Volume 11 Number 4, November 1995
IN THIS ISSUE
India and China have more people affected by IDD than any other countries in the world. Large goiters and cretinism were recognized as commonplace in the Himalayan foothills for many decades. More recent information has shown that large parts of the rest of India are also iodine deficient. A survey of 239 of the country's 457 districts have shown 82% to be iodine deficient.
The government has tackled the problem by promoting the use of iodized salt and banning the use of non-iodized salt. This massive undertaking has been actively assisted by Dr. C. S. Pandav, ICCIDD Regional Coordinator for Southeast Asia, his colleagues at the All India Institute for Medical Science in Delhi and many other ICCIDD members in India, and by very strong support from UNICEF in Delhi, where ICCIDD Board members David Haxton and Rolf Carriere were formerly Regional Director and Advisor for Nutrition, respectively. The following pages present recent reports from the field.
Dr. C. S. Pandav, ICCIDD Regional Coordinator, visited the Bhopal Indore, and Jhabua districts of Madhya Pradesh to report on progress against IDD. This article and the accompanying photographs are taken from the report prepared by Dr. Pandav and Ms. Nilima Chawla, ICCIDD Board member and ICCIDD's Communication Focal Point for South Asia.
In August 1994 the government of Madhya Pradesh (MP) established the Rajiv Gandhi Technology Mission for Eliminating Iodine Deficiency Disorders. Its purpose is to eliminate IDD by iodine supplementation for the entire 66 million people living in the state. Other missions also established to meet basic needs of rural people in the state include the Watershed Development Mission, the Shiksha Mission, the Mission for Control of Diarrheal Diseases, the Mission for Development of Rural Industries, the Mission for Development of Fisheries, and the Mission for Development of Advanced Technology. These missions represent the MP government's effort to prioritize certain "thrust areas" in development and make them a collective endeavor. Establishment of the missions received the strong support of the chief minister.
The mission has two clear goals: (1) to make communities aware of the need to use iodized salt, and (2) to ensure adequate distribution and sale of iodized salt. Community research had shown a very poor level of IDD awareness. To counter this, in January 1995 an IDD Elimination Week took place in every developmental block. Its components included a major information drive, house to house surveys to detect cases of IDD, and spot testing of all salt consumed by the community. Mass rallies and meetings were organized at 5,493 locations in 4,590 villages, with 1,543 exhibitions and films and 1,867 cultural shows. Salt was tested in 2,234 schools, 353,941 households were surveyed, detecting 10,362 IDD cases, and 255,360 salt samples were tested. After the IDD elimination week, four Rath Yatras (information vans), one each from Indore, Bhopal, Jamaipur, and Bilaspur, covered all the blocks of the state to spread the messages of iodized salt and oral rehydration therapy. With this highly visible and effective form of communication, along with the other channels used, the Mission successfully informed people that the additional cost of four rupees per month per family was a small price to pay to protect the family from iodine deficiency.
With regard to supply of iodized salt, communication efforts convinced the salt traders to promote iodized salt. By signing the Bhopal Declaration, they agreed they would not sell salt that was not iodized. The Nagarik Apoorti Nigam supplied iodized salt through public distribution outlets, and thus was able to quickly supplement the private salt trade. As a result, iodized salt comprises 84% of the salt consumed in the state. An independent evaluation will soon be conducted.
The achievement in Jhabua is all the more remarkable because it is one of the most backward districts in Madhya Pradesh, with the lowest literacy rate (19%) in the country, an infant mortality rate of 141 and severe economic and social deprivation. A key feature in the success of iodized salt introduction has been the extensive educational efforts, including those in the schools. At the same time, the government administration established a close link with salt producers and retailers, thus fostering greater understanding and a sense of social responsibility. This won their partnership by cooperation rather than coercion.
On Independence Day: Free at LastJhabua District, Madhya Pradesh: It is dawn on the 16th of August 1995. In the soft light of a cloud-filled monsoon morning, streams of village children hurry to their schools, each carefully carrying a fistful of salt. For the first time in the school at Mindal, they are going to test the salt to see if it contains iodine. As they settle into their places, their faces reflecting their suspense, young Kali, the class monitor lines up all the salt samples in front of her. From a small plastic bottle she adds a drop of liquid to each pile of salt. Immediately the salt changes color, one turning dark blue, another becoming a light violet, while some stay the normal white of edible salt. "This salt that didn't turn blue is bad salt", she tells her classmates. "It doesn't have the iodine we need to keep our bodies strong and our minds intelligent. So I'm going to throw away this bad salt." By throwing away the "bad" salt, Kali has symbolically encapsulated a silent revolution that is sweeping the tribal district of Jhabua. A revolution in which all the uniodized salt traditionally available to the people is being replaced with salt that contains iodine. It is only when they get iodized salt that the iodine-deficient population of this poor and underdeveloped district will be spared the mental retardation, stunting, deaf-mutism and birth defects caused by iodine deficiency. - C. S. Pandav and N. Chawla |
Dr. Umesh Kapil, All India Institute of Medical Sciences, New Delhi.
Himachal Pradesh, with a population of over 52 million people, lies in the iodine-deficient belt of northern India. India's national IDD control program has mandated iodized salt throughout the country. This study, conducted in late 1992, assessed progress in the implementation of iodized salt in Himachal Pradesh. Representative primary health centers were selected for detailed assessment by home visits to assess consumption patterns for salt as well as to analyze salt samples. The study also interviewed district officials, retailers, consumers, and manufacturers.
The government of India had allocated 30,000 tons of iodized salt for Himachal Pradesh, but only 12% of this amount was procured by traders that were recognized by the state government. Additional sources of salt came from private manufacturers and repacking units both within and without Himachal Pradesh. The traders preferred the salt from private producers rather than that from the government because the profit margin was better. In addition, the private traders delivered the salt to retailers in the requested quantities, had flexible prices, and supplied their product on credit. Private repacking units were not covered under the Pure Food Act because they were neither the manufacturers nor the producers of salt, and thus escaped both the regulations dealing with form and iodine content of salt and the penalties for noncompliance.
Much of the iodized salt came from Rajasthan, but its transport by rail was uneconomical, requiring transfer twice at different stations because of differences in railroad gauge. These conditions led to high transportation costs.
