Volume 19 Number 3, August 2003
IN THIS ISSUE
IN BRIEF
COMMUNITY-BASED APPROACH MAKES PROGRESS AGAINST IDD IN RURAL BALIFive years ago David Booth established The East Bali Poverty Project (EBPP), a foundation that has now transformed the lives of the people living in the forgotten villages of Bali. His quest had been to find the poorest community on the island and to identify ways in which to change and improve the lives of its children through sustainable economic development. What he discovered was a huge village of 19 remote hamlets covering an area of 90 square kilometers in the rugged hills. Here, in Desa Ban (Ban village), the 10,000 inhabitants were living in unimaginable poverty with no electricity, no running water and no toilets; isolated from the nearest health-centre and market, with no hope of an education for most of the children. It is hard to believe that such extreme poverty could exist only three hours drive away from the opulent luxury that can be found in many of the hotels, spas and private residences within central and southern Bali.
The majority of the villagers were illiterate and malnourished, practicing
archaic methods of farming. Most of the children were suffering from impetigo,
an infectious skin disease caused by lack of hygiene and nutrition. It also
transpired that the prevalence of iodine deficiency disorders (IDD) among the
children in Desa Ban was the highest in the whole of Indonesia: 84.5% of primary
school aged children in Desa Ban were found to have a palpable goiter as documented
in a prevalence study of iodine deficiency in Bali in 1997-1998 through a joint
program from the Departemen Kesehatan (Health Department) and Udayana University:
"Kegiatan Survei Prevalensi Gaky Dan Pemetaan di Propinsi Bali".
Overt cretinism was also documented in several of the most remote sub-villages
by Dr. Indraguna, volunteer doctor with EBPP and nutrition specialist at Udayana
University.
Prior to considering any kind of intervention, this subject was included in the detailed questionnaire that the EBPP developed in August 1998 to learn more about these people's lives. Over 1,000 families living in Desa Ban indicated how the lack of education in every aspect of daily life had affected their productivity, health and future; 95% of the population had never left their village.
David's "promise" was not to provide money or rice but to work with the community towards long-term solutions, starting by educating the children, the people's choice; not just in reading and writing, but also in nutrition, hygiene, sanitation, primary healthcare and self-sufficient organic farming (see figure 1 "Goals Diagram"). The first EBPP integrated education program was launched in a simple school building in Bunga hamlet on 31st August 1999. There are now over 200 children, aged between 6 and 14 years, in the four most remote hamlets in Desa Ban receiving the benefit of the education that their parents and elder brothers and sisters never had.
Figure 1
GOALS DIAGRAM
Early research into eliminating Iodine Deficiency Disorders
The East Bali Poverty Project's vision to implement a program to eliminate IDD
first began soon after David Booth answered the initial cry for help from the
inhabitants of this remote mountain village in 1998. It had already been noted
that many of the villagers in the isolated farming communities had huge goiters,
the size of large mangoes, on their necks. Goiters are unsightly, permanent
swellings that usually start to appear in young adults, and are a distension
of the thyroid gland to compensate for a lack of iodine in the diet.
The EBPP therefore decided to do some further research to find out the main causes, symptoms and consequences of iodine deficiency, due to the unusually high prevalence in this remote region. The first step was to ascertain just how many people in the nineteen mountain hamlets of Desa Ban had visible goiters.
It was soon established that the severity of IDD in these isolated communities could be linked to their remoteness from the basic facilities that most of us consider to be a fundamental right - roads, water, sanitation, market, health centers and schools. This was compounded by their limited knowledge of agriculture and their main staple crop of cassava, a goitrogen. It is the only crop, apart from corn, that they know how to grow on their steep and arid land - covered in granular volcanic ash from when Mount Agung erupted in 1963. Unless boiled for a sufficient period of time, a diet of cassava root will cause goiter by blocking the absorption of iodine by the thyroid. Lack of rivers, together with lack of education, knowledge and motivation regarding alternative farming methods and dietary needs, meant that there had been little change in farming practices since ancestral times.
The additional elements of their low nutrition diet are limited to whatever might be available in the local market during their once-monthly visits and do not include fish or iodized salt, the most normally accepted solutions for sufficient iodine intake. The sun-dried sea salt that the villagers purchase locally from the traditional market (an average of a three-hour mountain walk for most) does not contain any iodine. It is produced as a home industry in the nearby coastal village of Tianyar. The mountain communities still follow ancestral beliefs that Tianyar salt has special qualities, a special taste - and it is certainly much cheaper than iodized salt. Other causes of this deficiency can be attributed to illiteracy, and only very rare access to health centres, where information is provided on the importance of iodine in the diet and the key role it plays in normal body growth and development.
The next step for the EBPP was to try and find a way to eliminate this syndrome, as it was already quite clear that iodine deficiency was the cause of cretinism. Moreover, children with IDD can grow up stunted, apathetic, retarded and incapable of normal movement, speech or hearing. The effects can also cause reproductive failure and, worse still, child mortality. If a woman is suffering from IDD at the time of conception, the baby may well be born mentally retarded. As it clearly would be difficult to explain to parents in these very scattered communities, the children's education program presented the solution.
Children's Education
The concept of improved nutrition and the essentiality of iodine were included
in the children's education program. This way, the youngsters could take the
message back to their parents and hopefully persuade them to make some changes
and vary the foods that they were eating at home. This was made easier by providing
the kids with a nutritious daily meal at school - for to be sure they would
talk about what they had learnt if it tasted good! The need for iodine was introduced
into the classrooms by Pak Putu, the senior teacher who co-ordinates the EBPP
education program. He was able to demonstrate that, when tested with drops to
identify iodine levels, salt containing the correct quantity of iodine will
turn dark blue. The youngsters then conducted their own experiments with their
locally purchased salt samples brought from home. If it did not change color
when tested, this would prove that it lacked the essential iodine. If the color
of the salt changed only to a light blue, iodine was present but the quantity
was insufficient.
Once they saw the difference in the color of the iodized salt that the EBPP staff used for illustration, and the salt that was also used for their school meals, they were so excited that all of them went home to tell their parents about this new phenomenon: local salt stays white, whereas iodized salt turns blue. As a result, most mothers who attended the awareness program at the start of the first iodine supplement program in 2001 knew that they should use iodized salt for better health even though they probably were not convinced that the lack of it was the cause of goiter.
Moreover, these simple drop-tests verified that nobody was using iodized salt in the preparation of their food and that none of the sea salt that the villagers were purchasing locally contained iodine.
The First IDD Elimination Program in 2001
David Booth was aware that the cost of executing a program to eliminate IDD
would be very high, and the resources required would be quite extensive, but
also that the most likely source of support would be UNICEF. He approached the
UNICEF office in Jakarta in May 1999 where Mr. Ernest Schoffelen, UNICEF's Nutrition
Project Officer, initially expressed disbelief at the seriousness of IDD in
a Balinese village. So David showed him actual data from the 1998 national government
survey that had been designed to identify the rate of IDD amongst children in
Indonesia. Upon learning that the children in this isolated region suffered
from the highest rate of IDD in the whole of Indonesia, Mr. Schoffelen immediately
said that he would find a way to support the project, even though UNICEF did
not have a mandate to include Bali within their scope of provinces.
The first project, sponsored by UNICEF, went ahead in 2001. The initial stage was to provide iodine supplements, in the form of iodized oil capsules, to all males between the ages of 1 and 15 years old, and all females from 1 year old until menopause. One capsule is effective for twelve months. It is proposed that this supplement will continue for an initial three-year intervention period suggested by UNICEF (Jakarta), or until such time as dietary iodine intake is sufficient and the community is no longer at risk. This is determined before supplements are given, through the regular assessments of urine samples taken from the children and then analyzed in government laboratories to determine the iodine levels. The number of capsules actually distributed is carefully recorded in a computer database to ensure an effective tracking system for the future years of the program.
This was a challenging project because the EBPP's staff was dealing with a population that had very little knowledge of 'Stay Healthy Principles.' This is due to a lack of information and advice through school education programs and health centers, because of their remote environment. Another barrier, of course, was that the villagers' own parents and grandparents also did not know, and thus had not been able to inform them of this key nutrition need.
As the first stage of the program, the EBPP health team - including its expert advisors, Dr. Pinatih Indraguna, a senior nutritionist in Denpasar Udayana University and Dr. Denise Abe MPH - devised a comprehensive awareness and education program. Its objective was to educate the communities and help them perceive the importance of iodine in their diets. The main source of iodine is salt and sea fish, the highest natural quantities being found in prawns and squid. It was vital that the villagers were made aware of the easiest source of iodine, and that they completely understood that an imperative part of their diet should be iodized salt, the most practical long-term solution.
