HEAL London

It's not knowledge, it's attitude

"Patients who don't learn about mistakes from the history of medicine are condemned to have the arrogance of doctors repeated on them"

- What George Santayana might have said if he'd learnt about AIDS

Most people may think of the prolonged medical blunder of scurvy as being only of historical interest because of improvement in both knowledge and scientific method. However, what it also demonstrates how attitudes, especially those of medical professionals and others in positions of authority, contributed to repeated denial of reality. It also demonstrates very well how existing beliefs tend to distort people's perception of empirical evidence gathered by their own senses that people can be totally led astray by their own minds. When common misperceptions are widespread in a population, the whole population can be led astray. Even if only the people regarded as experts or professionals on a particular subject have a widespread misperception, this eventually is likely to lead to the rest of the population becoming misled. Those who have a clearer grasp of reality as it is can only look on in despair as first the ‘experts' and then the rest of the population go charging off down a blind alley, unwilling to listen to anyone who is pointing to a reality they don't want to see.

This is important because what has been repeatedly shown is that major blunders - any field of human endeavour - are rarely caused by of ‘lack of knowledge': It is almost always problems with attitudes resulting from natural human inclinations that led to the succession of progressive errors that resulted in the final calamity. I think it's fair to say that humans as a biological species have not evolved that much in the last 2000 years and that human failings prevalent over that period of time will be just as evident in any profession, including science and medicine today.

Scurvy - a horrible way to die

Scurvy is a horrible, progressive and ultimately potentially fatal condition caused by a prolonged lack of vitamin C. The primary symptom is haemorrhaging, such as wounds failing to heal properly, the skin may bruise easily, and internal bleeding into muscles and joints can be excruciatingly painful, because of the body's inability to make collagen. This description by MD Mark Anderson gives an idea of what a sailor might have experienced on board a ship on a long voyage at sea if there was no fruit or fresh vegetables to eat, culminating with being buried at sea.

"Wounds don't heal because you can't make collagen. Bleeding occurs into the skin around the roots of all your hairs, which later fall out. Swollen gums bleed, the jaw bone softens, and eventually your teeth fall out. Hemorrhagic spots develop in your eyelid linings. There's painful bleeding into your joints, and into the surface membrane of bones, causing crippling pain, and eventually spontaneous breakage of bones. Eventually you're coughing up blood and possibly asphyxiating. Bleeding develops in the intestines, leading to black, and then bloody, horrifically foul smelling stools. Anemia, weakness. Emotional lability. Bleeding into the sack around your heart so your heart can't fill with blood and pump. Bleeding around the brain, compressing it, causing headache, vomiting, eventually coma and death as your brainstem is crushed as your swollen brain pushes itself down into the spinal canal. Perhaps your spirit hovers overhead to watch your body committed to the deep"[1]

Truly a terrifying and excruciating condition, Sir Richard Hawkins describing Scurvy as "...The plague of the sea and the spoil of mariners". Scurvy might well be described as having been the AIDS of seafarers for hundreds of years, easily killing more sailors than weather, pirates or other diseases put together. Scurvy has been documented by Hippocrates (460-380BC), but the really devastating death rates of truly pandemic levels by proportion occurred when European seafarers started making long voyages on a regular basis. Estimates are that Scurvy alone killed probably at least 1 million sailors in 200 years between 1600 to 1800[2] - in times when the number of sailors making long voyages was a tiny fraction of what it is today.

To give you an idea of just how devastating a threat it was, on Vasco da Gama's first trip round the cape of Good Hope in 1497, 100 of his crew of 160 - ie, nearly two thirds - died of scurvy. Even though something dietary was suspected, there were other infectious diseases on board cramped, crammed, and unhygienic ships, and where the rats eating the food supplies of the poor quality diet were likely as not to end up as part of the food themselves eventually. It was probably pretty difficult for any doctor to truly separate out all the different symptoms. So it is perhaps not surprising that scurvy was thought to be an infectious condition, especially as it would appear to be spreading amongst the crew in the confined space of a ship. ‘Bad air' was the generally accepted wisdom, which was also subsequently blamed for of course ‘Mal aria'.