Five types of salt were available: crystalline iodized, powdered iodized, gumma rock, sindhu, and sanchar salts. The gumma and sindhu rock salts were mainly for animals, and were rarely used for food preparation. Consumers and traders preferred powdered salt, the latter because it made them less liable to prosecution in case the iodine content was unsatisfactory. There was also a preference for purchase of one to two LDPE packets, to last for several weeks. Liberalization of salt iodization to include private traders improved the quality of the salt, replacing the previous somewhat discolored salt obtained through the state designee. Himachal Pradesh, as well as neighboring states, had totally banned the sale of noniodized salt for edible purposes. There was a wide range in price by brand and form. For example, powdered salt was about twice as expensive as crystalline. Fifty brands of salt were available in survey districts, and of these at least 15 appeared under a label easily confused with that for Tata, a well-known reliable brand. The Himachal Pradesh government subsidized salt delivered to "difficult areas" for which normal transportation costs were high. Iodized salt for poor families was also highly subsidized.
During the study, 425 salt samples were collected in the field from 325 families and 100 traders. Fifty-four percent of the crystalline samples, 35% of the powdered and all rock salt samples had iodine contents less than 15 ppm.
At the state level, monitoring takes place in two departments, Food and Civil Supplies, and Health. The former monitors quantity traded and the latter its quality. Each food inspector of the Department of Health collects 10 food samples per month, including one or two of salt. These are sent to a central lab for analysis. In addition, the Department of Health has responsibility for monitoring morbidity and mortality, with a line item for IDD. The food inspectors had no fixed guidelines for collection of salt samples, and generally gave them less attention. IDD received a low priority in the morbidity and mortality reports of the health department, in contrast to programs on family planning, child survival, immunization, and others. A state-level committee for coordination among the health food and civil supplies and industries had been set up to review and monitor activities related to IDD, but meetings were held infrequently.
In regard to storage and packaging, most of the wholesalers and traders did not follow the government guidelines for storage. Often salt bags were kept on open ground outside shops, directly exposed to the atmosphere. Iron hooks were occasionally used during loading and unloading. Polyethylene bags were usually used for transportation and storage, but occasionally raw salt was procured in old polyethylene bags that had previously been used for transportation of fertilizers and gypsum. At the domestic level, salt was stored in polyethylene packets, plastic containers, earthen pots or wooden boxes. Most containers had no lid and the people were not aware that iodine could be lost when salt is open and exposed to the atmosphere. The accompanying figures show some conditions of storage.
Although training and re-orientation for traders had been recommended, the basic training had been limited largely to a one-hour theory lecture. Records of salt procurement and distribution were maintained but had a low priority. The health functionaries interviewed were aware of the problem of endemic goiter but most were not aware of the spectrum of iodine deficiency disorders. Communication efforts had been limited to printed handbills, and posters, and these were not widely used. Kits for spot testing iodine in salt were used only infrequently, and community members were not particularly interested in purchasing them.
As a result of the survey, a number of recommendations were made. Some of these included: (a) more surveillance on the quality of salt and its sources for Himachal Pradesh; (b) improvement of registering repacker units supplying salt to Himachal Pradesh, to achieve better regulations; (c) monitoring laboratories should be provided at the district level to strengthen quality control; (d) uniform guidelines for collecting salt samples should be developed, and the number of samples increased; (e) the community should be organized to create a pressure group to demand iodized salt; (f) the priority for IDD control should be increased for the Department of Health and for the Department of Food and Civil Supplies, and among food inspectors; (g) fuller labeling of packaged salt is needed; (h) workshops and training courses at district levels should be organized to create awareness and motivation among health officials and the salt trade; (i) more extensive education efforts are needed for all levels.
From these recommendations a strategy was developed, with three main components - training, education, and monitoring. Training was organized to include a wide variety of governmental, industry, and voluntary organizations, focused on creating a demand for iodized salt. A large number of placards, posters, booklets, leaflets, and stickers were distributed, as well as over 70,000 spot testing kits. Distribution was through the existing health infrastructure, and through voluntary organizations that were trained to organize education campaigns and rallies, and to monitor iodine content of salt consumed by families in their areas with the testing kit.
For monitoring, a state level multisectoral meeting was held for the heads of various departments, such as Health, Education, Food and Civil Supplies, Weights and Measures, Industries, and Social Welfare. Subsequently, meetings at the district and lower levels were held to diffuse this information. Workers were trained particularly in use of the spot testing kit and how to report results.
Currently, the Department of Food and Civil Supplies monitors the quantity of salt entering the state, with a system requiring salt traders to submit monthly reports. The quality of iodized salt was monitored at the traders' level, by collection of samples by food inspectors, with each inspector collecting two salt samples per month; at the beneficiary level, the workers trained in use of the kit collected a minimum of four salt samples each month from four households, tested them, and submitted a report to the block medical officer and up through the chain to the state program officer for IDD. Through January 1995, a total of 142,721 salt samples had been tested in seven districts. Of these, 3% had no iodized salt, 17% had less than 15 ppm, and the remainder (80%) had more than 15 ppm. In addition, various governmental and nongovernmental agencies received kits, to check samples during their routine activities.
In this campaign the Department of Food and Civil supplies (including Weights and Measures) listed the various brands of salt in different districts and took punitive action against traders whose salt did not adhere to packaging guidelines. The Department also ensured that only authorized brands were sold through the public distribution system, it monitored the quality of salt produced by repackers in the state, and it educated traders on the importance of iodized salt.
Constraints in the program have included a low priority given to the campaign by some departments, including Health, Food and Civil Supplies, and inadequate interaction among some of the governmental departments in coordinating monitoring. Although the national government had given high priority to IDD control, this priority did not reach the state level, perhaps because the effects of iodine deficiency are not as vivid as other needs.
by Dr. Pramesh C. Lakhera, Department of Zoology, HNB Garhwal University, Srinagar, Uttar Pradesh.
Introduction
The Himalayan mountains are one of the world's well known iodine deficient areas. Food from the iodine deficient soils cannot fulfill daily iodine requirements, and thus iodine supplementation from external sources is necessary. Salt has been assumed to be the best medium for fortification.
For this reason the government of India banned the supply of non-iodized salt in endemic goiter areas of the country. The Uttar Pradesh (UP) Salt Control Act of 1966 legally authorized the supply of iodized salt in eight hill districts of the western Himalaya in the UP. Salt iodization was initiated by different agencies, both government and private, and the current production is about 5 million tons per year. However, this figure does not give any idea of how much iodine reaches the consumer (1,2), and the iodine levels in salt have not been reported. The present paper addresses these points.
Methods
From previous surveys of IDD in three areas of Garhwal Himalaya (1,2) we chose two - one in Chamoli district and the other in Tehri district - for assessment of salt iodine. We collected a total of 797 salt samples randomly from different families in villages and 81 from the township, one sample per family. The salt was tested for iodine content from a standard test kit, supplied by UNICEF.
