**5. How sustainable are the reductions in VAD incidence achieved since the 1990s?**

The discovery of the huge hidden mortality due to VAD, from the 1990s, focused the attention of international communities, and national governments, on the excellent cost benefit of avoiding the preventable deaths and other morbidities associated with the deficiency. This included UN meetings in 1990, 1992 and 2004 [43, 52, 53],

as well as prominence in the Millennium Development Goals (MDGs) 1990–20153 . The huge benefit of addressing micronutrient deficiencies, compared with costs involved, was also endorsed by four rounds of the Copenhagen Consensus [54–57]. Good progress was made, although several MDG goals were missed [28]. The direction has been maintained by the sustainable development goals (SDGs) 2015–2030: It has been argued that staple biofortification with micronutrients can benefit SDGs: 1 (no poverty), 2 (zero hunger), 3 (good health), 4 (quality education), 5 (gender equality), and 7 (decent work and economic growth) [7].

Given the progress achieved in combatting VAD reducing from in excess of 23–34% of child mortality ("in excess of" because these are global percentages but VAD does not occur in industrialized countries) to circa 2% in Bangladesh and the Philippines, it is perhaps unsurprising that relatively little attention is given to VAD caused mortality currently. Much of the reduction is due to annual cycles of costly vaccination programs, including against measles, and expensive vitamin A supplementation, and community health and education as well as general economic development together allowing more food security. However, the sustainability of the reduction in VAD has to be questionable when it requires repeat annual expenditures on materials and labor. Additionally, vitamin A supplementation is not only about preventing mortality [58].

The year before the Covid-19 pandemic struck in Bangladesh and the Philippines was probably the year when child mortality due to VAD was at its lowest, as a result of the community health programs in place. Nevertheless, in 2019 nearly 15,000 children died from VAD-related illness (**Table 1**).


#### **Table 1.**

*Statistics on vitamin a deficiency (VAD) among children age 5 years and under, and child mortality in Bangladesh and the Philippines in 2019.*

**Table 1** provides estimates of VAD, and all-cause and VAD-related mortality rates, among children age 5 years and under in Bangladesh and the Philippines in 2019. Despite a decrease in VAD in some parts of the world [31], child VAD rates in both Bangladesh and the Philippines remain high, leading to preventable mortalities due to diarrheal and infectious diseases, among other sequelae. Hence, despite VAD interventions such as food fortification and vitamin A supplementation, additional

<sup>3</sup> Goal 1: Eradicate extreme poverty and hunger

Target 2 Halve, between 1990 and 2015, the proportion of people who suffer from hunger. Goal 4: Reduce child mortality

Target 5 Reduce by two thirds, between 1990 and 2015, the under-five mortality rate.

Goal 5: Improve maternal health

Target 6 Reduce by three quarters, between 1990 and 2015, the maternal mortality ratio

public health interventions to combat VAD are needed, even in normal, pre-pandemic, circumstances. We estimate that in 2019, VAD led to 8826 preventable deaths in Bangladesh and 5886 preventable deaths in the Philippines of children age five and under a total of 14,712.

For comparison, all ages COVID-19 deaths in calendar year 2020 in these two countries are recorded as nearly 19,000 (Bangladesh: 8127 and Philippines: 10,749) [62].

Thus, the scale of annual child deaths from VAD, pre-pandemic in 2019 and all-ages deaths from COVID-19 in 2020, the first calendar year of the pandemic, are of the same order of magnitude.

Even, at the time of writing4 , in the two countries, the cumulative total of Covid-19 all-age deaths 41,585 (the Philippines), and 27,814 (Bangladesh), in total 69,299, is of the same order of magnitude as VAD child-deaths circa 19,000 prepandemic in 2019 [63].

Each death, from whatever cause is a family tragedy. And all these numbers are a vulnerable to reporting errors and therefore approximate. What is important it that whereas no political interest was expressed in the 2019 VAD deaths, all politicians in both countries, as in all other countries in the world, were totally focused on Covid-19, and all economies of the world were brought to a stop by the arrival of the pandemic.

The Covid-19 pandemic has, severely, impacted the social structure and economies of all countries, including, directly and indirectly, low- and middle-income nations. In stark contrast to the global media interest in Covid-19 in all countries, the VAD deaths, which only occur in developing countries, have been seldom reported for the previous 30 years and were probably the lowest ever in 2019, pre-pandemic.

Regretfully, the Covid-19 pandemic has increased poverty and increased food insecurity through job losses and food price increases [64, 65]. Covid-19 has also decreased the effectiveness of community health programs, including reducing dramatically the number of measle vaccinations [66, 67]. It is to be expected that vitamin A supplementation programs have also been negatively affected: they often share resources with measle vaccination programs. Indeed, in 2020, in the first year of the Covid-19 pandemic, despite the potential benefits of this key child survival intervention, vitamin A supplementation programs only reached 41% of the target child population globally, and below 50% in all regions [68], compared with much higher coverage previously: circa 70% [69] to higher than 90% [68].

Often food price shocks lead to social instability, including riots, in LMICs [70] where food costs can be as high as 70% of family income. Such effects would further exacerbate delivery of community health programs.

As a result of the Covid-19-induced disruption of health service provision in South Asia, child mortality could potentially increase by 18–40% and maternal mortality by 14–52% over the next year [71]. Globally, the effect will be an additional 1,157,000 child deaths, and 12,200–56,700 maternal deaths [71]. As an indirect result of the pandemic, a reversal of the progress against the Millennium and Sustainable Development Goals from 1990 to 2019 reported above is to be expected.

Pre-Covid from the 1990s, simultaneous progress was made in reducing VAD, thereby improving the immunity of populations of vulnerable children to common diseases, and at the same time reducing the incidence of those diseases.

Post-Covid from 2020, simultaneously the immunity of populations of vulnerable children to common diseases could well decrease, at the same time as the incidence of those diseases increases.

Thus, it is likely VAD child deaths will increase, in Bangladesh and the Philippines only, as a result of Covid-19-induced conditions, from 2% of all

<sup>4</sup> October 24, 2021.

<5-y child deaths (~15,000 annually) in the direction of the previously normal 23–34% of all <5-y child deaths (170,000–250,000 annually).

We cannot know how long these second-order effects of the Covid-19 pandemic will continue, so cannot know how bad it will get. At the time of writing, 12.43% of the Bangladesh population are fully vaccinated against SARS-Cov-2 and 23.22% of the Philippine population [63], which are not indicative of a rapid return to pre-Covid normality. The VAD death figures could be even more startlingly bad if the post-Covid annual all causes child deaths in these two countries increases from the 2019 figure of 742,558 (**Table 1**).

The sustainability of VAD mitigation would be increased, and the dangers of the explosion of VAD child deaths could be significantly avoided if effective interventions appropriate to the current circumstances are quickly adopted in all relevant countries.

Practically speaking, Golden Rice is an excellent fit to the circumstances and is available.
