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Micronutrients, Macro Impact: The story of vitamins and a hungry world

Micronutrients, Macro Impact: The story of vitamins and a hungry world

Micronutrients, Macro Impact: The story of vitamins and a hungry world

Preface

Preface We cannot be successful, nor can we even call ourselves successful, if we live in a society that fails. This year marks the 25th anniversary of DSM’s humanitarian initiative Sight and Life and also the 50th anniversary of the founding of the United Nations World Food Programme (WFP). Yet today, we are faced with the scourge of hunger and the prevalence of malnutrition. The number of people going to bed hungry every night has reached almost one billion people and maternal and child undernutrition is the underlying cause of million deaths in children under five each year. Feike Sijbesma

Josette Sheeran

These are astonishing statistics by any stretch of the imagination. And we know that many people are suffering from hidden hunger when the food they eat does not have sufficient nutritional value. That is why filling empty bellies is no longer enough. We must ensure that we provide the right food at the right time to protect the minds and bodies of the most vulnerable. Micronutrients: Macro impact: the story of vitamins and a hungry world is being published at a time when no fewer than 2 billion people worldwide suffer from micronutrient malnutrition and face the physical and social – and therefore also the economic – consequences of that deprivation. This burden of knowledge compels us to act. That is why Royal DSM NV and WFP have joined forces to form the “Improving Nutrition, Improving Lives” partnership, leveraging DSM's research and development into food fortification to increase the nutritional value of WFP’s “food basket” through products such as micronutrient powders and fortified rice. Since its launch in , DSM’s Sight and Life initiative has played a key role in these efforts. The organization has evolved from a Task Force providing Vitamin A to the victims of a civil war to a think-tank that plays an influential role in shaping the way the world thinks about nutrition security. This book tells the story of that evolution, placing the development of Sight and Life in the wider context of the world’s growing understanding of micronutrients and their potential for good. We thank everyone who has contributed to the Sight and Life story during the past quarter-century and wish the initiative every success on its chosen path to build bridges for better nutrition.

Feike Sijbesma CEO and Chairman of the Managing Board Royal DSM NV

Josette Sheeran Executive Director United Nations World Food Programme

Contents

01 The Battle Against Vitamin A Deficiency

08

02  From Vitamin A to Micronutrients

18

03 Micronutrient Deficiency in the Developing World

36

04 Micronutrient Deficiency in the Developed World

58

05 Taking a Strategic Approach

68

06 The Role of Policy-Making and Advocacy

94

07 Science Leads the Way: New Approaches to Making Change

08 From Research to the Field

09 Local versus Global

10 Sustainable Solutions

Afterword

Acknowledgements

Index

Imprint

chapter 01

The Battle Against Vitamin A Deficiency

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01 The Battle Against Vitamin A Deficiency From scurvy to vitamin C

Jacques Cartier

The winter of was an unforgettably bitter one for the French explorer Jacques Cartier and his strong crew of sailors. In search of fabled lands rich in precious metals and spices, they had crossed the Atlantic Ocean and were exploring the St Lawrence River in what is today Canada. The harshness of the Canadian winter took them completely by surprise, however: holed up near Quebec, tormented by the cold and without adequate provisions of food, they began to succumb to disease. Their gums swelled and bled; their teeth grew loose; their joints became stiff and sore; and their bodies became covered with suppurating wounds. They were afflicted by the ancient enemy of mariners worldwide – scurvy. Scorbutus, to give the disease its Latin name, is one of the oldest nutritional disorders known to humankind. It is caused by a dietary lack of vitamin C. Twenty-five of Cartier’s men were to die of the disease before the local Iroquois, with whom the French explorer had established friendly relations, intervened to help. They showed Cartier how to boil the needles of the indigenous Eastern White Cedar to make a medicinal tea. This drink was to save the majority of the expedition. Only much later was this natural remedy proven to contain 50 mg of vitamin C per  g.

James Lind

More than two centuries were to elapse between that bitter winter on the St Lawrence River and the dissemination of a scientific theory linking nutritional intake to the prevention of scurvy. That work was the brainchild of James Lind, a Scottish surgeon in the British Royal Navy. Lind was not the first person to note a link between the consumption of citrus fruit and the prevention of scurvy, but he was the first to prove it. More than this, he proved it by means of the world’s first ever controlled experiment. As he records in his Treatise on the Scurvy, Lind provided certain sailors on a voyage undertaken in with two oranges and one lemon per day in addition to their normal rations. Other groups were given cider, vinegar, sulfuric acid or seawater to drink. The results clearly demonstrated that eating citrus fruit prevented scurvy. By , the British Navy had adopted lemons and limes as a standard feature of their rations at sea, prompting Americans to nickname British sailors, and all Britons by extension, ‘Limeys.’ It was not until the twentieth century, however, that the concept of vitamins was developed. The very term ‘vitamin’ was a neologism, in fact – the product of the research of the Polish-American biochemist Casimir Funk,

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who in coined the term to refer to the non-mineral micronutrients which are essential to health. Believing that all these micronutrients were amines, and perceiving their biochemical activity as vital, he named them ‘vitamines’. This name was later changed to ‘vitamins’. Human beings will develop scurvy if their diet lacks vitamin C, which is required for the synthesis of the group of proteins known collectively as collagen. Most other animals, by contrast, are capable of synthesizing their own vitamin C. The distinction of discovering vitamin C was not to fall to Funk, however. In the Norwegian biochemists Axel Holst and Alfred Fröhlich demonstrated that a condition similar to scurvy could be produced in the guinea pig by eliminating the intake of certain foods – and, even more significantly, that it could be cured by feeding the animals cabbage.

Albert Szent-Györgyi

Tadeusz Reichstein

This realization triggered a search for a specific anti-scurvy nutrient. Between and , two separate teams of researchers – one led by Albert Szent-Györgyi in Hungary, the other by Charles G King in the United States – succeeded in identifying a naturally occurring antiscorbutic substance. First located in the adrenal glands of animals, this substance was later found also to be present in paprika peppers. It became known as ascorbic acid on account of its ability to prevent scurvy or scorbutus. And, although not in fact an amine, it was given the alternative name ‘vitamin C’. The discovery led Albert Szent-Györgyi to receive the Nobel Prize for Medicine. Industrial synthesis of this naturally occurring nutrient followed hard on the heels of its identification in the laboratory. Between and , the British chemists Sir Walter Norman Haworth and Sir Edmund Hirst, and the Polish chemist Tadeusz Reichstein, acting independently of each other, succeeded in synthesizing vitamin C. Haworth was the first to do this, and was to win the Nobel Prize for chemistry in recognition of this achievement. It was Reichstein’s process, however – which derived the vitamin from glucose using the action of the fruit fly (Drosophila melanogaster) – that was to make large-scale vitamin manufacture a practical possibility. The Swiss pharmaceutical company Hoffmann-La Roche used Reichstein’s process to manufacture synthetic vitamin C from onwards. Branded ‘Redoxon’, these tablets – a mixture of the water-soluble vitamin C and the carrier sodium bicarbonate – are still available in the shops. Hoffmann-La Roche was to pioneer the industrial manufacture of many other vitamins, including the one with which Sight and Life has always been most closely associated: vitamin A.

What is a vitamin?

Vitamins are organic nutrients which are essential for life. The human body requires very small amounts of these nutrients to ensure normal metabolism, growth and physical well-being. Most vitamins are not made in the body, or only in insufficient amounts to meet our needs. They therefore have to be obtained primarily through the food we eat. Vitamins are classed as micronutrients, and are present in food in minute quantities compared to the macronutrients protein, carbohydrates and fat. In industrialized countries, the average adult eats approximately  g of food per day on a dry-weight basis, of which less than 1 g consists of vitamins.

chapter 01

Casimir Funk

10

The Battle Against Vitamin A Deficiency

Each of the 13 vitamins known today has specific functions in the body, which makes each of them unique and irreplaceable. No single food contains the full range of vitamins, and inadequate vitamin intake results in vitamin deficiency disorders. A balanced and varied diet is therefore vital to meet the body’s vitamin requirements. Of the 13 known vitamins, four are fat-soluble, namely vitamins A, D, E and K. The others are watersoluble: vitamin C and the B-complex, consisting of vitamins B1, B2, B6, B12, niacin, folic acid, biotin and pantothenic acid.

