What was more dangerous for sailors in centuries past: pirates, crushing canon, or storms and shipwrecks? The greatest scourge of sailors in the 16th and 18th centuries was… a lack of vitamin C.
Scurvy – a dietary deficiency caused by a lack of vitamin C – resulted in an estimated 2 million deaths in between the 16th and 18th century. The effects of the deficiency could be devastating. Sailors would lose teeth through softened, bleeding gums. Limbs would swell and develop foul, stinking ulcers. They would become emaciated and bleed from the nose and mouth before suffering a grim, painful death.
Ship surgeons would administer cures that would prove as brutal as the disease. How about drunken bloodletting or drinking diluted acid? One ‘cure’ was stuffing turf into the mouth of the sailor to counter the poisonous vapours of the sea air. Eating rats was another – although, ironically, their vitamin C content could actually help fend off the disease for many hardy sailors!
What have we learned from this gruesome tale? Well, using research evidence matters. It can even save lives, but it may take some considerable time to influence and change behaviour.
James Lind and undertaking research trials
James Lind joined the Royal Navy as a surgeon’s mate in the late 1730s. This humble doctor would ultimately go onto save countless lives at sea. His small, controlled trial would ‘eventually’ go on to change naval protocols and prove the scourge of scurvy.
In his ‘Treatise of the Scurvy’ (published in 1753), Lind would detail the small trial on board a single vessel – The Salisbury.
In 1747, on board HMS Salisbury, he carried out one of the first controlled clinical trials recorded in medical science. Twelve men suffering from scurvy were each divided into six pairs. The pairs were then administered various remedies including: a quart of cider; 25 drops of elixir of vitriol, three times a day; half a pint of seawater daily; a garlic and gum concoction; two spoonfulls of vinegar, three times a day; along with two oranges and one lemon a day.
What was the winner of the small but vital experiment? Oranges and lemons. The key active ingredient to fend of scurvy was vitamin C.
And so, did this eureka-worthy experiment change everything and immediately begin to save the lives of sailors? Well, not quite.
Unfortunately, Lind himself didn’t quite recognise the significance of his controlled trial. His lengthy treatise was written with a sprawling exploration of the condition so that most readers didn’t recognise the vital value of the trial findings. The vitil vitamin was lost in translation.
It took the Royal Navy around half a century to apply the findings of the experiment into practice. To save money, they substituted oranges and lemons out for limes, as these were cheaper fruits to purchase (you may note that the Americanism attributed to Brits is the term ‘Limey’ – which derives from this practice).
Not only were limes used – that were weaker in vitamin C – but methods to preserve the fruits, such as boiling the juice, could fatally reduce the vitamin C content. Sailors continued to perish for decades.
It took around 42 years before the Royal Navy ordered stocks of lemon juice for sailors.
What can we learn from this seminal research in the killer disease?
We will often hear of the scientific breakthroughs that have changed the world. In the last two years, we have lived the reality of scientific trials and advances transforming how we live and saving lives in a global pandemic. But what can we learn from the James Lind story?
Here are five insights from the scurvy story that could prove useful when it comes to using research evidence:
- Good leadership values the generation of evidence. It can be a little too easy to take for granted research and development. Though global success stories, such as Apple, invest billions in R&D, public services can see their budgets compromised and their time limited, so R&D gets squeezed out. Carving out research questions, accessing high quality evidence sources, monitoring and evaluating impact, and experimenting and learning, can be woven through our work with effort and intent.
- Money matters. The Royal Navy chose limes over lemons because of cost. Money matters in carving out time to experiment and learn, but we also need to ensure that generating evidence can save money too. Buying a bunch of useless limes may be an apt analogy for using good quality research to seek out the key ingredients for success. Of course, it will cost money to generate research, but it may saves millions, or even billions, if it stops us wasting money on the wrong solutions.
- Robust research evidence will still be subject to staunch beliefs and even rejection. Bloodletting and lopping off limbs lingered for years after Lind produced his treatise. We are wedded to our old habits. Even good quality research can be rejected because it clashes with our beliefs and hard won practices. More experiments can help build confidence in the research and go some way to build a shared understanding. We need to research and reason about that research. We need to debate and ask for evidence for prospective changes too. But we need to do more than produce research to support people to change.
- Clear communication can make all the difference. A regular complaint about research evidence is that is uses obscure language and it doesn’t make sense to the general population. Lind himself may regret labouring over such a lengthy treatise that obscured his key insights. We need to generate good quality research, but we must work just as hard to communicate it well. Busy colleagues also need time boiled into their professional development that offers access, and time to interpret and apply, such research evidence.
- Isolate your ‘active ingredients’. Good research and development – indeed, any change – works hard to isolate the ‘active ingredients’ of an approach. In short, what is equivalent of the ‘vitamin C’ for a proposed solution or change – the essential ingredient. This will likely require some careful experimentation and access to reliable existing evidence to steer our efforts.
(See the Education Endowment Foundation’s Implementation guidance report for more on ‘active ingredients’ HERE).
As scientific research has proven, the march of time can see solutions that save lives and improve our lot. From vitamin C solutions to school improvement plans, accessing research evidence, along with some careful and controlled experimentation, can make a positive difference.
If you want to accessible research evidence for education, then the EEF might be for you – see the website HERE.
In medicine, The James Lind Alliance (yes, that James Lind!) explores priority research questions for medicine – see the website HERE.