After discussions with the head of the village, it was decided to introduce the awareness program directly to the adults in each hamlet, and encourage them to bring their children, although it was a very long trek for most. The logistics of contacting the target population proved to be quite a challenge, but a suitable date and time were fixed and the heads of each hamlet agreed to gather their community in the 'bale banjar' (community meeting place). The field team comprised three EBPP members and two female nutritionists seconded from Karangasem Health Department. Using a series of eight very carefully designed illustrations, the team explained the reasons for the many terrible effects of acute IDD, and explained that the symptoms include cretinism, deafness, dumbness, stunted growth and deformed bones.
Prior to delivering the awareness program, the EBPP team asked the women a series of questions to test their present knowledge of goiter, iodine and iodized salt. Generally, ignorance was up to 100%. The first question to the mothers was, "Do you know what causes goiter?" Of course they didn't. Many thought it was because they ate too many eggs! Others believed it was bad karma for having spoken too harshly to family or neighbors. After the short presentation by the EBPP staff, the same questions were asked again to test the effectiveness of the awareness program. This time 60-100% answered positively, indicating that they understood what caused goiter, together with the importance of iodine in preventing such problems in the future.
It was essential that every woman and child was included in the program but the isolation of the villagers' houses made the distribution of the iodine capsules, and the collection of data, a demanding task for the EBPP field team. They often had to trek for hours through steep and rugged terrain in high winds and heavy rains only to find that families in the most remote houses were not at home. Hence, some households had to be visited up to three times. The biggest difficulty was finding all the children, as many of them stay with relatives in some of the more inaccessible locations to help with daily chores in the fields, or alternatively - during the harvesting periods - they are to be found camping out in their 'pondoks' (small bamboo shelters) in the middle of their expanse of cassava crops.
One of the key difficulties in this village was the lack of any kind of documentation, not even records of births and deaths: a result of total illiteracy. Hence in order to develop a comprehensive profile of people's diet and how the lack of dietary iodine probably affected their lives, a comprehensive questionnaire was designed, and each mother interviewed prior to receiving the iodine capsules. The most useful data for later verification of the efficacy of our program were on child mortality.
The results from the urine tests were very encouraging, indicating that most of the children in the hamlets benefiting from EBPP education programs were no longer iodine deficient, whereas those in all other hamlets still had serious problem, similar to that illustrated after the Government survey in 1998.
2002 Program
Before implementing the initial IDD elimination program in 2001, EBPP divided
the 19 hamlets within the village of Desa Ban into two zones: Zone A and Zone
B, based on degree of difficulty of access. It was agreed that Zone B, comprising
13 hamlets, was most at risk, and hence the priority, due to lack of infrastructure
and remoteness from all key facilities. This division of the areas had been
a necessary step due to budget limitations, coupled with the conjecture that
the remaining hamlets lower down the mountain would not be suffering too seriously
from IDD. A calculated assumption because the lower hamlets are closer to roads
and have access to the markets, education facilities and the health centre and
should therefore be more aware of the importance of a healthy nutritious diet,
prioritizing iodine.
In order to verify this supposition, it was agreed with UNICEF that in 2002 EBPP must determine the actual IDD status of the children in Zone A, prior to deciding if intervention was necessary. To ensure a more comprehensive result this year, it was agreed that not only would urine samples be taken, but also that Dr. Indraguna would palpate a representative sample of over 200 children in both Zone A and B. They were horrified to discover that from both urinary iodine result and goiter palpations, IDD was more serious in Zone A and affected a higher percentage of families than in Zone B. It was quite clear, therefore, that this year, in 2003, the EBPP must provide supplements to every family in Desa Ban in both Zone A and Zone B. The requirement has been revised, and the recipients are now all children aged 6 -12 years old and all women of reproductive age.
2003 Program
The program for 2003 was developed after consultation with Dr. Abdul Aziz Adish,
UNICEF project officer for nutrition, during his site visit to Desa Ban from
21st - 24th May 2003. In a visit to the market at Desa Ban, the team obtained
the crucial information regarding the availability of iodized salt. The EBPP
learnt that salt is sold in the market, but testing verified that there is no
iodized salt available. The EBPP team asked the salt sellers if they ever sold
iodized salt and the answer was "No." The EBPP hopes for the additional
support of UNICEF in its 2003 program, and is now providing IDD awareness through
education about the causes of goiter and the importance of iodized salt as a
long-term solution. In addition, the EBPP is developing a public relations program
within the market, to teach the villagers about the importance of iodized salt.
The aim is to create demand for iodized salt by convincing the sellers and the
consumers that it is essential for their good health. It is hoped that the program
will succeed and the EBPP will work with the local community and local government
to ensure that a sufficient and sustainable supply of iodized salt is available
for consumption by the whole population of Desa Ban. If the EBPP is successful
in creating a demand, it will have established a sustainable solution for the
prevention of IDD.
The key goal this year is to develop a program that initiates the demand for iodized salt, and a 3-pronged PR program is therefore being designed.
1. Salt sellers
It is essential initially that the salt sellers understand and appreciate the
importance and need for iodized salt. The ultimate aim of the EBPP program will
be to try and convince the sellers to iodize the salt prior to sale. There will
certainly be additional costs involved, as local research shows that iodized
salt is generally up to 50% more expensive than sea salt. To offset this in
the initial stages, and encourage locals to buy iodized salt, selling prices
will remain the same, all additional costs to the seller being supplemented,
most likely by UNICEF.
2. Awareness Program
All the hamlets in both Zone A and Zone B will be targeted in an attempt to
create a demand, through awareness, of the essential need for iodine. This campaign
has been planned in a three-stage approach:
a. An awareness program will be launched in every school in Desa Ban. All of the children will be asked to bring samples of salt from home, and these will analyzed via the simple drop test. The results will then be compared with iodized salt so that the children can see the difference. The need for iodized salt, together with the requirement of boiling all water before drinking it, will subsequently be explained to the schoolchildren and they, in turn, will be asked to promote the information to their parents. Once again the EBPP is basing the core of the program on educating the children in school and hopefully, in the future, these pilot model programs can be replicated in other villages throughout Indonesia.
b. With the agreed co-operation of the hamlet leaders, all 19 of the hamlets in Desa Ban will be provided with information about the need for iodine. This will take place at one of their monthly meetings. The EBPP has used this system in the past to impart information and will also endeavor to ensure that all the women are present at the meeting.
c. Simple flyers will be produced and distributed throughout the communities. The message will be printed not in words but in pictures, because the majority of the adult population is illiterate. The flyers will be distributed by key people within each of the different hamlets.
Interviews will be conducted, as in the first two years of the program, to determine what sort of salt people are using, and random testing of samples will be performed within the households.
Awareness turned out to be much greater within the hamlets of Bunga, Cegi, Pengalusan and Manikaji (in Zone B) where the EBPP has established schools and devised an effective method of educating the children on the importance of iodized salt.
3. Iodizing the water supply
A supplementary solution that has been studied by the EBPP, since 1999, is the
iodizing of the water supply - if and when a water supply is available. Great
strides forward have been made since 2002 thanks to the support of the UK's
'Thames Water', a domestic water supply company that has funded the exploration
and development of mountain springs with the engineering solution of spring
boxes (reservoirs). This is where an optimum flow from each spring is achieved
and the water is then filtered before entering a controlling reservoir prior
to distribution, via gravity, to a series of smaller reservoirs, each with taps
for drawing the water.
The benefits of iodine in the water are many. Iodine (if added as I2) actually purifies the water and kills bacteria. Furthermore, it provides the correct levels of iodine even without iodized salt.
However, there are still many hurdles in devising a sufficiently simple, yet sustainable way of providing iodine in the correct quantities to the water. Whilst research shows that various methods of water iodination have been tried during the past ten years - some to irrigation water and some directly to domestic supplies - EBPP is still seeking a near-foolproof solution that can be easily managed and gives no risk of excess iodine dosing.
The EBPP believes that there will be a sufficient surplus of water to include
a daily quantity to a single organic garden in each community so that all fruits
and vegetables are iodized through irrigation. The problem is how, without government
control, to maintain the facility? Already, all of the communities who will
benefit have agreed that they will give their 100% participation in the building
of the water supply. The EBPP will provide only the technical expertise and
the materials, coordinate the construction and then train the local groups in
all the basic maintenance requirements. In this way, the community will become
the owners. The villagers have now signed an agreement that they will be building
the infrastructure and that every family will be participating. Part of the
agreement is that they will be trained in how to maintain the facility once
they have got it and, most importantly, a small number of people will be instructed
in how to ensure that the correct iodine levels are maintained.
Of course, the EBPP is now only in the infant stages of this groundbreaking
project. During the last three years discussions and research have been taking
place with the support of experts in the field of IDD, including Dr. John Dunn
of ICCIDD. Supporters in the UK, Indonesia and Australia are also joining in
with the studies and exploration towards designing and developing a sustainable
solution for the supplementation of iodine, and the eradication of IDD, through
a safe water supply.