Results and Discussion
The salt samples obtained from the villages were from bulk packs. No families used iodized table salt. The testing showed none of these bulk pack samples contained iodine. Neither the villagers nor retailers in village markets were aware of proper procurement and benefits of the use of iodized salt, or standards of salt storage. Most suppliers kept the salt bags outside the shops, or on floors that were dirty and humid. Because salt is a low-cost item, sellers receive little benefit from it and do not consider its proper storage important.
The centuries old barter system is still in practice in these areas. Shop keepers exchange salt for local products like Marsha (Amaranths sp.). They procure salt once a year, in bulk quantity, to fulfill local demands. Villagers obtain 6-8 kg of salt in return for 1 kg of Amaranths. All families in the villages obtain through barter 25-80 kg of salt, enough to last the whole year. Usually this yearly transaction takes place during October and November. The whole year's supply of salt is stored in wooden or mattel (copper, silver, or brass) containers. By this system villagers save their currency and shop keepers more than double their profit through barter. The same process is also occasionally used to purchase rice.
The total salt demand of this area is met from the production center at Runn of Kuchh in Gujrat. This salt travels approximately 2,000 km by train to the nearest rail heads for this area, Kotdwara and Rishikesh, 100-250 km by road from these villages. Suppliers at the rail heads store the salt and arrange its transportation by road to the retailers. The suppliers and local retailers stock salt in sufficient quantity for the village demands. However, this study showed that they either did not know proper standards for salt storage or did not find it sufficiently profitable to follow such standards. The villages are reached from the roads by walking trails of 1-10 km.
The duration and conditions of salt transportation from production center to consumers are not very clear. However, this process clearly leads to storage of salt for long periods. In addition, even when optimal conditions of transportation and storage are met, iodine may disappear from the salt in a period of six months (3). Shop keepers and consumers share ignorance of iodized salt and its benefits for overcoming iodine deficiency.
On the other hand, township markets stock 1 kg polyethylene packages of iodized table salt of different manufacturers. When these salt samples were obtained from township families and tested for iodine, only 17% contained as much as 7 ppm iodine, and only 8% as much as 15 ppm. Thus, 75% of these so-called iodized salt samples did not contain any iodine. Purchase of this salt is limited to educated and small families because the cost of table salt is more than twice that of other salt sold in the market.
This study shows that essentially no iodized salt is reaching this area. The major cause is consumer unawareness of the use and value of iodized salt. To generalize further, this experience shows that the success of an iodine prophylaxis program is not achieved by simply passing legislation or by having bulk salt iodized at the production center. Success requires that iodized salt reach consumers within a reasonable time and contain the prescribed amount of iodine. A control program must be carried out so that every member of the whole population benefits. The following steps are necessary to ensure its effectiveness:
Acknowledgements
The author gratefully acknowledges the financial assistance from the University Grants Commission, India.
References
This workshop took place on April 27, 1995. The working document was submitted to the IDD Newsletter by Dr. U. Kapil. The workshop included general information about IDD and the current status of IDD in India. Attendees included salt traders, voluntary organizations, and various components of the state government.
A 1993 survey of schoolchildren showed a total goiter rate of 20% for children under 12, and 22.5% for those older. About 74% of salt samples brought in by students from homes contained iodine. In a study of 298 salt samples from an urban slum, of 226 samples of powdered salt, 64% contained less than 15 ppm, and of 72 samples of crystalline salt, 96% had less than 15 ppm. In this area, 76% of families consumed crystalline salt, so very few in this population received iodine from salt. In another study of salt from rural households and traders, 43% of powdered salt samples, and 82% of crystalline salt samples had less than 15 ppm iodine. Of 62 samples collected from salt traders, 51% had less than 15 ppm iodine. In another study the goiter prevalence in Delhi was found to be 29%, the incidence of neonatal hyperthyroidism, 6 per 1,000 births, and urinary iodine was given as Follis group 2 (no samples less than 25 mg iodine per gram creatinine).
The plan of action for elimination of IDD in Delhi by the year 2000 was presented. The strategy included sensitization, intensive education campaigns and monitoring. The design is similar to that described above for Himachal Pradesh. Salt will be monitored for quantity through monthly reports of traders and for quality through food inspectors implementing the Pure Foods Act. Quality at the household level will be assessed through the school health team, with children bringing salt samples from home and testing with kits. Voluntary organizations will also participate.
The report also provided tables for the status of IDD program in the different states and territories. Similar data have been presented previously in the IDD Newsletter. The ban against iodized salt has been imposed in almost all states. Of the country's 457 districts, 239 were surveyed, and of these 197 were found endemic for IDD. The ban in Delhi had been imposed in March 1989. It was declared by the director of the Prevention of Food Adulteration, Delhi administration, under the Prevention of Food Adulteration Act of 1954, and ordered that the sale of the noniodized edible salt be banned.
Mahatma Gandhi carried out his famous Salt March on March 12, 1930 to oust the British Colonial rulers. A second Salt March took place on July 9, 1995, as a step towards ousting the iodine deficiency disorders. A number of groups joined in this effort, including the Medical Health Department, Youth Welfare Department, the Integrated Child Development Scheme, the National Service Scheme, Bharat Scout and Guide, the National Children's Science Congress, the Network for Working and Street Children, and many others. The organization Nehru Yuva Kendra Sangathan (NYKS) of Uttar Pradesh and UNICEF supported the program.
The objectives of the March were to achieve mass awareness of the need for iodized salt, to decrease iodine deficiency, to emphasize that IDD can be prevented, to channel the energies or youth and voluntary organizations towards mass education for iodized salt, and to ensure the availability of iodized salt in rural areas by creating consumer demand.
Human input came from youth worker forces of a number of different organizations and volunteers. UNICEF provided folders and booklets. The state Health Institute provided iodized salt testing kits and pamphlets for distribution at the grass root level. In strategy sessions the areas to be covered were divided among the various participating organizations. The NYKS was responsible for 16,000 village panchayats in 300 blocks of 65 districts while the other organizations would cover 4,000 village panchayats of 100 blocks. Guidelines for proper salt testing and reporting were standardized. A cell was established in the state project office to keep and update records of the Salt March. In preparation, iodized salt was given wide publicity in newspapers, radio, and other media throughout the state. To coordinate the Salt March, local committees were formed at the village, block and district levels, each including important officials. At the central level a state coordination committee was also formed.
