Collateral damage in the battle against hypovitaminosis A?

Abstract

Chinese diplomats killed in the embassy of the People’s Republic of China in Belgrade, Red Cross workers bombed in a warehouse in Kandahar, and Afghani women crushed by a crate of humanitarian rations are recent examples of collateral damage, which occurs when innocent people become casualties of missions of supreme urgency and high moral justification. It is the consequence of being caught in the path of “friendly fire.” Collateral damage has its reflection in medical and public health risk assessment as well. When we and other young house physicians were undergoing clinical training in the 1970s, we would often discuss the example of smallpox vaccination and comment among ourselves that more people were succumbing to vaccinia from the vaccinations than were then actually dying of smallpox itself. Shortly thereafter, of course, obligatory vaccinations were suspended, and the book was closed on the smallpox pandemic. When 3200 persons were killed in the attacks on the Pentagon and the World Trade Center towers, the specter of biological terrorism with the smallpox virus reopened that book, with a call for universal vaccination of the 280 million residents of the United States. According to calculations from the Centers for Disease Control and Prevention, 2000‐3000 deaths would be attributable to any universal smallpox vaccination campaign, almost the number of deaths that occurred during the first strike of the new war. Such are the equations for collateral damage in the public health aspects of war and in public health battles. For some of us involved in micronutrient deficiency issues in developing countries, it has been disconcerting to see the brouhaha arising in the medical press over something gone (fatally) awry in a recent mass distribution of high-dose oral vitamin A supplements by the United Nations Children’s Fund to 3 million children younger than 6 y in the Assam province of India. Despite the flurry of commentary that appeared on the pages (1) and web pages (2‐7) of the British Medical Journal, the facts remain elusive, pending the filing of an official inquiry. What is clear, however, is that 1) the vitamin A preparation was a liquid, produced less expensively within India (rather than the more costly, imported gelatin capsules); 2) the possibility of giving more than the intended 2-mL dose was produced by shifting from 2-mL spoons to 5-mL medicine cups for dosing; and 3) it was widely claimed in the Indian press that numerous recipients of the vitamin A supplements were made ill and that the deaths of 14 recipients are attributable to the vitamin A distribution (1, 2, 4, 5). In belligerent tones from within India came the allegation that rates of vitamin A deficiency in the Assam province did not justify public health intervention and that vitamin A supplementation will not reduce child mortality (4, 5). In this latter