Understanding the Donor World
All international donors struggle to find new and more effective ways of investing money. What are the development problems? What are the local resources and capacities already mobilized to solve them? Which local resources have overcapacity and thus could quickly solve more problems if more funds were available? Which local organizations are effective and free from corruption? When I first began working as a full-time consultant to the Swedish International Development Cooperation Agency (Sida) in 1985, a wise, experienced consultant warned me, ”You need to realize that Sida’s job is quite tricky. They have to be relieved of large quantities of money without this causing any headlines in the papers.” Like Sida, most bilateral agencies’ main worry, kept of course to themselves, is about the risk of making bad investments and thus getting unwanted headlines. Once one donor has done the background work to decide that it is a safe bet to make a certain type of investment via a certain organization, other donors follow, saving themselves the trouble and expense and, they hope, reducing their risk of getting headlines.
Unfortunately, an issue as complex as nutrition rarely manages to get anything close to the donors’ attention and funding it needs given the size of the problem and the complexity of the approaches necessary to solve it sustainably (largely in terms of improvements in diets). Donors have typically turned to quick fixes like nutritional supplements based on faulty science that has proven to be difficult to discredit because entire systems of aid delivery have been built on its back. It’s easier—and more profitable, too, for pharmaceutical companies—to hand out vitamin pills than it is to tackle the underlying malnutrition in developing countries. As Amartya Sen has pointed out, malnutrition is not a result of food shortage, but of inadequate access to food. Donors have largely avoided this fact, but there are today pioneering efforts to change the nutrition debate and help communities to adequately feed their families.
The Nutrition Problem
Malnutrition has been a problem of the human race for millennia, though there is some evidence that humans were taller (and thus presumably better nourished) at some historical periods than others. In the 1960s, it was assumed that the main cause of malnutrition was protein deficiency, and most donors invested in finding and distributing novel sources of protein based on domestic interests and capacity. For Norway, it was exploring whether low-income people could begin consuming fish powder (the answer was pretty much no).
In 1974, Don McLaren, a British academic working in Lebanon, wrote an article in The Lancet entitled ”The Great Protein Fiasco” that had the influence needed to shift the paradigm.1 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. McLaren made the nuanced point that poverty was the cause of malnutrition. A few years later, Amartya Sen, an economics professor at the London School of Economics, argued convincingly that lack of entitlement was the cause of famine.2
Perhaps inevitably, this became simplified by donors to mean that simply getting more food to the people was the answer, with the focus shifting simply to calories. This presented its own problems. Most diets had already changed to a combination of traditional and modern (often based on imported food traditions if not food itself) diets which lacked enough nutrients. Solving the problem of food alone did not solve the problem of ”hidden hunger” or micronutrient deficiencies (vitamins and minerals). Literally billions of people suffered from deficiencies in iodine, iron, and vitamin A (zinc was later added to the list). These nutrients actually had little involvement in the common problem of growth retardation and thus were not really responsible for the huge remaining problem of nutritional stunting—poverty remained the leading cause of that. Nonetheless by the 1980s, the issue of micronutrient deficiency had risen to the top of the agenda.
Nutrition planners presented decision-makers with three options for dealing with widespread deficiency of a nutrient like vitamin A (at that time considered to be a cause of blindness in young children):
• The short-term, stop-gap measure of providing all young children with megadose capsules (200,000 IU) of vitamin A semi-annually.
• The medium-term but sustainable approach of fortifying some commonly eaten food or condiment with vitamin A.
• The long-term solution (enjoyed by the industrialized countries) of improving the diets of the vulnerable groups.
A fourth option, infection control, and a fifth, breastfeeding promotion, were sometimes added. The second and third options, 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, failed to show an impact on vitamin A deficiency (though it did reduce worm infestations and improved child growth).3 This suggested that a more intensive or longer period of program implementation might be needed.
Sadly this option was not explored because a new approach took center stage. Around 1990, several studies seemed to indicate that giving large doses of vitamin A periodically might reduce mortality in young children—for reasons that are still obscure. Only the quick fix would do. All developing countries were offered vitamin A capsules or nothing—it was their choice! This was funded largely by the Canadian bilateral aid agency CIDA and also by USAID and UNICEF with some recent support from the vitamin industry itself via the business-oriented NGO (so-called BINGO) Vitamin Angels.
