Remarks of David P Haxton
at the Intercountry Workshop on IDD Elimination
in Southern African Countries
April 18, 1992
It is my assignment today to share with you some inter related thoughts on programme planning and management; social communications and development; and the role of advocacy; as essential ingredients of national programmes to eliminate iodine deficiency disorders in each country. To do that, however, we need to discuss the global and political context in which we are working.
To begin, let us address a question which has bothered a good number of people in many lands on the question of elimination of IDD. The question, simply put is: If we have known what to do to deliver acceptable amounts of iodine to large populations at affordable prices, why have we not done so?
There is, of course, no one, simple, clear and final answer to that question. For the purposes of the discussion here today, let me suggest that among the major inter related and mutually supportive reasons are the following :
There was less known about the consequences of iodine deficiency and that knowledge was not made available to those that could act upon it nationally.
As a consequence, political understanding of the magnitude of the problem and its negative consequences on development was limited and the appropriate political decisions to formulate national policy were slow in coming.There was little encouragement to the general public to understand the problem and to demand resolution of it.
As science worked diligently to expand our knowledge base and to reveal the consequences of a range of disorders resulting from the absence in diets of a minuscule amount of iodine daily, a good number of nations introduced effective interventions principally based on the production, marketing, and consumption of iodated salt. During the 1960s a good number of governments began intervention programmes, and while some of those progressed, most suffered from lack of political commitment to the permanence of the programme, or from managerial problems,or from lack of collaboration between the public and private sectors, and lack of convincing communications with the buying public in order to demand iodated salt in the market.
International development agencies expressed concern about the problem and offered technical and other support, but not on a scale commensurate with the magnitude of the problem. During the 1970s and 1980s, science continued to expand our knowledge of the consequences of the problem and to provide us with alternative intervention methods all of which are mutually supportive.
During the 1980s, The International Council on control of Iodine Deficiency Disorders was created in response to a need for a non governmental organization which could bring to bear the best that science has to offer on the problems of IDD and to do so without the usual constraints of international agencies which have a multiple set of objectives. Formed officially in 1985 in New Delhi and officially organized a meeting in Khatmandu, Nepal in 1986, the ICCIDD is the international advocate for action to eliminate this ancient scourge.
Advocacy of the elimination of IDD has gained momentum. In the limited time I have today, I will not burden you with all of the actions which have taken place in national efforts, in regional promotional and training activities, nor in impressive gains made in many countries. I will remind you, however, that the WHO World Health Assembly has passed resolutions that state that IDD should be virtually eliminated in this decade. UNICEF at its Executive Board has passed similar resolutions with commitments to assist in financial and other support for effective national programmes. In addition, it is good to remind ourselves that the Second Conference of Heads of Government of the South Asian Association for Regional Cooperation accepted the gaol for each of the countries. The Central American Ministers of Health accepted the goal at their session in 1988. Through the WHO Regional Committee In Africa, resolutions have been adopted which call for the virtual elimination of IDD in this decade.
As impressive as these formal gains are, the Global Summit on Children at the United Nations in New York in 1990 when over 70 Heads of Government met and signed the Global Plan of Action for children for this decade once and for all gave global political endorsement to this grand effort. In clear terms, the Global Summit states that the political leaders of the world are agreed that the virtual elimination of IDD from each country before 2000 is an objective for people that must be reached.
The scientists of the world, the planners of the world, the economists of the world, all said to the world leaders that the goals could be achieved, and that to do so was, indeed, good politics. These leaders in accepting the advice from those professional groups said the goals should be achieved. It is now up to us to assure that they are achieved. So our first task becomes the need to consider how to implement the plans which exist and how to improve them, or how to encourage the preparation of comprehensive plans where they do not. This calls for successful communications plans, advocacy based on knowledge and competence, and the management of information and communications in such a way as to obtain and sustain political commitment to the process simultaneously with the creation of public demand for success.
One of the major reasons for the slow awakening of political leaders to the negative consequences of iodine deficiency disorders and their impact on investment, on development and on human progress, is ignorance of the problem. To overcome this, we need in each country an advocacy and communications plan and strategy which enables the establishment of a national political commitment to assure success and to sustain the programme as a permanent venture in national development and security. When political leaders have been presented the facts in clear and unequivocal terms, they have been quick to act. Now that they have acted through the instrument of the Global Summit, it is up to us to assure that they remain comfortable with their decision. This will assure that the appropriate decisions are made to guarantee adequate national leadership, adequate national resources, adequate legal protection and assurance, and adequate multi professional support.
