What's the Problem?

Vitamin A Deficiency is doing serious damage to our children. Although some of its other symptoms can be more critical, its best known symptom is night blindness, when young people simply can't see anything in the evening because their eyes are no longer capable of making the proper adjustments. Some children show clouding of the eyes and eye spots. In more extreme cases, the deficiency destroys the eyeball, eating away at it until it is gone. But these are the most obvious symptoms of Vitamin A deficiency. It does even more serious damage covertly-by weakening the immune system and so making the child susceptible to other diseases such as flu or even infections. Those who suffer the most from this deficiency are the children who do not survive long enough to experience the effects of the ghastly degeneration of the eyes, for they have already died of a condition that has been brought on, or at least worsened by, Vitamin A deficiency.

Vitamin A deficiency is a form of malnutrition. Like all kinds of malnutrition it weakens the body generally so that it makes the person susceptible to any number of diseases. In a small child these can often prove fatal. It's anyone's guess just what this might mean in terms of mortality, but medical researchers have suggested that Vitamin A deficiency could be responsible for 30 percent of all child deaths on Pohnpei.

How Bad Is It?

The answer to this varies from place to place, but there are two states in FSM-Chuuk and Pohnpei-that show especially high rates of this deficiency. The data is difficult to compare because it is sometimes based on different sorts of tests, but it points to a serious problem. In Chuuk about 18 percent of the children tested showed physical degeneration of their eyes (what is called xerophthalmia) as a result of Vitamin A deficiency. Pohnpei had no tests done for clinical Vitamin A deficiency, but if we were to extrapolate from other studies we might conclude that about 10 percent of Pohnpeian children show the same level of deficiency. Kiribati, which is also high, shows a rate of 15 percent, while the Marshalls rate is only 4 percent. The rate in the Solomons is 1.7 percent, while in the rest of the Pacific it is negligible. Interestingly enough, Palau shows a very low rate of Vitamin A deficiency. The World Health Organization (WHO) considers a prevalence rate over 1.5 percent to be a "major public health problem." Pohnpei is probably six times higher than this, and Chuuk is twelve times this rate.

Within Chuuk, the prevalence of Vitamin A deficiency is highest in the lagoon and on the capital, Weno Island. It is much lower in the remote outer islands to the west and northwest of Chuuk. This may indicate that a traditional lifestyle and diet guards against the deficiency, but other factors may also be involved. It also suggests that Vitamin A deficiency follows the pattern of many other forms of malnutrition in that it shows up the most in those geographical areas and social groups that are neither traditional nor fully modernized, but in the groups that are on the fringe of the modern sector. Characteristically, these groups live in the peri-urban areas, near but not in the center of town. Such groups lack the vitamin-rich traditional foods but often do not have the money to purchase adequate substitutes or do not understand the importance of including substitutes.

What Does It Do?

Vitamin A, also known as retinol, is found in certain kinds of foods: for example, fish oils, liver, butter and egg yolk. Beta-carotene, a precursor of Vitamin A and something that can be converted into Vitamin A by the cells in our intestines, is found in green leafy and yellow vegetables such as pele, mango, papaya, carrots, and a type of sweeet, reddish banana known as the karat. Excess Vitamin A can be stored in our liver and called upon when our intake decreases. Vitamin A is vital for the functioning of the immune system. It is also an important ingredient in the proteins that form the structure of the eye. While overdoses of Vitamin A can occur, they are difficult to achieve and are rare. On the other hand, lack of retinol leads to a host of health problems that can lead to an early death.

What Causes the Problem?

Although the problem is often thought to be dietary, our panel of experts pointed out that there is no single cause for Vitamin A deficiency. Deficiency might be due to inadequate intake of Vitamin A in the diet, but it could also be due to inadequate absorption (through malfunctions in our bodily system) or excess wastage (drained off through infections or diarrhea). This deficiency can, therefore, be linked to other conditions, such as the cleanliness of the water supply, since impure water will cause diarrhea, leading to the rapid expulsion of Vitamin A from the system. This deficiency also seems to depend on whether the body is getting its other requirements, such as iron and iodine, for there is a complex interrelationship between such elements in the human body. Yet, the condition is more directly related to the intake of foods that produce Vitamin A than anything else.

Then and Now

Are we worse off today than in former times? Because we do not have baseline studies that give us any hint of what the level of Vitamin A deficiency was in the past, we cannot conclusively answer that question. Someone suggested that the fact that Pohnpeians have no word for night blindness implies that this condition was not recognized as important in the past because the disorder was not commonly found in those days. On the other hand, it may have been that, while the problem was just as common then, those suffering from the deficiency simply didn't live long enough to develop the eye symptoms that mark long-term sufferers.

If, as seems to be suggested by these medical studies, changes in the diet in recent years have contributed to the problem, we might ask what specific changes we might blame. Several were pointed out. Breastfeeding has given way to bottle feeding in some areas, so the baby is getting less Vitamin A, not to mention the problems that can be associated with the use of contaminated water that is often used to mix formula or the improper preparation of the formula. Many more people today are eating unenriched white rice, poor in Vitamin A, rather than breadfruit. There may be less fresh fish eaten today and more canned fish being consumed. Even mangoes, which are eaten in great quantities by kids lucky enough to find some, are being eaten green today (that is, without the Vitamin A) rather than being eaten when they are ripe (and full of Vitamin A).

The problem may be not only the food items consumed but the way in which they are prepared today. Some participants pointed out that, although it was accurate to say that Micronesians in general did not have a real predilection for green leafy vegetables, they absorbed some of the vitamins from these greens in other ways. Food was prepared in pots, which were covered with plant leaves and boiled, allowing some of the juices of the plant to seep down into the water. Today no one uses these plants much anymore since their taste is not appreciated and gathering them is regarded as too much trouble in any case. Modern life styles, especially whe women work full-time, also lead to changes in food choices and preparation, practices that may lead to decreases in Vitamin A intake.

Strategies

Health Services in the FSM has been giving supplemental doses of Vitamin A to as many children as it can reach twice a year. Someone suggested that possibly more could be reached if the treatment were mixed with the candy (or other treats) that is distributed to the island children by Santa Claus around Christmas time. However it is done, distribution of Vitamin A supplements was presented as a strategy that is not only justifiable but also imperative, even if it is a short-term solution. In the long term, however, we must educate the population on the ways in which an adequate level of Vitamin A can be restored to their diet.

There are two basic strategies that can be used to accomplish this. We can have the people look back to their diet in the old days with an eye to restoring as much of the traditional diet and the ways of preparing it as are feasible. Alternatively, we can propose new solutions in lieu of any hope of restoring the old customs. In other words, instead of trying to persuade people to eat lots of breadfruit and certain tree crops, we may urge them to get used to eating new items that are demonstrably rich in Vitamin A. This could mean pushing the karat banana, pele, and other sources of the vitamin that might not have been used so often in the past. Perhaps the best strategy is one that combines bits of both. Or there may be some as yet unthought of innovative strategy. Whatever strategies are used, they must be culturally satisfying.