Moderate amounts of vegetables will have plenty of vitamin C to prevent scurvy, as will fresh meat - Many Inuit people have in history lived on a solely meat diet without suffering from scurvy - but vegetables would go off on board a ship very quickly, and the main diet of sailors was salt pork and biscuits. It typically takes two months or more with no vitamin C for the symptoms to start showing so it could be well into a long voyage before it started to show. One clue that it was not a standard infectious disease should have been that, compared to other illnesses, scurvy was only really observed in sailors on long voyages or sometimes soldiers involved in long campaigns when fresh supplies became depleted - ie, it remained entirely within its risk groups.

Recovery can be very quick when vitamin C becomes available, and when sailors suffering from scurvy started eating normal food again in port, landlubbers did not seem to catch it from them and the sailors themselves could recover remarkably quickly. This should have been a big clue that it was not infectious the way normal infectious diseases are. But the lack of real knowledge about the mechanisms of any diseases (as opposed knowledge that doctors only imagined they had) or how infections might be transferred from one person to another, or even the significance of diet and that the notion of scientific method had not even been properly invented and put in the public domain[3], meant that these subtleties were not apparently noticed.

Missed opportunities

Legend has it that Columbus, the man who allegedly discovered America and the West Indies (the natives that had been living there for possibly thousands of years already didn't count, obviously, because they were ‘just primitive natives' of course, and to acknowledge them as humans of equal standing would have meant having to recognise their prior claims to land too), had an early experience that scurvy could be cured easily and might be diet-related. During one voyage he had a number of Portuguese sailors suffering badly from scurvy and were expected to die.

Rather than wait to die on board ship and be buried at sea where they'd be eaten by fish, they requested to be dropped off at one of the local islands being passed, where they ate some of the local fruit and vegetables to survive. On the way back Columbus allegedly passed by the same island and was stunned to see the men waving at them, alive and healthy. Thus the island of Curacao got its name, which is the Portuguese word for ‘cure'. Apparently, it wasn't actually Columbus, it was a Spanish and Italian group, and the Island was originally called Curazon, the Spanish for ‘heart', and it was the Portuguese map-makers who changed the spelling to the archaic Portuguese word for cure[4]. But the essence of the story that it was the fruit and vegetables on the island that save the men from scurvy is not disputed.

One might have thought that the dramatic significance of this discovery of a cure for a disease that could cripple a ship would have resulted in the news spreading and perhaps lead to experiments, but apparently not. In 1536 Jacques Cartier had 25 crew die of scurvy on an expedition to Quebec before his local Indian guides showed him how to make a brew from Pine bark and needles, which saved the rest of the crew including those who were already falling ill. Did this additional evidence lead to widespread recognition that the right foods could make a significant difference to scurvy? No, because when Cartier brought the recipe back to France, doctors scoffed at the idea that a bunch of savages would know better than the medical profession[5]. The idea of testing it out did not apparently occur to them, or else they were perhaps afraid that the...er... ‘savages' might turn out to be correct after all which would have been an unthinkable humiliation - to be avoided at all costs, obviously.

As some people will recognise, the arrogance of the medical profession does not appear to have diminished much since then. The ‘Not Invented Here' syndrome was obviously invented a long time ago and ironically an idea many are keen to adopt. Today the same attitude is widespread, especially in AIDS research, where the scientific and medical professions combined have refused to even verify plausible explanations for apparently such a serious condition when it had no alternative effective solutions it could offer itself.