The March took place on July 9, 1995. Thousands of youth workers carried the message for use of iodized salt to hundreds of thousands of people who in turn would inform millions, spreading the message within one day. Thus, a message that could have taken months and years to reach the public was broadcast to a great mass in a very short time.
The central coordination unit is keeping computerized records of the results of the testing. In the data provided so far, of 387,488 salt samples tested in 52 districts, 32% had no iodine, 31% had 7 ppm, 22 had 15 ppm, and 15 had 30 ppm, by the semiquantitative color kit. Of urban areas, 29% had no iodine, 23% had 7 ppm, 21% had 15 ppm, and 27% had 30 ppm. Further data are still being processed. These figures show that less than half of the salt is adequately iodized in either the rural or urban areas tested.
A system is being developed for follow-up action. Studies will be undertaken to see how much the Salt March helped in creating demand for iodized salt. Meanwhile, the event provided a dramatic opportunity for accelerating Uttar Pradesh's drive towards universal salt iodization.
This program took place in Dakar, Senegal in February 1995, sponsored by ICCIDD, WHO, UNICEF, and the Micronutrient Initiative. The proceedings have been published, text by Francine Houle of Arbor Vitae. Copies are available through the Micronutrient Initiative in Ottawa, Canada. Dr. Benmiloud and Dr. Lantum participated on behalf of ICCIDD.
As stated in the preface by Dr. Benmiloud, the purpose of the workshop was to bring together small-scale salt producers, IDD program managers, and specialists in the fields of salt production, iodization, organization of cooperatives, communication, and iodine deficiency disorders. The goal was to draw some guidelines that could help each country define its own artisanal salt iodization policy to ensure the sustainability of the prevention program.
The workshop began with background information about IDD and its current status in West africa. Data summarized by the participants are given in the following paragraphs.
Prevalence - 19.1% goiter in 1994 nationally, but with some districts reaching 58% in surveys a decade ago. A total of 903 urine samples collected from three regions in 1995 had a median concentration of 4.1 mg I/deciliter, indicating moderate iodine deficiency.
Control program - A November 1994 interministerial resolution prepared regulations on importation, control, and commercialization of iodized salt. Representatives of three ministries in four departments spoke with decision makers, communicators, and economic operators to promote salt iodization.
Salt - Local salt production, about 5,000 tons per year, represents only 20% of the country's needs, but remains an important economic activity in over 150 villages and employs 2000-3000 people, mostly women. Production is usually by washing brine and boiling it for crystallization. Solar evaporation is also used. Problems for local production include scarcity of firewood, pollution with fresh water, a short season, lack of technical expertise, poor packaging, and little organization of producers. About 14 businesses control importation and distribution from Senegal, Ghana, France, Nigeria, Egypt and Algeria, Senegal being the largest. UNICEF is supporting iodization of locally produced salt, and has proposed two commercialization sites at Ouidah and Come, recommending continuous spray by batches.
Comments - The program needs laboratories for control of iodine content of salt and monitoring of imported salt. Proper storage and preservation of iodized salt needs address, as do the issues of training and quality control.
Prevalence - National data are insufficient but a 1993 goiter survey in poor elementary schools of the western, eastern, and central regions gave prevalences from 70-93%. A total of 2,227 urine samples collected from four regions in 1994 had a median concentration of 3.2 mg I/deciliter, indicating moderate iodine deficiency.
Control program - A national multisectoral committee on nutrition has been created at the Ministry of Health. Further action is awaited.
Salt - 90% of the salt is imported from Senegal. A small quantity comes from Sierra Leone, Great Britain, Belgium, and Germany. Local production occurs in three main sites, Bintang, Albreda, and Darsilameh. Some of the producers are loosely organized, but much of the salt is prepared by solar evaporation or boiling and sold in the market without any organization.
Comments - Promotional tours have been arranged by the committee to discuss the organization of small-scale producers into cooperatives.
Prevalence - A recent IDD Newsletter (11(3):34, August 1995) gave a detailed report of information gathered as of July 1994 on IDD in Ghana. The national goiter prevalence is about 20%, and the average urinary iodine about 7.7 mg/dl.
Control program - A multisectoral group meets regularly with small-scale producers. A law is being prepared, proposing iodization at the level of 100 ppm at the factory.
Iodized salt - Local production is estimated at 192,000 tons per year, of which 2/3 is exported, chiefly to Togo, Benin, Nigeria, Berkina Faso, Mali, Niger, and the Ivory Coast. Salt quality is fairly poor. The main producers and exporters have been identified and iodization equipment bought, but it is not yet operational; technical personnel need training.
Comments - The previous Newsletter article gave details on consumption habits, knowledge and attitudes, salt production and marketing, from the 1994 workshop in Accra.
Prevalence - A 1989 survey describes 74% goiter in the province of Gabu and 49% in Oio.
Control program - A national program was finalized in 1994. Its strategies include the administration of oral iodized oil for three years while waiting for effective salt iodization.
Salt - The output of small producers far exceeds the country's needs by about 5,000 tons per year. Nevertheless salt is imported from Senegal and Gambia. Production is carried out principally by women and is largely artisanal.
Comments - There are no recent data on production and importation of salt from Senegal.
Prevalence - A 1993 survey described a 63.6% prevalence of goiter; in 1994 the following regional distribution was reported - Maritime Guinea 40%, lower Guinea 40.6%; upper Guinea 73.6%, forest Guinea 74.2%, and middle Guinea 76.1%.
Salt - Between 30 and 80% of the salt consumed is locally produced. The rest comes from Senegal, and none contains iodine. Salt is also produced artisanally from brine, either by evaporation or boiling. It is poorly packed in used jute bags, and stored under humid conditions for long periods, sometimes up to two years. Locally produced salt is not available year around and distribution is erratic; it offers poor competition for the cheaper salt from Senegal.
Control program - There is no national program, although the Ministry of Health is recognized as the responsible agency.
Comments - An intersectoral conference took place in November 1994 with recommendations for legislation on salt iodization and importation and a plan of action.
Prevalence - No national data exist, but a high frequency of surgical operations for goiter has been noted casually.
Salt - The country produces about 15,000 tons per year and imports 250 tons of refined iodized salt. There are two large producers and about 15 smaller ones. The salt is exploited artisanally, rock salt is cut into blocks and then crushed before being treated.
Control program - A plan of action was being drafted in early 1995, but no legislation has been prepared and there have been no communication efforts or special committees.
Prevalence - No national data are available but a 1992 survey of the departments of Bakel and Kedougou showed an average of 37% goiter, with peaks up to 48%.
