COMMENTATOR (COMM): On Lake Mweru, in Zambia's Northern Luapula province, fishermen are bringing in the day's catch. But for local people, a plentiful diet of fish has had unexpected consequences. A survey showed that 57 per cent of blind people in Zambia come from Luapula Province. The cause: lack of vitamin A - a lethal public health problem which has a significant effect on child mortality deaths as well as increasing the risks to women dying in childbirth.
On the shores of Lake Mweru, Dr. Kunda runs a child health clinic serving the fishermen's families.
Dr. SIMON KUNDA, Kabuta Rural Health Centre: People here regard fish as their only nutritious type of food, so they deprive the children of other foodstuffs, giving priority to fish. Dietary supplements are so low, most of the mothers go for field work in the morning, they come back very late, so feeding is compromised. We usually detect that when there is diarrhoea and when a patient comes with eye problems that's when we see that surely there is a vitamin A deficiency. The impact of vitamin A deficiency, it has brought in high mortality and morbidity. This area, looking at the area it is one of the prone areas where children lack vitamin A. We need to encourage these mothers to be giving their children vitamin A supplements. As you can see, if you look at the conjunctive of the child, it's very, very red. So measles also affects the eye, so it's very easy for these children, especially if they are malnourished, to get blind.
COMM: In Zambia's capital, Lusaka, Freddy Mubanga is responsible for increasing vitamin A intake - both in Luapula Province, and throughout the whole country.
FREDDY MUBANGA, National Food and Nutrition Commission: We started investigating the micronutrient deficiencies in 1995 where we undertook a survey in one of the provinces, Luapula, which had recorded high levels of blindness. It was found that 16.2 per cent of children 6-72 months had subclinical vitamin A deficiency. That of course gave way to start thinking of some strategies to see how we can reduce the levels of deficiencies.
COMM: Since the 1995 survey, Zambia has implemented vitamin supplements for children at child health clinics - both throughout the country, and in the capital Lusaka.
FREDDY MUBANGA: We give children, six months to 72 months, a high dose of vitamin A every six months. So they get a least two capsules a year.
MATRON: George has got a very big catchment area - we see a lot of children, it's a really highly-populated place. And it's a very busy clinic. We have a lot of underweights, malnourished children. They are poor, they cannot have money. Everything's free at the clinic. We give vitamin A to the under fives. They can get it through breast-feeding - in case they don't get enough through the foods, then we supplement it at the clinic by giving them vitamin A capsules.
MOTHER: I think for my baby to be healthy, I need to be coming here to get medicine for her to be protected from various diseases. Breastfeeding's the best. And it's cheap, very cheap! You can buy vegetables, you eat, when the baby feeds she gets all the nutrients. It's very cheap - in fact, I like it!
FREDDY MUBANGA: Following the national survey on Vitamin A Deficiency in 1997, we realized that the problem is so immense. So we had to look at other options... In addition to supplementation, we thought of moving into sugar fortification. We looked around what food vehicles we can use, and sugar seemed to be the one that was produced centrally and it was found in almost every part of the country.
COMM: To add vitamin A to sugar, the government needed the co-operation of Zambia sugar - a private corporation and the country's sole producer.
JAMES MUKUKWA, Production Manager, Zambia Sugar: It was a programme that was introduced by the government to the industry - so it was very new to us. We knew literally nothing. People working with the government, they had contacts in Guatemala who were really the founders of vitamin A fortification of sugar. So the best way to undertake that project was to go to the experts, to the source...And me being the production manager, I had to go there because eventually I had to implement that project. Zambia Sugar agreed to help out with the national health problem that the whole country faced - as a sign of good will. So it's actually doing it for free - the company bears the cost of the vitamin A. And that cost is not passed on in the price of sugar. It's very expensive - every year we spend almost a million dollars to buy the vitamin A.
COMM: USAID has also been a major supporter - and initiator - of the sugar fortification programme.