In 1593 Sir Richard Hawkins, who estimated that 10,000 mariners had died of scurvy in Queen Elizabeth I's reign, said, "That which I have seen most fruitfull for this sicknesse, is sower [sour] oranges and lemons". Did this commentary by a respected British Admiral result in widespread adoption of these fruit as a preventative, or even a cure, by the British Navy, or even as the trigger for controlled experiments? It did not. In 1601, another 8 years later when scurvy was still the scurge of the sea, Captain James Lancaster set sail from England on a round trip to India with a fleet of four ships, of which he captained one. On his own ship he gave his men three spoonfuls of lemon juice each day until the lemon juice ran out, and then stopped off at Madagascar to pick up some fresh fruit.

At the halfway point, 110 of the 278 sailors on the other three ships (40%) had died[6] By the time they reached port after five months, the crews of other three ships were so decimated by scurvy that they were unable to even take their ships in to port without assistance from the crew of his own ship, who were untouched by scurvy. Captain Lancaster sent a report to the admiralty in London. This was in effect one of the first occasions when a medical trial allowed comparison between the experimental group and the control group, and the circumstances were exceptionally controlled and the results about as dramatic as one can get. If you like, one of the first long-term trials where there were good quality scientific controls, nowadays almost entirely lacking from AIDS research. But staggeringly, the ears his report fell on were sufficiently deaf that again nothing happened at an official level.

In 1636 John Woodall published a book ‘The Surgeon's Mate' unequivocally recommending fresh vegetables and orange and lemon juice both as a cure and a preventative for scurvy. Remember that at this time books on any given subject were still relatively few and far between so his book would have received significant attention among the medical profession, but although he persuaded The East India company to provide lemon juice for sailors[7], his recommendations on scurvy were ignored in medical circles.

Over 100 years later, in 1740, sailors were still dying of it en masse. George A. Anson set of to circumnavigate the world with a fleet of six ships containing 1,955 men. When he returned four years later he had lost 1,051 of them (53%) to scurvy alone[8].  This single tragedy, above the already-high background level of scurvy deaths, prompted Scottish naval doctor James Lind to investigate potential cures, seemingly overlooking James Lancasters's fairly unequivocal evidence. It wasn't until 1747 that he did a controlled experiment aboard HMS Salisbury, where he tried different diet combinations among sailors who were all dying of scurvy. One group were prescribed as part of their diet "two oranges and one lemon given each day". This group recovered so fast that within a week they were caring for the other groups, who all died. He published "A treatise of the Scurvy", which was widely acknowledged.  No, not really -  just joking. It was of course comprehensively ignored and the slaughter of sailors from Scurvy continued unabated.

In 1768 James Cook initiated a circumnavigation of the world, which he completed in three years. It is not known for certain whether or not he knew of Lind's conclusions or James Lancaster's report, but he believed in various healthy practices that included some diet changes. Although citrus fruit or juice wasn't given as a matter of course, and the diet was not that much improved from that a couple of hundred years earlier, he used orange and lemon juice to treat scurvy when it began to show up. He lost only one man from any disease, and that was from Tuberculosis. But still the importance of diet was ignored while deaths from scurvy continued unabated throughout the rest of the Royal Navy. It was only in 1795 that the admiralty finally mandated citrus fruit as part of the diet for all Royal Navy sailors, in particular using limes and thus earning them the nickname ‘limeys'. Scurvy dramatically ended in the British Royal Navy almost overnight. But even that powerful and unequivocal development did not affect all shipping. Unbelievably, it was another 70 years before the British Board of Trade finally ordered proper diets on merchant vessels, in 1865.

How did it take so long?

Scurvy perhaps holds the record for the disease where a simple and repeatedly well-demonstrated dramatic solution (even before the identification of vitamin C itself) for such a devastating disease was comprehensively ignored by medical authorities, naval authorities and sections of the population it directly affected for so long. As Winston Churchill might have put it, "Never before has so much ineptitude and arrogance by so few unnecessarily killed so many so slowly and painfully for such a long period of time".