The history of vitamins Vitamin

Alternative name

Discovery

Isolation

Structure

Synthesis

Vitamin A

Retinol

Provitamin A

β-carotene

Vitamin D

Calciferol

Vitamin E

Tocopherol

Vitamin K

Phylloquinone

Vitamin B1

Thiamine

Vitamin B2

Riboflavin

Vitamin B3

Niacin

Vitamin B5

Pantothenic acid

Vitamin B6

Pyridoxine

Vitamin B7

Biotin

Vitamin B9

Folic acid

Vitamin B12

Cobalamin

Vitamin C

Ascorbic acid

Figures in black are water-soluble. Other vitamins are fat-soluble.

How the vitamins got their names

The first vitamin to be named was vitamin A. The use of the letter A was the brainchild of the American biochemist Elmer McCollum. He rejected Casimir Funk’s term ‘vitamin’ in favor of ‘Unidentified dietary factor fat-soluble A’ because the substance discovered by McCollum did not contain nitrogen (amines are organic compounds derived from ammonia, and always contain nitrogen). In , the British biochemist Sir Jack Cecil Drummond suggested combining the use of letters of the alphabet with the term ‘vitamin’ to denote a range of related organic micronutrients. These micronutrients consequently became known as vitamins A, B, C and so on.

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The eight water-soluble B vitamins were originally thought to be a single substance, but were subsequently found to be chemically distinct from one another, which is why they are differentiated by means of suffixed numbers – B1, B2 and so forth.

Sir Jack C Drummond

Vitamin A – The vitamin of sight Industrial synthesis of vitamin A first occurred thirteen years after Hoffmann-La Roche had commenced the commercial manufacture of vitamin C. Unlike vitamin C, which is water-soluble and cannot be stored by the body, vitamin A is a fat-soluble alcohol and is stored by the liver. It is also known as retinol. The two vitamins share in common, however, the characteristic that – like most of the 13 major vitamins – they cannot be synthesized in the human body and must be derived from the diet. An association between eating liver and the prevention of night blindness was known even in Ancient Egyptian times, but vitamin A was not identified as such until The discovery was the work of the American biochemist Elmer McCollum and his colleague Marguerite Davis, who ascertained that butter fat and cod liver oil contained a fat-soluble nutrient. They were unable to identify its chemical structure, however.

Vitamin A manufacture in the early days

Paul Karrer

It took the best part of two decades for this breakthrough to occur. The discovery fell to Paul Karrer, a Swiss biochemist whose work on plant pigments not only elucidated the chemical structure of carotenoids but also showed that some of these substances are transformed in the bodies of animals into vitamin A. Carotenoids were identified as early as by the German analytical chemist Heinrich Wilhelm Ferdinand Wackenroder, who found β-carotene to be present in the roots of carrots and consequently named the substance ‘carotin’. Many forms of carotenoids exist in nature, but none of them can be synthesized by humans. They can therefore only be made available to the body via the consumption of particular types of food. In , Karrer elucidated the chemical structure for β-carotene, the chief precursor of vitamin A. This step made possible the identification of the chemical structure of vitamin A a year later – an achievement for which Karrer was awarded the Nobel Prize for Chemistry co-jointly with none other than Sir Walter Norman Haworth, who had been the first person the synthesize vitamin C chemically. Vitamin A may be consumed directly as retinol in the form of a diet rich in liver, for instance, or it may be produced within the body by consuming the provitamin β-carotene, which occurs not only in carrots but also in a wide range of fruit and vegetables displaying the yellow to red color spectrum as well as in dark green leafy vegetables. In either instance, appropriate dietary intake is the precondition of healthy eyesight. A diet lacking in vitamin A will lead to, amongst other things, night blindness – the inability to see in dim light. If left untreated, night blindness can cause xerophthalmia. Meaning ‘dry eyes’ in Greek, xerophthalmia is a medical condition in which the eye fails to produce tears. If it goes untreated, it can trigger the ulceration of the cornea, the clear structure overlaying the iris, or colored part of the eye. The ultimate consequence of this condition is blindness. The link between vitamin A and sight is intimate.

chapter 01

What is β-carotene?

The Battle Against Vitamin A Deficiency

12

β-carotene is one of more than carotenoids known to exist in nature. About 50 of the naturally occurring carotenoids can potentially yield vitamin A; they are thus referred to as provitamin  Acarotenoids. The term ‘provitamin’ denotes a substance which is converted into a vitamin within an organism. β-carotene is the most abundant and most efficient carotenoid in our foods. It has antioxidant properties that help neutralize free radicals – reactive and highly energized molecules which are formed either through certain normal biochemical reactions in the body (e.g., the immune response), or else through external sources such as air pollution or cigarette smoke. Free radicals can damage lipids in cell membranes as well as the genetic material in cells, and the resulting damage may lead to the development of cancer. β-carotene is the main dietary source of vitamin A. The best sources of β-carotene are yellow/orange vegetables and fruit and dark green leafy vegetables. The β-carotene content of fruit and vegetables varies according to the season and degree of ripening.

Otto Isler, a biochemist who worked for Hoffmann-La Roche, was the first person to synthesize vitamin A. Before , the synthesis of vitamin A was not considered technically feasible, despite the fact that the chemical structure of vitamin A had been known since Otto Isler, however, who had a profound interest in the chemistry of natural compounds, undertook on his own initiative to try to find a way of synthesizing the vitamin.

Otto Isler

Passionate in his search, Isler managed to convince his superiors within the company to fund major research into a potential synthetic route for producing vitamin A. Supported by a powerful team, he created a process whose main step is the Grignard reaction – an organometallic chemical reaction discovered by the French chemist François Auguste Victor Grignard, who was awarded the Nobel Prize for Chemistry in recognition of this achievement. The chemical process created by Isler and his team is still in use today at the manufacturing plant in Sisseln near Basel, Switzerland. The Sisseln plant formed part of Roche’s Vitamins & Fine Chemicals Division, which was acquired by the Netherlands-based life sciences and materials sciences company Royal DSM N.V. in

Victor Grignard

First piloted in , Isler’s vitamin A manufacturing process was so successful that regular production commenced in with a targeted yield of 10 kg per month. Only a few months later, however, this target had to be revised upwards to 50 kg per month, and demand for synthetic vitamin A only increased thereafter. Isler and his team became responsible for continuously optimizing their pioneering process. A decade and a half after pioneering the industrial manufacture of vitamin C, the chemists of Hoffmann-La Roche were leading the world again. Vitamin A, which they succeeded in synthesizing against all expectation, was to have a transformational effect on the lives of countless people around the world. But for this to happen, the humanitarian initiative Sight and Life had to be called into existence.