JAMES: Since we implemented the fortification program at Zambia Sugar in 1998, May 1998, we've had several delegations coming from other countries - Uganda, South Africa, Malawi and Kenya last year. They've been here to enquire and familiarize themselves with the vitamin A fortification, with a view of them also going the same way. COMM: It may cost a million dollars to fortify Zambia's sugar with vitamin A in the processing plant like this - but the cost per bag of sugar is just a few cents. And even that pales into insignificance when you add in the number of lives saved and the huge health benefits of vitamin A fortification for all Zambians.
FREDDY MUBANGA: Last year actually the Zambian Government passed regulations to say all the sugar that has to be consumed in households has to be fortified with vitamin A. Since we started enforcing that, the border areas - Zimbabwe, Namibia, Botswana and so forth - their sugar's still coming in. So it becomes a bit difficult to enforce, or to control, the influx of this. But all the sugar that enters through the border points, it has to conform to the regulations.
CHILUBA MWAPE, Plant Health Inspector, Chirundu Border Post: This is brown sugar coming from Zimbabwe. Now we've got one truck carrying sugar, brown sugar, 30 metric tonnes, from Zimbabwe. When the truck comes that is carrying sugar from Zimbabwe or South Africa, we take samples. When we get the primary samples, we submit them to Lusaka for further analysis at the food and drugs laboratory.
Mrs. SONGOL, Food And Drug Control Lab: We have the food and drugs regulations, where the levels of vitamin A in sugar are stated. So we make sure that from the analysis, we check whether the levels do conform to the standard. We receive the samples form all over the country. We also get samples from Zambia Sugar company itself. Part of their quality control programme is actually to bring the samples here for analysis. We discovered that through the quality control programme that we had with the sugar company, some samples of sugar was indicating there was no vitamin A, but when they were analysed at the factory they were finding vitamin A. But after storage the levels of vitamin A were going down, until at one point we were finding actually zero. Then from that time on, there's been regular sampling to make sure that problem, after it was rectified, does not occur again. We have to keep on checking on the quality of food, 'cause we can't relax and say 'well, since we've been testing so far, maybe now we should stop, it's an ongoing process.'
COMM: Although fortification of sugar has been a success in Zambia, it reaches only 52 per cent of the population in comparison to Zambia's staple food maize, or mshima, which is consumed by over ninety per cent.
FREDDY MUBANGA We felt that probably we need to diversify the food base for fortification, and one sort of food that we thought of was maize, because it's highly consumed in Zambia.
COMM: In Lusaka's Chawama township, government scientists are testing adding vitamin A supplements to maize at the local Hammer Mill.
Unlike sugar which is produced at one single source, 40 per cent of maize produced in Zambia is ground in local mills accessed by people in poor urban and rural areas. Simple methods had to be found to ensure local people would mix vitamin A into their maize meal. While Zambia has expanded fortification of foodstuffs with vitamin A, evaluating its impact can be difficult.
WARD SIAMUSANTU, National Food and Nutrition Commission: It's ideal to do the impact study now because the baseline was designed in 1997, and now it's almost like six years - we could actually find what has been happening. However, we have malnutrition levels very high, we have HIV problems we're going through, it will be very difficult actually to tease out which component has vitamin A supplementation has actually affected our population. It's very difficult because the amounts that are put in sugar are very minimal, so at the same time as you are looking at fortification, you have also to look at dietary levels which might take longer. It's one of the most important things to follow. Let's change our people's diets so that we don't even bother fortifying - supplementing from the dietary level, you could have a lot of vitamin A.
COMM: Back in Luapula province, nutritionists are working on improving people's diet and preventing future cases of blindness.
