Blaming the dispenser

The Assam Human Rights Commission indicts the State government for the vitamin A-related deaths of 23 children in November.

THE Assam Human Rights Commission (AHRC) has held the Government of Assam responsible for the vitamin A related deaths of 23 children after a "high dose vitamin A supplementation" campaign in the State in November last. In its inquiry report submitted to the State Chief Secretary on January 17, it said that a prima facie case exists that the deaths occurred owing to lapse on the part of the "agencies or instrumentalities or public functionaries" of the government, whether the children died "due to vitamin A poisoning or toxicity or allergy or coincident with the administration of vitamin A".

The mass administration campaign in the "pulse mode" approach, conducted to combat vitamin A deficiency (VAD) with the assistance and support of the United Nations Children's Fund (UNICEF), targeted 3.17 million children in the one to five age group. The high dose supplementation involved administering 2 ml (0.2 million International Units, or 60 mg) on a single day on November 11 and covered 2.8 million children. This resulted in 23 deaths and several hundred children suffered adverse toxicity effects (Frontline, December 21, 2001). Unlike two earlier rounds in Assam, which were linked to pulse polio campaigns, the one conducted on November 11 was a stand-alone vitamin A campaign as per the recommendations of the National Consultation of December 2000 that vitamin A supplementation should not be linked to pulse polio campaigns.

Significantly, the report has refrained from blaming UNICEF. One of the suspected causes for the deaths was the unilateral switch by UNICEF to the use of a 5 ml dispenser. The Government of India's stated norm is a 2 ml dose. The dispensing health workers were reportedly not warned of this or trained adequately. The Report, however, takes cognisance of the fact that a change in methods of dispensing in some areas might have resulted in the administration of a higher dose and that some children may have suffered side effects due to the plastic cup measuring out a mega dose.

According to AHRC Chairman Justice R.K. Manisana Singh, the Commission undertook a suo motu inquiry into the episode which, in its view, amounted to a prima facie case of human rights violation. However, since its jurisdiction was governed by the Human Rights Act of 1993, which is in respect of human rights violation by a public servant, and not a private individual, irrespective of any pending litigation - civil or criminal - in any court of law among the contending parties, the Commission did not have the authority to investigate the roles of NGOs like UNICEF.

Twenty-two children died within a week of administration. One child died on November 19. According to the report, 15 of these were in the one to three age group. Significantly, two cases were outside the target group - seven-month-old infant and a five-and-a-half year old child. Under the Central government recommended vitamin A intervention programme, the target age group is nine months to three years.

The AHRC considered two questions. One was whether the deaths were coincident with the vitamin A administration, and not due to vitamin A - a view expressed by some experts, given the high under five mortality rate (U5MR) in Assam. The second question was whether there was any violation of human rights by any public servant, and if so what steps should be taken by the government.

In order to substantiate the theory of coincidence, in his submission to the Commission the Director of Health Services of Assam had provided a statement detailing the cases of 31 children who died in the first post-week of the campaign. Of these eight had not received vitamin A.

However, having considered the causes of death from a medico-legal perspective, the Commission has rejected this premise on the grounds that the signs and symptoms preceding the deaths of several children were attributable to vitamin A toxicity or allergy, and distinct from other causes of common poisoning.

Further, a forensic examination of the viscera (stomach, kidney and liver) of two cases (of two years and three years respectively) was positive for vitamin A poisoning. The Commission has requested the authority concerned to preserve the viscera for future investigations. It also said that the opinions of experts were too theoretical and could not be accepted in the context of the case. Based on these considerations, the report has argued that there exists a strong prima facie case that some of the children died owing to vitamin A administration.

The Commission's conclusion with regard to the second question brings a better perspective to its conclusion with regard to the first. It has pointed out that the pamphlet (in Assamese) distributed to the health workers as part of the training did not contain any warning to the workers and the parents or guardians of the children about the possible side effects of high dose vitamin A administration. Also, the training did not give any consideration to the health status of the child and the pamphlet did not caution workers against giving vitamin A to sick or ailing children. Nor did it indicate whether vitamin A should be administered to a child suffering from chronic vitamin A toxicity, as even 2 ml may be a mega dose in such a case. Vitamin A may have precipitated the death of children already suffering from gastroenteritis, viral fever and other childhood diseases, the report has said.

It has pointed out that, significantly, the leaflet also did not warn the workers against exceeding the 2 ml limit while measuring out with a 5 ml cup. The supervision provided, in the form of one doctor for 10 booths, was also not sufficient to ensure safe administration. The Commission has also drawn attention to the report of the government analyst, the State Drug Testing Laboratory, Assam, in respect of the quality of vitamin A drawn from Batch No. VSD 22, which indicated "possible loss of potency on storage".

Acknowledging the importance of the vitamin A supplementation programme, it has made a set of recommendations for future campaigns, which includes examination of the quality of vitamin A, exclusion of sick and ailing children, supervision with one doctor per booth, warning against exceeding the dosage of 2 ml and that the dispenser should not have a capacity in excess of 2 ml.

The Chief Secretary and the Commissioner and Secretary of Health and Family Welfare Department will have to respond to the AHRC report, as well as state the actions taken, within two months.