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The creation of Sight and Life

Undernourished child, Ethiopia in the mid s

In  – famine struck the inhabitants of Ethiopia and what is today Eritrea. The effects of poor harvests (the result of record low rainfalls) were exacerbated by the horrors of war, as the Eritrean People’s Liberation Front and other Ethiopian rebel groups sought to break away from the Marxist Ethiopian regime, the Dergue. The magnitude of the calamity, which claimed the lives of hundreds of thousands and left millions more destitute, was extensively publicized. It stimulated a powerful response in the form of the multi-venue Live Aid concert of July 13, , in which musicians led by Bob Geldof raised $ million of relief funds for the stricken country. Roche was also quick to respond. As the pioneer of the chemical synthesis of vitamin A, the company well understood the link between malnutrition and eye disorders, and grasped how quickly hunger might trigger widespread nutrition-related blindness in the populations exposed to the devastation of the war and famine. The company therefore made available, free of charge, the oily vitamin A solution necessary for the manufacture of million vitamin A capsules. Dispensed widely in the famine-stricken region, these capsules saved thousands of children from the immediate threat of nutrition-related blindness. Although the most dramatic humanitarian intervention in the company’s history, it was not Roche’s first attempt to use proprietary knowledge to meet the needs of a hungry world. At the end of the s, the company had participated in a program in Central America to fortify sugar, an important staple food in the region, by adding vitamin A to liquid sugar and then drying the liquid back to a crystalline state. This involved making available application forms and mixing methods that would guarantee the homogenous distribution of the vitamin A in a stable form in sugar. Conducted under the umbrella of the World Health Organization (WHO), this program was highly successful, particularly in Guatemala. As Dr Hafdan Mahler, the then General Director of WHO, was to observe, “We know what strategies work. We must build on this experience by strengthening the current programs and introducing new ones – until all countries in which vitamin A insufficiency is a significant health problem are covered.”

A girl with xerophthalmia, Indonesia

The 37th World Health Assembly decided in on a program to combat xerophthalmia. As a short-term measure, it envisaged the periodic or spontaneous provision of high-dose vitamin A preparations to particularly vulnerable populations. In the medium term, the fortification of suitable staple foods with vitamin A was envisaged, and in the long term the encouragement of increased farming and consumption of foods rich in vitamin A. It was within this conceptual framework that the “Task Force Sight and Life” – as it was initially known – was called into being. In announcing this undertaking in its Annual Report, Roche wrote: “Naturally the solution of the entire problem far exceeds the scope of any individual company. This recognition nevertheless does not take away the obligation not only to provide help in situations of special need but also to try to improve the general situation by means of ideas, support and cooperation. For this reason, the Roche Task Force Sight and Life was created: it will initially systemize and intensify this activity within the framework of a three-year program. This covers the years  – The budget will be approved for each year by the company management and then translated into a detailed working program.”

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“The specialist knowledge available to us and the contacts which we have had for years with influential international and private organizations such as WHO, United Nations International Children’s Emergency Fund (UNICEF), Helen Keller International (HKI) and the International Eye Foundation (IEF),” the report continued, “put Roche in a position to make an effective contribution to solving this urgent health problem. The Sight and Life project was conceived in consultation with the aforementioned institutions. It is not Roche’s intention to develop new activities in parallel to already-running projects. Rather, worthwhile existing projects which are supported by the authorities should be encouraged. For the first stage, projects in Bangladesh, Honduras, India, Indonesia, Malawi and in the Philippines have been selected. In addition to this, a reserve fund for use in absolute emergency situations has also been allocated within the budget.” The initial commitment covered the following three areas: > The provision of scientific and technical support; > The provision of vitamin A in suitable forms either at reduced cost or else free of charge during the introductory phase of public programs and also in emergency situations; > The provision of financial support to research development and training programs. The Task Force Sight and Life was composed of representatives from Roche’s Vitamins and Pharmaceuticals divisions. These included doctors of medicine, nutrition specialists and researchers from other disciplines as well as communication specialists. Its initial President was Dr Werner Hausherr, while Dr John Gmünder assumed the role of Secretary General. A press release announcing the creation of the task force conveys the idealism of the group’s initial members, who defined their objectives and approach as follows:

The original Sight and Life logo

Sight and Life has set the following goals for its activities: > The number of children in the developing countries who become blind as a result of the lack of vitamin A must swiftly be reduced by means of comprehensive and targeted actions. This means that in the medium and long term, the death rates of children in the Third World can be significantly reduced. > In its activities, the task force is as un-bureaucratic as possible so that the available scientific and technical know-how and the financial means are used as efficiently as possible. Whenever possible therefore, the task force dispenses with creating new structures and concentrates on the collaboration with internationally active organizations – WHO, HKI, the IEF and others – which for their part in turn work together with the responsible national, regional and local authorities. > Besides this, the task force sets particular store by making the populations of the industrial countries aware of the problem of inadequate vitamin A provision in the developing countries and thus encouraging further organizations and companies to support concrete measures in the fight against the blinding of countless children in the Third World. Interviewed for the Roche Internal Newsletter in , Dr John Gmünder explained in detail what the task force Sight and Life was attempting to achieve. “The logo that we have created gives a clear indication of our purpose,” he said. “The stylized eye with the horizontally positioned A points to the shocking fact that every year hundreds of thousands of small children in developing countries become blind as a consequence of acute lack of vitamin A and die as a result. … Of course there are blind people in our latitudes, but more than three quarters

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of all blind people live in developing countries. These amount to – taking blind children and adults together – approximately 35 million people, which is to say almost 1% of the population of the Third World. This figure indicates the shocking dimensions of this suffering.”

John Gmünder

“The frequency of blindness is 10 – 40% higher in developing countries than in industrial countries,” Dr Gmünder continued. “In our regions of the world, the loss of eyesight is generally related to advancing age or else is the result of injury; in the developing countries by contrast, people become blind above all because they suffer an acute lack of vitamin A, because they develop inflammatory infections as a consequence of inadequate hygiene, or because they are subject to parasitic diseases, for instance ochoceriasis, which is known as river blindness. The condition of the eye triggered by lack of vitamin A is called xerophthalmia. Approximately 10 million children in the developing world suffer from this affliction. And the WHO puts the figure of children becoming newly blind every year at half a million. Experience shows that more than two thirds of these children with conditions of the eye die within a few weeks of becoming blind. This has to do with the fact that lack of vitamin A is usually associated with a general deficit in nutrition and a lowered resistance to infectious diseases, but it also frequently has to do with the fact that blinded small children are often ostracized by their families. Lack of vitamin A is, however, as we today know, the major cause of the blinding of small children in large areas of Asia, Africa, Latin America, the near East and the West Pacific.” Dr Gmünder’s analysis was confirmed by Dr Alfred Sommer, working at that time at the International Center for Epidemiologic and Preventive Ophthalmology (ICEPO), who was quoted in the same publication as saying: “Increasing the provision of vitamin A should in practical terms be the most effective measure to improve the chances of survival of small children in developing countries.”

A quarter of a century of Sight and Life

The Kubus building, Kaiseraugst – Sight and Life’s home at the HQ of DSM Nutritional Products in Switzerland

What needs to be appreciated from today’s perspective, 25 years after the founding of Sight and Life, is that the chemical synthesis of vitamin A was a still relatively recent breakthrough at the time, and that the link between lack of vitamin A, xerophthalmia and child death was the result of even more recent research. Dr Gmünder explained this when interviewed a year into the existence of the Task Force Sight and Life: “Roche’s first contribution to the improvement of vitamin A provision was the development of the process for the fully synthetic industrial production of vitamin A. This prodigious scientific achievement was the work of Dr Otto Isler precisely 40 years ago, in This meant that this chemically complex natural ingredient, which is essential for life, was in principle made available to an unlimited extent and at low cost. First to profit was initially the population of the Western Hemisphere, who had the opportunity to supplement their vitamin A provision by taking vitamin A preparations or by consuming foods fortified with vitamin A. Margarine and cooking oils are often fortified in this manner. To meet the vitamin A requirements of large populations in countries of the Third World, however, different methods must be developed which are tailored to the individual situations.” He went on to point out that Roche had been producing vitamin A in one of its own factories in India since The vitamin A was given to children in the form of a standardized oily solution or else incorporated into cooking oils. Originally conceived as a three-year initiative, Sight and Life commemorated 25 years of service to science and humanity in In almost a quarter-century Sight and Life was to evolve into a humanitarian initiative that

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would make donations totaling $36 million (US), support nearly 3, projects in more than 80 countries and donate more than 80 million vitamin A capsules, mainly for children aged six months to five years (based on Sight and Life’s Annual Report ). Sight and Life has received, among many other awards, the HKI Spirit of Helen Keller Award in recognition of its work towards the eradication of vitamin A deficiency in developing countries, and the IVACG Award for 15 years of contributions to Global Vitamin A Deficiency and Control.