From most contemporary historical accounts it is hard to imagine why it should take so long for such an obvious and dramatic preventative and cure to be finally accepted for such an economically devastating, terrifying, excruciatingly painful and ultimately deadly condition. It is easy and tempting just to blame the medical professionals for being stupid. While that is clearly a contributory factor, it is perhaps a little unfair over that period of time given that the mechanisms of disease, or indeed nearly every aspect of biology, were so little understood.

The notions of scientific method, statistical significance and rules of logic were not so clearly expressed or widespread so understanding about cause and effect was a lot more vague. One factor that usually goes unreported is that for some reason humans have a seeming obsession with the idea of infectious causes of diseases. It is probably a fundamental survival mechanism that has served us well since prehistoric times. It may well be those who were genetically or culturally conditioned to regard all diseases as infectious that survived plagues like the black death that wiped out an estimated 200 million people in the 14^th century. This kind of event alone would probably create a cultural obsession with infectious transmission of disease that would probably last many generations and over many countries at least, never mind the potentially cumulative evolutionary effect of survivors who were doing something different to avoid disease.

The lack of understanding about health and disease meant that not only were there poor preventative measures and cures, but poorer resistance to infection due to malnutrition was considerably more widespread. Poor standards of basic hygiene meant that germs spread considerably more easily. In developing countries, relatively cheap and unglamorous measures like clean water and effective sanitation make a massive difference to the well-being of a population. So it may be fair to say that evolution has probably produced survivors with an obsession about infectious causes of disease.

Unfortunately, the over-emphasis on infectious transmission rather than a rational appraisal of factors can easily lead us down the wrong path. Part of the problem is that a whole bunch of people living in the same confined space will tend to be eating the same foods, drinking the same water, and will therefore tend to be in a similar nutritional situation as well the fact that the food will tend to be cooked in the same kind of hygienic conditions (or not), exposed to the same poisons, breathing each other's air, touching the same objects as well as different kinds of social physical contact, and experiencing the same kind of hygiene generally. Therefore many conditions that are toxicological or nutritional and have absolutely nothing to do with anyone else's well-being directly may easily be confused with genuinely infectious conditions caused by some self-reproducing microbe transmitted from one person to another.

The restricted diet that inevitably led to scurvy was highly associated with a relatively large number of men living in close proximity and often in less-than ideally hygienic conditions - ideal for spread of contagious diseases. For example, a Dutch doctor called Echthius described scurvy in 1541 after watching outbreaks of scurvy in a single monastery and concluded it must be contagious. It was when Admiral Richard Hawkins reached Brazil and his crew ate oranges and lemons that he found they had a curative effect, but also incorrectly blamed unsanitary conditions on board ship for the condition occurring in the first place which, to be fair, probably had caused other symptoms he found hard to separate out completely[9].

A Frenchman called Francois Pyrard wrote about an expedition to the East Indies, in which he blamed scurvy on "a want of cleanliness", warning, "it is very contagious even by approaching or breathing another's breath" - clearly having no clear evidence to back it up as it isn't true. But given that the lowest class of sailors would sleep and work in the most cramped conditions in very close proximity to each other as well as having the lowest quality of food makes it easy to see how that association could be made, and also demonstrates how easily humans manage to confirm their existing beliefs by misinterpreting empirical evidence. The senior officers who were less likely to get scurvy had an easier life, slept in less cramped and more hygienic conditions and had better quality food, so it was easy to associate the living conditions as a reason why they were less susceptible. Even Pyrard discovered that citrus fruits could solve the problem, not realising that their absence was implicated as the cause. Even James Cook who, unusually for the time, had given his men fruit juice to treat scurvy, believed in fresh air and other hygienic practices, thereby obscuring that it was the vitamin C-containing foods that were entirely responsible for solving the problem.

