Volume 10 Number 1, February 1994
IN THIS ISSUE
The UNICEF-WHO Joint Committee on Health Policy met in Geneva in
January 1994. It briefly reviewed progress in IDD, and sharpened the focus on iodized salt. The report summarizes a number of positions and recommendations that have been formulated by ICCIDD jointly with WHO and UNICEF.
HIGHLIGHTS OF THE COMMITTEE'S REPORT:
At a ceremony in the throne room of the Royal Palace in Bangkok in January, 1994, ICCIDD's Chairman John Stanbury received the annual award of the Prince Mahidol Foundation for his work on IDD. The Foundation and the award were established by the royal family of Thailand on the occasion of the one hundredth anniversary of the birth of Prince Mahidol. Awardees are chosen each year by an international committee that presently includes three winners of Nobel prizes. Two prizes are given each year, one for contributions to public health and the other to medicine.
Prince Mahidol graduated in 1928 from the Harvard Medical School. He returned to Thailand, where he established reforms in medical education and public health before his untimely death two years later. His son, the present King, was born in Cambridge, Massachusetts. Dr. Stanbury also attended Harvard Medical School and spent most of his professional career on its faculty.
The award ceremony was an occasion of extraordinary pomp. Among those present was the US Ambassador, the diplomatic corps, and the Ministers of State in full dress. After a lengthy appreciation was read, the award was presented by Her Royal Highness, Princess Maha Chakri Sirindhorn. The award consisted of a gold scroll with a citation encased in acrylic, an inscribed medal, a painted ceramic bowl, and a check. Also receiving an award was Dr. Ciro Quadros of Brazil, the architect of the eradication of poliomyelitis from the Americas. He was supported at the ceremony by the Ambassador from Brazil. A cocktail hour and a state banquet followed.
The citation reads as follows: "The Prince Mahidol Award Foundation under Royal patronage confers the Prince Mahidol Award for 1993 upon John B. Stanbury, M.D., on January 21, 1994 in recognition of his outstanding work in medicine on the deficiency of iodine and the disorders of the thyroid gland, which have been proved to be of immense benefit to the health and well being of mankind. (signed) Her Royal Highness, Princess Maha Chakri Sirindhorn, Chair, Board of Trustees and President, The Prince Mahidol Award Foundation."
HRH, the Princess, has long had an interest in nutrition and especially the iodine deficiency disorders. She serves as Chairperson of the National Committee for IDD Control. Her support has given strong impetus to Thailand's drive to eliminate IDD (see IDD Newsletter 8(3), p 25, 1992).
A National Advocacy Meeting took place in Beijing in September 1993, to reaffirm the commitment to IDD elimination and to intensify efforts toward that goal. An accompanying article by David Haxton, ICCIDD Board member, who acted as Senior Advisor for the meeting, describes the planning and preparations that led up to the event.
BACKGROUND
Previous issues of the IDD Newsletter have described progress towards IDD elimination in China. (See IDD Newsletter, vol. 5, no. 4, November 1989). An updated map shows that only a few parts of the country are not at risk for iodine deficiency.
The report of the meeting traces the history of previous efforts towards IDD recognition and correction in China. In 1990, 20 of the 30 Provincial Leading Groups had reported that goiter was under control in their territory. However, by more careful assessment, many people were found still to have mild iodine deficiency. The need for applying stricter criteria was acknowledged. It was also recognized that problems existed in the manufacture and delivery of iodized salt. Frequently, iodine concentrations were too low, particularly at the household level. Recent economic developments have increased the number of small private producers of noniodized salt, and this situation has complicated the assurance of adequate salt iodization. At the time of the meeting it was recognized that the salt industry then had the capacity to iodize only 3.2 million tons of the 8 million tons of salt consumed in China each year. The government has found the IDD problem to be more severe than previously recognized and has called for further assistance from UN agencies and for advice from the International Working Group on Iodine Deficiency Disorders of which Dr. Hetzel, Executive Director of ICCIDD, is Chairman. In 1992, UNICEF, WHO, and UNDP signed with the Government of China an "IDD Program Framework." It charted a course that included the following targets:
A national leading and coordination group for IDD elimination was formed in March 1993. Originally, it consisted chiefly of health officials, but since has grown to represent more than 20 ministries and sectors, reflecting awareness of the widespread nature of IDD and the many groups that must be involved in achieving its elimination. This National Advocacy Meeting in 1993 was the first in this series of events planned to reach eventual IDD elimination.
MEETING ORGANIZATION
As described by Mr. Haxton, the strategy of this meeting was to reaffirm at the highest political level the commitment to eliminate IDD and to involve all relevant sectors in the fight towards this goal. Participants included very high level officials from the State Council, the Minister and many senior officials from the Ministry of Public Health, and top officials from the Ministry of Finance, the State Planning Commission, the National Salt Industry Corporation, the Ministry of Agriculture, the Ministry of Domestic Trade, the Ministry of Broadcasting, various medical colleges, the State Commission of Family Planning, the State Education Commission, and many others. All the provinces were represented by major administrators, including several vice-governors, most directors or deputy directors of the Bureaus of Public Health, directors of the Bureaus of Salt Management, and directors of provincial Offices of Endemic Disease Control. ICCIDD members were active in planning for the Congress and participating in its proceedings. These included Basil Hetzel, David Haxton, Robert DeLong, Minoru Irie, Glen Maberly, Venkatesh Mannar, C.S. Pandav, and the Regional Coordinator for the West Pacific, Dr. Ma Tai. Other foreign participants included representatives of UNICEF, WHO, UNDP, FAO, and AIDAB, and ambassadors from Canada, Laos, India, Pakistan, Nepal, and Myanmar.