This supplementation approach has grown continually for three decades, achieving global coverage rates of about 80 percent presently despite the by-now conclusive evidence that the capsules have little, if any, impact on children’s vitamin A status. Impact disappears after about two months, leaving even beneficiary children vitamin A deficient for most of the year. Since the widespread implementation of the vitamin A capsule (VAC) program, mild and moderate vitamin A deficiency has remained at about the same levels or declined very gradually.
Meanwhile, it turns out that any mortality-reducing impact the capsules may have had seems to have greatly declined. That original impact appears to have operated mainly via the close link between vitamin A and the measles, though there may be a link with some forms of diarrhea as well. But measles vaccination and diarrhea control have made progress in most countries since the initial 1990-era studies were done. Research done since then, including a trial of 1 million children in northern India, has not been able to confirm any mortality reducing impact of the capsules.4
What Doesn’t Work and What Does
The frustrations with the vitamin supplementation approach are twofold: firstly, it’s a colossal waste of money; and secondly, it has the effect of distracting attention from approaches that do work. In 1981 Sida began supporting a universal VAC program in Bangladesh via UNICEF. Some 30,000 children per year were going blind due to vitamin A deficiency (VAD). But by 1989, the program was clearly not working. The coverage rate was rarely over 50 percent, and one expert estimated that public health benefit began to occur only when about 65 percent coverage has been achieved. (In other words, the easiest half to reach was the children least likely to need it). They asked me to explore what else the government and other donors were doing to solve the problem, so they could consider shifting their support to something that might work better. Both the government and donors said something like, ”Well, we have so many other priorities here in Bangladesh so we don’t do anything for VAD. After all, we have the capsule program to fall back on.” Thus I realized that the program was not only ineffective, it was preventing anything else more effective from being done instead.5 Years later, as director of the Ultra Rice Program (conventionally fortified rice, not GMO rice) at a non-profit called Program for Appropriate Technology for Health (PATH), I attempted to interest several governments in fortifying their rice with, among other nutrients, vitamin A. They all said they had no interest, as their young children were already receiving huge doses by capsule and a fortified food might throw them into a state of excess.
food sources containing vitamins is one way to deal with hunger and malnutrition.
In addition to these passive ways in which VAC programs obstructed other approaches, well-meaning scientists and UN staff believed that other approaches took attention and resources away from achieving adequate coverage for the VAC program, and they actively criticized and downplayed other approaches in policy forums, especially for about a decade beginning in the early-1990s.
Thus an approach, originally considered to be a stop-gap measure, that was to be implemented only until more sustainable approaches could be put in place has actually prevented those other options from ever getting a chance to scale up and reduce or remove the need for the capsules.
The solutions include conventional fortification and biofortification, which deliver physiologic doses of vitamin A that do not cause side effects or harm children who already have enough vitamin A as VAC appears to do in some cases.6 A wide variety of common and indigenous foods have also been proven to be effective in improving vitamin A levels even in short-term trials. I recently reviewed the literature on the efficacy of high-carotene (the plant-based precursor of vitamin A) food outside of the context of fortification.7 Of 27 papers published since 1992 documenting results from trials on the impact of 38 foods listed in Table 1 (because many researchers were studying the same foods, only about a dozen foods were tested), 25 had a net (intervention subject changes – control subject changes) positive impact on serum retinol (SR) and 18 on serum beta-carotene (SBC). The statistical significance of these differences was in most cases not indicated. An additional five foods increased SR and SBC but had no control. In the case of two food trials, there was no impact on SBC; in four food trials, there was no net impact on SR, and in two trials, there was a small negative change in SR. Five food trials increased breast milk SR (one with no control) and one decreased it. Those findings are much more consistent than the findings on VAC.
Food-based approaches are complex to implement and evaluate and take time to mature and exert their impact. But unlike supplementation, they reach all members of the community, are safe for pregnant women, have no side effects, are sustainable, and confer a wide range of benefits in addition to improving vitamin A levels. Food-based approaches are also often portrayed as being expensive, but this is only true from a ”donor-centric” way of viewing costs. From the point of view of host countries, communities and families who grow vitamin A-rich foods, the economic benefits alone are likely to outweigh the costs.