DON KAYEMBE, Provincial Nutritionist, Luapola Province: These palm oil trees are imported from Costa Rica. We brought them because naturally there are the traditional ones along the Luapula Valley - but those ones are not bearing much fruit. Even the fruit received are not giving us much oil as expected. It's these improved seeds - they are helping to give us more and more oil from one bunch. Even us as nutritionists, we are promoting that you can take fruit, you can take vegetables, for vitamin A. But as long as there's no presence of oil, it can't be absorbed in the body. When they grow, after at least one year - when they come like this one - we start giving them out to the communities. Now the communities - there are some who are accessing them just at very low cost, just to promote this and to give them ownership. So far we've distributed about 57,000 which we've given away. And we've imported 65,000 or so since we started importing in 1997. Here is Lambeti Village where we meet Mr.Chichembe Njombo who bought some palm oil trees from the nursery.
Mr. CHICHEMBE NJOMBO: Palm oil trees are very healthy, and give people vitamin A for good vision. Apart from that, I want to sell palm oil - so I can recoup the cost of buying the seedlings.
COMM: It takes four years for the palms to bear fruit. In local villages women have been learning to make palm oil. Mrs Eskembene of Sensima Village was sent to Ghana to study palm oil production.
MRS.ESKEMBENE (Translation): We used to process palm oil before, but for no particular reason. Sometimes people would use it, others not. But after we knew the benefits of it, we decided to increase production.
Dr. STELLA GOINGS, Unicef: Zambians were quick to realize that vitamin a deficiency was contributing to very high rates of morbidity and mortality, especially among children, and they were also quick to understand the importance of supplementation, fortification and diversification programmes. Zambia is a country that is confronting a food crisis this year. This is forcing the government and people of Zambia to reconsider the way they handle food. As a part of this, and we hope Unicef will play a very active role. We will be making certain that people who are in charge of preparing food are equipped to establish and maintain household gardens - rich in vitamins - and that they know how to prepare the foods.
COMM: Back at Dr.Kunda's clinic, mothers are now taking cooking classes to learn how to prepare vitamin-rich foods.
Dr. KUNDA: We've started a programme where we encourage mothers to be using the local foods - like green vegetables, yellow fruits like paw-paw, oranges - and here we are lucky because we have these palm trees... Now research has discovered that these things are very rich in vitamin A, so we encourage mothers to be using the oil from palm trees.
COMM: For the people of Luapula Province, adding vitamin A to their fish diet now promises a future which everyone can see.
END
On the shores of Lake Mweru, Dr. Kunda runs a child health clinic serving the fishermen's families.
Dr. SIMON KUNDA, Kabuta Rural Health Centre: People here regard fish as their only nutritious type of food, so they deprive the children of other foodstuffs, giving priority to fish. Dietary supplements are so low, most of the mothers go for field work in the morning, they come back very late, so feeding is compromised. We usually detect that when there is diarrhoea and when a patient comes with eye problems that's when we see that surely there is a vitamin A deficiency. The impact of vitamin A deficiency, it has brought in high mortality and morbidity. This area, looking at the area it is one of the prone areas where children lack vitamin A. We need to encourage these mothers to be giving their children vitamin A supplements. As you can see, if you look at the conjunctive of the child, it's very, very red. So measles also affects the eye, so it's very easy for these children, especially if they are malnourished, to get blind.
COMM: In Zambia's capital, Lusaka, Freddy Mubanga is responsible for increasing vitamin A intake - both in Luapula Province, and throughout the whole country.
FREDDY MUBANGA, National Food and Nutrition Commission: We started investigating the micronutrient deficiencies in 1995 where we undertook a survey in one of the provinces, Luapula, which had recorded high levels of blindness. It was found that 16.2 per cent of children 6-72 months had subclinical vitamin A deficiency. That of course gave way to start thinking of some strategies to see how we can reduce the levels of deficiencies.
COMM: Since the 1995 survey, Zambia has implemented vitamin supplements for children at child health clinics - both throughout the country, and in the capital Lusaka.
FREDDY MUBANGA: We give children, six months to 72 months, a high dose of vitamin A every six months. So they get a least two capsules a year.