The Helen Keller Award

Dr Werner Hausherr, Sight and Life’s President from  –, was succeeded by Dr Guido Richterich (Member, F. Hoffmann-La Roche Executive Committee, President Sight and Life  –), Andres F Leuenberger (Deputy Chairman, F. Hoffmann-La Roche Executive Committee, President Sight and Life  –), Feike Sijbesma (Member and subsequently Chairman of the Managing Board of DSM, President Sight and Life  –) and Stephan Tanda (Member of the Managing Board of DSM, Chairman Sight and Life to the present). The role of Secretary General was occupied by Dr John Gmünder from to , passing then to Dr Martin Frigg ( – ) and then to Dr Klaus Kraemer as Director ( to the present). These facts and figures tell only a tiny fraction of the Sight and Life story, however, which is of a year journey that has touched the lives of millions. This book tells the story of that journey – of the road Sight and Life took, of the companions the organization met along the way, and of the many discoveries it made during that first quarter-century of its existence.

Growing the evidence base for micronutrients.

chapter 02

From vitamin A to micronutrients

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02 From Vitamin A to Micronutrients From foundation to a Helen Keller International Award The Sight and Life Task Force commenced operations on 1 April Its objective was to help combat xerophthalmia – an eye disease caused by vitamin A deficiency from which approximately 10 million children in the developing world suffered at the time. The Sight and Life Annual Report estimated that every year, one million of these children lost their sight. Of these, it noted that two thirds died after a short period.

Helen Keller

An active response to requests from the WHO, which in launched a ten-year program to fight against nutritionrelated blindness, the creation of Sight and Life was part of the wider move to tackle vitamin A deficiency, which had been identified by the 37th World Health Assembly as one of the five main nutritional problems in the world. The WHO set a budget of $25 million and targeted 60 countries in Africa, South-East Asia and Latin America. The initiative was supported by a wide range of international bodies and non-governmental organizations. Speaking for Sight and Life at the time, Dr Fritz Gerber, the then acting chairman of Roche, said: “Roche recognizes its responsibility as part of an open and free society and will contribute to solutions for health and nutrition problems in the Third World.” The initial activities of Sight and Life included the provision of scientific and technical advice, free distribution of vitamin A capsules in emergencies, and financial support for selected research programs. The Task Force was active only in those countries which were classified as problem areas by the WHO, and where the projects were supported by the local health authorities. From the outset, the approach of Sight and Life was collaborative, and agreements on coordinating efforts in the worldwide fight against xerophthalmia were made with a wide number of organizations, including HKI, the IEF, the ICEPO, the International Agency for the Prevention of Blindness (IAPB), the International Vitamin A Consultative Group (IVACG), and the WHO. Local organizations for the blind, private charities with an interest in the prevention of blindness and local health services were also important partners.

chapter 02

Dosing with vitamin A, Ethiopia

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From vitamin A to micronutrients

The Task Force acted in accordance with a clear set of principles: > To have no commercial intentions whatsoever; > To operate on purely humanitarian grounds; > To limit its activities to countries where xerophthalmia was recognized as a public health problem; > To cooperate with established organizations; > To aim to become a serious and reliable source of assistance to its partners; > To provide Roche vitamin A capsules where feasible; > To provide financial support to selected projects in research, social marketing and education; > To engage in information activities such as the publication of brochures and a newsletter, and the organization of video conferences; > To establish and strengthen personal relationships within the vitamin A community; > To stay out of politics.

The initial structure of the Task Force Sight and Life

President of Sight and Life (A member of Rocheâ€&#x;s management)

1

3

External partners

Task Force Sight and Life > Full-time project manager > Secretary

Roche internal experts

External partners: > WHO, UNICEF, NGOs (HKI, IEF, SRC, CBM, IAPB, ICEPO) > Local organizations for the blind > Local health services (health centers, flying doctors) External experts: > Scientists from WHO, universities Internal experts: > Scientists from the former Roche Vitamin Divisionâ€&#x;s > Research Department > Pharmaceutical Department > Technical Department

2

External experts

Roche affiliates

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From vitamin A to micronutrients

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Dr. John Gmünder, the first Secretary General of Sight and Life, recalls the challenges which the Task Force had to confront in its fledgling years: “It was crucial for us to establish strong partnerships with other organizations similarly committed to the fight against xerophthalmia. At the same time, we had to define the areas in which we were going to act – vitamin A capsule distribution, research, education and information. The first batches of capsules had to be produced, put through quality control, packaged and labeled while we simultaneously prepared a great deal of promotional and educational material and a wide range of communication activities. We participated actively in education and training events, and of course we had to create our own organization and ensure that it was working efficiently. So there was a lot to be doing in the early days. We needed to prove to the vitamin A community that we were a serious partner, offering valuable help in a reliable manner. We never lost sight of that objective.”

How Sight and Life got its name

“Roche had decided to make a formal commitment to the battle against vitamin A deficiency, building on the ad hoc interventions it had already been supporting for a number of years,” recollects Dr Alfred Sommer, Dean Emeritus, Johns Hopkins Bloomberg School of Public Health. “Dr John Gmünder would drop by from time to time to discuss this undertaking and seek advice as to where Roche should be focusing its efforts. We at Bloomberg were aware at the time that vitamin A had a huge influence on physical and mental well-being. The link had not yet been proven, however, and the rest of the world seemed reluctant to accept the theory.

Alfred Sommer

“One day John told me that Roche had decided to sponsor a new organization called Sight or Life – the implication being that if you couldn’t see, you weren’t living. I felt, however, that this sent too negative a message, and that it might be construed as offensive by people who were blind and lived very full lives. I therefore suggested calling the new organization Sight and Life, because vitamin A is important for sight specifically but also for life in general. This little change gave the Task Force a very positive name, and one which was intimately associated with vitamin A.” Over the years the name has proved itself. Research has come to show that vitamin A not only plays many vitally important roles beyond its effect on sight, but is also critical to life.

Initially set up for a three-year period in response to a famine and war which had shocked the world, Sight and Life was to look back on its initial period “with much confidence and optimism,” according to its Annual Report. “Worldwide efforts to improve vitamin A nutrition in developing countries are gaining momentum and vitamin A is increasingly valued as an important element in child survival strategies.” During the three years from to , Sight and Life supported a total of 52 projects in 29 countries, reaching over two million children. The Task Force described its activities as being to run vitamin A intervention programs (capsules; liquid vitamin A; food fortification), to assess and monitor the vitamin A status of children, to give financial support to selected research projects, and to provide training in the detection, treatment and prevention of xerophthalmia. The success of its efforts was measured by the number of children reached in intervention programs, the decline in the incidence of xerophthalmia, the number of countries, projects and

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From vitamin A to micronutrients

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conferences with which the Task Force was actively involved, and the feedback provided by partners within the vitamin A community. Even at this early stage of its existence, Sight and Life’s experience in the field made it necessary to adapt its initial focus and approach. Thus the following amendments to existing treatment policies were listed in the Annual Report as being of great importance: “ 1. In addition to use for xerophthalmia prevention and treatment, vitamin A is now also recommended for high-risk children suffering from severe infections, prolonged diarrhea or general malnutrition.     2. Furthermore, in an effort to safeguard young children of refugee families against the acute risk of blindness, the UN High Commissioner for Refugees has instructed that high doses of vitamin A should be administered immediately to all young children at the time of registration, with an extra dose to be given to those showing symptoms of xerophthalmia.     3. The WHO recommends using the services of the Expanded Programme on Immunization (which reaches 50% of the world’s children) to deliver vitamin A to target groups in high risk areas.     4. Finally, the WHO, in its Essential Drug List, has included besides the standard vitamin A capsules (, IU) also an oral oily solution (, IU/mL) and sugar-coated tablets (10, IU).”