One Donor’s Discoveries
Unlike the North American donor agencies, which have to constantly prove the worth and impact of their work to their doubtful taxpayers, European donor agencies tend to work quietly, knowing they have the support of most of the people whose money they are spending. They do little work in most technical areas (like nutrition) because they have small budgets for hiring domestic expertise, preferring instead to focus on very few areas in which they have some kind of comparative advantage. They do little operations research, make few presentations in scientific meetings, and publish few results of program-relevant research (the U.K.’s Department for International Development (DFID) is a partial exception.)
Thus the Swedish experience on the vitamin A front, while instructive and perhaps unique, is not widely known. Sida discovered that the VAC program they had been sponsoring in Bangladesh along with UNICEF was not working. It was started in the early 1970s, but by 1989 distribution campaigns still tended to reach only a little over half the children in the country. Yet estimates suggested that about 65 percent coverage was needed before there could be much public health impact.8 (The children who most need such an intervention tended to be in the most isolated and under-served areas and thus were the last to be reached). Additionally, some 22 million VAC doses were unaccounted for annually. These doses could do harm, especially if given to pregnant women.
Thus Sida decided to withdraw funding from the VAC program in Bangladesh. It did so cautiously over a few years in the mid-1990s and not until the World Bank agreed to pick up funding for it. Apparently there nevertheless was a period when funding was inadequate to keep the program going. Sida was then castigated at meetings for ”not caring that again 30,000 Bangladeshi children a year were going blind.” Bloem et al. even claimed in a scientific paper that the Swedish government stopped funding for the program after coming under ”political pressure.”9
Sida decided to shift its funding to some other approach. Among several alternatives available for reducing vitamin A deficiency in Bangladesh, they chose an innovative, large-scale communication and small-scale horticulture program run by a little-known local NGO called Worldview International. Even today, Worldview’s work is little known in the nutrition sector, because as a communication NGO, it works with neither the health nor agricultural sectors, but with the Ministry of Education.
Covering every rural household in entire districts (and reaching a total of 9 million people in districts with the highest prevalence of vitamin A deficiency),10 it was able to greatly increase the consumption of high-carotene (from which the body makes vitamin A) foods in the diet of preschool age children at a cost of US$0.13/capita/year.11 Once its systems were well developed (which required about eight years of gradually improving its methods in a few districts), it then required only about three years to achieve effective implementation per district. This involved using a range of media and face-to-face nutrition education activities in villages by ”female volunteers” to increase the demand for local high-carotene foods and using these same women to help villagers grow their own. To assist landless families, three seeds each of three varieties of plants that grow on vines (squash, pumpkins and beans) were provided to every household in the district. These foods were then widely planted on rooftops, trellises, and even on nearby trees.
Early results from this project were presented in some international meetings in 1993, but the main organization of relevance, the International Vitamin A Consultative Group (IVACG), declined to have them presented. This was despite the fact that developing countries were themselves calling into question the VAC approach.
Since this and other food-based programs received so little publicity, the fact that so much was achieved at such little cost was no embarrassment to supporters of VAC distribution and had little impact on donors. We might still be unquestioningly handing out Vitamin A capsules now if it wasn’t for the pioneering work of the late professor Michael Latham, who published a paper in 2010 entitled ”The Great Vitamin A Fiasco” to call attention to these problems.12 He was quickly attacked by the academic community linked to and benefiting from the current programs dependent on VAC. When I published a follow-up paper on the website Independent Science News two and a half years later,13 the main proponent for the continuation of the VAC approach refused another journal’s request for a written debate of the issues. The publication of two trials showing no mortality-reducing impact of VAC was delayed for many years, knowing they too would be subject to career-damaging attacks. Other scientists and I are finding it difficult to publish papers on this subject; journals use peer reviewers who advise against publication of anything that threatens the status quo. After Latham’s work, however, it is increasingly hard to ignore the facts and the solutions that work.
The Next Steps
It is important that global policymaking forums stop calling for an immediate elimination of vitamin A deficiency (which plays into the hands of the rapidly deployed VAC approach) and instead call for the replacement of supplementation programs with sustainable food-based approaches. Developing country governments should assign responsibility and funding to specific individuals or organizations that are then given benchmarks and are held accountable to meet them. Donors could greatly assist by funding simple dietary assessments and other components of national plans for making this shift.
