The idea: Provide vitamins to poorly nourished children in a developing country. (Who can argue with that?)
The plan: Ask people in the US to donate vitamins, have someone bring them to Cambodia, and deposit them in the office of a small NGO focused on children with disabilities so they can be distributed.
The result: 5,470 doses of vitamins ready to be distributed! Fantastic!
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| Vitamins - they're good for you (unless you overdose) |
The challenges:
- The vitamin collection includes various types and brands of vitamins. Some have iron and some do not. Some are about to expire or already have, and some are good until 2014 or beyond.
- We cannot give the vitamins in their original containers because they have mostly arrived in large bottles of 150-300 vitamins per bottle, and there aren’t enough bottles to distribute one to each family. Even if we had enough bottles, people here are unfamiliar with child-proof caps and tend to either not be able to open them easily even after instruction, or so frustrated that once they wrestle it open they prefer to just leave the cover off so they don’t have to struggle with it again and again. This would mean the vitamins would likely go bad due to moisture, or would be eaten all at once by the children because they look and taste like candy.
- We can repackage the vitamins in small ziploc medicine bags that even come with pre-printed no-literacy-required cues about how often to take them, but these are not child-proof, and keeping medicine out of reach of children is either impossible or not a priority. (Impossible, you ask? How can that be? Well, where can they put it if they live in a palm-leaf hut with no furniture? It’s not like they have a medicine cabinet, or even a drawer or cupboard. Even if they hang it on a nail high up on the wall, children here are have very little supervision and are excellent climbers. And it’s a foreign concept to keep children away from medicine – when we gave out meds at the clinic, the parents would often hand the little bags to their toddlers to carry home.)
- Iron-containing vitamins can be toxic – even potentially fatal – if you take too many. But how many do you have to take? A good bit of internet research reveals a good bit of info, and the most conservative estimates say that 10-20 mg/kg of iron is nontoxic. This means that for a 10 kg. (22 lb.) child, 100 mg of iron is probably the upper limit of safe. So giving out any more than 100 mg of iron at one time means taking the risk that as soon as we’ve left the family’s house, some kid is going to eat the whole bag of vitamins and get sick.
- As I mentioned above, the assortment of vitamins on hand vary in their iron content. Some are iron-free, some have 5 mg iron (a low dose, which means we could give up to 20 vitamins in one bag without potentially poisoning anyone), some have 9 mg, and some have 18 mg (which means anything more than 5-6 vitamins could be potentially toxic to a 10 kg child.)
- So now the vitamin bottles are all labeled in big fat Sharpie with their expiration date, their iron content, and most importantly, how many we can safely give out at one time. 5-6 vitamins isn’t much, especially since we see some families only once or twice a month, and there may be several children in one family who will share what we bring, but what else can we do? I’ve discussed this forever with the local project manager about how important it is to provide education to the families about giving all medicine properly, and we will give the vitamins out to parents in medicine bags rather than as loose “candy” in the bottom of a goodie bag that is handed to children, but he is not at all confident that parents will pay attention and heed our warnings. So we cannot give more than could cause damage, which means that in many cases we will be giving far less than anyone really needs.
This is a classic example of the challenges we face here every day. Something that seems simple rarely is. You have to contend with more than just sourcing the thing you need, you have to figure out how to distribute it sanely.
Anyone have any brilliant suggestions? All ideas are welcome.
9 comments:
That's tricky. Are your clients clustered? Is there someone in area that can be trusted to distribute the vitamins and keep them locked up and not charge for them?
Or you can invent a solar-powered, timed, medicine dispensing machine. :)
You should try and secure a large quantity of non-iron containing vitamins. Those vitamins should be water soluable and contain naturally occuring vitamins (not synthasized) which will increase the absorbtion rate thereby lowering the total needed dose. Maybe your brother, who used to be sponsored by Rexall Sundown Inc., Can help you find those things. :)
Megan, how about you and I invent that solar-powered timed vitamin-dispensing machine??? It has a better chance of happening than finding someone to distribute the vitamins the old-fashioned way, it seems. Unfortunately, the clients are not clustered in such a way to make your excellent idea very workable, but thanks.