Control program - A national committee and a multisectoral permanent secretariat were created in 1994. A multiministerial resolution is being approved; iodization norms for Senegal are being established.
Salt - Senegal produces 350,000 tons of sea salt a year, of which more than 80% is exported. Two industrial salt production units are Kaolack and Selsine; the first already has an iodization unit while the second is capable of it. Other small groups or producers are also active, and one salt exporter has begun to iodize the salt it exports to Nigeria. Small-scale producers use artisanal methods.
Comments - A collaboration between the Chamber of Arts and Crafts and Caritas is organizing small-scale producers with training sessions beginning in 1995.
Prevalence - A 1992 survey reported 97% goiter (53% as "severe").
Control program - A multisectoral national committee is in place and a national action plan is being prepared.
Salt - 7,000 tons of noniodized sea salt are produced artisanally by about 2,000 small-scale producers. The country also imports 4,000 tons of refined iodized salt from Europe and 2,000 tons iodized from Senegal. The local salt is of poor quality and poorly packaged.
Comments - Advocacy is aimed at decision makers and importers.
The workshop reviewed techniques of salt production and iodization and considered various managerial problems and their solutions. It emphasized communication to educate users on the importance of iodized salt, and discussed formation of cooperatives for groups of small salt producers.
The attendees also addressed a plan of action for small-scale producers. One component was the creation of cooperatives. These in turn would involve the development of appropriate and realistic policies following a national situational analysis, development of communication activities within the cooperative, and access to credit, technology, and training. For technology, it was felt most practical to continue manual salt iodization because it involves little investment and no expensive energy source. Obstacles to commercialization were discussed extensively. Some of the proposed solutions to these problems included improvement in production techniques, better equipment, and packaging, improved storage methods, and creation of demand for iodized salt. For control and evaluation, programs need to raise awareness among agents in charge of control, have the government establish standards and operational procedures as well as laws, and enforce the rules and standards on small-scale producers. A final component was improvement in developing sound financial plans, advocacy among funding institutions, and raised awareness of small-scale producers towards the importance of long-term self financing.
The workshop closed with the following recommendations: (1) governments should support the small-scale salt producers in enabling them to reach the goal of universal salt iodization; (2) the governments should strengthen associations among small producers; (3) governments should provide necessary information on technology and salt iodization, particularly to the small producers; (4) governments should have laws requiring fortification of all salt for human and animal consumption with iodine, and use of KIO3; (5) governments should prepare their strategies for education, information, and communication and should provide training for management and technologists, also, governments should set up networks for monitoring the control of salt quality.
A recent study to assess the effects of iodized salt on the color and taste of food was carried out by Dr. C. E. West, Dr. F. L. H. A. de Koning, and Dr. R. Merx, of the Wageningen Agricultural University and International Agricultural Centre at Wageningen in the Netherlands. Dr. de Koning has made a copy available to the IDD Newsletter.
The food industry in various parts of the world has been reluctant to use iodized salt in food preparation because of concerns that iodization will alter the taste or color. The current study addressed these concerns in two ways, one a critical literature review, the other blinded taste tests with or without iodized salt.
In the literature review, salt containing 92 mg iodine/kg as either potassium iodide or potassium iodate was added to canned tomato juice, green beans, yellow corn, and pickled olives. The iodine levels in the tomato juice were either 0.5 or 5 mg/kg, and that in olives 154 mg I/kg. After storage for two to three months, no change in color, flavor or texture was noted. A similar study in 1958 added iodine to several canned foods and again found no significant change. A later investigation added KI, KIO3, or calcium iodate to the salt used in processing white bread, potato chips, and frankfurters. Iodine retention was 50-80% and no differences were noted from the iodization. The use of iodized salt in cheese production in Switzerland has been studied over many decades, with the conclusion that it did not affect taste or quality. In Germany, a 1991 investigation examined the effects of iodized salt on cooked sausages, fresh sausages, dry cured ham and fermented sausages. The addition of potassium iodate had no adverse effects. Iodide losses from cooking and storage varied from 7 to 25%. Unspecified reports had raised the issue that iodide ions could accelerate the formation of carcinogenic nitrosamines from other amines and nitrate. However, a study by Wirth and Kuhne in 1991 found no evidence for this in the meat products they studied.
Older studies had shown that very large amounts of iodine (12.7 mg/L) as iodate could give a bitter taste during storage of milk, but this change was not noticed with half the dose (6.3 mg iodine/L). Both doses are extremely high, far above those that would be added to milk by iodized salt (in any event, adding salt to milk is not a common practice).
Currently, in Switzerland, with salt iodized at 20 mg KI/kg (15.6 mg iodine/kg) about 80% of the salt used by the food industry is iodized, as is 90% of that used in cheese manufacture. In the Netherlands cooking salt contains 18-22 mg iodine/kg and baking salt contains 42-50 mg I/kg; neither has led to reports of adverse effects.
The authors note "consistent rumors" that iodized salt may harm the quality of pickled vegetables, such as softness of pickles, and change of color. These charges at present do not have a scientific basis.
The authors conducted their own study in which potatoes and rice were boiled in water with iodized and non-iodized salt and assessed for taste by a blinded panel. Salt iodized with either KI or KIO3 at levels four times the maximum recommended (400 mg iodine/kg salt) were used. Batches of potatoes were boiled for 10-20 minutes with 10.5 grams of salt (3 g salt/kg potato and per 857 mL water). For rice, 1 kg was boiled in 1.9 L water with 15 g salt, for 25 minutes. Eighteen people were asked to compare the iodized and non-iodized potatoes and rice, being blinded as to their iodine content. The subjects could not distinguish between the iodized and non-iodized products.
The authors quote Ballauf (1988) that most of the iodine (70-87%) added to cooking water remains with it and is not absorbed by potatoes, rice, or macaroni, and 10-25% is lost with water evaporation.
Conclusion - Both by literature review and direct experimentation, the use of iodized salt for food processing or cooking does not affect flavor, appearance, consistency, or storage.
This conference took place April 10-12, 1995 in Dhaka, Bangladesh, to advance progress in Southeast Asia towards elimination of iodine deficiency. Sponsors included ICCIDD, CIDA, the Micronutrient Initiative, UNICEF, and WHO, in cooperation with the government of Bangladesh. Participants included members of these organizations and several representatives each from Bangladesh, Bhutan, India, Nepal, Pakistan, and Sri Lanka. C. S. Pandav, Hema Viswanathan, David Haxton, Venkatesh Mannar, and Rolf Carriere, all of the ICCIDD Board, figured prominently in developing and conducting the conference, in coordination with Dr. Katharine Esty and Mr. Gilbert Steil, consultants.