MATRON: George has got a very big catchment area - we see a lot of children, it's a really highly-populated place. And it's a very busy clinic. We have a lot of underweights, malnourished children. They are poor, they cannot have money. Everything's free at the clinic. We give vitamin A to the under fives. They can get it through breast-feeding - in case they don't get enough through the foods, then we supplement it at the clinic by giving them vitamin A capsules.
MOTHER: I think for my baby to be healthy, I need to be coming here to get medicine for her to be protected from various diseases. Breastfeeding's the best. And it's cheap, very cheap! You can buy vegetables, you eat, when the baby feeds she gets all the nutrients. It's very cheap - in fact, I like it!
FREDDY MUBANGA: Following the national survey on Vitamin A Deficiency in 1997, we realized that the problem is so immense. So we had to look at other options... In addition to supplementation, we thought of moving into sugar fortification. We looked around what food vehicles we can use, and sugar seemed to be the one that was produced centrally and it was found in almost every part of the country.
COMM: To add vitamin A to sugar, the government needed the co-operation of Zambia sugar - a private corporation and the country's sole producer.
JAMES MUKUKWA, Production Manager, Zambia Sugar: It was a programme that was introduced by the government to the industry - so it was very new to us. We knew literally nothing. People working with the government, they had contacts in Guatemala who were really the founders of vitamin A fortification of sugar. So the best way to undertake that project was to go to the experts, to the source...And me being the production manager, I had to go there because eventually I had to implement that project. Zambia Sugar agreed to help out with the national health problem that the whole country faced - as a sign of good will. So it's actually doing it for free - the company bears the cost of the vitamin A. And that cost is not passed on in the price of sugar. It's very expensive - every year we spend almost a million dollars to buy the vitamin A.
COMM: USAID has also been a major supporter - and initiator - of the sugar fortification programme.
JAMES: Since we implemented the fortification program at Zambia Sugar in 1998, May 1998, we've had several delegations coming from other countries - Uganda, South Africa, Malawi and Kenya last year. They've been here to enquire and familiarize themselves with the vitamin A fortification, with a view of them also going the same way. COMM: It may cost a million dollars to fortify Zambia's sugar with vitamin A in the processing plant like this - but the cost per bag of sugar is just a few cents. And even that pales into insignificance when you add in the number of lives saved and the huge health benefits of vitamin A fortification for all Zambians.
FREDDY MUBANGA: Last year actually the Zambian Government passed regulations to say all the sugar that has to be consumed in households has to be fortified with vitamin A. Since we started enforcing that, the border areas - Zimbabwe, Namibia, Botswana and so forth - their sugar's still coming in. So it becomes a bit difficult to enforce, or to control, the influx of this. But all the sugar that enters through the border points, it has to conform to the regulations.
CHILUBA MWAPE, Plant Health Inspector, Chirundu Border Post: This is brown sugar coming from Zimbabwe. Now we've got one truck carrying sugar, brown sugar, 30 metric tonnes, from Zimbabwe. When the truck comes that is carrying sugar from Zimbabwe or South Africa, we take samples. When we get the primary samples, we submit them to Lusaka for further analysis at the food and drugs laboratory.
Mrs. SONGOL, Food And Drug Control Lab: We have the food and drugs regulations, where the levels of vitamin A in sugar are stated. So we make sure that from the analysis, we check whether the levels do conform to the standard. We receive the samples form all over the country. We also get samples from Zambia Sugar company itself. Part of their quality control programme is actually to bring the samples here for analysis. We discovered that through the quality control programme that we had with the sugar company, some samples of sugar was indicating there was no vitamin A, but when they were analysed at the factory they were finding vitamin A. But after storage the levels of vitamin A were going down, until at one point we were finding actually zero. Then from that time on, there's been regular sampling to make sure that problem, after it was rectified, does not occur again. We have to keep on checking on the quality of food, 'cause we can't relax and say 'well, since we've been testing so far, maybe now we should stop, it's an ongoing process.'