The flames of stupidity - not quite extinguished and flaring up again

By the time the admiralty ordered citrus fruit as part of every sailors diet and had totally solved the problem overnight so dramatically, that - surely - should have been the end of it. In the intervening period however, bacteria had been discovered and most people enthusiastically embraced it as the mechanism potentially responsible for all infectious diseases (apart from many of the reactionary leading doctors of the day, of course, who ridiculed the idea that these tiny things could be what made people ill). Outside Britain, the dietary solution to scurvy had not taken hold, and even in the UK as time went on, the increasing ease with which bacteria could be identified meant that greater interest was shown infectious causes. It was almost as though finally having evidence of a mechanism that could explain some genuinely infectious illnesses gave an overwhelming boost to people's natural inclination to suspect infectious causes of almost anything.

Thus, even though the scurvy problem was already demonstrably totally solved, the debate about the cause of scurvy started up again. So, eighty years after scurvy had ended in the Royal Navy because of one simple action, a member of the Paris Academy of Medicine (in other words, a highly positioned doctor), declared, "Scurvy is a contagious miasm, comparable to typhus, which occurs in epidemic form when people are closely congregated in large groups as in prisons, naval vessels, sieges... ". To interrupt him for a moment, can you think of a plausible reason why people in prisons and sieges in the 19^th century and earlier might suffer from scurvy as well as sailors? But presumably, you can also understand - ignoring for a moment that the problem had been solved - why he thought it might be infectious.

And that is the issue. The problem had been now provably, easily, cheaply, and totally solved for a long period of time. To look for other causes now was a bit pointless and more ideological than pragmatic. He continued, "We have many examples of well-fed sailors and soldiers going down with scurvy, while others less well fed do not...". Here, we do not know exactly what ‘well-fed' or what ‘less well-fed' means. Given that he was clearly ignoring the importance of citrus fruit, he may regard well-fed as being given plenty of meat (with less vitamin C), and less well-fed as being given less meat and more vegetables (with more vitamin C). Also, it may well depend on the length of time that each person had been without vitamin C, a crucial factor. Jean-Antoine Villemin continues, "Also, we have positive evidence of the spread of the disease by contagion - for example, the introduction of scurvy intro French military hospitals by veterans returning from the Crimea, and the rapid spread of scurvy from one sailor to another in naval vessels". As we know that the ONLY cause of scurvy is a prolonged lack of vitamin C, and as it is therefore not contagious, it can only have been poor diet. Also, this is a good example of the vague statistical correlation that seems to be regarded as proof. It highlights again that even apparently a high correlation is not causation unless you have a clear understanding of the mechanism of action - something that is also missing in AIDS.

This also demonstrates another important point about medical investigations: As the change of diet, which could be regarded as the initial event, might have been several months before someone might begin to suffer from scurvy, it was hard to realise that the two were connected. It would be natural to look for any more recent, more sudden event that might be connected to it. One of your colleagues going down with scurvy shortly before you do looks much more like the cause of your own scurvy than the fact that you both had your last bit of fruit around three months ago. Doctors and scientists still tend to look for recent changes in circumstances rather than consider potentially cumulative toxicological or nutritional factors that may be starting to show their effects simultaneously in different people. Symptoms may only be noticed after a period of time when a threshold is reached where the body has run out of resources to cope with it. Thus, slow and cumulative nutritional or toxicological causes of disease will often be overlooked in favour of germ-related infectious causes.

Deja vu all over again

This is exactly what happened at what has been defined as the start of the AIDS epidemic - five cases of PCP in what were erroneously described as ‘previously healthy young men' were flagged up to the CDC as being part of a potentially infectious new epidemic[10]. The men were all gay and had been living part of the well-documented ‘fast track' lifestyle that some gay men participated in that arose as a result of a combination of sociological factors. They all been doing recreational drugs for years and were not quite as young or as healthy as had been made out, as well as having sex with an enormous number of people over the years. The potentially ‘sexually transmissible infection' aspect was leapt on by the CDC, while the potentially cumulative effects of years of recreational and prescription drug abuse were ignored.

