctors were supposed to arrive in the town, the organization would run newspaper articles in the local papers explaining hookworms and sent educational resources to the schools so that the children would find out about the hookworms and then go home and tell their parents.
They also asked the teachers to collect stool samples from their students so that they could be tested when the doctors got to town. Thomas D. Clark wrote in his memoir that “The Winston County Journal ran a bloodcurdling illustration of a greatly enlarged female hookworm that resembled a diamondback rattlesnake more than a worm. I became so frightened at the prospect [of being tested] that I was constipated for a week.” There were some rural schoolhouses that had their entire student bodies test positive for hookworms.
The doctors would then show up in town with their microscope and a large tent that would serve as their clinic. Some of the doctors visited towns that were so isolated that the townspeople still spoke Elizabethan English. After setting up his clinic, which was usually on the weekend so that people wouldn’t have to miss work, the doctor would welcome people to come listen to his presentations about hookworms and then his instructions about how to construct a well-built outhouse so that no one would get re-infected. People would then get in line to get tested for hookworms. Since they could be spending all day at the tent clinic, many showed up with potato salad and fried chicken to make a day out of it. Some couples showed up and asked if they could get married in the tent since it was one of the nicer structures around.
The people that tested positive for hookworms were given Epsom salt and thymol along with a set of very specific instructions on how to take them because thymol could be poisonous if taken with any food or drink that had alcohol, fats or oil in it. One patient suffered through a severe thymol poisoning after he took a large drink of milk shortly after taking the medicine. However, if the medicine was taken correctly, the patient could expect to be rid of their hookworms anywhere between one and ten weeks.
Results of the testing revealed that 7.5 million Southerners had hookworm which meant that up to 40% of the population from southeastern Texas to West Virginia and down were infected. The Rockefeller Commission ended after only five years, which was way too short to eradicate hookworm in the Southern United States, but it did help communities in the South realize that they did have hookworms and gave them the tools to fight back themselves.
It was also found out that this hookworm was different than the hookworm that Stiles had studied back in his days in Europe. So it was given a new scientific name Necatur americanus or American murderer. It is thought to have had it’s beginnings in the 17th century when infected Africans were brought to the Americas as slaves and the hookworms quickly grew accustomed to the South’s climate.
Several years after the Rockefeller Commission ended, studies were conducted that showed that before the hookworm treatments began, there was a strong correlation between low income per capita and high hookworm infections and after the commission ended, communities that had received treatment saw significant income inspection. There was also a study done that showed that children in the South that received treatment went on to have higher average incomes in adulthood than those children that didn’t have the commission come to their town, as much as 25% difference in income.
Though it seemed obvious of how to take care of this problem, the hookworm problem didn’t seem to go away until 1985. There were plants built in the 40’s in the South that would have ship in workers from the North, because the Southerners would be too weak to even push a wheelbarrow. In 1947, a baseball commenter said that the Southern players were coming from the ‘Hookworm Belt’ and the disease was still so common, that nobody needed an explanation of what he meant. However, when it did finally start to dissipate there were a few different factors that contributed to that including a rise in cheap and somewhat healthy food, indoor plumbing, more people moving to cities, more people started wearing shoes and the rise of machines used in agriculture.
However, it seems like hookworms are making a comeback in the South recently. The National School of Tropical Medicine at Baylor College of Medicine along with the Alabama Center for Rural Enterprise tested people living in Lowndes County, Alabama and found that 34% tested positive for genetic traces of hookworms. None of the people that were tested had ever been outside of the United States, however, 73% of them said that they had been exposed to raw sewage that ended up in their homes due to faulty septic tanks or waste pipes being overloaded with heavy rainfall.
People there only make about $18,000 a year on average and so trying to pay somebody to fix their sewer is hard. There’s also been a large number of criminal prosecutions launched by the state of Alabama against residents that had used open pipes to get the sewage away from their homes. There is also an estimate 477 million people around the world that infected with hookworms. Luckily, there is a vaccine in the works that would prevent kill a worm once it’s latched on.
“Blood Money: Hookworm Economics in the Postbellum South” by Rebecca Kreston
“Rockefeller Medicine Men: Medicine and Capitalism in America” by E. Richard Brown
“Hookworm, a Disease of Extreme Poverty, is Thriving in the US south. Why?” by Ed Pilkington
“Southerners Weren’t ‘Lazy’, Just Infected with Hookworms” by Sarah Emerson
“The Cure For Two Million Sick” by Frances Maule Bjorkman in The World’s Work: Volume 18
“How a Worm Gave the South a Bad Name” by Rachel Nuwer