Health experts have long known that lack of vitamin A leads to childhood measles, and blindness, as well as increasing the risks of child deaths and maternal mortality – and so undermining the health and development of many poor, developing countries. The problem facing doctors, health workers and government ministries has been how to deliver Vitamin A supplements to populations most at risk – and how to help people understand the vital role it can play in protecting their and their children’s health.
Guatemala was the first country to pioneer the fortification of sugar with Vitamin A. Now Zambia is following its lead by launching a new, nationwide programme to ensure Vitamin A reaches all its people, from the cities to remote rural communities. But, as this Life episode shows, sugar fortification is just one part of a multi-pronged strategy that also includes experiments with maize fortification in local mills, delivery of Vitamin A supplements in mother and baby clinics, and persuading rural communities to grow new varieties of high-yielding palm trees that provide Vitamin A-rich palm oil.
In 1995, the Zambian Government carried out a survey into micronutrient deficiencies. It found that in one province, Luapula, over 16 per cent of children aged 6-72 months had subclinical vitamin A deficiency. In Luapula Province, people traditionally ate a lot of fish which provides a good source of protein, but not vitamin A.
Since 1997, Zambia has given all children under 6 years old vitamin A supplements every six months. But as Freddy Mubanga of the National Food and Nutrition Commission explains, the problem was so huge that they had to look at other options. “In addition to supplementation, we thought of moving into sugar fortification. We looked around what food vehicles we can use, and sugar seemed to be the one that was produced centrally and it was found in almost every part of the country.”
Guatemala was the first country to pioneer the fortification of sugar with vitamin A, so Zambians were sent there to learn the technology of sugar fortification. The Government passed regulations to say all the sugar that has to be consumed in households has to be fortified with vitamin A. This creates a problem in border areas where sugar is imported, because that sugar has to be checked to make sure it is fortified. The Food and Drug Control Laboratory analyses all sugar – including that produced in the country – to make sure the vitamin A content is adequate and hasn’t been affected by long storage.
Although fortification of sugar has been a success in Zambia, it reaches only the 52 per cent of the population who actually buy processed sugar. In contrast, Zambia’s staple food maize, or mshima, is consumed by over ninety per cent. But all maize isn’t processed centrally, like sugar, so simple methods had to be found to ensure local people would mix vitamin A into their maize meal.
Ward Siamusiantu of the National Food and Nutrition Commission says that diet change is the best long-term solution: “At the same time as you are looking at fortification, you have also to look at dietary levels which might take longer. Let’s change our people’s diets so that we don’t even bother fortifying – supplementing from the dietary level, you could have a lot of vitamin A.”
You can encourage people to eat certain fruit and vegetables which are a source of vitamin A, but the most promising approach is to encourage the growing of oil palm, as palm oil, used in cooking, is an excellent source of vitamin A. And vitamin A needs to be associated with oil for maximum absorption. Over 65,000 high-yielding oil palm saplings have been imported from Costa Rica and distributed free to local farmers, and local people have been sent to Ghana to learn the best method of domestic palm oil production.
Unicef representative Dr Stella Goings says: “Zambians were quick to realize that vitamin A deficiency was contributing to very high rates of morbidity and mortality, especially among children, and they were also quick to understand the importance of supplementation, fortification and diversification programmes.”
At Dr Simon Kunda’s rural health centre in Luapula Province, mothers are now taking cooking classes to learn how to prepare vitamin-rich foods. Dr Kunda explains: “We’ve started a programme where we encourage mothers to be using the local foods – like green vegetables, yellow fruits like paw-paw, oranges – and here we are lucky because we have these palm trees… Now research has discovered that these things are very rich in vitamin A, so we encourage mothers to be using the oil from palm trees.”
For the people of Luapula Province, adding vitamin A to their fish diet now promises a healthier future and an end to unnecessary blindness.
Read Unicef’s pages on the Vitamin A Global Initiative, launched in 1997. Unicef has published a league table showing how countries are doing in Vitamin-A supplementation, and has produced a series of Public Service Announcements on Vitamin A as part of their Child Rights Campaign. It also has a factsheet on Vitamin A Deficiency.
USAID has supported the supplementation campaign in Zambia. Read the page on the USAID Child Survival Programme and Vitamin A Deficiency – they calculate that it only costs $11 for each life saved by the Vitamin A supplement.
Read an abstract of the World Bank report Enriching Lives: Overcoming Vitamin and Mineral Malnutrition in Developing Countries. The UN Food and Agriculture Organisation (FAO) has a page on micronutrients and Vitamin A.
The 1990 World Summit for Children set the goal of eliminating Vitamin A deficiency. The World Health Organization has published a website pages on Vitamin-A deficiency. The Micronutrient Initiative, part of Canada’s International Development Research Centre (IDRC), has published a report on the Global Vitamin A Initiative. The Canadian Government has been one of the main supporters of the Vitamin A Global Initiative. For the past five years it has provided Unicef with hundreds of millions of Vitamin A capsules through the Canadian International Development Agency (CIDA), and the amount donated in 2003 is worth $33 million. Unicef’s programme reaches over 200 million children.
CIDA funded research at the University of Toronto which showed that providing vitamin A to children under five can lower mortality rates by 23 per cent on average in target areas. This internationally-recognized study by Dr George Beaton, for which he won the Mead Johnson Award in 1998, is now the basis for many international policies to eliminate vitamin A deficiency.