Public health and nutrition researcher Dr. Daniel Franklin Milam used a pragmatic argument when he needed less-altruistic people to support his research: He pointed out that malnourished laborers are less productive.
But his real goal was to improve health for every race and class. And he did.
Because of Milam and his Duke University research team, North Carolina had school lunch programs in the early 1940s, before they became a national mandate. His team’s work on caloric intake and vitamins helped make the state healthier and helped the U.S. fight World War II.
With a master’s degree in public health and a doctorate in medicine, Milam and his Duke team painstakingly collected hard data on childhood nutrition and proved that children could be made healthier for only 18 cents per child per day, equal now to about $4.

Better still, the health benefits trickled into adulthood, and Milam’s work virtually eliminated nutrition-related illnesses for the state.
In the early early 20th century, even in the decades before the extreme shortages of the Great Depression, vitamin-linked diseases like scurvy, pellagra, rickets, and beriberi ravaged the United States. These diseases devastated children because their bodies failed to develop properly under nutritional deficits, leading to hospitalizations for bleeding gums or bowing bones at an alarming rate. Adults were not immune to malnutrition, but with their fully developed bodies they experienced less-permanent symptoms such as extreme fatigue and joint pain, and could more easily rebound to health.
The implementation of public health sanitation measures and vaccines in those same years curbed the traditional, more fearsome plagues like cholera and typhus. But with those scourges waning, the severity of malnutrition in America emerged from the shadows.
Daniel Franklin Milam grew up in Jacksonville, Florida, after the Great Fire of 1901 razed the city to the ground. Only seven people died, but thousands of buildings were destroyed and an estimated 10,000 people were rendered homeless. As a result, Milam and his three brothers, the sons of a local attorney, grew up simultaneously witnessing the harms of extreme poverty around them, and also watching their city’s infrastructure get rebuilt from scratch using the latest in disease-preventing science.
During WWI, Milam was an ensign on a transport ship that carried fresh troops to the trenches of France and then brought bedraggled survivors back home. After the war, he earned a doctor of medicine at the University of Chicago followed by a master’s in public health at Johns Hopkins. His early research was tracking the footprints of deadly infectious diseases like Rocky Mountain Spotted Fever through rural North Carolina, but in the process, he noticed another problem.
Children who do not grow well become adults who cannot work because extreme fatigue and joint pain make them less productive. In that era’s physical-labor, mill- and farm-based economies of urban and rural North Carolina, these insights were the basis of the state’s realization that nutrition was the cause of lost work force as well as massive, publicly born medical expenses.
During World War I, roughly 30 percent of American men had been deemed medically ineligible for the draft, with severe malnourishment as one of the leading causes. Growth defects from prior childhood malnutrition disqualified still more. In the 1930s, with Hitler rumbling in Europe, the same problem was about to happen again.
Vitamins and nutrition, Milam realized, should be analyzed as a public health crisis.
Milam and a nearly all-female team of scientists at Duke hosted a meeting with North Carolina state health officials in December 1939, where they suggested the idea. Their lab had designed a preliminary way to assess local communities for nutritional health. Chemists Janet McAfee, Ruth Foster and Mary Yarborough invented new, more efficient chemical tests to enable the research. They planned to refine their methods even further once they completed a pilot group.

Starting in January 1940, with support and funding from the state, Duke, and the Rockefeller Foundation, the Duke Nutritional Survey Lab evaluated the people of North Carolina in slowly expanding circles. They started small with 99 families in “a rather poor farming district” in Bynum, North Carolina on the Haw River in Chatham County.
Statistics from the first wave of results showed that some of their initial 11 laboratory tests were redundant or uninformative, as were most aspects of their physical medical exams. The dietary surveys, vitamin C tests, and calcium tests, however, were stunning.
The Bynum community was getting about 2,000 calories per day on average, and this original survey data seems to be part of the basis of this modern USDA recommendation. However, a growing body of work now suggests that 2,000 calories per day is insufficient, and even at the time, the Milam lab determined these farmers to be “manifestly undernourished in calories.” In their alarm, the researchers quickly conducted a similar survey of sedentary physicians at Duke as a high-income control group, and got about the same number. Two thousand calories, they concluded, were not enough for active people.
The blood tests of the Duke physicians showed they were getting sufficient nutrition from their food, but the people of Bynum were not.
The reason turned out to be that the Bynum community was getting a shocking fraction of their calories from hog fat, which provided little nutritional value. Several people were identified as being in the early stages of scurvy, which takes numerous months of total vitamin C deprivation to reach. Twenty-seven percent of the community had no trace of vitamin C in their blood at all. The researchers called it an “astonishing deficiency in vitamin C” community-wide.
Two Bynum children were in the early stages of rickets, which can be caused by lack of vitamin D, calcium, or phosphorus. On average, everyone was getting about half the calcium they needed, and two-thirds of what they needed of riboflavin, which is one of the essential B vitamins that helps calcium get absorbed.
The researchers had chosen this community because the farmland had poor-quality soil, and they theorized that their springtime survey was measuring the effects of a winter’s deprivation from home-grown produce and inconsistent access to dairy. The state immediately gave the project more funding. The Duke research lab used that money to put on a six-week camp for children to test their hypothesis, and to see if they could fix the problem.

