Doctors in La Ronge diagnose 27 cases of scurvy

By Glynn Brothen

Within the last six months, doctors in La Ronge have treated 27 cases of scurvy, bringing to light the severe impact of food insecurity in the province’s North.

It started with a sharp observation from a local clinician last May.

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“It was a bit surprising to the physician and the patient but it sort of made sense,” colleague Dr. Jeff Irvine said.

“The physician started to get some red flags from his other patients and started noticing that there’s even more signs and symptoms of scurvy in these other patients. So they started testing more and more and we’re finding more and more scurvy cases because of that now.”

The Lac La Ronge Indian Band hired Irvine to chair an investigation into vitamin C deficiency among members and the wider community. Of 50 vitamin C blood tests, 27 were confirmed to be deficient (scurvy), and 10 showed low vitamin C levels. All patients were over 20 years old and 79 per cent are Indigenous.

Scurvy presents in various ways from seemingly benign symptoms like fatigue or joint pain to the more acute: hair changes, wounds not healing, or loss of teeth.

The first case in La Ronge came almost by fluke — one of Dr. Yoseph Atreyu’s patients came to him with joint pain, and during examination, Atreyu noticed a curious pattern of corkscrew hairs on the person’s knee. He ordered a blood test, which showed vitamin C levels low enough to match a scurvy diagnosis.

“I just wanted to know,” Atreyu said when it came to ordering that test, admitting he thought scurvy was a long shot.

“On a national level, we’re expecting it to be such a low percent of the population. This person wasn’t low economic status, had a good paying job, ate well and was still having the issue,” he said. “This was the first case that I’ve confirmed. But thinking back in the past, I do wonder if I’ve seen it before.”

It’s also led him to wonder about more vulnerable populations, like children.

“I just don’t want to expose them to a poke for something that I know I can treat. I have been prescribing vitamin C a lot,” he said, noting some kids are coming to the clinic with low energy and dental issues symptomatic of scurvy.

The initial diagnosis, in its own way, was a symptom of a broader issue.

“Going around our small town hearing from other people that somebody in town had scurvy and how they were eating more greens and vegetables… but also telling people that they had it because they wanted it to be known ‘Hey look, even I can have scurvy, so maybe you can have it, too.’”

Atreyu said in his research the only data he could draw upon was a nutritional status study in 2013. For the prairie region, the sampling came from two urban sites. The overall results suggested 3.9 per cent of Canadians face vitamin C deficiency. When looking for data for La Ronge or the far north, there was none — something Irvine and Atreyu hope to change.

Despite scurvy’s rarity in modern medicine, the La Ronge diagnoses aligned with findings from a recent First Nations Food, Nutrition and Environment survey, which revealed 42 per cent of respondents couldn’t afford balanced meals. A 2022 Saskatchewan Health Authority report noted the average weekly cost of nutritious food for a family of four was $291.58, rising to $358.79 in the North and $464.37 in the Far North.

Fresh produce is hard to come by in the La Ronge area, and foraging for it has seasonal limitations.

For local retailers, co-ordinating a delivery of fresh food isn’t worth the minimal profit. The long travel distance leads to spoilage and fuel costs increases the consumer price.

“The prepackaged foods are more easy to ship and they’re more cheap because of that,” Irvine said. It’s “hard to encourage healthy eating and buying these foods from the source when one, they’re just too expensive or two, they’re just not there in the first place.”

Traditional foods like rosehip, Labrador tea, spruce needles, fire weed and mint have higher levels of vitamin C. Moderate amounts can be found in animal heart, liver and kidneys. But obtaining those foods is weather-dependent.

Further north, the problem intensifies and the solution, for many, is out of reach. The more pressing issue is the ongoing stress of meeting basic needs: stable housing and any type of food, let alone healthy options.

“You can’t be talking to people about healthy eating when they don’t have a place to live. That’s not something that even as physicians we feel that we can start talking to people about because we have even more important things to deal with in the first place,” Irvine said.

In assessing how widespread the problem is, the test for scurvy suffers from the same challenges as food transport.

Samples must be kept in darkness at temperatures below -70 C and, because of limited lab capabilities in La Ronge, they are shipped on dry ice to Regina’s lab for testing. Should the conditions deviate, it heightens the risk of test inaccuracy.

“Everything looks like it should be fine. The process is just to follow this, so we have no reason to suspect there’s any sort of false readings about this,” Irvine said. “But because it’s such a complex thing, it’s obviously something to consider.”

In the far north, these requirements present too large of a logistical hurdle, meaning blood drawing can only happen in La Ronge.

Atreyu said the scarcity of scurvy made him think the first test he sent came back as a false positive. He decided to test the system itself.

“I actually sent in a test on somebody that I knew was taking vitamin C and the level came back very high. So it seems to tell me that we’re doing the lab test appropriately and the lab is getting correct values back.”

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The first case and subsequent 26 cases are a tipping point; it’s clear scurvy isn’t rare anymore, but how widespread the issue is remains unknown. Atreyu said rather than mass testing the population, he and his fellow clinicians adopted the Rumple Leede method to check for likelihood of scurvy. It involves putting pressure on a patient’s arm via tourniquet and measuring if there’s an increased amount of red spots that appear once the pressure is released.

With further studying, Atreyu hopes to match the physical test in clinic to the blood results from the lab, letting other doctors know the “likelihood value” the person’s blood would test positive for scurvy based on the in-clinic test.

“It’s so important to get a ‘likelihood ratio’ for our physical exam findings because then it effectively makes the person’s own body, the lab test showing if you have this physical finding, you’re very likely to have the disease, and meaning we don’t have to go through the logistical issue of actually sending a blood vitamin C test,” he said.

The upshot is the cure for scurvy can be an easy one — over-the-counter pricing of vitamin C would be about 33 cents a month to satisfy the body’s needs, Atreyu said. It’s a matter of getting that information out to the masses.

Armed with their new knowledge, the goal for the team of doctors is to obtain federal funding to get a more detailed picture of scurvy’s impacts. Atreyu and Irvine hope to partner with other doctors in Saskatchewan and share their findings nationally, a herculean effort from the small La Ronge clinic.

“It’s a disease with a known cure,” he said.