Scurvy Is a Serious Public Health Problem...even for people who aren’t 18th-century pirates
(reprinted from the Medical Examiner November 20, 2015)
Sufficient C LLC notes: The cause and effect relationship between the lack of vitamin C and correlating physical ailments that are experienced by modern day society is worth noting as well as the "official" medical diagnoses for what may actually be undiagnosed scurvy.
In the winter of 2009, Eric Churchill was called to a patient’s bedside at Baystate Medical Center in Springfield, Massachusetts, to help out with a medical mystery.
The middle-aged man had shown up with bleeding gums, unexplained swelling, bruises, and fatigue. His team of internists suspected a skin infection, but every bacterial test came up negative. They were stumped until, Churchill recalls, “someone eventually thought to ask about this person's diet.”
It turns out the man, who was mentally ill and lived alone in one of the city’s poorest neighborhoods, had eaten nothing but white bread and American cheese … for years. “And this had led to these very severe nutritional deficiencies,” Churchill says.
The man’s vitamin C levels were so low, he qualified for a disease Churchill hadn’t thought about since medical school: scurvy. The same scurvy made famous by pirates and British sailors from the 1700s, who would go for months or years at sea without fresh produce, experiencing symptoms from rashes to hemorrhaging. Back then, scurvy killed more seafarers than storms and shipwrecks combined.
At first, Churchill and his team figured it was a once-in-a-career case. But a few months later, another patient came in to their clinic with similar symptoms. This time, the doctors were ready. They learned the patient had stomach aches that he believed improved only with ice cream—so he’d eaten almost nothing else for months. They did a vitamin C test right away, and bingo: scurvy.
Over the next five years, the Springfield doctors measured vitamin C levels in about 120 patients who came in with a range of mysterious symptoms, such as fatigue, mood changes, rashes, headaches, or joint pain.
Twenty-nine had vitamin C deficiencies severe enough to qualify for scurvy—more than had been found in any other recent study. (The closest was a study from the Mayo Clinic that found 11 cases between 1976 and 2002.)
The results were especially surprising, Churchill says, because the nutritional bar for preventing scurvy is so low. “You can have a handful of McDonald’s ketchup packets a day, and that’ll give you enough vitamin C to keep you from contracting scurvy,” he says.
That meant these patients were eating virtually no fruits or vegetables. And since their general fitness was poor, their symptoms had been attributed to other conditions. This was the first time, for any of the patients, that a doctor had mentioned scurvy.
“Some people didn’t know what it was,” Churchill says. “Others were kind of shocked, because—‘scurvy?’ Is that ‘Aar! Pirates!’ I think certainly for some people it was a bit of a sobering moment.”
Since there’s no reason to think Springfield’s population is unique, Churchill’s study suggests that scurvy could be endemic to communities across the country, and largely undiagnosed.
* * *
I learned about this topic while I was interviewing Churchill for a radio story on primary care trends and he mentioned the scurvy study as an aside. My reporter’s antenna popped straight up. Exotic disease that’s mostly taught as medical history—could it be making a comeback? Or did it ever leave?
But I also had to wonder: Wasn’t anyone else in the nutrition world concerned?
Churchill wondered the same thing. When his team started the research, they looked for other clinical studies on scurvy, and “we found almost nothing.” They couldn’t even find definitive criteria for diagnosing the disease. “I would have liked to talk to a scurvyologist,” he says, “but I wasn't able to identify one.”
Isolated scurvy case studies appear occasionally in the medical literature, but the disease is mostly associated with the elderly, chronic alcoholics, or severely neglected children. Tales of ramen-eating college students getting scurvy also pop up in urban lore, though most cases are unconfirmed.
Churchill says the at-risk population he’s identified has mostly been left out of the scurvy discussion: socially isolated, low-income people with high rates of mental illness and limited access to fresh food.
A Centers for Disease Control and Prevention study suggests this is a serious, underappreciated problem. Researchers collected vitamin C levels from 2003 and 2004 and found that 6 to 8 percent of the general population had scurvy-level deficiencies, with men on the higher end.
Deficiency rates were greater for low-income people (10–17 percent), and highest among male smokers (18 percent), likely because smoking affects how the body absorbs vitamin C. These numbers were actually an improvement over measures taken a decade earlier.
After I read the CDC study, I tracked down the lead author, Rosemary Schleicher. She confirmed the rates of deficiency, and conceded “it’s probably more than we’d like to see.” But she says not everyone with severe deficiency will develop full-blown scurvy, and if they do, “just a little bit of vitamin C will reverse it.”