Long-term Sustainability
For the long-term sustainability of not only iodine deficiency problems, the
EBPP hopes to work with the health department to introduce a comprehensive program
to train up to three volunteers in each hamlet to provide a primary healthcare
advisory service. The objective is that it will lead to a greater understanding
and self-help. It will be directed mainly at mothers, to support them in maintaining
their own well-being and to ensure healthier births and better knowledge of
how to raise their children. It will cover all of the problems faced by women
of reproductive age. Moreover, the volunteers will also be educated in many
aspects of the numerous other health issues and common sicknesses, together
with the solutions that are available - literally on their own doorsteps. The
ultimate goal is to end up with three or four healthcare workers in each hamlet.
This program will be a development and improvement of the present Indonesian
government system, known as 'POSYANDU' with a community health centre. This
is a scheme that is supposed to be available in every hamlet throughout Indonesia,
where one person, usually male, is given a short training course on how to advise
on pre-natal and post-natal care, together with the basic requirements of an
infant up to five years old. Unfortunately this type of facility has not yet
been implemented in more than three of the hamlets in Desa Ban. It is also one
of the reasons why the EBPP program has had to be so carefully and sensitively
designed, because it is crucial to ensure that information infiltrates even
the most isolated families in this very scattered set of hamlets.
These are just some of the Sustainable Solutions that the EBPP has provided for the previously uneducated and malnourished communities of East Bali, where tangible hope has now replaced the despair that once dwelt in these people's hearts.
Rachel Lovelock is a freelance writer from the UK, resident in Bali.
[Ed. Note: I visited David Booth and the EBPP with Dr. Indraguna in late 2001. The project has been especially impressive because it emphasizes education and allows the community to improve its own health, including IDD elimination. ICCIDD is following the project closely and providing technical advice on iodine delivery.]
For more information about the East Bali Poverty Project, or to make a donation,
please see its home page www.eastbalipovertyproject.org; e-mail: info@eastbalipovertyproject.org.
KIWANIS INTERNATIONAL LOOKS BEYOND
THE WORLDWIDE SERVICE PROJECT AGAINST IDD
By Constance S. Pittman, M.D., Member of Kiwanis International IDD Steering
Committee, Member of ICCIDD Board of Directors and Professor Emerita of Medicine
at University of Alabama at Birmingham, Alabama, U.S.A.
Since its launching in 1994, The Kiwanis International Worldwide Service Project for the Virtual Elimination of Iodine Deficiency Disorders (better known as WSP-IDD) has raised 75 million dollars to promote universal salt iodization for the prevention of mental retardation and iodine deficiency disorders in the world, in partnership with the United Nations Children's Fund (UNICEF).
Kiwanis International is a large international organization focused on serving young people. It has many independent components and thousands of individual clubs, united loosely by their history and their dedication to service.
A previous article (IDD Newsletter 13:49, 1997) briefly recounted the history of Kiwanis International until it first launched WSP-IDD, and noted the immense organizational and cultural challenges posed by the then new project. The present article is a brief account of the commitment and generosity of the hundreds of thousands of members in the entire Kiwanis, completing WSP-IDD in unity. It offers the benefit of hindsight to better understand the impact of WSP-IDD on world health and on the Kiwanis itself and describes two new initiatives to promote the sustainability of IDD elimination.
About Kiwanis
The beginning of Kiwanis in the last days of 1914 was rather modest. It was
first organized by 35 businessmen and professional people at the Edelweiss Café
in Detroit, Michigan. The club was to be an association for men to exchange
ideas and promote business opportunities. The membership grew rapidly to 250
after six months, as the economy of the Midwestern United States was expanding,
driven by the automobile industry and radio communication. One of the founders,
Allen Simpson Browne, was the national organizer who viewed the clubs only as
an opportunity for social relations, business patronage and profit. By 1918,
Kiwanis clubs were established in most major areas of the United States and
Canada and claimed 10,000 members, encouraging the parent organization to change
its name from The National Kiwanis Club to Kiwanis International.
However, some of the founders believed that the clubs could prosper only if they also offered philanthropic services to the local communities. Slowly the idea of service gained ascendancy and the reformers organized to change the direction of Kiwanis. Nearly one thousand Kiwanians and their families from 150 cities of the U.S. and Canada attended the next Kiwanis Convention in Birmingham, Alabama during May 20 to 22, 1919. At that time, Alabama had only one Kiwanis club and Birmingham had never accommodated one thousand tourists at one time before, according to the Birmingham News. Fortunately, the Rotary Club and Civitan Club in Birmingham joined the Kiwanians to make the visitors feel welcome. J. Mercer Barnett, a lawyer from Mobile, Alabama was the International President that year. Kiwanis had no office space in Birmingham and had to borrow an office for the convention from the Rotarians.
As it happened, the Birmingham Convention was a great success for the supporters of service-oriented clubs. The reformers were able to persuade Browne to relinquish his job as an organizer and to sell all the Kiwanis clubs as well as the name, Kiwanis, for $17,000. Afterwards Kiwanis International gradually evolved into a major player in the service club movement. Today it has a quarter of a million members. The building of Kiwanis International Headquarters in Indianapolis, Indiana bears the motto: Serving the Children of the World. Kiwanians had resolved to establish clubs beyond North America after World War II but the expansion was slow. WSP-IDD attracted a great deal of interest abroad. Kiwanis clubs started to grow in numbers, especially in Europe and Asia/Pacific where IDD were familiar and often personal. These new club members are among the most generous donors of WSP-IDD.
Kiwanis International is an organization of individual clubs. Each club enjoys a high degree of autonomy. A club is only required to have a certain number of members of character, each paying small dues and conducting service projects of its own choosing. The members are responsible for raising funds to support the club's own operation and project. The club leaders attend district conventions to elect the district officers and they attend international conventions to elect the International President, other International Officers and Trustees. Until the introduction of Young Children: Priority One in 1991 each International President promoted a personal theme for club service. However the term of Kiwanis International President is only one year, so his service theme often faded away before it could gain any momentum.
Kiwanis International Foundation is a US 501 (C) (3) not-for-profit corporation and it has its own president, officers and trustees. Its mission is to assist Kiwanis International to carry out service programs. The Foundation has progressively increased its profile and enlarged its scope of activities since the start of WSP-IDD.
Kiwanis International has sponsored a large number of youth service clubs which are its most cherished projects. They include K-Kids Clubs (elementary school students), Builders Clubs (middle school students), Key Clubs (high school students), Circle K Clubs (college students), Aktion Clubs for the disabled and the Kiwanis Junior Clubs, popular among young adults in Europe. Together, their membership approximates or perhaps even exceeds the membership of the parent organization.
A youth club must be sponsored and mentored by a regular club of Kiwanis International. Thousands of Kiwanis clubs have chosen to sponsor youth service clubs as their service projects. In general a sponsor club helps the young people to initiate service projects of their own. The sponsors serve many different roles depending on the age and interests of the sponsored club. They often welcome the parents to join in as well. The sponsors may also help the young people in reading, schoolwork, sports, recreation, scouting and leadership, as the adults mentor by example. Often the adults provide career guidance, serve as counselors or just are friends. Many sponsor clubs raise money for scholarships.
The oldest sponsored program for young people is the Key Club International for high school students. It was first organized in 1925. It has approximately 235,000 members throughout North America, Latin America and Asia/Pacific. UNICEF, March of Dimes and other known service agencies form partnerships with Key Club International in recognition of Key Clubs' success and influence among young people. Each sponsored program has its own service projects and its own roster of presidents, officers and trustees who are often candidates for early admission to outstanding colleges. The members of all of these sponsored programs are part of the Kiwanis family. Given the complex and decentralized governance, the lines of communication among the different Kiwanis components and the individual clubs can be long. In recent years, the presidents of Key Club International and Circle K Club have seats on the Board of Trustees of the Kiwanis International in an effort to improve communication among these organizational components.
The Worldwide Service Project against IDD
In retrospect the success of WSP-IDD seems most amazing, as WSP-IDD was an entirely
new concept to the Kiwanians in the beginning. Its goal of raising $75 million
dollars seemed wildly unrealistic and its contractual relationship with UNICEF
was a break from past procedures. WSP-IDD had other obstacles to overcome. It
needed the support of a modern and on-line organization at the International
office and the Foundation. It had to compete for Kiwanians' interest and money
against other popular projects. WSP-IDD did not follow the club culture of local
autonomy in project choice and some local clubs felt they were pressed to be
more accountable to the International office.
At the same time Kiwanis International has a long and strong tradition for
service. The younger and newer members of Kiwanis are fascinated by the subject
of IDD. Most of the Kiwanians are awed by the dramatic benefit of iodization
on millions of people all over the world. Kiwanis' new partnership with other
service agencies and with salt industries is increasing Kiwanis' possibility
for service. No less important, Kiwanis International appreciates the wide acclaim
for WSP-IDD and it enjoys the new status of becoming an international service
agency itself. In the end Kiwanis International is branded by its service to
eliminate IDD.
Communication between individual clubs was limited before WSP-IDD, as the clubs
had no common service interest or shared experience. Some leaders in Kiwanis
International came to realize by the late 1980s that the individual Kiwanis
clubs were doing too many kinds of short-term service projects. As a result,
their aggregate services failed to make much impact beyond their local communities.