STATEMENTS FROM NATIONAL GROUPS
The opening program was chaired by Xu Zhijian, the Vice Secretary General of the State Council, and featured speeches by State Councillor Mme. Peng Peiyun, representatives from several Chinese state organizations and UN agencies, and Dr. Hetzel, Dr. Ma, and Dr. Maberly of ICCIDD.
Leading government officials described the roles of their agencies in meeting the goal of IDD elimination. Zhu Rongji, the Vice-Premier responsible for national economic development, pledged economic support for the IDD elimination project. He pointed to the current emphasis on economic reform in China and noted that the elimination of IDD supports the country's economic goals by improving productivity and lowering health care costs. State Councillor Peng Peiyun announced the establishment by the State Council of a "national leading and coordination group for controlling IDD," to involve all relevant sectors towards the goal.
Dr. Chen Minzhang, the Minister of Public Health, outlined the following six activities for his Ministry: (1) coordination and advocacy to increase awareness of IDD; (2) comprehensive prevention by making iodized salt the only type available; (3) appropriate regulations to improve control of the salt iodization process; (4) improved popular education about IDD and its prevention; (5) research into all relevant areas; and (6) monitoring and surveillance of the iodine status of the population and of the iodine levels in salt.
The China National Council of Light Industry proposed strong regulations and legislation for upgrading iodization packaging and distribution systems. The Ministry of Agriculture emphasized the importance of correcting iodine deficiency in farm animals. Its Vice-Minister, Wu Yixia, noted that adequate iodine intake in animals improves agricultural productivity. His department pledged to work on iodine-producing plants suitable for incorporation in stock feed, and to promote awareness of the benefits of iodization to farmers.
The meeting also heard a pledge from the All-China Women's Federation to enlist in the fight against IDD. This Federation has more than 100,000 women in units that can provide a network for training and communication. They currently operate 230,000 parent education schools and provide radio broadcasts for 5 to 6 million people. Over ten million people visit their family counseling services every year. Each of these contacts provides an opportunity for disseminating information about the damage from iodine deficiency and about the means for its correction. Another group, the China Disabled Persons' Federation, listed its contributions, specifically the distribution of iodized oil to areas of high risk and provision of educational material, as described by Deng Pufang, Chairman of the Federation.
The conference also included reports on three regions where IDD has been particularly severe, Tibet, Jilin, and Sichuan. Tibet has complex problems with salt distribution, which make iodization particularly difficult to introduce. Iodization of brick tea has been developed, but is still not widely available. An iodized oil program has also been used. In Jilin, the iodine deficiency has been severe. Reports of decreasing prevalence several years ago were in error, but led to a relaxation of elimination efforts. Administrative changes also tended to obscure the importance of the IDD problem. The regional authorities are now emphasizing cooperation between sectors, increased financing, improvement in salt supply, regulations against distribution of inadequately iodized salt, and education. Sichuan had an effective iodized salt distribution program in the 1970's, but production decreased in subsequent years, leading to increased manifestations of iodine deficiency. The government is now promulgating programs to increase accessibility to iodized salt, to reach 70% of the population by 1995 and 100% by 1997. Sichuan also recognizes the importance of far-reaching educational activity to involve leadership, the salt industry, and the general public.
NATIONAL PLAN OF ACTION
The conference included working sessions to enable the participants from the individual provinces to discuss a draft national plan of action and deal with specific technical and implementation issues. At the conclusion, the provincial officials endorsed a revised national plan, which is now in the hands of the State Council for approval and circulation to provincial and regional governments. The key principles of the national plan of action are:
MULTISECTORAL COORDINATION
The meeting discussed multisectoral collaboration and management. The Ministry of Public Health and the salt industry, under the China National Council of Light Industry, have the major responsibility. Others include: the State Planning Commission; State Education Commission; Ministries of Agriculture, Legislation, Chemical Industry, Transportation, Railway Transportation, Internal Trade, Finance, Civil Affairs, Tax and Tariffs, Broadcasting, Movies and Television; the State Pharmaceutical Administration Bureau; Bureau of Legislation (under the State Council); National Bureau for Industry and Commerce; National Family Planning Commission; National Youth Work Commission; All-China Women's Federation; China Disabled Persons' Federation; China Association of Science and Technology; and the National Patriotic Health Campaign Committee.
PROVINCIAL RESPONSIBILITY
The major responsibility for IDD elimination rests with provincial governments. Each must adapt the guidelines of the central government to the particular situation of their own province. Each is preparing its own plan of action and will be responsible for its implementation.
INTERVENTION
The meeting pledged improvement in production, distribution, regulation, information and pricing of iodized salt, with a specific plan of action for the salt industry. A licensing system for salt sales will be in place in 1994. Equipment will be upgraded and quality control strengthened. Universal salt iodization will be introduced in 1995 and completely in place by the end of 1996. Sustainability should be achievable because the cost of iodine in the iodization process can be absorbed by the consumer.