The Helen Keller International Award, “La Pleureuse”

Sight and Life is awarded La Pleureuse

Nevertheless by , according to the Sight and Life Annual Report of that year, in some 37 countries, as many as 50 million children under five were suffering some degree of vitamin A deficiency. The weakening of the body’s natural defenses associated with vitamin A deficiency exposed these children to increased risk from infectious diseases such as measles, diarrhea or respiratory tract infections. More than half a million new cases of child blindness were reported annually, most of these due to vitamin A deficiency. Not that Sight and Life had reduced the scale of its support: on the contrary, the number of its intervention projects had risen from the figure of 52 to 91, and the Task force was additionally supporting 38 research projects and 6 training and education projects. The value of the Task Force’s efforts was recognized in by the presentation of the prestigious HKI Award at the United Nations (UN) in New York, followed by a congressional reception at the US Capitol in Washington. The honor was shared with two distinguished Latin American ophthalmologists, Dr Francisco Contreras, Director General, Instituto Nacional de Oftalmologia, Peru, and Dr Newton Kara-José, Director of the Blindness Programme at the University of Campinas, Brazil. The two gatherings offered a unique opportunity not only to focus public attention on the worldwide problem of preventable blindness but also to commemorate Helen Keller’s lifelong humanitarian crusade for the blind as well as her role as founder of HKI.

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Helen Keller and George Kessler

From vitamin A to micronutrients

HKI traces its history to the life’s work of two extraordinary individuals, Helen Keller and George Kessler. Helen Keller was the first deaf and blind person to earn a Bachelor of Arts degree. She was taught to communicate by Anne Sullivan, a visually impaired former student of the Perkins Institute of the Blind in South Boston. Their relationship was immortalized in the play The Miracle Worker by William Gibson, which was turned into a film in Helen Keller became well known as a pacifist author, political activist and lecturer who campaigned on a range of progressive issues, including women’s suffrage. George Kessler was a wealthy New York merchant who survived the sinking of the Lusitania in While recovering in London, he resolved to devote his remaining years to helping soldiers blinded in combat. With the support of the then year-old Helen Keller, George and his wife Cora Parsons founded the Permanent Blind Relief War Fund for Soldiers & Sailors of the Allies in New York in This organization was to become in due course HKI. Source: rushbrookrathbone.co.uk,

Helen Keller International at a glance

Founded in , Helen Keller International (HKI) is among the oldest nonprofit organizations devoted to preventing blindness and reducing malnutrition. Headquartered in New York City, HKI works in 22 countries: 13 in Africa, eight in Asia, and the United States. HKI builds local capacity to combat blindness and malnutrition by establishing low cost, sustainable programs. It also provides scientific and technical assistance, as well as invaluable research and data, to governments and international, regional, national and local organizations around the world to help expand current approaches and develop effective new approaches. Mission HKI’s mission is to save the sight and lives of the most vulnerable and disadvantaged. It combats the causes and consequences of blindness and malnutrition by establishing programs based on evidence and research in vision, health and nutrition. Vision HKI envisions a world where … > No one suffers from preventable or treatable blindness or low vision; > No one suffers from undernutrition; and > Fewer people suffer loss of their productive years due to disability and premature death. Source: rushbrookrathbone.co.uk,

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Example intervention: Vitamin A Child Survival Project in Nepal

Mother with child, Nepal

Bitot’s spots

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The Vitamin A Child Survival Project in Nepal was a large-scale social intervention study with three major components reflecting divergent opinions on the appropriateness of different strategies relevant to the establishment of a national vitamin A deficiency control program in Nepal. The three major project components were: > Semi-annual distribution of high-dose vitamin A capsules; > Provision of high-dose vitamin A capsules plus basic primary health care services (immunization, de-worming, acute respiratory infections, oral rehydration therapy); > Provision of basic primary health care services plus nutrition education of mothers on the signs and symptoms of vitamin A deficiency and the dietary sources of vitamin A, but no capsule distribution program. 65, children aged six months to 10 years from seven districts of Nepal were enrolled in the study, which started in late and was concluded in June The Vitamin A Child Survival Project was run under the auspices of Nepal Netra Jyoti Sangh and responsibility for program development, implementation and evaluation was shared with the University of Michigan, USA. While some of the consultants and support staff came from the university’s Department of Population and International Health, the majority of the project team (about people) was recruited from the Ministry of Health of Nepal, the King Mahendra Eye Hospital in Bharatpur and the local communities involved in the project. The vitamin A capsules required by the project were supplied by Sight and Life. The project results clearly demonstrated that large-scale vitamin A control programs are feasible in Nepal and, by utilizing village volunteers, can easily be integrated into the existing primary healthcare system without additional salary costs for the government. Nutrition education, potentially a very powerful means of controlling vitamin A deficiency, was found to be the most expensive and most difficult approach. The capsule distribution approach was the cheapest alternative, with immediate results and high coverage rates. A well-motivated community health worker can contribute tremendously to high participation rates in capsule distribution programs, which, for many areas of Nepal, are the intervention of choice. However, in areas where the risk of Bitot’s spots1 and the levels of wasting are high, the implementation of more extensive vitamin A deficiency control programs which also focus on maternal literacy, nutrition education, and food security is recommended. Another interesting finding was the fact that the risk of xerophthalmia was higher in the age group of five to year-olds than among children less than five years of age, and it was, therefore, recommended that the vitamin A distribution program be expanded to include children aged five to 10 years. Source: Sight and Life Annual Report

1Bitot’s spots are the buildup of keratin debris located superficially in the conjunctiva, which are oval, triangular, or irregular in shape. These spots are a sign of vitamin A deficiency and are associated with conjunctival xerosis. Bitot’s spots are superficial, foamy gray spots on the white of the eyeball.

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Sight and Life’s early achievements Sight and Life’s first Secretary General, Dr John Gmünder, stepped down in By this time the organization had provided 16 million doses of vitamin A in either liquid or capsule form to different intervention projects in 52 countries. Reflecting in on its early efforts, he said, “The most important achievement was the findings of Dr Alfred Sommer and his team at the ICEPO. They found that providing vitamin A supplementation to children older than six months reduced mortality by 30 per cent, cut the severity of infectious diseases in general, lessened the incidence of severe complications and fatality in the case of measles, and provided a protective effect against severe diarrhea. Above and beyond this, they brought to the fore the importance of complementary strategies for promoting better health among populations in developing countries. These included creating awareness by disseminating basic information about nutrition and child health, promoting breastfeeding, maintaining high levels of immunization, improving standards of hygiene and sanitation and providing clean drinking water, giving families access to health services and other community-based services, and reducing the adult illiteracy rate, especially amongst women.”