The conference used the "future search" methodology, which brings together representatives of many groups involved with a particular problem. The stated objectives were to: (1) renew commitment to the goal of IDD elimination by the year 2000; (2) forge alliances between all stakeholders involved in IDD elimination; (3) facilitate interdisciplinary and intersectoral networking to help sustain IDD elimination; and (4) facilitate the development of strategies for sustaining IDD elimination and foster combined efforts towards this end. The conference was attended by over 72 participants, most from South Asia, representing IDD experts, the salt industry, government, salt regulators, policy makers, communicators, educators, non-governmental organizations, and health care providers.
During the sessions, participants considered the important forces and trends that affect efforts to eliminate IDD, reviewed achievements and shortcomings in their countries' efforts to eliminate IDD, examined each stakeholder's current efforts and how they might be improved, and considered common ground among stakeholders as well as promising ideas for future progress. On the final day participants met as groups, either by country or by interest area, to formulate specific strategies for what should be done and what can be achieved.
A highlight of the Partnership meeting was an address by the Prime Minister of Bangladesh, the Honorable Begum Khaleda Zia. She reviewed efforts by her country to correct IDD and encouraged participants at the meeting to work hard for global elimination. In her words "We are committed to the elimination of iodine deficiency disorders by the year 2000. To achieve that goal, we have taken all the possible measures. The Iodine Deficiency Prevention Act has been strengthened. At the same time, import of non-iodized salt in the country has been banned. Iodization machines have been installed free of cost in all salt mills. We hope by the end of the year we will be able to ensure supply of iodized salt for all."
This conference took place on April 10 and 11, 1995 in Dhaka. It was organized by Professor H. K. M. Yusuf and Professor Anisul Haque of the Institute of Postgraduate Medicine and Research in Dhaka. It was attended by a number of ICCIDD members as well as IDD experts from Bangladesh and elsewhere in Southeast Asia. Speakers from ICCIDD included Ramalingaswami, Stanbury, Delange, C. Pittman, J. Pittman, Kavishe, Ekpechi, Pretell, Gerasimov, Chen, Ma, Thilly, Lantum, and Karmarkar. The topics included iodine nutrition and human development, neonatal hypothyroidism, a geographical review of IDD elimination by regions, neurological consequences of iodine deficiency, monitoring and legislation, and role of agencies in IDD elimination. A major component was the careful review of IDD in Bangladesh, by a number of distinguished Bangladesh scientists.
This article abstracts an address written by Dr. Jack Ling and Mr. David Haxton, both of the ICCIDD Board, and delivered by Dr. Ling at the Conference on Nutrition and Micronutrients, Second World Congress on Child Health 2000, June 1995, Vancouver, Canada.
The authors begin by citing the pledge of the 1990 World Summit for Children to virtually eliminate iodine deficiency by the year 2000. They emphasize that it is essential to sustain the political commitment, which can be strengthened by broad public understanding of the issues. Because of the nature of IDD it cannot be permanently eradicated. Therefore, a policy needs to include quality assurance to sustain achievements towards IDD elimination.
The article continues by reviewing the characteristics of IDD. They emphasize that brain damage is perhaps its most devastating component. They also note that iodine deficiency is a "nationwide, worldwide problem," contrary to previous concepts that it was localized to a few unimportant areas.
The authors call for the development of a new behavioral norm. "It is axiomatic, yet not always appreciated, that unlike other public health measures which aim to reach groups of people to take actions some of the time, an IDD program is a venture that involves action by all (at least passive action) for all times. To virtually eliminate IDD and to sustain the elimination, all IDD programs must aim to establish a new social norm, i.e., taking in small quantities of iodine on a regular basis for life via the use of iodized salt.
Establishing a new behavioral norm, however simple, is no mean task, and the road to any new universal behavior is likely to include unknown terrains from which surprises might spring. A norm is not a norm unless it embraces all segments of society. Setting norms involves leaders, legislators, schools, churches, mass media, community organizations, authors, consumer groups, and all others who have a stake in introducing and reinforcing the new practice.
A multisectoral framework for IDD work is therefore critical. To change attitude and practice, communication becomes the underpinning element for information dissemination, dialogue, and resolution of conflicting interests."
The authors emphasize the importance of a social mobilization strategy, defined as "a broad-scale movement to engage people's participation in achieving a specific development goal through self-reliant efforts. It involves all relevant segments of society: decision and policy makers, opinion leaders, bureaucrats and technocrats, professional groups, religious associations, commerce and industry, communities and individuals in the household. It is a planned decentralized process that seeks to facilitate change for development through a range of players engaged in interrelated and complementary efforts. It takes into account the felt needs of the people, embraces the critical principle of community involvement and self-determination, and seeks to empower individuals and groups for action.
The paper concludes with a detailed description of key operational issues as follows, taken almost verbatim from their paper.
1. Shift from a biomedically driven to a social-behaviorally oriented approach. While scientific support is needed in IDD measurement/diagnostic techniques, IDD program implementation should be management and communication focussed.
Because consuming iodized salt seems such a simple act, it is often assumed to be problem free. But, changing behavior, and in this instance, establishing a new norm, involves a complex process, and the road ahead may well include unexpected obstacles. People need to be prepared for change, preferably by popular institutions, trusted peers or familiar individuals, before they are told by non-interactive agents, i.e., mass media or legislative actions, to change. Established institutions resist change and sometimes cast suspicion on unexpected demand for change. Rumors do spread fast in a vacuum of information and in uncertain and unfamiliar circumstances. In one country, for instance, fallacious reports about IDD programs being stalking horses for family planning projects and iodized salt causing infertility have led to the cessation of the iodized salt production by a number of salt plants because demand for iodized salt suddenly dried up.
2. Sustain the international political commitment, strengthen national commitment where necessary, and generate sub-national and community level commitment where it is lacking.
Leaders who have committed to IDD elimination need to be reminded to "keep their promise." They should be kept informed of progress or the lack of it, especially in areas they have the means to help.
As many countries are in the process of decentralization, and decisions to operationalize social programs are devolved to lower levels, sub-national advocacy is essential to generate the necessary political will for action. Economic cost-benefit data for provinces and municipalities are essential for such advocacy. If these data do not exist, such studies could be commissioned at relatively low cost involving research institutions in the developing countries.
3. Form broad alliances of stakeholders where they do not yet exist, and maintain and sustain those which have been formed, by timely communication efforts. Partners in the alliances - the salt industry, wholesalers and retailers, food processors, consumer groups, school administrations, teachers unions, women's associations, agriculture and animal husbandry business, religious organizations, medical and health institutions - should each play their respective part in establishing and sustaining the standard habit of using iodized salt.