It is recognized that iodized salt is not currently feasible everywhere, and other fortification methods need to be developed, such as iodizing brick tea, water or rice. However, it is anticipated that the demand for refined salt will eventually make this the preferred measure everywhere. The plan calls for iodization of 80% of all salt for human and animal consumption by 1995, and 100% by 1996. Iodized oil will be used as a short term measure in regions where IDD is particularly severe and salt iodization is not currently feasible. The production of iodized oil will also be improved.
SOCIAL MOBILIZATION AND ADVOCACY
Following the National Advocacy Meeting, each province plans to hold similar meetings to develop provincial plans of action and advocacy. A national meeting will be held in 1995 to assess progress.
The National Health Education Institute is responsible for developing and coordinating health education activities. It will develop broadcast films, media articles and logos.
SURVEILLANCE
Monitoring is necessary both for iodine levels in salt and for indicators of iodine deficiency in populations. Surveillance has been hampered by undertrained staff and outmoded equipment. Laboratories capable of conducting appropriate tests will be established in 50% of the provinces by the end of 1995 and in all by 1996.
RESEARCH AND DEVELOPMENT
The importance of research is recognized, for example the effects of iodine deficiency on domestic animals. The need for improved facilities and funding is also recognized. The National Consultative Committee on IDD should draft a research program, and international cooperation should be encouraged.
TARGETS
The meeting listed a number of objectives and detailed intermediate targets. The overall objective is "the virtual elimination of IDD from the whole of China by the year 2000 (i.e.: by the end of 1999)." An intermediate goal is "To iodize all salt processed for human and animal consumption (including salt used in food processing) by the end of 1996 (i.e.: universal salt iodization)."
A number of intermediate targets were presented. For 1993, these included declarations for IDD elimination by provincial governments, approval of a national plan of action by the State Council, and a master plan developed by the National Salt Industry Corporation. In 1994, targets included development of provincial plans of action for elimination of IDD, regulations on iodization of human and animal salt with quality assurance systems, development of a communication strategy, training plans,establishment of salt iodine monitoring laboratories, and provincial surveillance systems.
By the end of 1995, 80% of all salt for human and animal consumption will be iodized, training for provincial personnel in management, iodization, communication, and laboratory methods will be completed, 50% of all the counties should reach the appropriate standards for the elimination of IDD with sustainable programs, and a national meeting will assess progress.
By the end of 1996, all salt for human and animal consumption will be iodized, 80% of all counties in China should declare sustainable IDD elimination, and alternative sustainable methods of iodine fortification should be in place in areas where iodized salt is not feasible.
By the end of 1999, virtual elimination of IDD should have been achieved (98% of all counties) and verified by national and international experts. An effective monitoring system should be in place, salt iodization should be universal, and iodized oil, where necessary, will be used as a routine intervention.
David Haxton, ICCIDD Board, Greensboro, NC, USA
The single greatest preventable cause of mental retardation in the world is lack of iodine in the daily diet. This simple fact is not as well known as it should be among political and financial decision makers of any country. In most places where there has been impressive work on IDD identification and assessment, the program managers (and others) lament the lack of priority political support, but are often not able or willing to risk the attempt to reach senior political leaders and demonstrate that "IDD elimination is good politics." This is true in most iodine deficient countries, but it is particularly dramatic in China, where one-third of the iodine deficient people on the globe live.
There is a growing recognition of the need to advocate for good public health in modern ways. Two such channels come readily to mind : the political channel (to obtain commitment and to create will) and the communication channel (to create public demand, sustain political will, and inform and enlighten people on facts of life). What is progressing more slowly is the acceptance by national public health and scientific groups of the need for careful and long range advocacy planning. It is a process extending over time and involving variable factors and positions. Too often, advocacy on IDD (and other good subjects) is treated as an event. This limits the planning for it, the power of it and the follow up required to sustain the interest achieved.
The effectiveness of a planned advocacy strategy for social development issues has been demonstrated in a number of countries on a variety of issues over the past 20 years. In Brazil, the power of communications through television of drama, sports, news, and discussion was demonstrated in the successful effort to arrest bottle feeding and protect breast feeding for infants (1). Also in Brazil, the power of social communications of nongovernmental groups and massive national media attention were instrumental in altering Government policy in development projects in the rain forests and the Northeast. In Indonesia, the combined power of modern communications and traditional media created a demand for a cluster of basic services (baby weighing, growth monitoring, supplementary feeding, breast feeding, oral rehydration therapy, immunizations, iron and vitamin A consumption) which later was promoted globally, principally by UNICEF and known by the mnemonic, "GOBI" (2).
UNICEF has shown the power of advocacy of essential ideas based on good science and economics by "going public" through its annual "State of the World's Children Report" which has become the most read UN document. The Report, combined with coordinated UNICEF staff efforts in all countries, has brought issues like diarrhea management and education for all to the editorial pages and the discussion centers of all countries. It is not only quoted, but has become the framework for reconsideration of national priorities. An essential point to remember is that while the publication itself is an event, the process is a carefully planned one.
Sooner or later it becomes clear to the national IDD program leadership that access to large resources is limited; access to political decision making is missing; communicators associated with the program are geared to "health education" in the traditional ways; and access to the private productive sector is limited or nonexistent. It then becomes evident that an important decision has to be made : to continue to be a small band of people with a pocket full of coins; or to elevate the subject of IDD on the public agenda.
