ON APRIL 16, 1913, ALBERT SCHWEITZER arrived at Lambarene, a small village in the interior lowlands of West Africa, to establish a missionary hospital on the banks of the Ogowe River. Attended by his wife, Helene, who had trained as a nurse, he began treating patients the very next morning. Schweitzer estimated that he saw almost two thousand patients in the first nine months, and then averaged thirty to forty a day and three operations a week for the better part of four decades. The chief complaints, at least in the beginning, were endemic diseases and infections: malaria, sleeping sickness, leprosy, elephantiasis, tropical dysentery, and scabies.
Forty-one years after Schweitzer’s arrival, and a year and a half after he received the Nobel Peace Prize for his missionary work, Schweitzer encountered his first case of appendicitis among the African natives. Appendicitis was not the only Western disease to which the natives seemed to be resistant. “On my arrival in Gabon,” he wrote, “I was astonished to encounter no cases of cancer…. I can not, of course, say positively that there was no cancer at all, but, like other frontier doctors, I can only say that if any cases existed they must have been quite rare.” In the decades that followed, he witnessed a steady increase in cancer victims. “My observations inclined me to attribute this to the fact that the natives were living more and more after the manner of the whites.”
As Schweitzer had suggested, his experience was not uncommon for the era. In 1902, Samuel Hutton, a University of Manchester–trained physician, began treating patients at a Moravian mission in the town of Nain, on the northern coast of Labrador, or about as far from the jungles of West Africa as can be imagined, in both climate and the nature of the indigenous population. As Hutton told it, his Eskimo patients fell into two categories: There were those who lived isolated from European settlements and ate a traditional Eskimo diet. “The Eskimo is a meat eater,” he wrote, “the vegetable part of his diet is a meager one.” Then there were those Eskimos living in Nain or near other European settlers who had taken to consuming a “settler’s dietary,” consisting primarily of “tea, bread, ship’s biscuits, molasses, and salt fish or pork.” Among the former, European diseases were uncommon or remarkably rare. “The most striking is cancer,” noted Hutton on the basis of his eleven years in Labrador. “I have not seen or heard of a case of malignant growth in an Eskimo.” He also observed no asthma and, like Schweitzer, no appendicitis, with the sole exception of a young Eskimo who had been “living on a ‘settler’ dietary.” Hutton observed that the Eskimos who had adopted the settlers’ diet tended to suffer more from scurvy, were “less robust,” and endured “fatigue less easily, and their children are puny and feeble.”
What both Schweitzer and Hutton had witnessed during their missionary years was a “nutrition transition,” a term now commonly used to describe a population’s Westernization in diet, lifestyle, and health status. The World Health Organization recently described the current version of the nutrition transition this way:
Changes in the world food economy have contributed to shifting dietary patterns, for example, increased consumption of an energy-dense diet high in fat, particularly saturated fat, and low in carbohydrates. This combines with a decline in energy expenditure that is associated with a sedentary lifestyle…. Because of these changes in dietary and lifestyle patterns, diet-related diseases—including obesity, diabetes mellitus, cardiovascular disease, hypertension and stroke, and various forms of cancer—are increasingly significant causes of disability and premature death in both developing and newly developed countries.
This is little more than an updated version of the changing-American-diet story Ancel Keys and others had invoked to advocate low-fat diets: we eat fewer carbohydrates and ever more fat then we did in some idealized past, and we pay the price in chronic disease. Keys’s reference point was the American diet circa 1909 (as portrayed by USDA estimates), or the Japanese or Mediterranean diets of the 1950s. When it was suggested to Keys that other nutrition transitions, including those witnessed by Schweitzer and Hutton, could be edifying, he argued that not enough was known about the diets or about the health of those isolated populations for us to draw reliable conclusions. He also insisted that in many of these populations—particularly the Inuit—relatively few individuals were likely to live long enough to develop chronic disease, so little could be learned.
This argument, too, has taken on the aura of undisputed truth. This could be called the “nasty, brutish, and short” caveat, after Thomas Hobbes’s pithy interpretation of the state of primitive lives. But earlier generations of physicians had the advantage of observing conditions of nutrition and health considerably further back on what anthropologists refer to as the curve of modernization. In this sense, their job was easier: noting the absence of a disease in a population, or the appearance of diseases in a previously unaffected population—the transition from healthy populations to sick populations, as Geoffrey Rose would put it—is an observation less confounded with diagnostic and cultural artifacts than are the comparisons of disease rates among populations all of which are afflicted.
Most of these historical observations came from colonial and missionary physicians like Schweitzer and Hutton, administering to populations prior to and coincidental with their first substantial exposure to Western foods. The new diet inevitably included carbohydrate foods that could be transported around the world without spoiling or being devoured by rodents on the way: sugar, molasses, white flour, and white rice. Then
This led investigators to propose that all these diseases had a single common cause—the consumption of easily digestible, refined carbohydrates. The hypothesis was rejected in the early 1970s, when it could not be reconciled with Keys’s hypothesis that fat was the problem, an attendant implication of which was that carbohydrates were part of the solution. But was this alternative carbohydrate hypothesis rejected because compelling evidence refuted it, or for reasons considerably less scientific?
The original concept of diseases of civilization dates to the mid-nineteenth century, primarily to Stanislas Tanchou, a French physician who served with Napoleon before entering private practice and studying the statistical distribution of cancer. Tanchou’s analysis of death registries led him to conclude that cancer was more common in cities than in rural areas, and that the incidence of cancer was increasing throughout Europe. “Cancer, like insanity,” he said, “seems to increase with the progress of civilization.” He supported this hypothesis with communications from physicians working in North Africa, who reported that the disease had once been rare or nonexistent in their regions, but that the number of cancer cases was “increasing from year to year, and that this increase stands in connection with the advance of civilization.”
By the early twentieth century, such reports had become the norm among physicians working throughout Africa. They would typically report a few cancers in towns where the “natives mingled with Europeans” and had copied their “dietetic and other domestic practices,” but not in those areas where lifestyles and diets remained traditional. These reports, often published in the
In 1908, the Smithsonian Institution’s Bureau of American Ethnology published the first significant report on the health status of Native Americans. The author was the physician-turned-anthropologist Ales Hrdlika, who served for three decades as curator of the Division of Physical Anthropology at the National Museum in Washington (now the Smithsonian’s National Museum of Natural History). In a 460-page report entitled
