David P. Haxton
A Statement prepared following the National Consultation on Elimination of IDD, Islamabad, Pakistan, 1994, a meeting sponsored by the Office of Prime Minister Bhutto, the Ministry of Planning, and UNICEF for use in a PAMM course.
10 March 1994
In many countries there is a growing awareness that good public nutrition policy and good business make for good politics. National advocacy meetings bring together senior political leaders, scientists, food producers, consumer organizations, government officials, communicators and public health personnel to learn how the professional competence of each contributes to improvement of national public health.
Many of these have been concerned with plans to eliminate iodine deficiency disorders (IDD). IDD is a term used to describe the maladies caused by lack of iodine in the diet. These comprise: mental retardation at birth; stillbirths, miscarriages, neonatal and juvenile thyroid deficiency, dwarfism, deaf mutism, cretinism, goiter, spastic weakness and paralysis. Daily consumption of milligrams of iodine during pregnancy will prevent those caused from iodine deficiency.
Iodine is an essential element for human growth and development. Each human must consume about 0.1 to 0.15 milligrams per day. That is one reason for the description of iodine as a "trace element." The thyroid gland uses iodine to produce the essential hormones for human growth. It was present during the primordial development of the earth, but glaciation, snow and rain leached large amounts from the soil and much carried by wind, rivers and floods into the seas. The significant thing to remember is that once iodine is gone from the soil it is essentially gone forever because the amount returned through rain water released by the sea is oxidized and made volatile by sunlight and thus lost. This fact ensures that all plants, animals and humans dependent upon such soil will be iodine deficient in their diets, unless provided through fortification of foods or through supplementation.
Over 100 governments now see this as a major public health problem. The United Nations Global Summit on Children recognized it as a significant nutritional issue and set the goal for all governments to eliminate IDD by 2000 by universal access to iodized alimentary salt. The world has known for over 70 years that the most effective way to deliver appropriate amounts of iodine to large populations at acceptable prices over extended periods is through iodized salt.
To iodize all salt for humans and animals sounds a simple task but it requires all parts of a society be aware of the significance of IDD and to be willing to undertake the elimination of it from the national territory. This means that governments must understand that salt is a product of the market for the most part produced by private entrepreneurs: they mine it; or harvest it from the sea and process it and sell it. On the other hand, salt producers and food processors must understand that government has a role to protect society through good public health management; quality assurance; regulation and licensing; and to maintain a level playing field for competition.
Since 1988 I have been associated with initiating national IDD elimination programs in a number of countries and for arranging for national advocacy meetings in some of them. On the surface, these actions sound straight forward, and because of their subject, dull and routine. But each his its unexpected outcomes and surprises.
In China, where IDD has been a problem for 4000 years and where the first known treatment of goiter with seaweed was recorded in the third century, One third of the global problem of IDD still exists. We organized a meeting of 600 national scientists, political leaders, party members, health and education officials, managers and leaders of the salt industry in the Great Hall of the People. Madame Peng Pui-yun, Member of the State Council, became convinced that the family planning program limiting each family to one child would be at risk unless every effort was made to prevent mental retardation at birth. It is estimated that of the 50% of all newborns that suffer from thyroid disorders caused by lack of iodine in their mothers, most will suffer irreversible intellectual disability. The potential loss to China thus adds up to 60 million IQ points annually!
The negative impact on human development and investment in education was evident to the Premier of China and he agreed at the meeting to change the managerial responsibility of the national effort to deliver iodized salt to all of the people of the entire country (including Tibet, not included in previous undertakings) from the Ministry of Health to the Ministry of Industry, a decision very much welcome, but unexpected. He also agreed to seek a bank loan to finance the modernization of the massive salt industry in the country.
Trade patterns and the location of salt sources in the subregion indicated that a meeting of all 5 Central American Republics on this issue would be most appropriate. Consequently salt in all countries will be iodized uniformly. The salt producers formed their own session and agreed to pool some resources and as a group to seek a loan from an international bank to provide the increased capital required to modernize the salt industry, improve packaging, sustain quality assurance and adequately train human resources. With private sector commitment so intense and spontaneous the Presidents of the Republics at their next Summit Session recognized the potential for peace, progress and good political development and made the commitment required to assure success including tax incentives and lifting of tariff restrictions. In the Philippines at the National Advocacy Meeting held in Malacanang Palace President Ramos learned of the results of our studies of new borns in urban hospitals that showed that 30% of children in Metro Manila were at risk of IDD. The assumption had been that IDD is a problem of "poor people," in "rural" or "remote" areas. The full day of discussions with 3 Cabinet Secretaries resulted in new government action, but it was the reaction of the private producers present that added drama. They agreed to undertake to modernize their own plants; to pay for the training of their own people; to assist the government in establishing a monitoring program; and to share skills and experience in marketing with smaller family owned producers to eliminate this ancient scourge from the island Republic.