COMM: Although fortification of sugar has been a success in Zambia, it reaches only 52 per cent of the population in comparison to Zambia's staple food maize, or mshima, which is consumed by over ninety per cent.
FREDDY MUBANGA We felt that probably we need to diversify the food base for fortification, and one sort of food that we thought of was maize, because it's highly consumed in Zambia.
COMM: In Lusaka's Chawama township, government scientists are testing adding vitamin A supplements to maize at the local Hammer Mill.
Unlike sugar which is produced at one single source, 40 per cent of maize produced in Zambia is ground in local mills accessed by people in poor urban and rural areas. Simple methods had to be found to ensure local people would mix vitamin A into their maize meal. While Zambia has expanded fortification of foodstuffs with vitamin A, evaluating its impact can be difficult.
WARD SIAMUSANTU, National Food and Nutrition Commission: It's ideal to do the impact study now because the baseline was designed in 1997, and now it's almost like six years - we could actually find what has been happening. However, we have malnutrition levels very high, we have HIV problems we're going through, it will be very difficult actually to tease out which component has vitamin A supplementation has actually affected our population. It's very difficult because the amounts that are put in sugar are very minimal, so at the same time as you are looking at fortification, you have also to look at dietary levels which might take longer. It's one of the most important things to follow. Let's change our people's diets so that we don't even bother fortifying - supplementing from the dietary level, you could have a lot of vitamin A.
COMM: Back in Luapula province, nutritionists are working on improving people's diet and preventing future cases of blindness.
DON KAYEMBE, Provincial Nutritionist, Luapola Province: These palm oil trees are imported from Costa Rica. We brought them because naturally there are the traditional ones along the Luapula Valley - but those ones are not bearing much fruit. Even the fruit received are not giving us much oil as expected. It's these improved seeds - they are helping to give us more and more oil from one bunch. Even us as nutritionists, we are promoting that you can take fruit, you can take vegetables, for vitamin A. But as long as there's no presence of oil, it can't be absorbed in the body. When they grow, after at least one year - when they come like this one - we start giving them out to the communities. Now the communities - there are some who are accessing them just at very low cost, just to promote this and to give them ownership. So far we've distributed about 57,000 which we've given away. And we've imported 65,000 or so since we started importing in 1997. Here is Lambeti Village where we meet Mr.Chichembe Njombo who bought some palm oil trees from the nursery.
Mr. CHICHEMBE NJOMBO: Palm oil trees are very healthy, and give people vitamin A for good vision. Apart from that, I want to sell palm oil - so I can recoup the cost of buying the seedlings.
COMM: It takes four years for the palms to bear fruit. In local villages women have been learning to make palm oil. Mrs Eskembene of Sensima Village was sent to Ghana to study palm oil production.
MRS.ESKEMBENE (Translation): We used to process palm oil before, but for no particular reason. Sometimes people would use it, others not. But after we knew the benefits of it, we decided to increase production.
Dr. STELLA GOINGS, Unicef: Zambians were quick to realize that vitamin a deficiency was contributing to very high rates of morbidity and mortality, especially among children, and they were also quick to understand the importance of supplementation, fortification and diversification programmes. Zambia is a country that is confronting a food crisis this year. This is forcing the government and people of Zambia to reconsider the way they handle food. As a part of this, and we hope Unicef will play a very active role. We will be making certain that people who are in charge of preparing food are equipped to establish and maintain household gardens - rich in vitamins - and that they know how to prepare the foods.
COMM: Back at Dr.Kunda's clinic, mothers are now taking cooking classes to learn how to prepare vitamin-rich foods.
Dr. KUNDA: We've started a programme where we encourage mothers to be using the local foods - like green vegetables, yellow fruits like paw-paw, oranges - and here we are lucky because we have these palm trees... Now research has discovered that these things are very rich in vitamin A, so we encourage mothers to be using the oil from palm trees.
COMM: For the people of Luapula Province, adding vitamin A to their fish diet now promises a future which everyone can see.
END