With the multiple pressures on national leaders when making determinations on the use of national resources, we need to understand that we shall need entry points in a range of systems to assure that the resources for IDD are stable and regular. National priority setting does not take place in a vacuum, after all, nor is it sufficient to assume that a well formulated and scientifically accurate determination is sufficient to assure permanent provision of the resources necessary. We shall have to get our interests inserted into national policy and national plans in a spectrum of ways and not just in one sector. In the case of IDD elimination, 30 years of experience should have taught us that we cannot leave the question of elimination to one sector in government alone. Moreover, we cannot assume that government alone...using all sectors at its command...is sufficient. It is a combination of public and private sector interventions which points the way to permanent success.
This is another illustration of the importance... the historic importance of this workshop. It is the first time in this part of the world that government and private organizations meet together to work out ways to eliminate IDD from national territories. Such a blend of interests will help to assure that we insert our requirements into financial channels; into communications channels; into the agriculture sector; into the education sector; into private citizens organizations; into universities; and into private industrial, productive and commercial organizations. This unique combination of interests will help us to demonstrate how a public health problem can be addressed by these interested groups in the private sector successfully. This implies and demands adequate communications and the sharing of solid information as a vital requirement of getting started and of sustaining access once achieved.
Conventional wisdom seems to suggest that there is an identity of interests between principals and agents in social development. It sometimes assumes that with a well defined social goal...(the elimination of IDD for example)...is an entity with a single mind, with a single good thing to do and with a noble purpose. We need to look at this suggestion a little more carefully before we accept it, however. We know, for example, from observation that the practice of bribery, price fixing, nepotism, political appointment, imaginative bookkeeping and rule interpretation all exist. What we need to understand in face of these facts of life is that what appears perfectly abhorrent, or stupid, or irrational to most of us, makes a certain "logic" or rationale to others. We must assure that our plans are not only clear and well stated, but that they can become the property of others.
And this leads me to another key issue in essential communications at the political and advocacy level. Good communications...and good management...implies the need to share information in ways which are mutually beneficial and which cause acceptable results. Most of the professional groups associated with IDD heretofore have not been...in my opinion...as aggressive as they might be in sharing information in the first place, and in enlisting the professional support and collaboration of professionals of other disciplines...like communications itself. I understand that coming from the professional field of economics. One of the problems of economists is that they have made the language so abstract and obtuse and the theories so convoluted that most people feel that the subject is too difficult and too dull to be worth the effort to grasp essentials. This practice of professional obfuscation is not exclusive to economics by any means. There are other professions which provide...or discuss the provision...of public services which are smothered in caveats; cautionary phrases; worries; "ifs"; "buts"; "howevers". (I sometimes call these "posterity protectors"). IDD elimination..and the terrible consequences of inaction..must be demystified.
We must, therefore, be aware of the conventional wisdom which may suggest to us that one the problem is posited by a well meaning expert, based on an impeccable study, that the leaders and the people will respond rationally and in ways which the health planner can predict. I suggest that all that we have learned in 30 years of health and nutrition education contests this dramatically. Moreover, if it were true, we would not be required to have these meetings!! There are factors involved in decision making in elements of society which require us to consider communication with and between them as essential to our success. I am proposing that communication be more than the persistent attitude that suggests that once the scientists, or planners, or economists have " a good thing to do" that all that needs to be done is to "explain it to the public" through "information campaigns" or "health education", or direct mail.
It is not, in other words, good enough to provide leaders or the public with what we think that they need. We need to provide them with what they think that they need to decide. It is not good enough, in the case of foreign aid, for the foreign experts to arrive with technical, financial and other potential support with their own time table to apply it and use it, especially if what is being proposed cannot be sustained nationally over time.
Part of our communications and advocacy strategy must include the creation of strategic alliances at the national level. For example, we need the executive authority on our side for political leadership and commitment and to assure that all elements of the executive branch of government are seized with the problem of the consequences of IDD in the country. We need the educationalists to support IDD elimination endeavors because of the potential for negative consequences on investments in learning and on learning itself. We need the agriculture sector since we know that animals also require iodine in the diet and the lack of it has a negative consequence on animal growth, animal productivity and thus on national productivity and development. We need the professional communications sectors as allies because they provide to the national development endeavors the talents of social communications, social marketing and demand creation. We need the active and open support and collaboration of private industry. It is the private sector, after all, which is the one which produces food; processes it; packages it; transports it; sells it. We need the economists to assist in providing the information and the data which show the positive economic consequences to the country of the elimination of IDD.
A good communications plan in the national strategy to eliminate IDD will assure not only adequate alliance creation and development, but will improve the e exchanges and mutual support required between and with government sectors and professional groups. How often have we heard in our work that professionals in various sectors of government often meet outside work as friends, but seldom do they meet and communicate in work as colleagues. This is not only true in the executive branch, but in the legislative branch as well. We need also to assure adequate, sustained, and intelligent support from legislative leaders and groups. It is, after all, very good politics to eliminate IDD.We also need the enlightened support of the judicial branch so that not only is there adequate law to assure sustained fortification, but adequate support to enforce legislation.
