'Rx for Survival: A Global Health Challenge'; Episode Three of the PBS Series: 'Back to the Basics/How Safe Are We?'

Byline: Alfred Sommer, MD

The series "Rx for Survival" highlights public health breakthroughs and interventions that have more than doubled life expectancy in developed countries within the past century. The series, filmed in more than 20 countries, also explores how the lack of access to basic health interventions leaves many impoverished countries plagued by preventable diseases. The series aired on PBS on Tuesday, Nov. 1 - Thursday, Nov. 3. (Check TV Schedules.) Brad Pitt narrates.

Alfred Sommer, MD, professor and former Dean of Johns Hopkins Bloomberg School of Public Health, was online Friday, Nov. 4, at 2 p.m. ET to discuss Thursday night's episode of the series.

About Episode III: (Aired Thursday, Nov. 3, 9-11 p.m. ET)

"Back to the Basics" -- This first hour of the episode explores the connection between health and essential requirements such as clean water and sanitation. It also examines how America's overabundance of nutrition, in the form of overconsumption, is causing problems such as obesity and adult-onset diabetes, which are beginning to spread to the rest of the world.

"How Safe Are We?" -- This second hour of the episode examines some of the most critical and emerging health threats, and the need to strengthen public health systems and leadership worldwide.

About Alfred Sommer, MD:

Sommer is professor of Epidemiology, International Health, and -- at the School of Medicine -- Ophthalmology; he was dean of the Johns Hopkins Bloomberg School of Public Health from 1990-2005. His research interests include outcomes assessment, child survival, epidemiology of visual disorders, glaucoma, vitamin A deficiency, blindness prevention strategies, cost-benefit analysis, the growing interface between medicine and public health, and clinical guidelines.

The latest research by Sommer and his colleagues has shown that supplementing women of childbearing age with vitamin A or beta-carotene can reduce maternal mortality by an average of 45 percent. These results are now being tested in a new, large, randomized, controlled, field trial in Bangladesh, where the potential benefits of simultaneous supplementation with other micronutrients (zinc, folate, iron, B-complex) are being determined.

The transcript follows.

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Alfred Sommer, MD: This is Al Sommer and I'm delighted to join this discussion and hope that I can be helpful.

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Harrisburg, Pa.: Since clean water is one of your topics, I would like to learn your opinion on fluoridated water. I agree that it has helped reduce cavities. Yet, there are claims it may increase cancer risks. Are these cancer risks real, and if so, are they significant?

Alfred Sommer, MD: There is no good scientific evidence that fluoridation causes cancer. In areas of the country where fluoride naturally occurs in high concentration in the water there can be some mottling of teeth and bones but this is not harmful. At levels at which is added to water it does not cause this and simply reduces cavities which is an important public health advance.

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Alexandria, Va. (Ret'd USPHS Officer): Dr Sommer, the greatest risks to human health resulting from the human environment today are all directly or indirectly related.

Alfred Sommer, MD: I would agree with the retired USPHS officer.

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Winnipeg, MB, Canada: Has there been any consideration given as to whether certain vegetables or fruits that contain vitamin A (such as cranberries) could be introduced to developing countries to prevent illness?

Alfred Sommer, MD: There are many fruits and vegetables that are available in the developing world which do contain beta-carotene. This is the only form in which vitamin A occurs in vegetables and fruits. Unfortunately, the body converts the beta-carotene in dietary fruits and vegetables very poorly so that we do not get as much Vitamin A as we need. In fact it is practically for a young child to consume enough green leafy vegetables and fruits whatever their beta-carotene content to satisfy their vitamin A requirements. What they need in their diet are animal sources of Vitamin A like dairy products, eggs, breast milk, cheese, liver and the like. Or, if they don't have these, they need to get vitamin A from other sources than their regular diet, like vitamin A capsules or cod liver oil.

