Vitamin A Wars: the Downsides of Donor-driven Aid

Ted Greiner, Professor of Nutrition, Hanyang University, Korea (Photo Credit: Jon Orlando)

Surely one of the most precious of human dreams is to become rich and famous by doing good for others. And what could do more good than eradicating global malnutrition? Subtle variations on that theme have muddled the field of international nutrition for decades. Donor governments vary, but most want some proportion, and some want the vast majority, of their “donations” to poor countries to come back to them. Sometimes this is achieved by building up a cadre of domestic experts, or by providing products, including foods to the poor countries that will create preferences that will have to be satisfied by imports in the future. Meanwhile, those who feel uncomfortable with this way of doing things, and who ask why the capacity of developing countries cannot be built, and funds be provided to allow them to independently solve their problems, tend to get labeled as radicals.

Growing leafy greens in India

The major focus of international nutrition, in its early years as a serious profession, was protein. Companies and entrepreneurs in the rich countries began to show their concern (all the way to the bank) by developing fish protein, single cell protein, and even protein from microorganisms grown on petroleum. But this agenda came to a screeching halt after 1974 when Don McLaren published “The Great Protein Fiasco” in The Lancet (McLaren, 1974). He pointed out that in nearly all cases traditional diets, when adequate in quantity, provided enough protein. From being at the top of the nutrition policy agenda, protein deficiency has since been relegated to a position of minor importance.

First calories, and then micronutrients (certain vitamins and minerals) began to take center stage. Nowadays the nutrient companies are in the saddle, to the delight of those whose ideology labels the private sector as the source of all that is good. This article summarizes the battle over vitamin A. It looks at how a simplistic and unsustainable donor-driven “solution” rose to prominence and has unscientifically fended off the competing approaches preferred by developing countries. And it asks, now that donors have flooded the world with vitamin A capsules (VAC), what are they going to do once they no longer want to continue pumping so much money into this unwelcome approach.

Mobilizing for vitamin A

In the 1970s and 80s, nutrition planners presented decision-makers with three options for dealing with widespread deficiency of a nutrient like vitamin A (thought at that time to mainly be of concern as a cause of blindness in young children): (1) the short-term, stop-gap measure of providing all young children with megadose capsules (200,000 IU) of vitamin A semi-annually, (2) the medium-term but sustainable approach of fortifying some commonly eaten food or condiment with vitamin A, and (3) the long-term solution (enjoyed by the industrialized countries) of improving the diets of the vulnerable groups. A fourth, infection control, and a fifth, breastfeeding promotion, were sometimes added. The second and third, it should be noted, provide the nutrient to everyone and the third and fifth options provide additional important nutrients.

An early study found that after two years of implementation, a broad approach, called the public health approach, comprising basic health care and sanitation as well as assistance in growing high-carotene vegetables and fruits (Solon et al, 1979), failed to show an impact on vitamin A deficiency (though it did reduce worm infestations and improved child growth). This suggested that a more intensive or longer period of program implementation might be needed. Another evaluation (Greiner and Mitra, 1995) of a very intensive three-year program (home gardening plus nutrition education) found that the third year alone doubled the proportion of preschool age children regularly consuming green leafy vegetables. The study was unable to show a biological impact (on an early stage of vitamin A deficiency, night blindness), but neither was higher VAC coverage.

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