All too often, health and nutrition workers view IDD work as their problem when production of iodized salt, the principal weapon, is in the domain of another sector. The powerful outreach of the market generated by private food producers and processors can be an effective ally for improved nutrition, if appropriate approaches are made to them. Food supplementation is today a multi-billion dollar industry.
Existing alliances sometimes fall short of being comprehensive. Besides the salt industry, identify as many elements of society as possible and include them as stakeholders in IDD elimination. In each country, each province, each locality, the list of stakeholders would be different.
4. Intensity information and education work through mass media and various social institutions, including participatory activities such as poster contests and cooking events, to fill the large void of public understanding of the profound human, social and economic impact of IDD. Rely on modern mass media to reach the general public and focus on interpersonal and traditional channels and institutions to educate the most vulnerable groups, particularly those in the areas where IDD rates are high. Such efforts should involve members of various stakeholding groups.
The salt people, a major stakeholding group, are not well enough informed about IDD. Educate the "salt chain." From salt company owners to producers, from wholesale traders to retail sales people, those who are engaged in iodized salt trade at all levels need to know, especially the retail people who come into direct contact with the key group, the salt buyers. There are probably more people selling salt than there are health educators. They are potential partners in disseminating IDD information directly to mothers and food preparers; they can also be potential sources of misinformation. A case of iodized salt overdose, possibly a result of the mistaken belief that iodized salt itself could actually increase a child's IQ, is enough to cause an unnecessary setback. Little effort has been devoted to bringing up to date all health and medical personnel, many of whom are either uninformed or ill-informed. They are obvious sources of IDD information, or misinformation. Many medical and public health text books still refer to iodine deficiency mainly as a cause of goiter and cretinism. Old books are still in circulation and new texts have not yet been written.
All IDD information materials, print or audiovisual, should reflect the diversity of regional and ethnic characteristics, urban and rural, as well as various economic levels of the people. Poor tribal television viewers may not identify easily with sophisticated middle-class urbanites portrayed in public affairs spots. Pretesting and formative evaluation of information materials are necessary before dissemination.
There exist relatively little human interest stories of individual IDD victims, the physical and emotional impact of IDD on their family and community. These can be placed in key media outlets. Leading journalists and/or broadcasters could be invited to see for themselves the consequences of IDD. Since some villages have as high an incidence of cretinism as 15%, such stories should not be difficult to obtain. These moving stories lend themselves to photo, videos and soap opera treatment.
5. Introduce a sense of urgency in IDD messages. Because goiter, the "non-life-threatening cosmetic disease" and the most visible sign of IDD for the lay public, is the label under which IDD is often perceived, it is necessary to introduce a sense of urgency in IDD message designs. Punchy, more powerful messages are needed. Since the scientific community has labeled the IDD situation "SOS:IDD" and has described IDD's effect as "Brain Damage," message designers need not be shy in "telling it like it is." It would not be desirable to use scare and fear tactics, but scientific facts must be given forthrightly to encourage action.
Too many IDD information materials give a chronological description of the fight against IDD, which often begins with the visible goiter; instead, the journalistic "inverted pyramid" should be applied, so that the latest development, i.e., brain damage angle, comes first and goiter can be used as the reference to the tip of the iceberg of a much larger pool of mental retarded victims.
Of people interviewed in one country who learned about IDD and iodized salt from IDD public service announcements on the television, only one in four chose to use iodized salt. Persuading consumers to choose iodized salt over non-iodized salt should not follow certain standard commercial practices, whereby the purpose is to garner a bigger market share of a given product for a specific brand, i.e., the preferred choice. It matters a great deal more than a preferred choice for the expectant mother with the growing fetus in her body and for any young child whose brain growth is in progress.
No exaggeration is necessary but, in avoiding graphically too shocking pictures, message designers should not go overboard and make light of the tragic impact of IDD. While messages should focus sharply on iodized salt as the chosen instrument against mental retardation, the program must also inform the public about the ill effects of IDD and the consequences of not using iodized salt. It is important to remember that to effectuate a change, rational arguments based on solid scientific data alone are not enough. A strong emotional tug often provides the added push that triggers action.
Negative information on the programs should be dealt with promptly. Quick action is needed to counteract erroneous information, point by point, via a steady flow of positive announcements from credible sources (political, religious, scholastic, sports, radio and television personalities as spokespersons or goodwill ambassadors); at the same time, investigate sources of such misinformation and directly confront the sources for corrective action; invite competing media outlets (TV and press) to do investigative reports on the misinformation and on the set-back. It is important not to push any panic button, but do provide calm, deliberate, measured responses based on scientific facts. A facts and fallacies leaflet may be helpful to key groups of allies (salt processors, sales, community groups, etc.) enabling them to counteract the false information.
Also, involve selected producers, store owners/salesmen, customers in designing counter-rumor efforts and new promotional strategies. Share ownership of the trial and tribulation of the program with other stakeholders/partners.
6. Include children as active players in the IDD program by introducing IDD information in school health curricula at the primary school level. New generations of children knowledgeable about IDD will reinforce the behavioral norm of using iodized salt.
Among IDD programs, with a few exceptions, school health instruction has received little attention. It is important to make IDD a part of the regular primary school curriculum and get it adopted nationally. The child-to-child, parent-to-community through schools approach is as valid with IDD elimination as with other public health measures. This should be a key medium-term strategy to sustain IDD virtual elimination and to maintain the social norm of using iodized salt for the oncoming generations.
7. Give special attention to the most vulnerable groups. They include the expectant mothers, newlyweds and adolescent girls. If an expectant mother does not ingest small quantities of iodine through her intake of salt now, in a matter of weeks the fetus can bear the scar and in months can be born a cretin! The newlyweds can probably be reached at marriage registration bureaus; they can be asked to read a small leaflet on IDD and then be required to give correct answers in a short test on IDD before the certificate is issued.
8. Introduce legislative/regulatory support, i.e., import, export, manufacture, trading of iodized salt, food processing, whenever there is enough public education support for such measures to be supportive and not counterproductive.
Appropriate legislation is lacking in many countries. Legislative and regulatory support is needed to discourage the use of non-iodized salt and to encourage the use of iodized salt. However, legislation must not be too far ahead of public education and the availability of iodized salt supply. In one country, an enthusiastic district officer used his vested authority to ban non-iodized salt in his district before a sufficient supply of iodized salt was made available; a black market for non-iodized salt ensued. Such frustration and confusion on the part of the public is avoidable.
