Building the Case
Interviewed by Richard M. Cohen, 2002.
Richard Cohen: We should start by having you tell us really what the stakes were, the human stakes of vitamin A.
Al Sommer: We had originally gone into this vitamin A deficiency issue because I'm an ophthalmologist by training. I was concerned about the impact of vitamin A deficiency on eye disease. We already had a fair amount of evidence that this would be a major problem in the developing world. Then quite by accident, we discovered as went through our data and planned our studies and analyzed the results, that it was having a very significant impact on childhood disease and childhood mortality rates. Now our estimates are that at its peak, one to one and a half million children were dying every single year, because they didn't have adequate vitamin A. And perhaps half a million children were going blind every year because they didn't have adequate vitamin A.
Cohen: Now this is measles-related.
Sommer: Some of it was related to measles; some was related to diarrhea; some was related to general malnutrition. Measles was an important precipitating factor to make children who were on borderline vitamin A status suddenly have their vitamin A status depleted because of the metabolic burden of an acute attack of measles. So measles played a significant role, but by no means was it the only important role. Some kids went blind and died from vitamin A deficiencies without any measles. The majority, in fact. But if you had a single major cause that would precipitate acute deficiency, it would be measles.
It's very common in many traditional societies for night blindness, which is one of the early ocular manifestations vitamin A deficiency, to be a common occurrence during the third trimester of pregnancy. People would accept night blindness as a normal part of pregnancy. Now a lot of people laugh about that, but I remind them we accept, without any reason to accept it, that nausea and vomiting are a normal part of the first trimester of pregnancy. There's no obvious reason why that should be a normal part of pregnancy here in the United States, so it's no more bizarre that people accept it as a normal part of pregnancy because it was so common — night blindness in woman during their third trimester.
Cohen: How much of that is related to vitamin deficiency?
Sommer: Relatively little. The reason why it's relatively little is that the children who go blind from vitamin A deficiency also die. They're not there to be counted.
Cohen: It seems to me that it's one thing for you or other public health physicians to identify a problem and it's quite another thing for the people of that country to accept it, understand it and be willing to do something about it.
Sommer: When we first published the first paper, an observation that we made, in a very large study, [was] that children who were vitamin A deficient were dying at considerably higher rates than their controls who were less deficient. All kids were deficient in Indonesia, where this was done, and there was this dose-response relationship. The more deficient you were, the more likely you were to die. Nobody in the scientific community believed it, so there was not a single letter to the editor. So the first job we had was in fact convincing our colleagues in the public health research community, the nutrition community, infectious disease community, the pediatric community, that this was really real.
So we had spent about two years and probably a couple of million dollars preparing the field site for the intervention program, terrific local people who we recruited to staff the project. We got through Marcos' regime, having fallen. The new government absolutely supported and wanted us to go forward. This was in an area called Alby Province, which was a hotbed for guerilla activity. The guerillas came to us, they wanted our maps because we census the areas, we knew where everybody is. We said, "No, we can't give you the maps, because that would put peoples' lives in danger." They both accepted that. The day before we actually began the formal study where people visited houses and gave out vitamin A and so forth; we had done one practice round and one of the members of this Communist movement, who turned out to been a physician who was denied a residency visa in the United States, got on the local radio and said that this is an Imperialist plot, Americans are here to kill Filipino children — the usual sort of rubbish — and the study was gone like that.
I mean, there's no way, we need close to 95 percent compliance, cooperation with the population. In the Philippines, anybody can buy air-time, anything they want — there was no way we were going to get that back.
Cohen: But see, you're raising an interesting question. Because if somebody made a breakthrough of this magnitude in this country, people, very quickly it seems to me, would be clamoring to be treated. Whereas over there...
Sommer: There's a lot of suspicion.
Cohen: Tremendous resistance.
Sommer: No, there was suspicion. People will use that to their political advantage. Actually, the way we overcame the scientific disagreements was simply by saying we're not getting up on a soapbox; we're not going to write argumentative and competing letters to the editor.
Cohen: Once you convert the science community, what happens?
Sommer: Well, that's very interesting. Two things actually happened. One is it was a lot easier then to get WHO behind the program. UNICEF in a way was behind the program earlier than the conversion of the entire community because Jim Grant, who was a very effective director of UNICEF, died a few years ago and was always looking for magic bullets that would be inexpensive, simple programs that could make a dramatic impact on children's health.
The political process is a critical one — any public health issue. Even one which is as non-controversial as vitamin A. It's not touching on anybody's gender; it's not touching on anybody's religious beliefs. It's not changing any cultural patterns. Even something as neutral as vitamin A did have to go through a political process.