Let me say a word or two about "ownership" or "turf". We need to accept that the elimination of IDD is not "our programme" with which others are duty bound and expected to collaborate. Rather it is a national endeavor which all own...and it is a national problem from which none are automatically immune. We need to develop a different attitude toward alliance creation and a more humble stance in the public arena in order to create the allies we require.
I have been told from time to time that all of these things cost money. And that is certainly true. However, experience tells us that we must do these things or risk lack of permanence in the national structure. In addition, please consider this : What are the costs of not doing so? or of delay? or of unwillingness to share in useful ways the knowledge we have gained but which others need in order to move the nation forward?
As we accept the principle that the elimination of IDD from a country is not the concern solely of one ministry, but requires the commitment of all professions, we must equally recognize the need for improved management of an enterprise of this complexity and public concern. And many of these elements apply equally in the public as the private sector.
We need a senior management approach with experience in management of multi-sectoral activities and which has the technique and style to pull together the various professional disciplines needed for success. A manager is required with the stature to deal with senior government officials while also capable of working with high level scientists, the food industry and communicators as well as political leaders.
The manager will develop a comprehensive plan which covers the three basic essentials of any such venture : l) the product; 2) the support mechanisms; 3) the external influences. This will cover the range of topics from raw materials; processing; packaging; logistics; sales; quality control and assurance; training; laboratory facilities; finances; evaluation and other forms of measurement of progress; communications; prices; market problems; competition; taxes; transport facilities; political support; alliances; and the applications at appropriate times of new knowledge in food fortification as that is revealed.
Modern management in this sector must work with education, agriculture, industry and commerce, as well as the public. It must handle those that produce knowledge; those that apply knowledge through technology; and those that translate knowledge into social change...and to do so in a cohesive and productive manner. Public health management has improved almost everywhere over the past decade or so, and this activity presents additional challenges. Think of this: Not only could the elimination of IDD from the globe be the next public health success after the eradication of smallpox, but it could be the one which was lead by the public and private sectors acting together in the national interest in a public health venture that in the end will be paid for directly by the public in the consumption of the product!!
The manager will make sure that from the very beginning, we plan for permanency. This implies the need to understand the public health structure and its limitations; the salt market and its potential; the ways in which planning for applications with oil differ from the long range solution of iodation of salt. The manager will understand the need to manage a public health venture with private sector intonations. In other words, we need mangers for performance and which can covert a good intention into a national endeavor. And this leads me to say a few words about costs and budgets.
Each government operates a little differently in establishing national policies, from which flow national decisions, and therefore the commitment of national resources. What ever the method, it is my contention that the national endeavor to eliminate IDD must be prepared to be financed..regardless of what that implies. It should not be prepared to be partially financed, or partially implemented. IDD must be eliminated. That is the main thing!! Our ethics and our professionalism are on the line! IDD interventions must be sustained. So we must keep in mind that the most difficult thing to keep in mind is that the main thing is the main thing!!
So, we should prepare for, say, a decade and take all elements into account on the revenue side as well as the expenditure side. If government alters the amount available to the national endeavor, we need to review it to determine if that can be covered from additional revenue from elsewhere, or if the individual actions to be financed from various sources or sectors can be adjusted to accommodate. Whatever, the result of this review, if in the end the total available is less than the total proposed, then we must alter the factor of time. That is to say, that what was planned for 10 years, will now require 12. to alter one venture in the plan other than time is to risk failure.
Of the many budgets I have seen over the past years, one planning fault seems to stand out. While I believe it easy to correct, one wonders since the problem seems to persist. A budget is more than a mere list of expenditures topped off with expected projections of income. It is a financial and operating reflection of the policy of the organization which it supports and thus all revenue and expenses are to be included. What usually happens, however, is that the "budget" for IDD is stated in terms of expenditure alone and is usually limited to those of but one Ministry or unit. To understand how managers can mange without considering that as but an abstract of a national table of expenditures is beyond me. Some of this problem stems from our own fear that to list all of the costs only attracts criticism...and that usually negative. If we do not include ...as illustrations only...the position regarding iodine and its importation; the situations regarding packaging, storing, transporting, and quality assurance efforts, we will be remiss. We need to include adequate support for quality control from the plant to the consumer; and in the public health sector, adequate surveillance and monitoring to measure success and to sustain it.
In conclusion, permit me to suggest that we should leave here with our commitment reinforced. With the variety of things we need to look at and understand, it is tempting to become distracted. However, when we understand that the main thing is to eliminate IDD, then we can focus on remembering that the main thing is the main thing!!
We have the next global public health success in our hands. We know the problem. We know how to prevent it. We know the science. We know how to apply it. We know the cost.
In 1978, The Executive Director of UNICEF speaking also for WHO at the International Nutrition Conference in Rio de Janeiro, said, "It ought to be a crime to allow one more child to be born mentally retarded for these reasons when we know how to prevent it".
He was right then. He is right now.