9. Maintain scientific research and surveillance of the IDD impact and build such technical capacity in the developing countries.
10. Begin in earnest in designing monitoring, evaluation, and verification of IDD virtual elimination efforts at the international and national levels.
SUMMARY
The authors conclude as follows: let us reiterate that we have the knowledge and the instruments to fight this micronutrient deficiency. We have the global policy commitment to virtually eliminate it. We need to focus now on program implementation.
We have also learned from past development experiences, both successes and failures, that a broad strategy is needed to mobilize all relevant elements of society for any development program to have a good chance to succeed. This is the more so for the fight against IDD, because it involves a habit for all and for all times. But actions are needed today not tomorrow, especially for the most vulnerable groups.
Lest we forget, the goal of virtual elimination by 2000 is only a short five years away. The countdown has already begun.
ICCIDD Executive meets in Ottawa, September 1995 - Participants included Delange, Dunn, Hetzel, Kavishe, Ling, Mannar, Mutamba, Pandav, Pretell, and Stanbury. Sonya Rabeneck of CIDA and David Alnwick of UNICEF attended for a session with donors. The following are some highlights:
IDD Activities at the 11th International Thyroid Congress, Toronto, September 10-15, 1995 - ICCIDD sponsored a satellite symposium to the Congress on September 10, attended by approximately 125 people. Many were thyroid scientists; others included representatives from other disciplines and several members of Kiwanis. The session included talks on IDD in different parts of the world, recent advances in technology, research needs, and an overview, followed by a general discussion. Speakers were Drs. Delange, Kavishe, Pretell, Pandav, Dunn, Stanbury, and Hetzel. Attendance was good, the discussion was lively, and the symposium provided a forum for many thyroidologists worldwide who are interested in IDD.
On September 11, several ICCIDD members (Drs. Boyages, Pinchera, Medeiros, Dunn) presented a workshop on IDD, focussing on its interface with the more basic sciences of neurophysiology, genetics, and immunology. In addition to members of the Executive, other ICCIDD Board members attending the International Thyroid Congress included Drs. Gerasimov and Djokomoeljanto. A number of presentations within the scientific part of the Congress dealt with iodine deficiency and its effects on humans. The meeting offered an opportunity for making other thyroidologists aware of ICCIDD and of the importance of IDD correction. Interest, particularly in Europe, Asia, and Latin America, is strong.
African Micronutrient Task Force - The Eastern and Southern African subregional group had its first meeting in Addis Ababa, August 28-30, 1995, convened and organized by OAU and UNICEF, and supported by UNICEF, WHO, and the MI. Fifty participants attended from six agencies and 18 countries, including Botswana, Cameroon, Egypt, Ethiopia, Gambia, Ghana, Kenya, Lesotho, Liberia, Madagascar, Rwanda, South Africa, Sudan, Swaziland, Uganda, and Zimbabwe. ICCIDD was represented by Drs. Mutamba, Lantum, and Kavishe. The meeting focussed on current IDD status, advocacy, and governmental planning. Based on main issues identified, the group recommended the following actions: (1) community level - community demand for foods fortified with essential micronutrients, and community activation to ensure sustainability; (2) national level - develop national strategies, integrate with other programs, including other nutrition programs, continued advocacy, better planning of fortification, analysis of existing information, and targeted training; (3) subregional level - development of appropriate legislation, assist countries in developing guidelines, coordination of training programs, short-term courses, and monitoring networks; and (4) international level - stronger international advocacy and technical support for programs, emphasis on monitoring and evaluation, continuing technical support, clearing house for micronutrient information. The group endorsed the proposed All African Conference on IDD in Harare, April 21-26, 1996, introduced by Ms. Mutamba, ICCIDD Subregional Coordinator for Eastern and Southern Africa, and recommended that the meeting be supported by high level participation of governments, and that it involve other African countries with iodized salt.
Symposium on "Iodine Deficiency Disorders in Bulgaria: Present Status and Prospects" - Dr. Delange, Executive Director of ICCIDD was a featured speaker at this satellite to the Fifth National Congress of Endocrinology in Bulgaria, October 17-20, 1995. Bulgaria now strictly controls the quality of imported iodized salt and is offering supplements of potassium iodide to pregnant and lactating women and to infants and children. The present results show median urinary iodines in the iodine- sufficient range, a marked reduction in goiter, and no complications from iodization. Dr. Delange has worked closely with the Bulgarian Ministry of Health to provide continuing consultation from ICCIDD.
Mozambique's Prime Minister launches universal salt iodization - At a town meeting in Lichinga, Niassa on October 5, 1995, the Prime Minister, Dr. Paschal Mocumbi, formally launched universal salt iodization for Mozambique. Producers in Nampula donated the first iodized salt to Niassa as a symbol of solidarity between the two provinces. This salt was transported by truck from the coastal port of Nacala to Linchinga, a distance of over 1000 km. Niassa province has the most severe IDD in the country. The Prime Minister stated that "it is heartwarming for me to launch [this program], having started this effort in 1981 when I commissioned a study on the prevalence of goiter in this province." At that time he was Minister of Health, becoming Minister of Foreign Affairs in 1987. His remarks were made in the presence of the governor of the province, national and provincial authorities, business leaders, and citizens. Universal salt iodization is being supported by a strong mobilization campaign as well as by legislation that has been drafted and is currently being studied by the government.
IDD Day, October 21, 1995 - This day was designated to draw global attention to iodine deficiency. Dr. Jack Ling of ICCIDD was active in the proposal and promotion of the event, with UNICEF and Kiwanis International. UNICEF prepared a press release distributed to all its national committees and field offices. It included a media kit, a statement by Carol Bellamy, Executive Director of UNICEF and quotes from Basil Hetzel (Chairman, ICCIDD), Roger Moore, and Sir Edmund Hillary. The material emphasized key facts about IDD - that it is the greatest single cause of preventable mental retardation, that 1.6 billion people risk its consequences, that Kiwanis has pledged to raise $75 million to combat it, and that iodized salt is the best overall preventative.
All We Expect: Nutrition, A Basic Human Right
- This video was produced by the Micronutrient Initiative as part of a presentation at the Fourth UN Conference on Women, in Beijing, China, September 1995. The video focusses on micronutrient deficiency as a problem particularly of women and children, and emphasizes nutrition as a basic human right. For further information, contact the Micronutrient Initiative (c/o IDRC, P. O. Box 8500, 250 Albert Street, Ottawa, Ontario, Canada K1G 3H9.