Such was the situation in South Asia regarding the political priority for development issues for women and children, (including the elimination of IDD) when the SAARC (South Asian Association for Regional Cooperation) agreed at the Head of State level that childrens' issues deserved their vital political support. The Summit Conference endorsed unanimously the proposals of a Ministerial level meeting, and national policies, including IDD elimination, were adjusted accordingly. The issues of children remained on the political agenda, supported by regular public discussion of the issues (3).
Following the Global Summit on Children and the Montreal Conference on Ending Hidden Hunger, it became evident that more political advocacy on the question of iodine deficiency elimination was required. The major criticisms had to be addressed: for example, if prevention of the problems was so simple, why was the world not taking action? or, if the problems were so pervasive as ICCIDD and others were suggesting, why no aggressive action to attack them? If the per capita costs were so low, what financial hurdles had to be overcome? If a good national response was to iodize alimentary salt, why not start a discussion with the owners of the product?
Until recently, discussion of these issues was contained within scientific or government meetings. The results, when published, often long after the discussion, while known to those interested and involved, were not part of the political agenda of the country.
The idea of "Mini Montreals" was first broached during discussions in Central America in 1992. The idea to pull political, public health, communicators, producers of food, and other professionals together for a single national purpose was proposed for large countries, for subregional opportunities, and for existing political groups. It was slow to be taken up but was gradually recognized as a way to bring political leadership and authority and public health policy makers into direct discussion with private producers for a common purpose.
It became clear that a planned strategy of advocacy was required in each country to address: (a) how to demystify information on IDD; (b) how to present the information on IDD in operational and action oriented language; (c) how to convince political leaders that eliminating IDD was good politics; (d) how to convince the scientific community to share its knowledge with other professional groups who could act on it; and (e) how to create effective alliances with agriculture, education, communications, economic processes, and the productive industrial sector in the country. This was a new field of endeavor for ICCIDD. However, UNICEF, a major ally of ICCIDD was comfortable with it, having used the technique of public advocacy effectively for raising the level of awareness of problems of children in the UN, in Member States, and with nongovernmental organizations. PAMM (Program Against Micronutrient Malnutrition) had incorporated national advocacy planning in its courses for national management The subject had received enthusiastic acceptance.
Experience on meeting dynamics has become a cottage industry. A good number of people have become well known for their persistent attendance at them. While expertise exists on organization of scientific discussions and on organization of public policy debate, the practice of blending both into a cohesive national event is in short supply. Too many people still confuse the difference between the two. Moreover, suggesting that such a national advocacy event take place requires meetings with the very political leaders one is trying to influence. This requires access and a different communications style and approach than is usually found in academic circles and in public administration.
The Government of China, through the Ministry of Health, had been working for many years on elimination of goiter. In the last decade or so, it expanded its ambition to include elimination of IDD. The problems of iodine deficiency have been known in China for over 4000 years and there are medical texts on the subject available from the third century B.C. The course of work on iodine deficiency in China has been one of energetic application of known science and techniques followed by waning interest, leading to lower management and political interest, to stagnation of progress. Antigoiter efforts received prominent political attention in the early to mid 1950's and were, in fact, associated with the "National Development Guidelines," a priority Government planning document. The high level program to eliminate goiter was established directly under the Central Committee of the Communist Party, but it seems that the political recognition and support atrophied through a lack of advocacy to sustain it and a lack of a communications strategy to maintain involvement and interest among decision makers. The Great Cultural Revolution also had a negative impact on program developments, but once it subsided, a plan to eliminate endemic goiter was revitalized by General Deshal Li of the People's Liberation Army, and a national leading group.
Still, the effort was, and was seen to be, a sectoral endeavor, albeit one with an expressed need for collaboration from others. Foreign assistance was sought and obtained. A long term investment by the Government of Australia began to alter thinking about iodine deficiency in the country and to propose application of modern methodology of assessment, evaluation, training, and quality assurance to the national program (4). By the mid 1980s, studies were revealing the tragic impact of the loss of intellectual development of children born in iodine deficient areas. While the exact correlation of the numbers may lead to discussion, one could postulate that of the 30 to 50 percent of all newborns in China who have thyroid disorders caused by iodine deficiencies in their mothers, most will suffer irreversible intellectual disability as a result. IQs of school children were on average some 10 points below those of other children. This could mean a "loss of intellectual capacity" each year of more than 60 million IQ points (5).
The major problems to be addressed regarding full penetration of the country by appropriately iodized salt were becoming clear. The Government approached UNDP and WHO to assist, and a technical assistance program was designed. UNICEF was asked to join the group. Among other significant improvements in this approach was the designation of a permanent senior scientific and technical advisor to the program, Glen Maberly of Australia, ICCIDD, and PAMM. Meanwhile, the International Working Group on China, which ICCIDD Executive Director Basil Hetzel had helped to create, had regular meetings to review progress. The IWGC became part of the revised national plan.
The new program called for accelerated efforts in human resource development; collaboration with other sectors, especially salt producers; and improvement in management information systems and quality assurance procedures. It stressed the need to reach the provinces with sound management teams and suggested a national multisectoral meeting on IDD elimination. There were weak spots in the plan, however, and these needed to be addressed in the context of planning for any next stage. Among the major questions to be addressed were: (a) how to elevate the political consideration of this public health issue to the level of national commitment; (b) how to increase the Government's investment in the venture by enrolling all sectors and elements of society in the endeavor; (c) how to make the program truly nationwide; (d) how to create demand from the provinces for more significant action and more timely investment; and (e) how to set realistic targets enroute to achieve the goal of elimination by 2000.