This is exactly Churchill’s point: Something that is this easy to treat should be among the first solutions doctors seek, not the last.
Another expert on vitamin C, Mark Levine at the National Institutes of Health, says it is possible in our modern world to end up with a severe vitamin C deficiency. In fact, in the 1990s, he ran a nutritional experiment in which he created near-scurvy conditions in healthy people by limiting what they ate—even within a mainstream diet.
“If you take a bunch of people who have no access to fruits and vegetables and are eating ice cream all the time, yeah they’re going to have Vitamin C deficiency,” Levine says. “It’s just the way it is.”
“I’m really quite curious now,” she says. “I mean, the consequences for people’s basic functioning and quality of life is pretty dramatic.”
After pouring over the data, Bertone-Johnson has a theory for why she hadn’t heard of the problem, and why her colleagues don’t talk about scurvy at public health conferences.
“I think it’s not a sexy topic from a research point of view,” she says. “We've understood what causes [scurvy] for several hundred years and we know how to reverse scurvy. We know how to improve vitamin C deficiency with fruits and vegetables and supplements. So it's old news.”
* * *
But it’s not old news for people walking around with an 18th-century disease who could be feeling so much better with a few orange slices and an hour of nutritional education.
That’s what I was thinking when I met a 47-year-old man named Mark (who didn’t want his last name used) at Springfield’s largest Walmart store. A patient of Churchill’s, Mark agreed to let me follow him around while he did his weekly shopping in the super-retailer’s grocery section.
Mark is a slightly chubby man, with a sweet face, crooked teeth, and bright pink gums. About a year ago, he’d gone to the community clinic with vague symptoms—fatigue, joint pain, gum problems—***that he assumed were related to his diabetes and heart disease. He was not expecting to hear he had scurvy.
“At the time, I had remembered that it was something that the sailors had had when they used to go on their voyages across the waters,” Mark says.
But looking back at his food choices over the previous year or two, it made sense. “It was 90 percent take-out,” he says. Chinese food, grinders, pizza. Even his “home-cooked” meals consisted mostly of frozen pasta dinners and cold-cut sandwiches. He opens a Walmart freezer to point out his favorites: Bird’s Eye chicken Alfredo, sweet and sour chicken, and beef lo mein.
Mark is not a fringe patient with extreme mental illness. He is a quiet man, prone to mild depression, raising a teenage daughter alone. He works 12 hours a day or more as a maintenance worker for commercial property, spending most of that time driving around in his truck from job to job. You could see how fruits and vegetables might fall out of his routine.
“Even if you grab the right stuff out of the refrigerator and you're going out the door with it,” Mark says, “sometimes it'll sit in the truck and I won't even think about it.”
He hadn’t quite realized how bad things had gotten until the scurvy diagnosis. “So I started eating an orange in the morning and an orange at night,” he says. “And then some pineapples.”
Now, when he goes shopping, he makes himself start in the produce section. He tries to remember to pick up grapes, carrots, or broccoli, though he admits they often rot in his kitchen before he remembers to eat them. When we walk by the Brussels sprouts and leeks, he crinkles his face. “We haven't really gotten into the more exotic vegetables as of yet.”
* * *
Churchill and his colleagues are still writing up the results of their scurvy study. Once it’s published, he’s hoping the public health world will follow up with more rigorous, randomized clinical trials, and he’d like to see many more doctors screen their patients for scurvy.
Eventually, he’d like to map the scurvy cases, to find out how far those patients live from a major supermarket or farmer’s market, and how close they live to fast-food joints or convenience stores.
In the meantime, Churchill continues to diagnose scurvy in his clinic. “I came across one patient yesterday who had a vitamin C level of zero,” Churchill tells me. “I was working with one of the new residents, and he was just floored. He said, ‘I thought you were crazy when you told me to test him [for scurvy]. But you were right.’ ”
Unfortunately, getting labeled with a sailor’s disease is not always enough to transform someone’s diet.
The first patient Churchill diagnosed did better for a while, but Churchill believes he slipped back into his bread and cheese ways. After all, citrus and vitamin C supplements are not going to solve the social isolation and mental health problems that can lead to scurvy, he says. “And it’s not going to solve the devastating problems of urban poverty that we have, or obesity or food deserts or any of the other things that might be causing it.”