Martin Frigg (middle) with ICEH alumni

A new Secretary General and an expanded newsletter Under Dr Martin Frigg, who succeeded Dr John Gmünder in January when Sight and Life was in its tenth year, the role of the organization continued to evolve. “My first objective on taking up the position was to turn our budget from an annual into a permanent one,” he recollected shortly before his death in “This was achieved, and the organization’s budget remained constant at 1 million Swiss francs per year for a long period. It was important to ensure that Sight and Life occupied positions in the vitamin A arena that were unique. This endeavor was supported by a heightened focus on the newsletter, whose format was reworked and whose focus was turned more sharply on activities directly initiated or supported by Sight and Life itself. The Xerophthalmia Club Bulletin, whose origins lay in the International Agency for the Prevention of Blindness, was incorporated into the newsletter, whose distribution within the vitamin A community was significantly broadened. An important part of my role was to review very efficiently scientific papers and to disseminate their content via the newsletter. I also used my computer-programming abilities to develop databases that facilitated the steering of the organization, which had to efficiently manage a wealth of information regarding finances, projects, addresses and specialist literature.” Writing in the Sight and Life Annual Report, Dr AF Leuenberger, the then President of the organization, looked back on the Task Force’s development: “When the Task Force Sight and Life was founded almost ten years ago, it was decided not to create any new structures but to work together with existing organizations with the necessary field experience. This has proved to be a wise decision, and the concept has been successful beyond all expectations: the Task Force can concentrate on its function as a hub of experience, information and support. It can hence employ its resources to maximum effect.” “But this concept only works because there are organizations combating vitamin A deficiency that not only are highly competent, but also justify the trust placed in them. Most of all, time and again we were able to observe how professionally our partners operate, even in very difficult conditions, and how well they are able to adapt to the manifold cultural environments in their target areas. This is because efficient research and aid need not only cost consciousness and management skills, but also creativity and inventiveness.

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“When I read this year’s Sight and Life Annual Report, I realize the extent of the efforts of our many partner organizations. I would like to thank them here for their excellent co-operation. I am proud that F. Hoffman-La Roche Ltd through the Task Force Sight and Life is able to contribute to the worldwide efforts in fighting vitamin A deficiency.”

Sugar fortification: An important route to improved eye health International Conference on the fortification of sugar with vitamin A Guatemala, 12 –15 March

Sugar crystal with vitamin A beadlet attached

Fortified sugar, Guatemala

In Guatemala, sugar fortification has been implemented since the sixties. When the importance of vitamin A for child health was recognized, the Institute of Nutrition of Central America and Panama (INCAP) devoted much effort to reducing vitamin A deficiency. Sugar was identified as the best vehicle for vitamin A supplementation as it is consumed in regular quantifiable quantities by the majority of the population, it is relatively cheap and accessible and it is produced largely by a centralized process. Based on a special water-soluble form of vitamin A, a relatively simple method of fortifying sugar with a shelf-life of approximately one year was developed. The vitamin A level in the sugar was set at a concentration of 15 micrograms (50 IU) per gram of sugar. Importantly, this level does not cause any negative taste, texture, color or flavor changes in the final product. The case study of the success of the Guatemala sugar fortification was summarized in a document issued by UNICEF. Guatemala was therefore not surprisingly chosen to be the venue of the International Conference on the Fortification of Sugar with Vitamin A. At the opening of the conference, the president of Guatemala, Mr Alvaro Arzu, welcomed the participants, and received an award on behalf of the Republic of Guatemala for its pioneering role in the fight against vitamin A deficiency. At the meeting, the status of knowledge on the consequences of vitamin A deficiency on health and development of children was presented, as well as the role of sugar fortification and the fortification of other foods. Dr Keith West of Johns Hopkins University, Baltimore, USA, pointed out that vitamin A deficiency was never likely to be eliminated but could and should be kept under control. This had been shown in Guatemala as, when sugar fortification was discontinued, vitamin A deficiency had once again become a public health problem. There was a general feeling and agreement among the participants from all over the world, representing ministries of health, universities, research institutes and industries, that collaboration was essential when addressing vitamin A deficiency. It was also felt that there were still many technical problems to be solved, especially in vitamin A fortification of foods. The key to successful sugar fortification would be for new sugar production factories to install customized equipment to mix the vitamin A into the sugar. And, as the technology was simple, the basic investments required were considered almost negligible when set against the public health benefits. The meeting stressed that the lesson learnt from salt fortification with iodine was that one should not wait to take action until perfect solutions were found. Rather, interventions should be begun that were known to work and these should continuously be improved over time. This lesson remains valuable today. At the end of the conference, a declaration named the ‘Guatemala Declaration on Combating Vitamin A Deficiency through Sugar Fortification’ was signed by representatives of at least 33 countries, 28 enterprises and 39 organizations. This was an important milestone as it set the scene for fortification of not only sugar but also other staple foods. Source: Sight and Life Newsletter 1/

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Interview Dr Donald S McLaren

Donald S McLaren

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Distinguished scientist Dr Donald S McLaren is one of the great pioneers of the study of vitamin A deficiency disorders. Throughout his extraordinary life, he has been at the forefront of research in this field, publishing many groundbreaking books, papers and other key texts. In the period since his retirement, he has played a significant role in Sight and Life’s work. “When considering my career,” observed Dr McLaren in an interview with Sight and Life Magazine in , “you have to remember that it took place in a totally different era from today. Everything was entirely different; there’s no chance that anybody else would follow the same path today. “I studied Medicine at Edinburgh. After qualifying in with an MB ChB degree, I ended up in a hospital in a tribal area in Orissa, India. Through this experience, I felt directed towards scientific work. I submitted my research to Edinburgh University and was awarded a Clinical Doctor of Medicine degree. Most of my work had to do with xerophthalmia, the most common blinding disease prevalent in young children in the world at that time. “After five years, I joined the London School of Hygiene and Tropical Medicine, to start my PhD in nutrition. As my PhD studies came to a close, an opportunity arose to work for the World Health Organization (WHO) as consultant in Indonesia. I found that very severe blinding – occasioned by vitamin A deficiency – was prevalent in number of big cities in Indonesia. The report I wrote on the subject was the first that WHO had ever issued on the disease. After a year, I was invited to attend the very first international meeting on xerophthalmia – my paper was only one of two on findings in young children. “By the early s, WHO had become much more interested in my work. They commissioned a scientific research program, including a survey of the whole world – I traveled in Africa and the Middle East. This was the very first time, scientifically, that understanding of VADD and xerophthalmia was put together and published. Part of this research, funded by the National Institutes of Health in the US, was the first ever trial in the field, under experimental conditions, of vitamin A capsules aimed at preventing the disease. I was responsible for carrying out that work, along with another colleague from WHO. I wrote the very first book on the subject, Malnutrition and the Eye, published in I was able to pioneer research into that phase of vitamin A deficiency during the early days of the conquest of xerophthalmia. “In terms of my achievements, the area that I was able to contribute to in the case of vitamin A deficiency was, largely, communicating what was known in the laboratory and the hospital to governments, to international organizations, to the public – and to broadcast it, and bring people to understand how serious it was and what a terrible disease it was. I could help people understand that only few units of vitamin A in the diet could prevent everything going wrong. My work was very influential in that regard.” Abridged interview with Sight and Life Magazine, 3/

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A widening focus Towards the end of the twentieth century, two new developments were to influence the course of Sight and Life. One was the creation of the Millennium Development Goals (MDGs) by the United Nations; the other was a widespread broadening of research and focus to include a more extensive range of micronutrients in supplementation and fortification programs, and not just vitamin A. The MDGs are discussed in greater detail in chapter 3, which outlines the world’s growing understanding of the complex interactions of a wide range of vitamins and minerals and their impact on health and well-being and the severe negative consequences of deficiencies on individuals, communities, and nations. Sight and Life had been founded as a short-term response to a single vitamin deficiency; a decade and a half into its existence, based on the ever-developing science, it was starting to reconsider the appropriateness of this exclusive focus. In doing so, the organization was reflecting the thinking that was happening in the wider micronutrient arena, and which was to lead in to the establishment of the Micronutrient Forum. This new forum was created to reflect the recent evolution of science and program development in the field of micronutrient nutrition. It replaced the International Vitamin A Consultative Group (IVACG) and the International Nutritional Anemia Consultative Group (INACG), both of which had been set up in with funding from the United States Agency for International Development (USAID). Through its formation, the importance of multiple micronutrients for health and development was acknowledged.

