Food security, not vitamin supplements, is vital for public health

2001 – A year ago, Unicef’s vitamin A campaign in Assam caused the death of 30 children and sent over 1,000 to hospital with vitamin A toxicity. The larger question is whether such mass campaigns to combat malnutrition-related deficiencies in India are still required. Or do we need a more sustainable approach?

On a single day last year, health workers gave 3.2 million children vitamin A syrup in the Indian state of Assam. The mass administration of syrup was part of Unicef’s vitamin A campaign, a much-publicised effort to counter vitamin A deficiency among children in developing countries. That night, about 1,000 children who were administered the syrup fell ill, showing symptoms of vitamin A toxicity, including vomiting, nausea and headache. Children in the more remote villages were unable to access medical care in time. Ritu Konwar, a two-year-old girl died that night, and the next day local hospitals overflowed with sick children. Over one week around 29 children died of acute dehydration.

The children’s deaths sparked off a debate amongst scientists about the validity of the vitamin A campaign in India.

Is vitamin A deficiency among children a public health concern in India? Does the country need vitamin A campaigns at all? This has been the subject of controversy between Indian scientists and Unicef for over decade. Scientists in India argue that vitamin A deficiency in children is no longer a concern, except in isolated, geographical `pockets’ of the country. According to Unicef, such campaigns are necessary as they help reduce child mortality significantly in India.

After considering both arguments, the central government issued directions to discontinue the campaign in 2000. Despite this, Unicef launched a campaign in Assam last year.

Indian scientists say such campaigns are merely `short-term fixes’ and that vitamin A deficiency is better combated by educating people about eating food rich in the vitamin and by making these foods available to them.

Malnutrition is a serious problem among children in developing countries. Caused by lack of food, improper diet and unsafe drinking water, malnutrition leads to deficiencies in micronutrients such as iron, iodine and vitamins. Of these, vitamin A deficiency is the most lethal.

Children are vulnerable to vitamin A deficiency from the time they are born right upto three years of age. During this time, vitamin A deficiency can cause permanent blindness, even death. The risks become less in older children, but vitamin A deficiency reduces overall immunity and makes all children susceptible to diseases like measles and diarrhoea. Unicef estimates that vitamin A deficiency is a public health concern in 72 countries in Asia and Africa.

According to World Health Organisation (WHO) guidelines, vitamin A deficiency is a public health concern if the mortality rate of children below five years is greater than 70/1,000. This means that the death of more than 70 of every 1,000 children indicates vitamin A deficiency. In 1970, the mortality rate of children under five years in India was 130/1,000, thereby making vitamin A deficiency a public health concern (Hindu Health, December 8, 2001).

The Indian government began its campaigns to combat vitamin A deficiency in 1970. Supported by Unicef, the campaigns gave children between the ages of six months and five years vitamin A every six months. Besides this, the government also supplied kits containing vitamin A, folic acid and iron to villagers as part of its regular healthcare programme. However, since their launch, the campaigns covered only 30 per cent of the targeted children.

Though campaign coverage is low, vitamin A deficiency in India is no longer a public health concern, according to studies conducted by the National Nutrition Monitoring Bureau of India. The mortality rate of children under five years is down from 130/1,000 in 1970 to 70/1,000 in 1997. This suggests that factors other than vitamin A deficiency contributed to reducing child mortality since 1970.

Poverty in India has come down in the last 30 years. Healthcare has improved and food availability increased. The number of malnourished children has declined from 15 per cent in 1970 to six per cent in 1997.

Bitot’s spots — the appearance of foamy grey spots in the whites of the eyes — are an early symptom of vitamin A deficiency. The incidence of these spots has gone down significantly: although 1.8 per cent of children had Bitot’s spots in 1975, the figure is now down to 0.7 per cent. Also, immunisation campaigns against communicable diseases such as measles, that reached just seven per cent of children in 1970, now cover almost 80 per cent. This means that fewer children suffering from vitamin A deficiency succumb to diseases.

Unicef, however, maintains that campaigns are responsible for reducing child mortality. Werner Schultink, officer-in-charge of nutrition at Unicef, says that vitamin A supplementation through campaigns reduces child mortality from measles by 50 per cent, and from diarrhoea by 40 per cent. Overall, supplementation reduces child mortality by 23 per cent (Vitamin A Global Initiative).

Based on studies showing a decline in malnutrition and vitamin A deficiency, Indian scientists urged the government to reconsider the necessity of campaigns. In September 2000, the ministry of health and welfare organised a panel of paediatricians, nutritionists, Unicef and WHO representatives, and government officials. Called the National Consultation, the panel assessed the efficacy of vitamin A campaigns in India.

The National Consultation decided that vitamin A deficiency was a problem only in certain drought-prone parts of India. It also noted the lack of strong evidence linking vitamin A supplementation with reduced child mortality. The panel directed state governments to discontinue vitamin A campaigns. It also said that in areas where deficiency is a concern, supplements should be given using approaches other than campaigns.