In June 1993, the UNICEF Representative to China, Mr. Farid Rahman, in consultation with his colleagues the UNDP Representative, Mr. Arthur Holcomb and the WHO Country Representative Dr. Kingsley Gee, asked me to visit Beijing for discussions to determine what might be done in this regard. After preliminary discussions with middle level and some senior officials it became clear that (a) the problem was not perceived as a national one; (b) the problem had more to do with management issues than with science and technology; and (c) the desire to meet the publicly announced midterm goal was sincere, but a program and policy framework was required.
We proposed to senior government and political officials that:
In a meeting in the Great Hall of the People on June 19, 1993, Madame Peng Puiyun, State Councillor responsible for oversight of 17 Ministries and Organizations, in the presence of the Minister of Health and the UN Agency Heads, agreed to all of the proposals. She felt that the Government could only achieve full coverage with iodized salt by the end of 1996, but offered to review that target, and also agreed to a meeting in September 1993. She told me that her briefing and study had been enlightening and that she had not earlier understood the magnitude of the problems caused by iodine deficiency. She recognized that it was most important to China that no further time be lost in preventing mental retardation. The date selected left little time to get organized, but in many ways that was a "plus" since it made everyone focus on the major issues of the National Advocacy Meeting and to set aside secondary issues.
We had enough information and data to proceed to formulate national policy to meet the needs of the decade and to support economic development, which was accelerating at unprecedented pace. A major stimulant to rapid action was the need to eliminate preventable mental retardation, now seen as an important political issue in light of the "one child per family" planning policy. This again demonstrated that when IDD is seen to be good politics, major political decisions follow rapidly. The obligation of national program managers is to create such opportunities and to seize them with fresh outlooks and imaginative ideas that look forward to the solution, not inward to the problems.
A Leading Group was formed. Its challenge under the leadership of the State Councillor was to prepare the meeting while simultaneously preparing a revised national plan of action, to take advantage of the momentum created. An outline of work for both tasks was prepared and the UN Agencies named me as the Senior Advisor to the Meeting while Dr. Maberly continued as Senior Advisor to the Program and helped to guide the documentation through the process of discussion. The division of responsibility was effective and efficient and could serve as a management model in future events. The preparations required a team to gather and collate existing information and data; a team to work on the revision and publication of a new plan; a team to work on the physical arrangements for the meeting; and a team to work on the political and program processes of the event. All groups worked simultaneously reporting to the State Council regularly. Documentation for the conference was to be minimal. But that minimum required full review of the existing structures of management; of the salt industry in all its aspects; of the roles of social communication; and of social demand for a solution to the problem and political leadership to provide it. This in turn would govern the selection of the people and organizations to be invited.
The first major decision was that the meeting would be national. This had two implications : the first, that international organizations and experts would be few in number and not major components of the program; the second, that the discussion would be truly national by significant leaders from all provinces and autonomous territories. Each governor would be asked to attend with a team representing a range of interests and professions. It was relatively easy to obtain the full and rapid concurrence of the Government of China to this concept to attend.
Because of the enormous interest in IDD in China, and because of the magnitude of the problem and the consequences to the globe of its solution, interest in the meeting came from all continents. The Government of China made it clear that it welcomed any government to attend as an observer if there was something to learn from the experience, either on the part of the Government of China or of the visiting delegation. It also made it clear that it welcomed senior leaders from development organizations who could collaborate with a renewed effort and assist in bringing it to fruition.
The Senior Consultant for the Meeting was assigned the task of preparing the list of organizations and people to attend from outside China, and to assure that once the invitation was issued, that attendance at the appropriate level and with the appropriate information was assured. A direct communication between the Premier and the Executive Director of UNICEF was arranged.
A review of progress was made in late July. A meeting with Madame Peng Puiyan and the representatives of 17 organizations led to the conclusion that all was on track for September. The only major points yet to be absolutely confirmed were (a) the decision to iodize all alimentary salt, (for both animal and human consumption); and (b) the decision on the deadline to be established to complete that undertaking.
Discussions were intense and involved a range of sectors and opinions. Issues included questions of cost, of the need for all salt to be iodized (as opposed to just that for consumption directly), of decentralization of the salt industry, of how far to "privatize" the salt industry, of concern over waste of potassium iodate, and of the practicality of reaching each salt producer to accomplish the task. In the end, the evidence and the logic of accepting the proposal to iodize all alimentary salt appropriately was made.
The major factors supporting that decision were : the additional cost of doing so was minimal in comparison to the costs of problems created with more than one product in the market place; the need to assure that all people were reached with only iodized salt; the potential to create a sustainable quality assurance methodology regardless of geography and logistics; the potential of allies like farmers to help create demand for iodization; and the potential for prevention of mental retardation. The contributions of ICCIDD Board members Mr. Venkatesh Mannar on salt management and technology and Dr. C. S. Pandav on economics of production, packaging, marketing and programming were indispensable for the preparations and subsequent success of the meeting.
The decision to iodize all alimentary salt was made just before the meeting itself and was announced at the session. The Government expressed its full intention to press for full iodization by the end of 1995, but could not publicly promise to achieve this until resource assurance was in hand. It did promise that the goal would be reached by the end of 1996.
The National Advocacy Meeting in Beijing demonstrated forcefully the positive merging of major political interests in dealing with a serious public health problem. It illustrated the process through which often unconnected ideas can be blended for rapid application of existing knowledge and resources. It showed that political leadership responds positively to information that is useful for policy making when such policy is shown to be good politics and good for the nation.