These leaders consulted with experts, sought out international service agencies,
including UNICEF, and examined various options. In the end they decided to offer
a common project for the entire Kiwanis family as an experiment. They tried
to keep the Kiwanis tradition of serving young people but to narrow the project
by focusing on the needs of children under five years of age, the critical period
for early development. Led by 1990-1991 International Presidents, Wil Blechman,
M.D., a rheumatologist from Florida, Kiwanis International adopted a service
project for the entire Kiwanis at the 1990 International convention in St. Louis,
Missouri. The project was named Young Children: Priority One (YCPO) and was
well received by the individual clubs.
Around that time, the World Health Assembly and the World Summit for Children
had taken place in 1990. Many national representatives at these meetings pledged
to eliminate malnutrition among children by the year 2000. The next year UNICEF
invited Kiwanis International to send two representatives, Dr. Wil Blechman
among them, to attend: Protecting the World's Children; Keeping the Promise
and Ending Hidden Hunger, two follow-up meetings convened in Montreal during
October, 1991. Kiwanis International and UNICEF signed an agreement at the meetings,
which allowed the two parties to develop a close relationship.
Soon UNICEF suggested to Kiwanis three choices for possible bilateral collaboration,
one being the global elimination of iodine deficiency disorders through universal
salt iodization. After months of evaluation and discussion with Dr. Peter Greaves,
then the UNICEF Senior Nutrition Officer, and led by successive International
Presidents between 1990 to 1994, Dr. Wil Blechman, William L. Lieber and Arthur
D. Swanberg, the Kiwanis International announced the adoption of a first worldwide
project against IDD at the 1993 International convention in Nice, France. The
Kiwanis International Board of Trustees signed a contract with UNICEF committing
Kiwanis to undertake this immense service project. It was named Kiwanis International
Worldwide Service Project for the Virtual Elimination of Iodine Deficiency Disorders,
or WSP-IDD. . It was intended to be a worldwide project for the whole Kiwanis
family. The adoption of WSP-IDD was approved by the Kiwanis International House
of Delegates at the1994 Kiwanis International convention in New Orleans, Louisiana.
The contract committed Kiwanis International to form a close Kiwanis-UNICEF partnership to raise $ 75 million dollars to fund WSP-IDD through UNICEF exclusively. The project was to be finished by the year 2000, together with the completion of projects on the elimination of other forms of micronutrient malnutrition. The envisioned role for Kiwanis International was limited initially to advocacy to promote universal salt iodization and to raise money to fund WSP-IDD.
According to the protocol, each recipient country is required to implement a national program for IDD elimination in order to qualify for receiving WSP-IDD money. The proposal for funding is submitted by the responsible government agent to UNICEF for evaluation of feasibility and need. Those proposals rated favorably are then advanced to the Kiwanis Worldwide Service Allocation Committee, which has the final authority to release the requested WSP-IDD funds to UNICEF.
In the later years of WSP-IDD this funding protocol became more flexible for pragmatic reasons. For instance, the WSP-IDD fund was used to support iodization for the victims of Chernobyl accident in Ukraine. The WSP-IDD fund had once supported a private experiment studying iodization of irrigation water in the desert.
The WSP-IDD campaign is finally closing in 2002. Accounting by countries rather than by dollar amounts, Kiwanis International Foundation, (WSP-IDD), has supported 98 country proposals, with 86 of them fully funded by the end of 2002. Fifteen more country proposals have been approved but not yet funded, for lack of money. Nearly half of the early grants were allocated to countries in Africa, while half of the recent grants are directed to countries in Eastern Europe and to the republics of the former Soviet Union. The Kiwanis-UNICEF partnership remains close and it is planning to raise more money to fund the remaining approved but unfunded country proposals.
At the beginning of WSP-IDD, very few Kiwanians understood iodine deficiency either as a medical problem or as a permanent global affliction that can be prevented. There followed a hiatus of well over two years of organization building and member education. Every club was encouraged to have an IDD meeting, to invite a speaker who could explain WSP-IDD or why a person needs a spoonful of iodine in his lifetime. There were IDD speeches at conventions and IDD articles in the club bulletins and district newspapers. The monthly magazine, Kiwanis, which has been a major education tool of Kiwanis International, carried articles about IDD and photographs of people with goiters in almost every issue. The better IDD articles were even circulated among the club secretaries on their e-mail.
There was no roadmap for an IDD campaign and most Kiwanis clubs just collected money through whatever means were available to them. Kiwanians were energized by WSP-IDD and the knowledge that iodized salt can prevent mental retardation in children. They enjoyed the experience of working together and comparing experience with fellow Kiwanians.
The young people have been the most enthusiastic and generous supporters of WSP-IDD. Once some middle school students from a Builder Club in North Carolina raised thousands of dollars worth of pennies for WSP-IDD, attracting the attention of the "20/20" TV Program. These students appeared with the host Hugh Downs on his last 20/20 show. Later they also appeared in an interview by Hugh Downs in front of thousands of Kiwanians and guests at a convention. The Key Club International raised $2.2 million dollars for WSP-IDD, which they chose to donate to India.
In the later years of WSP-IDD, Kiwanians became more active through personal visits to salt plants. Small groups traveled around the world to see IDD firsthand in the developing countries. Some Kiwanians found there were still villages along the southern Silk Road two years away from easy access to iodized salt in the year 2000. WSP-IDD, through UNICEF, provided money to produce a plastic floating device containing a slow release capsule of iodine which the villagers put in their crock of rock salt and water used for cooking. Its green color fades when iodine is depleted. Each family pays 2 REB a year ($ 0.24) for an iodine releaser which provides enough iodine for a family of five for one year, or 150-300 mcg of iodine per person per day. A group of Kiwanians visited a salt mountain over 37 miles long near the northern Silk Road where the local villagers transported the free un-iodized rock salt home by horse cart. The members become enthusiastic supporters of WSP-IDD after one of these first hand experiences.
The Kiwanis International has a long tradition of raising money for service projects. They provide hundreds of thousands of dollars yearly, not by taxation but through voluntary donations. They raise money by countless kinds of project, large or small, by individual enterprise or by club activity. The Key Club International raises a lot of money each Halloween by their project of Trick or Treat for UNICEF. Many Kiwanis clubs sell salt during their weekly meeting. They can collect 50 cents for WSP-IDD by selling one can of Morton Salt for US $1.00. These projects to raise money are part of membership education but they also provide fellowship, fun and a feeling of participation.
Kiwanis International Foundation has several levels of honor like the Hixson Fellowship, the Tablet of Honor and the Founders Circle. The members purchase special pins for these honors, either for themselves or for their friends while making donations of $1,000 to $25,000 to WSP-IDD. WSP-IDD is fortunate to have the support of very generous donors. Some are individuals like Ted Turner. Some are corporations like Morton Salt. WSP-IDD has received donations from service organization like the U.S. Fund for UNICEF and charitable foundations like the Bill and Melinda Gates Foundation. Some of these donations are small and some are large. Some are simple gifts while others must be matched.
Together these examples of generosity helped WSP-IDD to reach its goal of raising
US $75 million dollars.
Kiwanis International has used partnership as a major outreach strategy for
WSP-IDD. The organization has individual partners like Sir Roger Moore, known
for his role in James Bond movies, who attracts members and adds publicity for
WSP-IDD by serving as its Honorary Chairman for a number of years. Kiwanis International
also has corporate partners; among them, Morton Salt has been a partner for
the longest time and is also a large donor to WSP-IDD. Other partners come from
U.S. government agencies, including the Centers for Diseases Control and Prevention
and U.S. Agency for International Development, and still more from major service
organizations like UNICEF, WHO, MI and ICCIDD. Certainly there would have been
no WSP-IDD without the partnership with UNICEF. Recently, some Kiwanis leaders
have been invited to be members of their Boards. Dr. Wil Blechman, Eyjolfur
Sigurdsson and Robert McCurley have been members of the Board of Directors of
ICCCIDD. Robert Moore is serving on the Board of Directors of Micronutrients
Initiative. Dr. Juan Torres, Jr. will take the place of Nettles Brown to represent
Kiwanis International as a member of the Network for the Sustainable Elimination
of Iodine Deficiency, a recent partnership of international service organizations
and salt industries.
The United Nations General Assembly convened a Special Session for Children in New York City in May, 2002, attended by most national governments of the world as well as by UNICEF, WHO, ICCIDD and other international service organizations, including Kiwanis. There, Kiwanis International was recognized for the transforming contribution of WSP-IDD to help 70 % of the world's families gain access to iodized salt.