The Micronutrient Forum

The Micronutrient Forum focuses on the impact of micronutrient deficiencies on public health and development, concentrating primarily on populations that are deficient in what can be called the “big five”: vitamin A, iron, folate, iodine, and zinc. The Forum does this primarily through global meetings and consultations. The global meetings create a forum for leading scientists, policy-makers and programmers to discuss the latest scientific and programmatic evidence supporting the role of micronutrients in health, thereby providing the mechanism for experts to review and advance policy-relevant science. Source: rushbrookrathbone.co.uk

The 2nd Micronutrient Forum, Beijing

The Copenhagen Consensus Dr Martin Frigg retired as Secretary General of Sight and Life in , having served in the position for eleven years. He was succeeded by Dr Klaus Kraemer, who, in his initial editorial for the Sight and Life Newsletter (2/), wrote: “Providing micronutrients to fight malnutrition was ranked number two amongst the factors having the highest impact on solving the world’s greatest challenges by a panel of internationally renowned economic experts in the Copenhagen Consensus This encourages us to be at the forefront when it comes to improving the nutrition and health of children and mothers in developing countries. We cannot accept that one billion children are malnourished and live in poverty, and that more than ten million children under the age of five years still die every year of diarrhea, pneumonia, measles, malaria and AIDS. Many of these fatalities could be prevented by an optimal supply of vitamins and minerals.”

chapter 02

Micronutrient supplementation rated top priority at Copenhagen Consensus

The Copenhagen Consensus,

Bjorn Lomborg

From vitamin A to micronutrients

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In the spring of , a panel of the world’s leading economists determined that eliminating micronutrient deficiency in children offers a better rate of return than combating global warming, disease or terrorism. The expert panel, which included five Nobel laureates, met at the Copenhagen Consensus to evaluate 30 proposed solutions to 10 of most serious challenges facing the world today. The “winning” solution addressed the lack of vitamin A and zinc in nearly million children. The solution? Provide vitamin A to 80 percent of children aged two and below in Sub-Saharan Africa and South Asia, where current vitamin A coverage is 73 percent and 71 percent respectively, according to UNICEF. For zinc, provide supplements to infants aged 6 – 12 months to reach 80 percent of children in need in South Asia and Sub-Saharan Africa, where current zinc coverage is essentially zero. The estimated cost for this solution was $60 million a year, with a return of more than $1 billion annually. More simply, for every dollar spent, the world would realize more than $17 in benefits from better health, greater earnings potential and fewer deaths.1 Douglass North, a Copenhagen Consensus panel member and Nobel laureate told Reuters, “It [micronutrient supplementation] has immediate and important consequences for improving the wellbeing of poor people around the world, that's why it should be our number one priority.”2 First held in , the Copenhagen Consensus was established by Bjørn Lomborg to help policymakers, NGOs and philanthropists around the world determine how to best invest capital to address pressing global concerns. This year, panelists considered the following issues: malnutrition and hunger; air pollution; conflicts; diseases; education; global warming; sanitation and water; subsidies and trade barriers; terrorism; and women and development. Reviewing each issue, the panel answered the following question: “If you had an extra $75 billion to do good in the world, where would you spend it over the next four years?” The panelists selected micronutrient supplementation as the best way to improve the world based on a challenge paper and proposed solutions authored by economist Sue Horton of Wilfrid Laurier University in Canada, Harold Alderman of The World Bank and Juan Rivera of The National Institute of Public Health, Mexico. To explain the consequences of micronutrient deficiency to the economists, the Horton paper provided data on the causal relationship between micronutrient deficiency, undernutrition and increased mortality, morbidity and reduced economic output. The paper outlined how on a global scale, undernutrition threatens the world’s ability to meet the first Millennium Development Goal, which focuses on the eradication of extreme poverty and hunger. An unmet first goal will impede progress on subsequent goals. Finally, Horton explained that while the cost of undernutrition is high, there are inexpensive ways to deliver micronutrients to populations in need. Other proposed solutions outlined in the Horton challenge paper included: > Biofortification or fortifying staple crops with micronutrients. These agricultural improvements would cost approximately $60 million annually, with benefits of $1 billion – a benefit-cost ratio of more than > De-worming of pre-school children. For $ million the program would yield $ million annually – a benefit-cost ratio of The benefits include reduced anemia, improved growth, cognitive development and future income potential. 1 Copenhagen Consensus , Press Release 2 Reuters, 30 May. Story edited by Tim Pearce

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> Community-based nutrition promotion. While the previous solutions all focused on specific micronutrient deficiencies, a community-based program would attempt to promote improved overall nutrition. Techniques might include children’s health days where immunizations, vitamin A supplementation and de-worming activities take place; programs focused on growth promotion and nutrition education. The cost of community-based nutrition programs was estimated at $ million annually for a benefit of approximately $10 billion; a benefit-cost ratio of Panel composition and ranking The Copenhagen Consensus Panel members included: > Jagdish Bhagwati, Columbia University > François Bourguignon, Paris School of Economics and former World Bank chief economist > Finn E Kydland, University of California, Santa Barbara (Nobel laureate) > Robert Mundell, Columbia University (Nobel laureate) > Douglass C North, Washington University, St Louis (Nobel laureate) > Thomas Schelling, University of Maryland (Nobel laureate) > Vernon L Smith, Chapman University, (Nobel laureate) > Nancy Stokey, University of Chicago For each challenge, the panel addressed the following question: “If you had an extra $75 billion to do good in the world, where would you spend it?” More than 50 experts spent two years developing solutions to the top 10 global issues. The solutions were presented in the form of 10 challenge papers, each containing one or more solutions. The panel reviewed and discussed each paper with the principal author and with two other experts who provided written critical appraisals. The panel then met in a closed session to individually rank proposals in order of importance, based on benefits and costs. The final ranking was determined by taking the median of the individual rankings.

By , Dr Kraemer was able to write in the Sight and Life Annual Report that the mission of the yearold organization was being advanced “on the basis of our new strategic framework focusing on the broad family of essential micronutrients,” stressing that “an integrated, sustainable approach is needed to ensure overall human well-being.” He noted that “We still face the problem of two billion people worldwide being affected by micronutrient deficiencies, particularly of vitamin A, the B vitamins, iron, iodine and zinc, at greatest risk among whom are infants and young children as well as pregnant and nursing women. At the same time, the phenomenon that has come to be known as the Double Burden of Malnutrition – where there is concurrent underweight and stunting among young children and overweight and obesity in older children, adolescents and adults within the same population – is an emergent public health problem that leads to increased childhood mortality or a higher risk of chronic disease in later life. About one third of all children under five years of age worldwide are stunted and almost 50% are anemic, while at least million school-age children are overweight or obese.” Micronutrient deficiency – which affects extensive populations not only in the developing world but also in the developed world – is the subject of our next chapter.

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Thus, from its initial role of focusing attention on vitamin A and the part it played in the protection of eyesight, especially in the developing world, Sight and Life has adapted with science to become an advocate for the role of multiple micronutrients in health and development, not only in the developing world but in all individuals, communities, and nations. Much work is still to be done, however, to ensure optimal health for all.