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Ashburn, Va.: Some reports suggest that India or China will be AIDS Capitals of the World, so how those countries prepared or trying to prepare to deal with AIDS pandemic?

Alfred Sommer, MD: Both China and India have belatedly but recently begun to acknowledge the growing HIV/AIDS problem in their countries. They have begun to establish centers where people can get testing and counseling and they have begun to aggressively educate people to the risks of contracting HIV. They have been somewhat slower in their approach to providing treatment for those people who are known to be infected with HIV or have AIDS. While the spread of HIV in both India and China is alarming given the vast numbers of people in both countries, if the governments move quickly and effectively they should prevent rates reaching as high as they do in some sub-Sarahan African countries. But even at low rates if things are not put in place rapidly they will in fact in absolute terms have large numbers of cases.

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Washington, D.C.: 1. What percentage of the population in Bangladesh are vegan? Vegetarian? Is it healthier/less risky to disease to avoid animal products? 2. Are you related to Leonard Sommer, former Dean of the University of Miami School of Medicine?

Alfred Sommer, MD: No I'm not related to Leonard Sommer, or for that matter Larry Sommer, the President of Harvard. The proportion of Bangladeshis who are vegan is very tiny. The number who are vegetarian is slightly larger. Vegetarians are more commonly found in South India than they are in Bangladesh. As the philosophers have frequently said, "All things in moderation." A vegan who doesn't consume any eggs will find it difficult to obtain all the Vitamin A and some other nutrients that they need. Obviously too much fatty meat will raise the risk in well fed populations of heart disease and stroke.

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Washington, D.C.: How did you get involved in this series?

Alfred Sommer, MD: I was invited to be a member of the advisory board because people who advised the producers early had told them about my work and the global importance of Vitamin A deficiency which I had discovered. I therefore worked with the producers in helping to develop this series.

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Washington, D.C.: I have a question about night blindness. I watched last night and saw that many children are eating mostly white rice, which doesn't provide them with vitamin A. Why does this cause night blindness first, and then can progress to full blindness? Am I understanding this correctly? In other words, is night blindness the "first step" in going blind? Please help clarify this for me. Thank you very much for the help. Also, I'd like to follow-up with ... what are your thoughts on helping impoverished children get more nutrition and vitamin A?

Alfred Sommer, MD: The writer is absolutely correct that white rice does not contain any beta-carotene and therefore no Vitamin A. Individuals store Vitamin A in their liver. When one stops consuming sufficient Vitamin A the stores in the liver make up for the difference until the stores become depleted. As the stores become depleted, the Vitamin A available for various bodily functions declines. One of the first manifestations is the inability of the retina in the eye to adapt to see under low levels of illumination. As we normally adapt when we walk into a dark movie theater. At about this stage the child's risk of severe infections and death also begins to rise dramatically. If the child does not die in the interim, as the deficiency becomes more severe other parts of the eye begin to suffer from deficiency. The most dramatic is ulceration and melting of the cornea of the eye which is what leads to permanent blindness.

As to improving childrens' status, UNICEF and the Canadian government are assisting many countries in distributing large dose vitamin A capsules to poor children twice a year which prevents their death and blindness from VItamin A deficiency, and are also working to improve their diets so that they will consume more vitamin A naturally.

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Arlington, Va.: What are your experiences overseas? Where have you traveled and what have you witnessed first-hand in terms of malnourished populations? Has any progress been made in helping to feed those in need all over the world over the last couple of decades in your opinion?

Alfred Sommer, MD: My family and I have lived for years in Indonesia and the Asian sub-continent. And I travel regularly to Africa, Asia and Latin America to assist governments and carry out studies on how we can improve childrens' nutrition. There has definitely been progress in improving the nutrition of most people in the world which has stemmed primarily from the "Green Revolution", which has provided farmers with the tools to grow much better yields of local staples and a wide variety of other products. However, in countries like sub-Sarahan Africa, HIV/AIDS, and political disruption, as well as droughts, have curtailed and interfered with the progress we have seen in much of Asia.