The future
Not surprisingly, Kiwanis International evolved and changed during the decade
from 1993 to 2003. It now conducts its affairs with the telecommunication technology
of the 21st century and makes future plans embracing clubs that are sprouting
on distant continents as well as those in North America. These changes have
accelerated since the recent appointment as Executive Director of Eyjolfur Sigurdsson
from Iceland, a past Kiwanis International President (1995-1996), successful
builder of the Europe/Central Asia/Africa Division of Kiwanis International,
and a recent ICCIDD Director. To facilitate administration, services and growth,
he plans to add new regional divisions for Asia/Pacific and Latin America in
addition to the current North America and Europe/Central Asia/Africa Divisions,.
The roadmap also includes the publication of Kiwanis magazine, the organization's
official publication, in six languages (English, French, Chinese, German, Spanish
and Italian).
The current membership of Kiwanis International includes increasing numbers of women and minorities. Kiwanis International began to accept women members in 1987. Now 20 to 30% of the club offices are held by women. Some have become district governors and one is on the Kiwanis International Board Trustees. African-American as well as candidates from Australia, Iceland, Canada and Philippines were elected to the office of Kiwanis International President during the past decade. Likewise, the regions of rapid growth of members and clubs are Europe and Asia/Pacific. These new clubs also contribute to a greater diversity of club culture and innovation of services. They have been strong advocates and generous donors for WSP-IDD.
The current number of Kiwanis youth members in the sponsored programs nearly
matches that of Kiwanis International, totaling approximately half a million
members in the Kiwanis family. The young people continue to be fascinated by
the dramatic outcome of WSP-IDD. The Key Club International, an organization
of high school students already donated $ 2.2 million dollars to WSP-IDD. It
has now pledged an additional $ 700,000 to the new 113 K campaign to fund the
remaining unfunded country proposals and protect 113,000 children born daily
in those regions.
Kiwanis International remains committed to IDD elimination through universal
salt iodization. The commitment was evident during the recent annual convention
and by two new initiatives to raise more money for IDD elimination. The 88th
Annual Kiwanis International Convention was held in Indianapolis, Indiana in
June, 2003. Over seven thousand Kiwanis International members and guests gathered
in the Indiana Convention Center to enjoy fellowship and visit the exhibition
booths that promote a great variety of service opportunities. The Kiwanis International
Foundation, which was recently assigned to oversee the new initiatives to raise
money for IDD elimination, put up a large booth well stocked with IDD literature
and videos. The booth was full of visitors every day of the convention. They
were curious about the new 113 K Campaign for IDD. The new IDD Steering Committee
met for the second time to plan launching of the new 113 K Campaign. The 2002-03
International President, Dr. Juan F. Torres, Jr., who is an endocrinologist
and nuclear medicine specialist from the Philippines, added a new one-day offering
at the Indianapolis convention, the International Conference on Children. Dr.
Torres led the program with a review of the history and the successful outcome
of WSP-IDD. Other speakers at this very successful conference were Dr. Kul Gautam,
the Deputy Executive Director of UNICEF, Dr. Wil Blechman, one of the founders
of Young Children: Priority One, and Dr. Bill Dietz of the Centers for Disease
Control and Prevention, an expert on obesity in young people.
The last two days of the Indianapolis convention were devoted to the affairs
of the House of Delegates, where 4,388 duly accredited Delegates from all Kiwanis
clubs were seated with access to simultaneous translations in Spanish and French.
They gathered to elect officers and trustees and to vote on amendments and resolutions.
The Indianapolis convention elected Robert L. Moore of Florida, an attorney
and a member of the Board of the Micronutrient Initiative, to be the Kiwanis
International President for 2003-04. The Indianapolis convention also passed
a resolutions which pledges to achieve the goal of eliminating iodine deficiency
disorders.
Kiwanis International Foundation announced at the Indianapolis Convention that
it would continue to accept future donations specified for WSP-IDD, and it was
also planning two new initiatives. The first one is called, the 113 K Campaign.
Kiwanis International will work to raise additional $ 3 million dollars by 2005.
This money will be leveraged by matching funds from Kiwanis partners to become
a total of US $ 9 million dollars. It will fund the remaining approved but unfunded
country proposals and offer protection from iodine deficiency to an additional
113,000 children born each day.
The second campaign is a permanent one called the Iodization Sustainability
Fund, which the Kiwanis International Foundation will set up. Donations will
be collected to build up a permanent endowment, and its income will support
IDD monitoring, education, advocacy and other necessary activities to sustain
iodization and eliminate IDD globally.
All of us welcome these initiatives and wish for their early and successful
completion.
Resolution Passed at Kiwanis International Convention, June, 2003
113,000 Reasons to Complete Our Worldwide Service Project Pledge
In 1994, the Kiwanians of the world pledged to help virtually eliminate iodine
deficiency disorders (IDD) worldwide. Kiwanis made a commitment to wipe out
this scourge responsible for preventable mental retardation, physical disabilities
and death. All Kiwanis clubs and Kiwanians were urged to do their part to ensure
the success of this ambitious endeavor. By 2000, 70 percent of households in
developing countries were using iodized salt and in 2002, Kiwanis International
achieved a goal with worldwide impact raising more than US $ 75 million in contributions
and pledges. This great work continues across the globe.
As we celebrate our success, IDD is not virtually eliminated, and universal
iodization is not yet a reality, 113,000 infants are born each day under the
threat of diminished mental capacity and worse. There are 113,000 reasons why
Kiwanis clubs and Kiwanians need to join forces to collect our pledges and to
complete our mission.
THEREFORE, BE IT RESOLVED THAT:
The members of Kiwanis International and all its sponsored organizations join
forces in a continued commitment to achieve our goal to eliminate the leading
cause of diminished mental capacity, and iodine deficiency disorders. This was
our mission in 1994, and we will complete the mission by 2005.
AND BE IT FURTHER RESOLVED THAT:
Kiwanis made a commitment to improve the lives of millions of the world's children,
and we will achieve that goal.
IODINE NUTRITION IN THE AMERICAS - 2003
This article is the latest of many in the IDD Newsletter that describe iodine nutrition in the Americas. An overview appeared two years ago (vol. 17(1):1-9, 2001). The most recent issue (vol. 19(2):31, 2003) briefly reported a one-day symposium sponsored by ICCIDD as a satellite to the Latin American Thyroid Congress near Cordoba, Argentina. In it, ICCIDD national coordinators and others described activities in their countries; some of these are summarized below.
Argentina - Dr. H. Niepomniszcze, ICCIDD National Representative in Argentina, recently described the work of the Argentine Federation of Endocrine Societies in monitoring iodine nutrition (IDD Newsletter 19:11-12, 2003). That article provided data on the provinces of Chaco (median urinary iodine 136 mcg/L), and Catamarca (median urinary iodine 152 mcg/L). Two cities from the Patagonian coast had median urinary iodines of 133 and 314 mcg/L, respectively.
At the Cordoba meeting, Dr. Niepomniszcze and colleagues from the Argentine Federation presented further data, as follows.
La Pampa (2002) - Among 460 students from two communities, the goiter prevalence was 10.6% in Santa Rosa (the capital) and 17.6% in Ataliva Roca (a rural community). Data on iodine content in urine and salt are not available.
San Juan (2000) - Endemic goiter was severe in the province before the mandatory use of iodized salt, with goiter prevalence greater than 30% and urinary iodine levels below 24 mcg/day. The investigators examined 616 students from three localities, with the following median urinary iodine concentrations: San Juan (capital), 95 mcg/L; Punta del Medano (rural), 111 mcg/L; and Colonia Fiscal (rural), 120 mcg/L. The corresponding goiter prevalences were 8.5%, 9.7%, and 11.7%. Samples of salt brought by students from their homes were from brands that contained adequate iodine.
In a further study of Colonia Fiscal by Dr. J. D. Morando et al., the serum TSH of the children with goiters was significantly higher than was found in a control group (2.51 ± 1.43 vs 1.62 ± 1.13 mU/ml); the goiter prevalence was significantly higher in children who consumed well water compared with those who had running water, and a familial incidence of goiter was noted. These differences did not occur in Punta del Medano. The authors suggested that goitrogens from well water, family history, and iodine nutrition might play roles in Colonia Fiscal.
Rio Negro - The goiter prevalence among 793 children in two communities was 4.3% in San Carlos de Bariloche and 8% in El Bolson, with median urinary iodine levels 134 mcg/L and 163 mcg/L. respectively. Salt samples showed an optimal level of iodization. In two communities of the Alto Valle of the same province, the goiter prevalences in schoolchildren were 6.9% and 5.6%, respectively.
Jujuy - This province previously had a high goiter prevalence. In two communities, San Salvador (the capital) and Tilcara, palpation of a total of 692 schoolchildren showed goiter prevalences of 4.1% and 10.9%, respectively. Samples were taken for iodine analysis of urine and salt but have not yet been reported.
Santa Cruz - A total of 820 schoolchildren in Rio Gallegos (Atlantic coast) and El Calafate (mountainous region) had goiter prevalences of 3.1% and 5.7%, respectively. Samples have been collected for analysis of iodine in urine and salt, but not yet reported.