Still, Unicef launched a campaign in Assam through the state government’s department of health, on November 11, 2001. The irony is that Unicef did not consider WHO guidelines whilst launching the campaign. According to the WHO, vitamin A deficiency is a concern if Bitot’s spots are seen in more than 0.5 per cent of children. A survey conducted just months before the campaign, by the Indian Council of Medical Research, found Bitot’s spots in only 0.3 per cent of the 11,000 children examined in each district of Assam. Also, Unicef did not implement the `Triple A’ approach that it recommends for assessing the seriousness of a problem. Triple A is short for `Assessment, Analysis, Action’. In Assam, Unicef skipped the first two.

The cause of the deaths of children following the campaign remains a mystery. Until now, Unicef administered vitamin A syrup using two ml spoons. In Assam, these spoons were replaced with five ml cups. Health workers, not used to the cups, may have administered an overdose. Dr Umesh Kapil, professor of nutrition at the All India Institute of Medical Sciences, says that because health workers gave 3.2 million children the syrup in a single day, they may have become negligent and overdosed the children. However, according to Kapil, vitamin A is a `safe drug’ and the amount of overdose that could cause toxicity and prove lethal has still not been established.

It’s possible that an overdose did not cause the deaths. But what is striking is that the illnesses were not uniformly spread across the state, but occurred in clusters.

India spends about Rs 120 million a year on Vitamin A that it buys from multinationals like Roche. This is besides the vitamin A donated to India by foreign agencies.

Unicef’s aim may be charitable, but such campaigns benefit pharmaceutical companies like Roche that are exploiting vitamin A deficiency in developing countries, says Kapil. However, the larger issue is whether these campaigns are still required in India.

Indian nutritionists have long argued that more sustainable approaches are needed to combat malnutrition-related deficiencies like vitamin A deficiency. Nutritionists like Kapil say that vitamin A should come from such foods as papaya and mango rather than a pill or syrup. For this, India will have to achieve `food security’ where every person is able to access and afford a balanced diet.

Achieving food security in India is a challenge. Food production has increased and malnutrition has decreased over the past 30 years. But the food produced is mostly carbohydrate-rich wheat and rice. Foods rich in vitamin A are still in short supply. The paradox is that many cannot afford even the available food. According to James Levinson, director of the International Food and Nutrition Center at Tufts University, the poorest 65 per cent in India do not even get enough food to eat. This year, India’s granaries had an excess of 55 million tonnes of grain; yet 200 million people went hungry.

Thus far, the Indian government has addressed food insecurity quite diligently. The Integrated Child Development Programme is the largest of its kind in the world and covers 80 per cent of rural India. The programme provides nutritional supplements to children less than two years of age, education to mothers about child nutrition, and vitamin A supplements to pregnant mothers. Another programme provides free mid-day meals to schoolchildren. However, Ahmad Akhtar, a nutritionist at the International Food and Policy Research Institute, says the latter programme has backfired. Because children get free meals at school, they are not fed properly at home.

For people who cannot afford food at market prices, the government has set up the Public Distribution System that sells food at half the market price. This programme cost the Indian government Rs 53 billion in 1994, making it the costliest anti-poverty programme in India. However, according to Levinson, only 50 per cent of the food meant for low-income groups actually reaches them. The rest, through corrupt officials, is sold elsewhere or ends up in the free market.

Fortification of food with vitamin A is another approach that nutritionists suggest. But this is possible only where food is sold centrally. In rural India, most people grow and consume their own food. Or food is bought and sold locally, making fortification difficult. Fortifying commodities like sugar will probably work. But ensuring that children consume enough sugar to get their supply of vitamins is not easy.

The National Institute of Nutrition in India has a programme to support and educate people about growing and consuming foods rich in vitamin A. Nutritionists educate people on the importance of vitamin A intake. Agriculturists provide the technical support to grow fruits and vegetables in home gardens. Gopalan, the institute’s director says that vitamin A deficiency is now rare around Hyderabad where the programme was implemented.

Programmes like that of the National Institute of Nutrition have serious limitations. Most people in India do not own land for home gardens. Also, vitamin A in nature is present in an inactive form called beta-carotene that is converted into active vitamin A, called retinal, in the body. Studies suggest that only one-fourth of beta-carotene is converted into retinol. In malnourished children this is even less. Moreover, fat is required for the absorption of retinol in the body, and in India people get only five per cent of their calorie requirements from fat; the recommended amount is 20 per cent. Consuming vitamin A, therefore, does not ensure its utilisation in the body.

There is no single solution to combating vitamin A deficiency in India. The government launched campaigns in 1970, aiming to replace them with food-based approaches in a couple of years. But the campaigns have continued, as they are easier than enticing people to grow and consume vitamin A foods. Campaigns are not a long-term solution. Providing capsules and syrups of vitamin A without educating people on why they need the vitamin makes them dependent on the government.

Campaigns are necessary where vitamin A deficiency is a proven public health concern. Unicef must assess and determine this before launching a campaign. Campaigns are an emergency solution, not an alternative to consuming vegetables and fruits. The money spent by the Indian government and international agencies on campaigns could be used to improve the quality and quantity of subsidised food and perhaps start the free distribution of food. If this money were used to raise the salaries of poorly paid government officials, levels of corruption may decrease, thereby largely improving the effectiveness of food programmes already underway.