Very few low-income countries are willing to pay for VAC programs themselves. Most are also likely to be unwilling to fund careful VAC phase-out programs. (Many of those countries that could, like India, Brazil, and Vietnam have gone their own way and avoided getting stuck in the VAC paradigm.) Therefore, no real attempts to learn financially, technically, and managerially how such a phase-out can best be accomplished are likely until donors are willing to fund them. As discussed earlier, this will require a single donor to get the ball rolling and, if it succeeds without too much trouble and risk for unwanted headlines in one country, others may be willing to follow suit elsewhere.
The following steps describe how such efforts could be organized:
1. Put in place, perhaps on a pilot scale first, various programs designed to raise vitamin A levels and tailored to local needs, which could include the following:
a. Fortification of a staple food (vegetable oil or rice are probably the best alternatives) is likely to be the simplest, cheapest, and most effective method. But governments will need convincing to try it. Since overdosing may be a problem, a temporary monitoring system could be established to ensure that excess vitamin A problems are not taking place among the young children getting VAC. If overdoses are found to be common, VAC would be phased out (or phased into disease-based approaches, or distributed to people with a proven deficiency) more rapidly.
b. Other food-based approaches such as nutrition education combined with an increase in the availability of food sources containing vitamin A (or carotene), including home and community gardening, dissemination of fruit-tree seedlings, village-level solar drying of fruits, increased local production of eggs, and increased availability of small amounts of liver. Programs based on animal foods will not need to focus much on nutrition education except where there are local taboos to their use in infant and young-child feeding. However, any animal food program must add a third component: addressing the additional food safety needs involved in the production, storage, and home preparation of animal foods.
2. Set up some kind of dietary monitoring program to assess micronutrient status. For food-based programs, Helen Keller International established a very simple dietary assessment tool that was validated for use at the community level.14 However, in some countries, one cannot ignore milk or breast milk as that method recommends.15,16 If a very commonly consumed fortified food or condiment were expected largely to replace VAC, then perhaps only consumption of that vehicle for the nutrient need be monitored. A monitoring system examining young-child vitamin A levels a few months after each VAC dose was provided could also be useful. (If it remains high, VAC is no longer needed).
3. Set up routine decision-making systems, perhaps at district level, for deciding when to phase out universal VAC at that level. The Tanzania Food and Nutrition Centre developed and utilized such a system with Sida funding for shifting from iodized oil capsule distribution to fortified salt.17 Decision making in that case was done at district level every two years using a combination of simple survey and qualitative methods.
Getting Rich by Doing Good
For decades, one money-making scheme after another has been sold to industrialized countries and to big donors as the approach guaranteed to end hunger. Most are transparent and not taken seriously. Others, like VAC, though benefiting the multinational vitamin companies, were at least not driven directly by them. But it is difficult to avoid calling some of these companies nefarious. The one that comes to mind as the worst of its kind is also within the vitamin A area: golden rice. We can start with the question of why it had a $50 million promotional budget for many years, likely decades, before it was ready for actual implementation. (It is probably the single most widely known nutrition program, though it has yet to be routinely implemented somewhere.) The answer can be seen in the GMO industry’s response to every criticism leveled at it since then, ”What, you want to criticize and threaten this unique solution to a world hunger problem?”
Having worked for years with vitamin A and with conventional food fortification, I am convinced that golden rice will never solve any nutrition problem outside of situations in which people are pressured or bribed into using it. Most people in the world are hesitant to accept even very minor changes in the appearance of rice caused by the less expensive conventional fortification technology (the addition of a small number of cold-extruded grains made from rice flour and nutrients, usually slightly off color). The enormous investment that would be required to get hundreds of millions of low-income consumers to switch to rice with a bright yellow color could better be spent in poverty alleviation per se!
Perhaps the best example to date of a country that has largely eradicated hunger and malnutrition via government effort (rather than just by making economic progress) is Brazil. Its Fome Zero program of the past decade, among many other approaches, offers a monthly stipend, a conditional cash transfer, to all poor families. Moving cash into depressed areas works. All the nearby small business owners benefit hugely. The big companies quickly figure out what the poor want to buy and gear up to sell it to them. Even the IMF is starting to realize that recent evidence ”tilt[s] the balance towards the notion that attention to inequality can bring significant longer-run benefits for growth.”18