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New York, N.Y.: What role do you think "First World" countries should play in assisting developing countries with their heath care? Taking into consideration the looming insurmountable health care costs that countries like the U.S. are facing in the coming years.

Alfred Sommer, MD: The health care costs in the U.S. have nothing whatever to do with assisting poorer countries. We spend very little money - in fact much less per capita GNP than any other developed country - in assisting poor countries overseas. There are a number of things we could do:

1. We could spend a great deal more, and better carry our "fair share" in funding those governments which are accountable, transparent and use their assistance appropriately .

2. We could important support changes in world trade agreements, such that we reduce the enormous subsidization of our own farms, which would allow farmers overseas to compete with our agricultural commodities. The costs of our agricultural commodities are extremely inexpensive because of the high subsidies we pay to large agribusinesses. And foreign farmers from poor countries, where they cannot obtain subsidies, can't compete with us. And the French, in particular, could do the same.

3. If we wanted our overseas assistance dollars to have the greatest possible benefit for people overseas, we should allow them to use those dollars in famine situations to buy crops from nearby countries rather than require them to buy American crops and use a lot of the money - often a majority of the money - to ship those crops from the U.S.

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Anonymous: So then, what happens when a child takes a vitamin A capsule, but has no other vitamins due to lack of nourishment? Could the child be susceptible to Vitamin A overdose (is there such a thing?)? Would taking the Vitamin A with no other nutrients somehow harm the child? Or would it simply be a step in the right direction -- hopefully leading to that child acquiring more overall nutrition in their diet. Thanks very much.

Alfred Sommer, MD: In all of the studies that have been done, and there are many, the net benefit of taking a large dose Vitamin A supplement two or three times a year has been overwhelmingly positive. One can get an overdose of vitamin A, but that would only occur if one took very large doses for very long periods of time. It is quite possible that these children often need other vitamins as well. We are in fact studying ways in which we might provide them. The practical problem, however, is that since Vitamin A is stored in the liver we only need to give the Vitamin A two or three times a year. Most of the other vitamins need to be given every day or so which poses difficult logistical problems. Nonetheless,we are trying to discover how much benefit these children would derive from frequent, if not daily, multivitamins. If we can demonstrate a significant benefit like that which we have demonstrated for vitamin A, we will simply have to find a practical way to reach them with these additional nutrients.

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Washington, D.C.: You mentioned you discovered the Vitamin A deficiency. Can you expand on how your discovery came about? Thanks.

Alfred Sommer, MD: I didn't actually discover the existence of Vitamin A deficiency. We knew that children were Vitamin A deficient in many parts of the world. The two things that I discovered were that the extent and numbers of children who were deficient were much larger than anyone had previously thought. And perhaps more dramatically, that Vitamin A deficiency was not just a problem for eyes and for vision but that even very mild vitamin A deficiency, before children even develop night blindness, increased their risk of severe and deadly infectious diseases. I was studying the effects and severity of Vitamin A deficiency in a number of areas of the world, but at the time these discoveries were made my family and I had been living in Indonesia for three years focused on these particular issues.

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Alfred Sommer, MD: I appreciate everyone's interest and the very good questions that were raised. And I would urge everyone to become involved with solving the problems of global health and health inequalities by supporting international agencies like UNICEF, or non-government agencies of their choosing like CARE and Save the Children, and most importantly letting their political representatives know how important it is for the U.S. to do everything it can in support of global health and the funding of health programs in poor countries. It is important to each of us as Americans because there is a humanitarian imperative to help people who are far less well off than we are. That is a traditional and long-standing American impulse. In addition, as we've learned from HIV, the recent SARS epidemic, West Nile virus, and now the threat from Avian flu, all diseases are global and none of them stay nicely contained in poor countries. It's in our own best interests to help eliminate these problems from around the world.

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