Cohen: But you talk about a political process. I would categorize it in different terms. I would say that what you did on vitamin A was a simple solution to an enormous problem and took a Herculean effort to sell it to people who were suffering from the problem and the job's not done. What does that say about what you're up against on issues of public health and the developing world?
Sommer: Well, you know, you look at HIV, and you look about — those are truly politicized processes. It's difficult because you're asking countries who have a very different belief system. Now the average Minister of Health in Africa knows as much as I do about public health. You go down to the community level, we go to areas to do whatever studies we're doing — whether it's vitamin A or it's malaria research or vaccine trials, what have you. And we always go through the process of real informed consent, at least as much as we can.
Many countries had never done randomized trials before — don't know anything about informed consent, so we actually build institutions; we build institutional review boards in countries so that they can make an informed decision about whether the country wants to participate in this research project. And then how to explain this to the people who are actually participating. So, you can imagine, you go to a rural area of almost any poor country in the world. Most of the people are illiterate; they have a totally different belief system as our ancestors did before 100 years ago, and [believe] that diseases are spirits or decisions by God.
Cohen: Is there a public education component to what you do?
Sommer: There's always public education. You just have to educate people in order to get them, first at the government level — the Ministry of Health level — to agree that this is an issue that they're facing and that this may be a solution in something that they want to participate in. The scientists in the country are smart, well-educated; they're never an issue. Their problem, however, is they often can't convince their Minister of Health; it often takes a foreigner. The foreigner can be from the next country, but it often takes a foreigner because the people won't believe the experts in their own country. Then once you've done this study, of course, then you come up with this very difficult problem — these are resource-poor countries.
I remember when I first got interested in vitamin A and initially, entirely from the perspective of blindness and visual impairment. We already had plenty of evidence that it was an important problem that half a million children were going blind a year; ten million children had other evidence — eye evidence of vitamin A deficiency.
Cohen: Do these people understand how much blindness, just to use one example, costs them annually?
Sommer: It costs one dollar per day, let's just say, whereas treating child leukemia costs $250 or $2500. The problem is that in a country where you've got lots of kids, they're considered replaceable. I mean, people love their children; they're heartsick when a child dies. But from an economic perspective — if you talk to any economist about what is the value of an infant in economic terms, it's minuscule.
Cohen: The resources that are made available in developing countries, for this kind of work, must be minuscule.
Sommer: Well, in absolute terms, the money is minuscule, but in relative terms, that is spending on health, which means predominantly public health, is proportionally much greater than it is, say in the United States because originally, just in the early post-colonial era, these countries wanted to be just like the U.S. and Europe.
Cohen: How involved is the Agency for International Development in these kinds of programs?
Sommer: The Agency for International Development is one of the most significant funders of public health, research and public health interventions in the developing world. When I first dreamt up this vitamin A and blindness, let alone this vitamin A and mortality, the only reason it got funded (and it was originally funded by USAID) was because the fellow who was then the director of the Office of Health and Nutrition was a believer. They had a National Academy of Sciences committee review my project proposal and they said, "It's hopelessly complex and ambitious; it'll never be carried out. Vitamin A by itself can't possibly have a significant impact on children's lives when they live in such an impoverished environment."
Cohen: Do you see medical reassertion intervention in the world as an effective tool of American foreign policy?
Sommer: In the broader context, if we improve health in the world, we're improving our own health at the same time.
Cohen: Well, let's talk about smallpox. You've been very outspoken about the need to destroy the smallpox viruses that are being held by the U.S. Talk about that.
Sommer: Had people known what they know now, I think there's no question that everyone would have agreed to get rid of the smallpox virus a year or two after the last case occurred. The argument for keeping it for four or five years was we're not sure there aren't some cases hibernating in the Amazon jungle or something, so we better keep this thing around, just in case something funny happens that we need to do some research on it.
Cohen: You know, there's just something a little goofy about a situation where government works to eradicate an illness and then keeps it alive. The virus of the illness.
Sommer: I think it's real goofy but governments have multiple objectives — one of them is warfare, and one of them is peace, and one of them is health, and sometimes they get them confused.
Cohen: I think we've agreed that public health is a lot more than science.
Sommer: If you're going to make a change, it is a lot more than science — and that's really what distinguishes it in many ways from medical care research. I'm an ophthalmologist. So when somebody develops a better cataract technique, bam, it's out there.
Public health is almost always a publicly funded intervention and requires resources, and therefore gets caught up in the political mill. Smallpox and things like that get caught up in others — military mills, defense mills, all kinds of things that don't affect the delivery of medical care, per se, and that's why medical care is a more direct response from research to application. Public health gets, by definition, into the political process.