J, I think my brother is just the guy who should call the vitamin company and make things happen! (Unfortunately, some of these kids could really use the iron, but we can always supplement that with nasty-tasting iron pills for those who really need it.)
Get on that, will ya? You know, in your spare time...
I shared your blog about the vitamins with my friend Sam Conant who lives in Colchester and this was his response: "Public health education, ease of access to the supply: I'd think about recruiting village elders/leaders into the distribution system. Get them on board re the need for daily nutrition which includes daily vitamin regimen for children and adults. Trying to deliver anything from outside, by folks who don't live or are not integral in daily activities/lives in the villages can be a real barrier.
"Don't ignore Margaret Mead's much touted awareness that it really does "take a village to raise a child." It is important to understand that neighborhoods take the place of villages in suburban and urban areas whether those neighborhoods are on land or on rivers and seashores."
Also, we have new school of pharmacy here in Hilo at the University of Hawaii. I am going to take your puzzlement there and seek some thoughts.
Tom
I wonder if the vitamins could be given out at school, by the teachers. It would only help school-age kids I realize...
Nancy, I like your idea, but unfortunately, none of these children go to school. Education isn't available/accessible for those with significant physical or mental disabilities. The long-range vision of the NGO is to build a school for these children, where some may live as residential students.
But keep the ideas, coming, folks!
Tom, thanks for your efforts. I agree that it takes a village, and we will give some thought to Sam's idea about using the village chiefs as a resource. I have no idea how/whether that fits with their role, culturally-speaking, but I certainly have access to people who can figure out whether it's a viable option.
I will be curious to see what the pharmacy school resources have to say about this.
It's not like a handful of vitamins are going to save the world, but I am really enjoying the results so far of "crowdsourcing" the question!
I think I would look at the problem from a different angle.
1) What are the micronutrient deficiencies that most plague these at risk kids and do the donated vitamins meet that need? (donated items, medications / supplies are such a mixed blessing ..)
-iron deficiency anemia- ( causes about 50 % of the anemia of kids in CAmbodia
-Vitamin A deficiency
-zinc deficiency
-protein deficiency
- and some kids will have B12 deficiency, folic acid, magnesium deficiency , selenium deficiency though the top 4 are the most prevalent in Cambodia. (Iodine deficiency is apparently no longer a problem because of iodinized salt. )
I will attach the latest (2008) nutritional data for Cambodian kids an moms
http://www.wpro.who.int/NR/rdonlyres/7290A421-9624-4CD1-A0DE-A79AA67562A4/0/NutCam2008.pdf
Clearly the vitamins won't help with the protein but may help with other micronutrient deficiency.
SO ...What is in the vitamins is important. To be of value they should have vitamins and minerals.
2) THe toxicity question Re: the possibility of overdose of iron is a concern but the reality is that if you limit the number of iron containing vitamins that even if they take them all at one time most of the iron will not get absorbed ( protein deficient kids don't take in iron well) and it is highly unlikely that it will lead to iron overload unless they are constantly given supplemental iron or iron supplemented food.
The only other toxicity concern would be fat soluble vitamins . Though it would take a lot of A, D, E and Kto lead to a problem. One would have to over-consume the vitamins for a long time.
SO...YOu can probably pass out a reasonable # of vitamins to each family 20? 30 ? with your verbal and non verbal dosing cues ...but when you run out ...the next "ask " for the donors of the NGO might be more specific for the kids you are seeing. Many countries are using "sprinkles" micro nutrient packets and others( this is a lot harder) are supplementing diets with natural foods that contain the nutrients. (Google the "spoon foundation" which is a nutrition resource ctr for international orphans/ adoptees) .
joe
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