The meeting elevated the discussion of IDD elimination to the maximum political level. The Premier of China stated the problem as a priority for the nation. All the participants were called to the Zhong Nan Hai Palace to meet the Deputy Prime Minister. After the protocol discussions, he stated for the record that he had not clearly understood until that time the severe negative impact of IDD on China. Now that he understood it, he said the program would not only receive his full personal support, but he would make available all necessary financial and other resources promptly. Each province brought to the meeting a progress report that was analyzed by a multidisciplinary professional team. A National Government Position Paper was prepared. A draft proposal for action was agreed upon and presented to the State Council for consideration.
In China the State Council has direct management over two major arms of governance: the political arm (represented by the Party and the People's Congresses); and the administrative (the usual national, provincial, country administrative services). It is also connected with the third main arm of political society in the country, the People's Liberation Army. Thus, to have the State Council in charge of this national program assures that each arm of political and administrative action of the Government will be involved in the ownership, development, and execution of the national elimination program. While the Ministry of Health will lead the work in technical matters, the Ministry of Light Industry will have the main thrust, since it manages all salt production and marketing in the country. The education sector, has the task of informing all people about iodine deficiency and the need for appropriate diets to prevent it. The Ministry of Agriculture will work with farmers and others to correct iodine deficiency in domestic animals in order to advance productivity in the rural economy.
Despite the great success of the meeting, problems remain. For instance, the need for investment capital at affordable rates to modernize the salt industry must still be arranged. This requires readjustment of the country financial plan to assure sufficient domestic resources as well as readjustment of negotiations with the World Bank for a loan to the salt industry. These considerations arise during a time of rapid economic expansion and decentralization and privatization of infrastructure.
But, financial security is only one part of the question of iodized salt production. An equally important element is that of stability in the industry itself. As the Government and people of China seek to privatize functions owned and operated by the State, active discussion is taking place on questions of how much of the salt industry should be privatized, and how quickly it should occur. Understanding this issue entails recognition of the positions of those who are accustomed to central management and of those who desire decentralized development. It also entails questions on how to sustain quality and quality control, how to assure appropriate price structures for this essential public health product, how to assure appropriate training and placement of people in key functions, which plants should receive priority attention for investment and how long they will stay government owned, how many plants will not be modernized, and how heavily the government should borrow from the World Bank compared with commercial bank arrangements. There are also questions of licensing and enforcement.
But, despite the problems, no one questions the determination to press on to successful elimination of iodine deficiency. Advocacy and Policy meetings at the provincial level have been held and met with enthusiastic, positive interest and results. The key to so much in China.. as in many large nations.. is the will and commitment of leadership and people in the provinces. Provincial plans have been modified to include the conclusions of the National Advocacy Meeting. Training plans for the nation, and some of the provinces are in place. UNICEF and UNDP are looking at ways to improve collaboration with the existing efforts and to prepare for future investments in the new plan. Training visits and exchange of knowledge visits have been completed.
Moving from policy to performance is a political act. There is still much to be learned about the process of advocacy in public health, but it is already evident that IDD elimination is an issue that properly informed political leaders readily support. National advocacy meetings are "good politics" when they use a range of professionals to state national policy and to design practical ways to apply existing knowledge for public benefit. They provide a unique opportunity to achieve a true multisectoral collaboration for the public benefit.
REFERENCES
by John B. Stanbury, Chairman, ICCIDD, Chestnut Hill, MA, USA
The damaged nervous system of the endemic cretin is evident in mental retardation, squinting, deaf mutism, gait disturbances and spastic proximal muscle involvement. These changes are attributed largely or entirely to severe iodine deficiency during fetal and early postnatal life. The question has repeatedly been raised whether lesser degrees of iodine deficiency result in lesser but significant degrees of damage to the brain. This question was addressed at a two day symposium at the Franklin Institute in Philadelphia in May of 1993. The conference was concerned not so much with the effects of iodine deficiency on the biochemical and microanatomical effects of iodine deficiency as on the outcome in neuromotor and cognitive function. The proceedings are now being published. (Cognizant Communications Corporation, 3 Hartsdale Road, Elmsford, New York, USA, 10523).
As background for the symposium B.S. Hetzel (Australia) reviewed the historical development of concepts on the relationship between brain and thyroid. Epidemiological evidence from the middle of the last century linked cretinism with the goiter, and the linkage was amply confirmed by the disappearance of cretinism when populations were sufficiently replaced with iodine and thyroid function restored to normal. Hetzel described the more recent concept of a spectrum of disorders resulting from iodine deficiency, including cerebral hypothyroidism and deficiencies in learning and work performance.
Several papers discussed in detail the neuromotor deficit of endemic cretinism, among them those of DeLong (USA) and Halpern (Australia). Timing of the insult resulting from iodine deficiency received special attention. The most vulnerable period appears to be in the middle and last trimester of pregnancy. DeLong classified the neurological types of cretinism into four categories depending on pattern and severity. He presented evidence supporting his concept that brain size as reflected in head circumference is an important and useful indicator of damage.
Connolly and Pharoah (U.K.) pointed out some of the problems and hazards of assessing "subclinical" effects of iodine deficiency, since the changes may be subtle and the subjects usually live in remote regions and have a culture, education and behavior quite different from those of the examiner. In this paper and elsewhere, a distinction was drawn between permanent effects on the nervous system and those from reversible changes in thyroid function i.e., treatable hypothyroidism, as shown by abnormalities in thyroid function tests.