Meeting ever-changing needs

“The various people who have led Sight and Life to date have all had very different personalities and perspectives, but they have all wanted to do the right thing. More than this, they have always been sensitive and responsive to the issues of the day. So the initiative has evolved to meet the changing needs of the world in which it operates, demonstrating considerable creativity and flexibility along the way. Today Sight and Life is playing an extremely valuable role as a facilitator that brings together the best in the worlds of scientific research, policy-making and program development.” Professor Alfred Sommer, Dean Emeritus, Bloomberg School of Public Health

Interview with Richard Oosterhoff Site Director, Sisseln Branch Site, DSM Nutritional Products AG

I’ve been here for four years and run the site. We have 11 manufacturing plants at this location; they employ 1, people and produce vitamin A, folic acid, and vitamin E, among others. The process of producing vitamin A involves complex chemistry, which makes it exciting for us. We also know that the whole world uses vitamin A as a nutritional ingredient – it’s something you need for life, and to stay healthy, so it’s very appealing. It’s important for us to bring the best quality products to the market. Regulations and guidelines have dramatically increased over the years, and the way in which we produce vitamin A is very different now to how we did it in the past. We’ve been investing in this area to make sure our customers have genuine peace of mind. We are one of the few suppliers of vitamin A in the Western world, so, if you buy our products, you are buying something that’s really good quality. After all, if you’re swallowing something, you need to know that the quality is there, and we’re working hard to ensure this. We are also innovative in terms of bringing new solutions. We formulate products for different kinds of application, such as the nutritional programs we have in developing countries, beverages, or stable products that are acceptable to different religions around the world. We’re also trying to innovate our process, so that we can deliver the highest quality product at the lowest possible cost to the market. What I enjoy above all is that we really contribute something. Because we have large manufacturing capabilities, and we have a large market share, we make an equally large contribution to the nutritional health of people around the globe. What makes me especially proud is that DSM has an active partnership with the WFP. Of course we do our work for profit, but we are also doing

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From vitamin A to micronutrients

something important for people who are not as fortunate as ourselves. To look at photographs of kids in the developing world and see them taking our products, which have been produced and shipped almost door-to-door from our site to people who really need them that’s a very good feeling indeed.

Obituaries An expert on international nutrition and tropical health, Prof. Michael C Latham was a physician, public health worker, nutritionist, author and academic. He taught nutrition at Harvard and Cornell and consulted in Africa, Asia and South America. His research embraced infant nutrition, the control of parasitic diseases in humans, and the supply of micronutrients to poor populations.

Michael C Latham,  – 

Philip Musgrove,  – 

Michael consistently served the international health and nutrition community, often exceeding expectations, for close to six decades. He contributed to the achievement of the many ambitious goals in technical fields, policy, programs, information sharing and capacity building in the USA and internationally. He was one of the pioneers in moving a global public health agenda to one that embraces public health nutrition; nowhere is this needed more than in low- and middle-income countries where malnutrition continues to affect millions of women and children. Michael established a technical and policy foundation that continues to serve us well as we face a future of challenges embodied by financial uncertainty, climate change, diminishing natural resources and insecurity. Economist, academic, author and Health Affairs journal Deputy Editor Dr Philip A Musgrove, an expert in the economics of global health and development, died in a tragic boating accident at Iguazu Falls, Argentina. Phil previously worked as an editor at the Fogarty International Center of the National Institutes of Health (NIH) on the Disease Control Priorities Project. Prior to that, he was a principal economist at the World Bank, where he was especially expert in health systems in Latin America. In – he was seconded by the Bank to the WHO. From to , he was Advisor in Health Economics at the Pan American Health Organization, having already served as a consultant to the World Bank’s Living Standards Measurement Study, among other roles. He taught at the University of Florida, Johns Hopkins University’s School of Advanced International Studies, George Washington University, and American University. He also lectured at Latin American universities and research institutions and edited and co-authored numerous publications.

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Martin Frigg was a leading research scientist, an accomplished painter and sculptor, and the Secretary-General of Sight and Life from to He studied biology in Zurich before taking a research position with Hoffmann-La Roche, where he dedicated himself to researching the effects of vitamins on the health of animals. He published countless research papers, was involved in numerous international research projects, and spent many weeks on research activities abroad. Martin Frigg,  – 

Martin believed that the results of basic research should serve people’s well-being. During the s, he followed this principle himself, giving up his work as a researcher and taking over the leadership of Sight and Life. He was very familiar with vitamins and their effects, and so devoted himself to combating their deficiency, working alongside major global and local organizations and NGOs. He also created the Sight and Life Newsletter, which was distributed to affected communities worldwide. José María Bengoa Lecanda supported the Basque government in the organization of military health services during the Spanish Civil War. He later sought refuge in Venezuela, working as a rural physician and subsequently developing the Nutrition Section of the Ministry of Health and Social Assistance. He founded the Venezuelan School of Nutrition and Dietetics, as well as the scientific journal Archivos Venezolanos de Nutricion.

José María Bengoa Lecanda,  – 

In , Dr Bengoa joined the Nutrition Unit of the WHO in Geneva, which he led from until his retirement in He returned to Venezuela as head of the Planning Department of the Venezuelan Council for Scientific Research and professor of Food and Nutrition Planning. He was advisor to the Health Commissioner of newly democratic Spain’s first Basque government and became Executive Director of the CAVENDES Foundation. His awards included being named a Hero of Public Health. The founder of the academic discipline of international health, Carl E Taylor, MD, Dr PH, dedicated his life to the well-being of the world’s marginalized people. Born in the Indian Himalayas, his career began as a pharmacist’s assistant in his medical missionary parents’ clinic in the Indian jungle.

Carl E Taylor,  – 

Following medical school at Harvard, he worked in Panama before returning to India in as Director of Fategarh Presbyterian Hospital. In , he conducted the first ever health survey of Nepal. He later founded the department of preventive medicine at the Christian Medical College Ludhiana. Taylor was the founding chair of the Department of International Health at Johns Hopkins and instrumental in designing the global agenda for primary healthcare in the s and s. He was also China Representative for UNICEF, senior advisor to Future Generations and more recently Future Generations Graduate School, then Afghanistan Country Director for Future Generations.

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John Lawrence Beard,  – 

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John Beard was one of the world’s most renowned iron researchers and President-elect of the American Society for Nutrition, among other distinguished posts. He received his PhD in nutrition from Cornell University, served as a Penn State faculty member for 25 years, and was named “Distinguished Professor” in the Nutritional Sciences department. His Sight and Life obituary notes “he had an unparalleled commitment to science, his colleagues, and his students”. He was considered to be one of the most influential and well-respected experts in the world on iron in the brain and neurobehavioral function. His research was instrumental in changing the way scientists think about how the brain uses iron. It has influenced approaches to dietary supplementation in developing countries, and has offered new perspectives for the treatment of clinical disorders. He was most interested in translating these findings into “real world” applications, in order to help those in need. Sight and Life Magazine notes that “Guillermo (Willy) Arroyave … was a man and a scientist for all seasons, and a major contributor to the honor and nutritional reputation of his native Guatemala, and to our knowledge of human nutrient deficiencies and their control.”

Guillermo Arroyave,  – 

Dr Arroyave began his career working with a single micronutrient (iodine) and ended with the formulation of a vision for world agricultural and food policy. He worked at the Institute of Nutrition of Central America and Panama almost from its inception in , before moving to the United States to train further in nutritional biochemistry. He received a PhD from the University of Rochester in Over 40 years, he had a publication record of over contributions. His work in fortification in Guatemala was honored by a conjoint award from INCAP, UNICEF, the Committee for the Blind and Deaf, and San Carlos University. A scientist who led the field of carotenoid research to unexplored places, Norman I Krinsky devoted more than half a century to research with these plant pigments. He examined nature’s yellows, oranges and reds, and discovered the secrets of their importance to our lives. Few research publications on carotenoids do not include a reference to his work. Dr Krinsky began his research into carotenoids in , when he was awarded a PhD in biochemistry.

Norman I Krinsky,  – 

His interest in this topic was a platform for the next phase of his illustrious career, when he worked at Harvard University as a US Public Health Service Postdoctoral Fellow. In , he became an assistant professor at the Tufts University School of Medicine, where he remained for the rest of his rich and colorful career. His work provided valuable insights into the actions of carotenoids, including the bioconversion of carotenoids in various food vehicles to vitamin A.

chapter 02

Rainer Gross,  – 

Clive E West,  – 

From vitamin A to micronutrients

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