Ninety children enrolled, both Black and white, designed to mimic a cross-section of the state. The researchers divided them into three groups, each group was treated the same but divided to allow manageable oversight from nutritionists and nutrition students. Parents brought their children to the camp each day and helped by allowing blood draws from themselves and their children. They also filled out information about what food was available at home.
While at camp, the children were provided with fun, engaging activities to keep them occupied, then given selected, inexpensive additional items on top of normal meals comprised of commonly available local foods. The additional items were focused on the identified deficits in vitamin C, riboflavin, and calcium. The researchers selected fruit juices and milk as the sources.
By the end of the six weeks, vitamin C levels had tripled for many of the children. On average, the group saw a 64 percent improvement. The children were running, playing and noticeably less lethargic. Many of them were no longer underweight. The researchers had not thought to include a measurement of play at the start, but “improvement in energy, vitality, or general body vigor [was] noted by many observers.”
Dr. Bailey Webb joined the Duke nutrition lab after getting her Ph.D. in biochemistry so that she could participate in the experiments, with the goal of establishing a more permanent future lab through the state health department. She worked with Milam’s existing crew to add community after community into the work, including monitoring select groups across all four seasons to see if their theory about the deprivations of winter held up. It did.
Everyone, child or adult, was more nutritionally deprived in the spring and early summer — right when they most needed their health in order to work, before their labors could bear them literal fruit. The winter months, the researchers deduced, were the time to provide food-based help.
The start of World War II also provided a natural but powerful experiment. The Surplus Commodity Corp., a federal organization established to redistribute food surpluses and thus limit food waste, was particularly active during the rationing times of war. In the spring of 1941, by coincidence, the corporation gave a bulk delivery of “large quantities of canned citrus juice and canned milk” to both the white and Black segregated schools in North Carolina. White children who had some access to fresh milk refused to drink the canned milk because they disliked the taste. The Black children, however, “drank all the canned milk they could get” and were therefore provided with it in abundance.
All of the schools showed nutritional improvement compared to years with no additional food sources. Compared to other years, the white communities showed similar, if low, levels of calcium and riboflavin— two elements present in milk — while the Black children’s levels skyrocketed. With the year’s abundance of canned orange juice, levels of vitamin C in the schoolchildren had almost quintupled. Unsurprisingly, the children’s overall health improved too.

Technician Mary Yarborough finished her Ph.D. at Duke by showing that vitamin A levels could not be indirectly measured by testing eyesight. That allowed the group to eliminate a time-consuming “dark adaptation test” from their protocol, which reduced the cost per subject, and let them expand even further.
The researchers started to be able to separate out the nutritional needs of communities, not only along the lines of segregation, but by the type of work the communities did.
For example, the mill and factory workers made more money, but needed more vitamin C than the farmers, because they were not able to grow their own produce.
Bailey Webb shifted to part-time work at the lab so that she could enroll in Duke’s School of Medicine and add a medical degree to her Ph.D. As a result, Duke demoted her to the title of technician, even though her higher-ranked male counterpart was also part-time, but she did it anyway so that she could keep participating in the research. When Webb graduated, she used the methods developed by the Milam group to establish a parallel lab for the state government.
Daniel Frank Milam and the under-titled chemistry women of the Duke lab continued to build their nutritional research, traveling far and wide to collect blood and conduct surveys. Experiment after experiment, community after community, they buttressed their initial discovery: with only eighteen cents per child per day, purchasing at minimum canned fruit juices and milk, they could substantially improve the health of an entire community in a way that lasted into adulthood. The addition of fresh, leafy green vegetables, and providing the same foods to adults further improved health statewide.
Medical demand for nutrition-related diseases plummeted. More adults were able to earn their own incomes.
Fruit juice, milk, and green vegetables became staple requirements for school lunches, which eventually became a federal requirement, once their spectacular public health benefits became publicly known. For at least 30 million American children today, school lunches remain a primary source for the key nutrients found in combinations of these foods.

Milam continued his research at the request of the federal government when the hard, lean years of World War II demanded healthy factory workers to build the arsenal of democracy. The nutrition group implemented their work to medically rehabilitate populations of employees in the feverishly scheduled industrial factories, because many of the men employed had, as predicted, failed to meet medical requirements for the draft due to malnutrition.
Throughout the studies, not one word in the hundreds of pages of reports shows an inkling of judgment by Milam and the research team, either about the income level or race of their participants. All studies with children included active participation from their parents. Groups were segregated by race in a reflection of the segregated society, workplaces, and schools of the time, but all groups were treated the same and provided the same treatments. Other divisions were just as neutrally drawn by town, type of farming, or factory location, with only potential scientific relevance, and without a hint of social or eugenics-based bigotry.
The benefits, as a result, reached everyone.
There is no way to calculate the healthcare value Milam and his nutritional team provided to the residents of North Carolina. But their impact can be gauged by the plagues we have forgotten: diseases like scurvy, beriberi and rickets almost unheard of in the United States.
Milam’s interest in public health expanded to the realm of birth control in the 1950s. He advocated for the public availability of birth control methods through Planned Parenthood. He used his experiences with malnutrition to point out that, unless the government plans to fund their food, families need to be able to control their numbers in order to ensure they can feed themselves.