Much work at the Child Development Scientific Coordinating Center in Jamaica has been done on the effects of helminth infestation, which has useful parallels to iodine deficiency. N. Scrimshaw (USA) summarized problems in studying the effects of iron and protein-calorie deficiencies on cognition. The motor and cognitive effects of thyroid hormone deficiency are expressed in molecular and anatomical substrates in the brain. Stein (USA) presented an exhaustive review of these substrates and their interaction with the thyroid hormones. In a remarkable summary of thyroid hormones in the fetal-maternal relationship, the Escobars and their colleagues (Spain) described their extensive research in this field. They recounted in some detail their rat model of iodine deficiency, and Hetzel (Australia) described the studies of his group on hormone nurturing of the developing brain in sheep and marmoset models. All concluded that a satisfactory animal model of endemic cretinism has not yet been produced.
Endemic cretinism appears in two rather distinct forms: neurological and myxedematous, the latter being the principal form found in central Africa. Although much controversy has surrounded the differences, all agree that iodine deficiency is the root cause of both, but that additional factors determine the phenotype. Selenium deficiency may be one of these. Dumont, Contempre and their colleagues (Belgium) summarized their studies and points of view, as did Boyages (Australia) from his observations in China. Geelhoed and Downing (USA) reported their observations on iodine deficiency in the Uele of Zaire, as did Querido (Netherlands) in Irian Java, Ma Tai in western China, O'Donnell and DeLong (USA) also in China, Thilly et al. (Belgium) in Ubangi (Zaire) and Malawi, Nordenberg et al. in Poland, and Pretell (Peru) in his country. Surprisingly, iodine deficiency disorders are found in several regions of Europe. These foci were summarized by Pinchera et al. (Italy), and the point made that iodine deficiency still exacts a toll in neuromotor function in those regions.
One endemia of iodine deficiency disorders that has been particularly severe is that of Papua, New Guinea, where iodinated oil was initially used prophylactically. At the symposium Pharoah and Connolly (U.K) described their studies there that provided the most convincing proof that cretinism is prevented by community-wide distribution of iodine.
Two presentations of unusual interest were from Ecuador. Fierro-Benitez explored the impact of the Spanish conquest on the Incan culture and how its collapse and that of its empire led, among other disasters, to a disruption of the traditional economy and the appearance of iodine deficiency. Greene (USA) complemented these insights with his own extensive observations on the pathophysiology of iodine deficiency in Andean Ecuador and the effects on psychomotor and cognitive function.
The reversibility of effects of non-iodine deficient congenital hypothyroidism on the central nervous system has been a controversial issue. Dussault (Canada) and colleagues have found permanent changes in their hypothyroid subjects identified in the course of newborn screening programs, but Mitchell (USA) presented evidence that these changes are due primarily to non-compliance with the prescribed therapeutic regimen.
One of the characteristics of the neural impairment of iodine deficiency is hearing loss. The majority of cretins are deaf. Indeed, Querido (Netherlands) has pointed out that this is the most frequent marker for endemic cretinism. The nature of the hearing loss and studies of the hearing abnormality in these disorders were described by Halpern (Australia). In China, he found audiometric deficits that were both conductive and sensorineural, and ascribed the damage to a time at which thyroid function begins in the fetus.
What are the societal costs of iodine deficiency and the benefits of prophylaxis? Dunn (USA) addressed these questions and provided answers from several analyses, including his own, that there is indeed a very large benefit to cost ratio. Particularly convincing were data that he presented from Germany. While it is intuitively certain that prophylaxis is decidedly worth the cost and effort, it is useful to have the supporting information displayed, as was done here.
The conference concluded with a summary by Carl Taylor (USA), who found convincing the evidence that indeed milder degrees of iodine deficiency exact a cost in intellectual function that can be very roughly estimated at a loss of about 10 I.Q. points, but noted that significant investigative problems remain. Particularly needed are simple tests of neural function that can be reproducibly and meaningfully applied in the field. More information is needed on correlative risk factors, such as goitrogens and environmental stimulation.
The conference was intense, but accomplished the goals that were set for it. It succeeded in summarizing existing information and in identifying what further information is needed. A principal anticipated result may be the development of better field test instruments for assessing the physical, social and intellectual capabilities of children and identifying factors that impede them.
Further summary of individual papers from the conference will appear in the Newsletter as space permits. We offer the following abstract now because it deals with how much damage iodine deficiency does to the developing brain. This question arises frequently in advocacy discussions, and this abstract provides the most recent summary.
This paper, entitled "A Metaanalysis of Research on Iodine and Its Relationship to Cognitive Development" by Nico Bleichrodt and Marise Ph. Born, Free University of Amsterdam, examines the results of some twenty-one studies that deal with the effects of iodine deficiency on mental development in the non-cretinous portion of the population. The studies involved a total of 2676 subjects of ages ranging from 2 to 30 years, from 8 countries and used a number of different intelligence tests. Each study contained information on the general cognitive functioning of children and adults living in an iodine deficient area and provided sufficient statistical data for metaanalysis. To remove a heterogeneity factor, the authors excluded three studies which were restricted to children in school, on the grounds that data were not available on dropouts. Of the remaining 18 studies forming a homogenous group, the effect sizes of the individual studies varied from 0.12 to 0.57. Using the effect size weighted for the population size in each of the various studies, gave a weighted mean correlation coefficient (r) of 0.40, with a 95% confidence interval lying between 0.36 and 0.43, on a total of 2214 subjects.
