Vitamin A deficiency (VAD) experts in India have been engaging in a vigorous debate over the last few years on the effectiveness of Vitamin A Supplementation (VAS) programs vis-a-vis dietary alternatives. According to the WHO, VAD causes severe visual impairment and blindness, and significantly increases the risk of severe illness, and even death, from common childhood infections such as diarrhoeal disease and measles.

Assessing the magnitude of the problem in India, the Nutrition Transition in India 1947-2007 report by the Women and Child Development Ministry notes that: prevalence of clinical and subclinical VAD in India is among the highest in the world; India remains the home of more than a quarter of the world’s preschool children suffering from subclinical VAD and a third of preschool children with xerophthalmia [dry eye syndrome].

Despite being one of the first countries to launch a VAS program, India’s countrywide coverage is poor. The visualization below reinforces this point by illustrating recent estimates of VAS coverage and overall immunization rates at the state level, while simultaneously offering a few unexpected insights.

What explains these unexpected regional differences? A study of VAS determinants by the South Asia Network for Chronic Disease finds that a state’s social and economic status and mother s education rather than household wealth largely determine children receiving Vitamin A supplementation in India. While this context may explain the relatively poor performance of the Big 4 BIMARU states (Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh), the reasons for the poor performance of better-developed states such as Kerala become even more puzzling. [AB1]

However, socio-economics may not tell the full story. When organizations such as the Indian Academy of Paediatrics do not include Vitamin A supplementation in their immunization schedule, opposition to VAS does seem to influence VAS demand. As a fascinating study on the history of opposition to VAS in India explains, opponents to VAS not only question the motives of global health organizations but the very effectiveness of VAS programs. This culminates in a sentiment among some experts that governments are abdicating their responsibility of improving diets by resorting to supplements.

It seems that while dietary diversification and food fortification need to be an important component of a country’s VAD strategy, it is unclear how much more effective a strategy without VAS would be. As this article points out, higher food prices increase the risk of vitamin A deficiency among preschool children in poor families, because a larger part of the household food budget is spent on grain foods and less on vitamin A-rich foods.

An alternative to supplementation is to use genetically modified (GM) common food grains to increase their Vitamin A content a strategy known as GM fortification. A recent cost-effectiveness analysis of mustard seed GM fortification by CDDEP researchers found that while this strategy is significantly more expensive, it has the potential to reach more people, particularly groups with high risk of VAD such as pregnant mothers. The strategy holds more potential as the biotechnological advances further lower the cost of modifying widely-consumed grains.

Visit our Golden Mustard project page to find out more about the cost-effectiveness of mustard seed supplementation and biofortification strategies to prevent VAD.

Image: Mustard flowers in Himanchai Pradesh, India, via Akhilesh Mathur/Flickr