How a preventable vitamin A deficiency became a public health crisis in displaced populations
In the mid-1990s, as Rwanda grappled with the aftermath of devastating conflict, hundreds of thousands of refugees fled to neighboring countries, carrying with them invisible wounds—and an unseen nutritional deficiency that would threaten the eyesight of an entire generation.
While the world focused on visible trauma, xerophthalmia quietly spread through refugee camps, threatening children's vision.
Xerophthalmia refers to the spectrum of ocular manifestations caused by vitamin A deficiency, a condition that remains the leading cause of preventable childhood blindness in developing countries worldwide 2 .
Vitamin A plays two crucial roles in eye health:
Appears at retinol levels below 0.7 μM
Abnormal dryness and wrinkling
Foamy, whitish patches on conjunctiva
Develop at levels below 0.35 μM 2
| Stage Code | Name | Clinical Features |
|---|---|---|
| XN | Night Blindness | Difficulty seeing in dim light |
| X1A | Conjunctival Xerosis | Dryness, thickening, wrinkling of conjunctiva |
| X1B | Bitot's Spots | Foamy, whitish patches on conjunctiva |
| X2 | Corneal Xerosis | Hazy, dry cornea |
| X3A/X3B | Corneal Ulceration/Keratomalacia | Corneal melting involving less/more than one-third of cornea |
| XS | Corneal Scar | Permanent opacity from previous ulceration |
| XF | Xerophthalmic Fundus | Retinal changes 2 5 |
A 2017 prospective clinical study in North India provides crucial insights into how vitamin A deficiency manifests in vulnerable populations with similar risk factors to Rwandan refugees 6 .
Researchers conducted a six-year prospective study (2010-2016) involving 2,946 children aged 2-6 years using a comprehensive approach:
| Indicator | Prevalence in Study | WHO Threshold for Public Health Significance | Status |
|---|---|---|---|
| Night Blindness (XN) | 2.93% | >1% | Severe Problem |
| Bitot's Spots (X1B) | Not specified | >0.5% | Moderate Problem |
| Corneal Xerosis/Ulceration (X2/X3) | Not specified | >0.01% | Moderate Problem |
| Corneal Scar (XS) | Not specified | >0.05% 6 | Moderate Problem |
Semi-quantitative food frequency surveys that evaluate intake of vitamin A-rich foods 6 .
Blood tests measuring circulating vitamin A levels, though rarely available in field settings 2 .
| Age Group | Treatment Dose | Prevention Dose | Frequency |
|---|---|---|---|
| <6 months | 50,000 IU | 50,000 IU | Once within 3 days after birth |
| 6-11 months | 100,000 IU | 100,000 IU | Every 4-6 months |
| 12-59 months | 200,000 IU | 200,000 IU | Every 4-6 months |
| Women of reproductive age | 200,000 IU (for corneal disease) | 200,000 IU | 2 doses 24 hours apart, third dose after 6 weeks 2 |
Understanding xerophthalmia in Rwandan refugees requires appreciating the perfect storm of risk factors that characterize humanitarian emergencies.
A 2009 study of Rwandese and Somali refugees in Uganda's Nakivale settlement documented extreme trauma exposure:
This mental health burden compounded physical challenges of displacement.
Researchers measured wealth by counting essential household assets:
This level of poverty directly impacts dietary diversity, pushing vitamin A-rich foods out of reach.
Depression and PTSD can affect caregiving behaviors, potentially reducing attention to children's nutritional needs. The constant stress of survival in refugee settings may shift priorities toward immediate food needs over dietary quality 9 .
This complex interplay of trauma, poverty, and malnutrition creates ideal conditions for xerophthalmia to flourish, transforming what should be a rare condition into a public health crisis.
The story of xerophthalmia in Rwandan refugees represents both a public health failure and an opportunity for meaningful intervention.
Vitamin A supplementation programs have proven remarkably successful, with capsules costing as little as 10 cents each 8 . When implemented systematically, these interventions can reverse night blindness within 24-48 hours and heal corneal lesions within weeks 2 .
The global health community has made significant strides—between 1990 and 2020, the prevalence of vitamin A deficiency in sub-Saharan Africa decreased from 39% to 15% in preschool children, showing that progress is possible with sustained effort 2 .
The goal must extend beyond treating xerophthalmia to creating resilient food systems and stable societies where vitamin A deficiency no longer threatens children's sight—or their lives. The technical tools exist; what's needed is the political will and sustained investment to ensure that every child, regardless of their circumstances, can access the simple nutrients that preserve both vision and life itself.
Xerophthalmia serves as a canary in the coal mine for broader systemic failures—when it appears, it signals breakdowns in multiple layers of the food, health, and social protection systems.