Mendoza - Neck palpation in 783 schoolchildren found goiter prevalences of 5.2% in San Rafael, 5.7% in General Alvear, and 8.5% in Villa 25 Mayo.
Cordoba - Dr. Mereshian and colleagues, noting a reported high prevalence of congential hypothyroidism in Cordoba, studied 79 pregnant women and found that 48% had goiter. Median urinary iodine levels were 14.8 mcg/g creatinine in the second trimester, and 13.8 mcg/g in the third. The authors noted the high prevalence of iodine deficiency in this group and recommended routine measuring of urinary iodine in pregnancy and supplementing where necessary.
Bolivia - Dr. M. C. Daroca and Ms. M. De Yale discussed recent developments in Bolivia. Although the country was declared free of iodine deficiency in 1996, subsequent conditions have led to its return. Contributing factors were a general economic crisis in the country and reduction of financial support for the program. Two problems had a major negative impact on the strategies of the program, especially salt iodization. The first was the continuing prevalence of primitive technology for production of the salt among the great majority of salt producers. The second was the difficulty in going from a vertical program controlled by the Ministry of Health to a decentralized one where responsibly was diluted from one institution to nine Departmental services of health and 314 municipal governments. Reorganization of the program and especially the control of salt iodization are among the many circumstances that have changed over more than four years. The country is now working on adjusting to these new conditions, with local strategies for control of salt iodization and implementation of a strong communication program, appropriate to the local level, that emphasizes the consumption of iodized salt. Additional actions are epidemiologic vigilance through sentinel communities and construction of a map showing communities at risk.
Brazil - Drs. Heijblom and Carvalho (Ministry of Health) assessed the household use of iodized salt and knowledge regarding iodine deficiency in a rural part of the Federal District in Brazil. Such communities pose a high risk because of much immigration and the use by humans of salt graded for livestock and not assessed for iodine content. Livestock salt in Brazil should be iodized to 10 ppm but it is not regulated by any government agency. The authors collected questionnaires and samples of salt currently used in households. They found that 19% of the samples did not have any iodine, and that 81% contained iodine, but quantities were not established according to law (40-100 ppm). On the questionnaire, 48% of respondents had no knowledge about iodine deficiency, and 71% knew of no relationship between iodine deficiency and iodized salt. Of those using livestock salt for their families, 37% did so because it was easier to obtain, 19% said the cost was less, and 6% said the salt would be the same as salt for humans. Another 31.2% stated that they used livestock salt if they ran out of iodized salt. These results show the need to establish a policy on iodine deficiency and its prevention. The people should abandon the use of livestock salt that has not been graded for human consumption. Despite the low prevalence of goiter in the country, lack of knowledge regarding iodine deficiency and high-risk behavior, such as using livestock salt, may increase the prevalence of goiter in the future.
In another communication, the Ministry of Health reviewed various actions against iodine deficiency. The required iodization of salt and adequate legislation to decrease the prevalence of goiter have been established since 1953. Studies in representative sections of the school population from areas of endemic goiter were carried out in the years 1955, 1974, 1995, and 2000, and found goiter prevalences of 20.6%, 14.1%, 1.3%, and 1.4%, respectively. Between 1955 and 1974, the prevalence decreased 6%, although there was no oversight in the production sector or educational campaigns for consumers. Awareness campaigns began in 1980, and led to a significant reduction in goiter prevalence by 1995. In 1999 the Ministry of Health created an inter-institutional commission for prevention of iodine deficiency, which it coordinated. The commission discusses strategies and actions to decrease iodine deficiency. It implemented the national program of health inspection in factories that produce salt for human consumption, and promoted training programs in best practices for salt iodization.
The last survey (ThyroMobil) showed a virtual elimination of endemic goiter
in Brazil and also demonstrated high levels of iodine concentration in urine.
This led the government in 2003 to decrease the iodization level to 20-60 ppm.
In the current year, the government will undertake education of health professionals
in the primary care setting and conduct a radio campaign in all of Brazil for
education about iodine deficiency. The experience shows that proper fortification
of salt, health inspection, communication and education of the population, and
joint work with the private sector provide the foundation for goiter reduction
in this country.
Chile - Drs. Muzzo and Leiva in 1994 described four zones of the
country where goiter remained below 10%, salt was adequately iodized according
to legislation at that time (100 ppm), and urinary iodines were high. These findings led to a lowering of the iodization level to an average of 40
ppm in the year 2000. To assess the effects of this change the authors studied
3,712 students in four areas, Calama, Santiago, Temuco and Punta Arenas in 2001.
The goiter prevalence was 6.4% without differences among the four locations.
The concentration of iodine in the salt ranged from 25.4 to 36.2 ppm, again
without clear differences. However, urinary iodine excretion was still very
high: 2,838 mcg/g of creatinine in Calama, 1,318 in Temuco, 701 in Santiago,
and 407 in Punta Arenas. Despite the change in regulations, the urinary iodine
levels decreased only in Punta Arenas and remained high in the other three sites.
The authors called for further investigations.
Cuba - Dr. D. Zulueta and colleagues (Institution of Nutrition) discussed the control program initiated in 1993. The magnitude of iodine deficiency was assessed in 1995 by analysis of urinary iodine in schoolchildren. At the national level, deficiency was slight, and only in the mountainous areas was it severe. The country started monitoring the production, distribution, and consumption of iodized salt, providing information for adjusting levels of iodine and changes in procedure. The content of iodine in the salt for human consumption in the country is assessed from production to the consumer both by titration and by kits. Mean values reach 22.45 ppm at the level of production, and the percent of samples with adequate levels was 79.8% on distribution and 73.4% in homes. A campaign of social communication was carried out to gain the acceptance of the product by the people and a Ministerial Resolution required fortification at adequate levels of iodine. Cuba plans to request certification as a country free of IDD in 2005.
Ecuador - Dr. V. M. Pacheco and Dr. P. Canelos (Ministry of Public Health) reviewed the use of sentinel sites for assessing the impact of iodized salt. They compared urinary iodine values from the sentinel sites with those from other populations in the Sierra region. The median urinary iodine for the sentinel sites was 146 mcg/L (n = 495) compared with 165 mcg/L for the other regions (n = 657). When examined in categories of < 100 mcg/L, < 50 mcg/L, and fractions from 100-199 mcg/L, there were no differences; however, of the samples > 300 mcg/L, those from the sentinel posts were higher. A total of 13.5% of samples were > 300 mcg/L, indicating the need for better control in following the mandatory levels for iodine content.
The same authors related urinary iodine concentration and the legally mandated levels of iodine in salt. The regulation required 50-100 ppm from 1968 to 2001, then lowered to 30-40 ppm in 2001, and modified to 30-50 in 2002. For the years 2000, 2001, and 2002, the median urinary iodines were 260 mcg/L, 132 mcg/L, and 146 mcg/L, respectively. For the same three years, the fractions of salt samples > 15 ppm were 99.5%, 90.9%, and 94.9%, respectively, while the fraction > 50 ppm was 20.5%, 8.7%, and 6.7%, respectively. The authors concluded that for Ecuador the standard of 30-50 ppm, although different from the 20-40 ppm recommended by WHO/UNICEF/ICCIDD, satisfied the criteria for sustainable elimination as a problem of public health and that the risk of iodine excess was low and acceptable.
Guatemala - An abstract by Dr. Erik Boy and colleagues reviewed the country's history of salt iodization, its first food fortification program. In 1967 Guatemala demonstrated to the world that crude marine salt could be fortified with potassium iodate and that this prevented and controlled IDD. Fifty years ago goiter affected 38% of schoolchildren. An iodization law was implemented in 1959 and produced immediate reduction in goiter. By 1962, when 90% of the salt contained at least 15 mg iodine/kg salt, the goiter prevalence had been reduced to 14%, then to 8% in 1964 and to 5% by 1967, indicating that the problem was under control.
Unfortunately, the program was neglected, and by 1979, the goiter prevalence reached 11%, coinciding with a reduction in the fraction of adequately iodized salt to 20%. The situation was worse in 1987, when the goiter prevalence reached 20% and only 11% of the salt was iodized. The government, UNICEF, and INCAP/PAHO combined forces and reactivated the program through a general law of food fortification in 1992, with regulations for iodized salt in 1993. Although the goiter prevalence has not been measured in recent years, it is estimated to now be less than that found in 1987. However, the fraction of salt adequately iodized at the household level (40-50%), shows that iodine deficiency continues to be a problem of public health in the country. This deficiency affects all the population, unrelated to geographic location and economic position, and salt without iodine is now encountered in all regions. The achievement 33 years ago of providing sufficient iodine to the population through iodized salt has not been maintained, and now, at the beginning of the 21st century, IDD continues to be a problem of public health in the country.