In the case of Scurvy, the rejuvenated interest in finding infectious causes meant the nutritional / toxicological solution for Scurvy was slowly pushed aside. In 1899 explorer Frederick Jackson did an experiment to see if older meat would cause scurvy, believing that something poisonous was in it. And he was partly right because Inuit people living solely on fresh meat did not suffer from it, whereas explorers living off preserved but stale meat were more likely to, but the experiments were a classic example of the failure to identify the relevant factors and to be misled by the results[11].

The belief among medical staff that scurvy was caused by an infectious agent continued. The diet-related theory was increasingly discredited by more and more (now obviously flawed) research which seemed to indicate some kind of infectious factor, and so increasing beliefs in an infectious cause gradually overwhelming the empirical evidence of diet being the critical factor. The desire to kill microbes meant that milk was beginning to be pasteurised, coincidentally destroying the vitamin C in it, and causing more scurvy in children in Europe and America. This was certainly not the last time that the medical intervention for a disease actually caused the illness it was intended to prevent.

From the discovery in 1907 that guinea pigs were also vulnerable to scurvy (one group of animals that don't produce their own vitamin C) and reports of some of the biological functions of vitamin C in 1927, it took until 1937 for the causal connection between vitamin C and Scurvy to be definitively established by Charles Glen King.

Science needing a re-vamp

The research that claimed to show infectious causes of Scurvy were clearly fundamentally flawed and empirical evidence that showed how to solve the problem totally was ignored or not incorporated effectively into the experiments. What this means is that the studies should have been able to be determined to be flawed even then. The fact is that effective guidelines for the construction of experiments were not in place, and they are still not in place in modern science, despite vague notions of ‘scientific method'. And alas, scurvy is not alone. It is merely one of a string of fundamental and sustained medical blunders.

If science was truly operating within rigorous guidelines that ensure the conclusions are robust, then science would not have been able to go so far off track with AIDS research. Clearly, the principles under which scientific experiments are designed need urgent revision and some good old-fashioned external moderation on science itself. We can confidently add science to the list of areas of human endeavour where unquestioning faith by the majority of the public creates the climate where fundamental principles are slowly abandoned in favour of the more expedient race for power. Because as famed mathematician the late Serge Lang said, "The Gallo affair shows science cannot police itself".

[1] http://www.riparia.org/scurvy_sx.htm - a lovely description of the symptoms of scurvy and its biochemistry, from a very interesting nautical site. How to make a paper canoe even.

[2] http://www.riparia.org/scurvy_hx.htm - a short history of scurvy.

[3] http://www.ted.com/index.php/talks/kary_mullis_on_what_scientists_do.html - Nobel Laureate Kary Mullis describes the invention of scientific method.

[4] http://www.curacao-travelguide.com/history/index.shtml - an official version of how Curacao got its name. The bottom line is that the vitamin C in the fruit on the island saved the men from certain death, much to their own surprise and that of the sailors who left them there to die.

[5] http://www.mnwelldir.org/docs/history/vitamins.htm - the medical profession obviously knows more than anyone else could possibly do, so any alternative theories and suggestions are automatically ridiculed and ignored.

[6] http://extension.usu.edu/files/newsletters/PestNewsJune03.pdf - Utah University Pesticide and Toxic news, June 2003, with mention of a variety of situations where factors that affect health are ignored for as long as possible by authorities.

[7] http://www.emedicine.com/med/topic2086.htm - even more on scurvy, as if you really needed it

[8] http://members.aol.com/greenmagik/magnumc.htm - Some interesting writing about vitamin C and the body by Larry J Milam

[9] Peter Duesberg and Bryan Ellison, ‘Inventing the AIDS virus', Regenery Publishing inc, 1996, Chapter 2: The Great Bacteria Hunt - Scurvy, page 37.

[10] http://www.virusmyth.com/aids/books/mkbintro.htm - introduction to Martin Kitzerow's book ‘The AIDS Indictment'

[11] http://books.google.co.uk/books?id=kx5JHTuDE84C&printsec=frontcover#PPA147,M1 - a preview of Kenneth J. Carpenter's "The History of Scurvy and Vitamin C"