The oldest known representation of goiter is in the Buddha frieze from the 2nd century in Gandhara, Pakistan. It shows Buddha surrounded with animals and humans seeking guidance, among which is a man with a large goiter carrying a drum another is beating. His facial expression suggests idiocy and one could speculate deafness because of the proximity of the drum. The situation in Pakistan is one of the most severe anywhere in the world.
The Prime Minister, Mrs Benazir Bhutto announced that a priority of her government was to eliminate IDD from the national territory in this decade. A National Consultation was arranged under the leadership of her Senior Advisor, chaired by the Secretary of Planning, attended by 3 Cabinet Secretaries, 7 private salt producers, a range of government, science and other professions. It concluded that a new law was required. to standardize regulations, and to facilitate licensing of the product. In addition, the Government agreed to borrow a good bit of money from the World Bank to modernize the industry and to expand work in food fortification to attack such problems as iron deficiency, as well. But as usual, unexpected results occur.
A good bit of background information had been prepared for the Prime Minister and her advisors, some of which ended up in statements by her representatives. One indicated that about 60% of the population is at risk of IDD. The implication of this to mental retardation at birth was that Pakistan lost each year millions of IQ points and gained all the other maladies arising from IDD.
A day after the meeting she was attending a seminar on the carpet industry in Pakistan and in her spontaneous remarks, said, "we should be using iodized salt in the country because doing so will prevent IDD and the loss of IQ points." Some in the audience did not completely grasp what was said and one or two journalists were heard to chuckle. She offered a smile to them, and then said, " . . . we will feed iodized salt to the journalists first and then to the politicians as well!". This was the key news item on national television that evening!.
The comment gave rise to a number of supportive cartoons in major papers and sparked spirited discussion in editorial pages and opinion columns in the country.
At present, IDD affects about 1 billion people on the globe. It is one of the oldest scourges known to humankind. Ivan the Terrible insisted that salt for the Kremlin come from but one source (perhaps indicating the presence of iodine). Napoleon refused to accept soldiers from areas where goiters were found, (indicating he knew those people made poor soldiers). Men called for conscription from the Middle West of the US for World War I were found unable to march properly and to lack physical coordination, revealing the presence of iodine deficient diets. It is reasonable to assume that a good number of people are poor because they are mentally and physically damaged at birth. It is not accidental that most of those are in iodine deficient lands of the world.
"Ignorance is not bliss" ought to be part of the call to action.
In Switzerland, the elimination of IDD through the mandatory production and marketing of iodinated salt in the country, was completed in less than a decade and has been reported by Swiss scientific and medical authorities to have been the most cost effective public health measure in their history. The total cost was about US 20 cents per person for a decade! The Federal Republic of Germany in 1992 reported an expenditure by insurance companies of DM2 billion (about US$1 billion) to correct problems of iodine deficiency and the thyroid revealed only after unification of the country.
This is a public health venture for which the public will pay. Salt is a product of the market; bought and consumed in villages all over the world every day it salt is an essential ingredient of the market basket. Adding potassium iodinate to it at the manufacturing source is effective, efficient, inexpensive. IDD elimination demonstrates dramatically and conclusively the interrelated potential for national good of private industry and public health in creative alliances.
To allow one more child to be born mentally retarded from this set of problems when we know perfectly well how to prevent them, is the ultimate obscenity of our times. The elimination of IDD is an idea whose time has come.
- Haxton, David P, "The Child in South Asia", New Delhi, 1988, "The Stealthy Scourge", Johnson Press.
- Hetzel, Basil S "The Story of Iodine", New Delhi, Oxford University Press, the history of IDD.
- Husain, Shakir, "Iodine Therapy for the Brain Dead", the Friday Times of Pakistan, a political column, 23 February 1994, Islamabad.
- Bhutto, Benazir, public remarks as quoted in The Daily Frontier and on "Khabarnama", (the Urdu Television System), on 10 February 1994, Peshawar and Lahore.
- "Ending Hidden Hunger," A report on the National Advocacy Meeting in Manila, 9 and 10 June, 1993.UNICEF, Manila,
- Haxton, David P, "Private Enterprise- Public Health, An expanding Alliance" as published in "First Call for Children" April 1993, New York.