Mexico - Dr. Gonzalez Trevino and colleagues reviewed available studies. The first publication was over 100 years ago, and noted especially the region of Michoacan and Guerrero, the states crossing the Sierra Madre Oriental, Occidental, Istmo and Sierra de Oaxaca. Thirteen studies have appeared since 1962, showing that goiter has decreased in the last 40 years through the implementation of iodized salt. By 2001 the prevalence had decreased to 2.3%. The ThyroMobil visited 23 communities and found a median urinary iodine excretion of 176 mcg/L. Of the salt samples, 74% had at least 15 ppm iodine. From 1992-1997, the consumption of iodized salt has increased to 80% of the population. The current economic crisis has especially affected the population with iodine deficiency. Programs of control should be directed to children and mothers among rural and indigenous peoples with nutritional problems, including iodine deficiency.
S. A. Moreno Huitron of the Mexican Association of the Salt Industry described iodized salt in the country. A law in 1942 mandated iodized salt, especially in the zones with high goiter prevalence. However, in 1991, only 24% of the salt for human consumption complied with the specifications for iodine content, leading to an intensified collaboration between the sanitary authorities and the Industria Salinera Mexicana to diminish iodine deficiency by consumption of adequately iodized salt, especially in the most deprived sectors of the Mexican population. As a result of these actions, Mexico now is classified by UNICEF as a country with more than 90% of its population consuming iodized salt, and the benefits can already be observed. The median urinary iodine excretion was in an acceptable range and the goiter incidence has decreased in children 6-12 years of age. The Mexican salt industry is very proud of its contribution to this success. It recognizes the necessity of continued cooperation with the sanitary authorities and civil society, and has pledged its ongoing support.
Panama (presented by M. Mas) - The goiter prevalence of 32% in 1958 had decreased to 9.8% by 1999. In 1993, the Ministry of Health developed a national plan of action for control, with support from Kiwanis, UNICEF, and PAHO, and from the salt industry, education, agriculture, and other sectors. The components of the project are: monitoring of iodization of salt for human and animal consumption; monitoring of iodine nutritional status; education and communication; special attention to patients with goiter; and adjustment and revision of the regulations as needed. Currently, the volume of production of iodized salt is sufficient to satisfy the demands of the population. More than 95% of the salt at production meets the iodization standard established by legislation. Ninety-five percent of the salt in the retail market contains more than 15 ppm iodine. The country has legislation and regulations for production and marketing of salt for both human and animal consumption, a system for monitoring nutritional status, and laboratory access with internal and external controls. A permanent system of information monitoring is in place. The salt industry has pledged to continue the universal production of iodized salt. An expert committee from ICCIDD, PAHO, UNICEF, and the Network for Sustained Elimination of IDD concluded in 2002 that iodine deficiency as a public health problem is virtually eliminated in Panama, with good prospects for its sustainability [see IDD Newsletter 18(2):27-30, 2002].
Paraguay (Dr. Jara and colleagues) - Results from the ThyroMobil have already appeared in the IDD Newsletter (17(1):3, 2001), reporting a median urinary iodine of 258 mcg/L, and a median salt iodine content of 46.7 ppm. These data showed great improvement over those of previous reports, e.g., in 1988 the prevalence of goiter by palpation was 48% and median urinary iodine was 72 mcg/L. Recent data from the National Institute of Food and Nutrition (INAN) show that the fraction of adequately iodized salt at the market level has now reached 91.4%.
Peru - Dr. Pretell and colleagues reviewed the sustained elimination of IDD in Peru. Progress in this country has been frequently documented in the IDD Newsletter (most recently 17(1):4, 2001). The strategies have included development of a work plan, an educational program, coverage of the population at high risk with iodized oil at the beginning, aggressive increase in the production and consumption of iodized salt, and monitoring and surveillance of iodine in salt and urine. The program has received steady political and financial support from the Ministry of Health. The production of adequately iodized salt (> 15 ppm) has been maintained at greater than 90% for the last seven years, and more than 90% of homes consume it. The median urinary iodine has been in the normal range since 1995 (139 mcg/L) to the present (180 mcg/L). Thus Peru has attained the sustainable elimination of IDD with a control program that can serve as a model for other countries. External confirmation has been requested by the government.
Uruguay - Dr. C. Salveraglio reviewed the history of a National Honorary Commission for Study and Prophylaxis of Endemic Goiter and Iodine Deficiency, which began in 1953. Initially, its members examined 70,000 children, showing that the highest intensity of goiter was in the northern zone, at 20%, progressively decreasing towards the south. This was followed by a law in 1963 establishing norms for prophylaxis using iodized salt, which was mandatory in the northern part of the country. From the beginning, major emphasis was put on constantly educating the national medical authorities and all of the population about IDD and iodized salt. Subsequent studies showed the disappearance of visible goiter and great diminution in palpable goiter. Urinary iodine levels in 1994 showed that iodized salt was an adequate method to achieve sufficient levels, but that the parts of the country where it was not obligatory showed mild deficiency, and the mandatory use of iodized salt was extended to the entire country. The Chair of Clinical Analysis from the Faculty of Chemistry periodically assesses the level of iodine in salt. In 2002, the Ministry of Public Health designated a chemical pharmaceutical inspector to be responsible for control of compliance with the iodization law. Also, the country has carried out systematic detection for congenital hypothyroidism by determining TSH levels in the blood of all newborns, and this has permitted the diagnosis of 20 new cases per year and avoidance of its severe consequences. After 50 years of uninterrupted work, the Commission hopes to have Uruguay declared free of iodine deficiency disorders.
Venezuela (presented by Dr. J. L. Cevallos and colleagues) - An external evaluation team in late 1999 declared the country virtually free of iodine nutrition disorders. The National Institute of Nutrition (INM) of the Ministry of Health and Social Development had coordinated the program with several groups, including the National Council for Control of IDD, the National Commission for Iodization and Fluoridation of Salt, and the Venezuelan Association of Salt Producers. Recent activities from several sources included measurements of urinary iodines in 2001, from 1,600 schoolchildren in three Andean states, showing a median of 291-382 mcg/L; only 0.42% showed less than 50 mcg/L. In a neighboring state (Lara) the median was 227 mcg/L. In Apure in 2002, of 240 children, the median was 321 mcg/L. In the Andean provinces in 2002, 94.4% of salt samples in the market contained 40-70 ppm iodine. In 2000 and 2001, 90% of the salt samples taken from households were > 15 ppm iodine. The national consumption of salt in 2001 was about 11 metric tons per month, and 9,800 in 2002, 80% being iodated. The program has conducted rural educational programs such as cultural activities, training sessions for teachers on IDD, and instructions for salt producers on quality control of iodization. It has also provided messages for radio, TV and the press. Salt excretion in Andean schoolchildren was 9.3 grams per day and in non-Andeans, 8.3 grams per day. Current priorities include continued monitoring, maintenance of education and training programs, and overcoming difficulties in acquiring KI and KIO4.
Overview
The Americas have shown some of the most impressive progress against IDD of
any region in the world. However, the goal of optimal iodine nutrition is not
yet achieved, and some earlier successes are fading. A review by ICCIDD reports
the following:
This tabulation shows that some countries are still deficient and that the status of many is not well established. The classification is based principally on urinary iodine data. The number of countries regarded as "likely sufficient" is large, because reliable national information is not available. Only a few have adequate systems for monitoring iodine nutrition, e.g., Peru. Several countries, e.g., Bolivia and Guatemala, are now deficient after previously achieving sufficiency. Other countries, e.g., Venezuela and Colombia, do not appear to be keeping their commitments to support national IDD programs. As personnel change in governments and agencies, iodine nutrition becomes less visible, complacency sets in, and deficiency may well return, even in the countries that now seen solidly sufficient.
Declarations on IDD
A landmark meeting in Quito in April 1994, attended by high-ranking officials
from governments, UNICEF, PAHO/WHO, and ICCIDD, reviewed progress, and issued
a declaration, signed by representatives from 23 countries in the region (IDD
Newsletter 10(2):13-22, 1994). It noted that a large proportion of the people
living in the region risk iodine deficiency, recognized the severe consequences
of iodine deficiency on the development of children, and pledged that:
The United Nations General Assembly Special Session in May 2002 (IDD Newsletter 18(2):17-19, 2002) included a pledge by agencies and governments, including those from Latin America, to achieve the virtual elimination of iodine deficiency from the world by the year 2005.
Conclusion
Clearly, much needs to be done if the goal is to be reached. PAHO/WHO, UNICEF,
ICCIDD, and others are conferring with governments on ways to accelerate progress.
In discussing the presentations at Cordoba with the National ICCIDD Coordinators, Dr. Eduardo Pretell, ICCIDD Regional Coordinator and one of the meeting's organizers, says, "Compared to other regions in the world, the American Region is the one that has made the most impressive progress towards the elimination of IDD, but it concerns me that only a few countries have regular monitoring programs for iodine in salt, and even less for iodine in urine. Also of great concern is the decrease or lack of governmental support for control programs in some countries.
"We must not repeat the errors of the past, when apparent success led us to complacency and the iodized salt programs broke down. Now, our actions must ensure that our progress so far is sustained by regular monitoring of iodine nutrition and iodized salt. In accomplishing this task, the role of all - ICCIDD and its partners - is very important, and I encourage them to support their governments in promoting sustainable elimination of IDD."
ICCIDD PARTNERS WITH BHARAT SCOUTS AND GUIDES FOR IDD ELIMINATION IN INDIA
For more than five years, Dr. Chandra. S. Pandav, Regional Coordinator for the South Asia region, has spearheaded a collaboration between ICCIDD and the Bharat Scouts and Guides (BSG) to promote greater awareness of IDD and the value of iodized salt in India. Others on the ICCIDD team - Professor M. G. Karmarkar, Ms. Saroja Narayanan, Dr. Denish Moorthy and Mr. Peter Parekattil - were also involved in these activities.
The Boy Scout movement began in the U.K. in 1907, and was introduced in India the following year. The Girl Guide movement began in India in 1911. Prominent national leaders, including former Prime Minister Nehru, encouraged these activities. Several different organizations combined in the early 1950's to form the Bharat Scouts and Guides. They numbered about 400,000 in 1950 and are now close to four million. The organization is voluntary, non-political, non-sectarian and non-communal, devoted to developing character in the rising generation and to promoting a feeling of selfless service to the country. The general members are mostly between 8 and 25 years old, in addition to adult leaders.
BSG has its National Training Center at Pachmarhi for teaching its leaders and conducting specialized courses and workshops. It also houses a National Adventure Institute to promote appreciation of nature through adventure activities. Thousands of young people have participated in its programs.
Recent conferences and workshops on IDD in India have emphasized the need for incorporating various groups into the NGO network and for consolidating existing ones, in order to promote sustainable IDD elimination. The participation of civil society in this campaign has become increasingly attractive, and experience has shown that a program like IDD elimination, mostly planned and implemented by public health professionals, can be effectively supported by other systems in the network. To this end, ICCIDD has entered into a partnership with BSG and its national network of students.
An important result of this collaboration took place in 1997-98, when ICCIDD and BSG organized a joint program for collection and analysis of salt samples at the national level, using both the titration method and field-testing kits. Also, BSG, represented by Mrs. Pushpa Nadkarni, Joint Director, participated in a sensitization workshop on IDD held at the All India Institute of Medical Sciences (AIIMS) and sponsored jointly by UNICEF, ICCIDD, and AIIMS in March 2002. Later, ICCIDD participated in the BSG camps held in New Delhi, Pachmarhi (Madhya Pradesh), Raipur (Chattisgarh), and Gadpura (Haryana), in addition to programs at the National Headquarters in New Delhi.
The regular interaction of ICCIDD with BSG is spreading the message for IDD elimination widely among schoolchildren and BSG officials. The present Director, Mr. D. L. Sharma, is an enthusiastic promoter of the collaborative program, and sees it as a great opportunity for both ICCIDD and BSG to contribute jointly to India's development.
Recently, an ICCIDD team composed of Dr. S. Srinath, and Mr. Pritam Singh visited the Bharat Scouts and Guides' National Training Center at Pachmarhi, Madhya Pradesh, as part of this continuing relationship. They met with a total of 545 Scouts and Guides and BSG officials, made presentations in several different courses and programs, and held interactive sessions with various groups. Their program offered brief introductions to ICCIDD and the team, a screening of the film "Trishna" on IDD in India, a discussion highlighting the important aspects of IDD and the role BSG can play in the campaign against IDD in India, demonstrations of testing the iodine content of salt with kits, question and answer sessions on various aspects, and exhibition of books and posters on IDD. These sessions impressed on the participants that IDD and the consumption of adequately iodized salt are important, and they pledged to spread awareness and participate wholeheartedly in the campaign against IDD in society.
The Joint Director of Scouts, Mr. J. Sukumara, met with the ICCIDD team and
discussed large-scale involvement of the BSG in the program to eliminate iodine
deficiency and monitor iodized salt. He proposed introducing a "proficiency
badge" on IDD elimination into the BSG curriculum and asserted that this
would ensure the energetic participation of the Scouts and Guides throughout
the country on a sustainable basis.
To introduce a proficiency badge, ICCIDD would prepare a syllabus that is objective
and achievable. It would recommend the symbol of the badge, print booklets of
about 1-2 pages on the syllabus and the activities to earn the badge, devise
an evaluation procedure, train teachers how to guide their students in earning
the badge, prepare examiners for evaluating performance, and supply materials
and equipment for the recommended activities. These points are being further
discussed with the Joint Director and a schedule for more partnership events
has been developed for the remainder of 2003 and early 2004.
The association of ICCIDD with BSG has helped it to expand the NGO networking to the neighboring country of Nepal. The recent meeting of the ICCIDD team with Nepal Scouts and Guides functionaries is an outcome of this collaboration.
ICCIDD has participated in Scouting activities in several other parts of the world, as well. Dr. Sangsom Sinawat, an ICCIDD Director, organized a booth at the 20th World Scout Jamboree in December 2002 in Bangkok, Thailand (IDD Newsletter, 19(1):13, 2003) to introduce the young attendees to IDD and iodized salt. In early 2002, Ms. Judith Mutamba, Subregional Coordinator for Eastern and Southern Africa, met with UNICEF and the leaders of the Kenya Scouts Association. An IDD Day took place at the Scouts training camp in Nairobi in October 2002 with processions, newspaper messages, speakers, an interactive TV program, and a workshop. ICCIDD sees this collaboration with national youth groups as a promising means for promoting elimination of iodine deficiency through the use of iodized salt, and most importantly, sustaining it thereafter.
As a pupil at the National Model School, Aga Khan Palace, in Pune city in the Maharashtra State in the early sixties, I have been a 'Sea-Scout' for many years. (It was while imprisoned at Aga Khan Palace that Mahatma Gandhi gave the call in 1942 for 'Quit India'.) In point of fact, 'once a Scout, always a Scout'. We often had to attend various adventure programs associated with seas. While at sea during these occasions and later at the beach, I often remembered Mahatma Gandhi's final call for freedom by picking up a fistful of humble salt from the beach of Kutch in Gujarat.
In a strange process of evolution, the sea (because of its bounty of salt), the Scouts and Guides Movement and my vocation have come to a conjoining point - 'being in' for a call to freedom from IDD. Gandhiji called for 'Quit India'. For me it is an inspiration for a united call to 'eliminate IDD forever.'
It may be relevant to remember the words of Baden Powell, the founder of Scouts and Guides Movement. "A scout does everything he can to help others, especially old people and children [ital. added]. He does at least one good turn a day". Doing something for the children is a commitment. It comes in full measures by helping him or her to attain the optimum physical and mental potential. In case of ICCIDD, it is by ensuring that they get iodine optimally from womb to tomb.
- C. S. Pandav
IODIZED
SALT AND THE CURING OF MEAT
by Hans Bürgi, M.D., Solothurn, Switzerland
The
process of curing
Nowadays it is often forgotten that before the availability of refrigerators
and freezers, salting (curing) was the only way to preserve foodstuff of animal
origin, such as meat, fish, and cheese. The process of curing foodstuff requires
enormous amounts of salt, a reason why salt was a strategic item of vital importance
to populations in antiquity.
For curing, meat or fish is soaked with a 15 to 20% solution of NaCl or it is treated with dry salt, e.g., by packing one layer of fish between two layers of dry salt. To the NaCl 1 to 2% sodium nitrate (saltpeter) is added. The latter is reduced to nitrite by bacteria. As an alternative, nitrite may be added directly. Nitrite in turn is transformed into NO, which combines with myoglobin to nitrosomyoglobin, which gives the cured meat a "nice" pink color. This color change does not affect the taste of the meat, but without it the meat takes on an unappetizing pale color. Occasionally, ascorbic acid is added, which enhances the color change. Commercial curing salt of the Swiss Rhine Salt Works contains a fixed admixture of 0.5 to 0.6% sodium nitrite.
Curing
of meat and iodized salt
Nitrite oxidizes iodide to molecular iodine (I 2), which in turn evaporates
and is lost, the reason why the Swiss curing salt does not contain iodide. In
Germany, which uses iodate in its salt, 40% of the curing salt contains iodate
since 1995 (1). Neither iodide nor iodate, however, affect the process of curing
or the quality of the meat (2-4). In particular, salt iodized with iodate was
tested in the preparation of liver sausage, blutwurst, as well as of other sausages
and of air-dried Parma ham (4). Nitrosamine formation, a theoretical possibility,
did not take place in relevant amounts (4). During preparation, only 25% of
the iodine from iodate is lost in boiled sausage and only 7% in fermented sausage
(4).
Conclusions
Neither iodide nor iodate in salt affects the curing process of meat. Iodate
remains stable during the curing process, and the theoretical possibility of
nitrosamine formation has not materialized. Iodide is oxidized to I2 during
curing and is lost by evaporation. Thus, salt iodized with iodate or iodide
may be used for curing, but in the case of iodide it does not contribute to
the dietary iodine supply.
References
In Brief