A common means of expression in metaanalysis is the d-value, where d is the difference between the two group means divided by the standard deviation. The authors describe a classification in which d-values are classified on a base of small effects (d=0.2), medium (d=0.5) and large (d=0.8). In the present metaanalysis the d-value was 0.90. This means that the mean scores for the two groups studied, the iodine deficient and the non-iodine deficient group, differ by 0.9 SD. This translates into 13.5 IQ points. Stated another way, the average iodine sufficient child scores higher than 82% of iodine deficient children in comparable studies.
The authors note that while this is a useful beginning, much additional information is needed. The metaanalysis depends on a normal distribution of scores in both populations, and they quote DeLong (IDD Newsletter, Vol 6. No. 3 1990) who asks ". . . whether the low mean scores in the iodine deficient group are accounted for by a few sub-clinically cretinous children, or whether iodine deficiency shifts the entire population distribution of skills to a lower level." The authors also note that these studies represent only a portion of the data probably available. Further studies should also look at more specific features of intelligence, such as memory, spatial orientation, and perception. Finally, the authors request further data and urge investigators with relevant studies that examine mental performance in relation to iodine deficiency to submit them for inclusion in subsequent metaanalysis efforts.
E. Martino, A. Loviselli, F. Velluzzi, M. L. Murtas, M. Lampis, R. Murru, M. Carta, A. Urru, T. Rago, F. Aghini-Lombardi, Cattedra di Endocrinologia, Istituto di Medicina Interna, University of Cagliari and Istituto di Endocrinologia, University of Pisa.
INTRODUCTION
The existence of severe iodine deficiency, endemic goiter and cretinism in Sardinia, Italy, has been well known since ancient times. The first scientific observation was reported in the last years of the 19th century. More recently, sporadic epidemiological studies have documented the persistence of iodine deficiency and a high prevalence of goiter in selected villages of Sardinia (1-5). Most of these studies did not apply the PAHO criteria for goiter assessment. In the present paper we report preliminary data on an extensive epidemiological survey carried out according to the recommendation of WHO in the districts of Cagliari, Oristano, and Nuoro in the central-southern part of the island (see map).
MATERIALS AND METHODS
Study population - The study was carried out in 1,851 students, aged 11-21 years, of whom 1,408 lived in rural areas (representing 98% of all schoolchildren) and 443 in the city of Cagliari.
Goiter evaluation - Three expert examiners separately estimated and scored thyroid size according to the PAHO criteria. When the estimations did not coincide, the lowest score was chosen.
Urinary iodine excretion - Urinary iodine excretion was measured on casual samples by a colorimetric assay using a Technicon Autoanalyzer according to the method of Zak. Subjects with urinary iodine excretion of more than 300 mg/gr of creatinine were excluded because of putative ingestion of non-dietary iodine. Results were expressed as mg iodine/g of creatinine.
RESULTS AND COMMENTS
The mean urinary iodine excretion for the whole rural population was 73 ± 56 (53 as median) mg/gr of creatinine. Goiter was found in 568 of 1,408 subjects (40.4%), the majority being grade 1A (88.2%), with 12% grades 1B or 2. In the urban control area the mean urinary iodine excretion was 92.4 ± 58.2 mg/gr of creatinine (median 78) and the goiter prevalence 19.2%, the majority (94%) having grade 1A.
Table 1 summarizes data from each village. In the district of Nuoro the median urinary iodine excretion ranged between 30 and 73 mg/gr of creatinine and the prevalence of goiter between 16% and 61%. In the district of Oristano the median urinary iodine excretion ranged between 32 and 56 mg/gr of creatinine and the goiter prevalence from 25% to 56%. In Carloforte, a small island in the district of Cagliari, the mean iodine excretion was 82.6 (median 67) mg/gr creatinine, and goiter occurred in 28%, of which 79% were 1A and 22% were grades 1B or 2.
The present data indicate that moderate iodine deficiency and endemic goiter persist in Central-Southern Sardinia. The urinary iodine excretion is lower and the prevalence of goiter higher in rural areas than in the city. It is interesting that Cagliari, capital of Sardinia, has an inadequate iodine intake and a goiter prevalence greater than 5%.
Nevertheless, the production and distribution of iodized salt are not legally mandated and, therefore, its consumption is very unsatisfactory. In spite of the absence of an iodine prophylaxis program, urban Cagliari has increased its urinary iodine excretion, and had a consequent reduction in goiter prevalence, relative to the rural regions. This situation probably results from a more effective trade and communication system (silent prophylaxis) in the urban areas (6).
In conclusion, this survey confirms that mild to moderate iodine deficiency is still present in Sardinia, mostly in the rural districts but also even in urban areas. Although silent prophylaxis is somewhat effective, it cannot be considered a satisfactory measure in eradicating endemic goiter and other iodine deficiency disorders. In the absence of a law, it is necessary to carry out other measures to ensure iodized salt availability and consumption by the whole population.
This paper has been supported by grants from the National Research Council (CNR, Rome, Italy), target Project: Biotechnology and Bioinstrumentation, Grant #91.01219.PF70, Target Project "Prevention and Control Disease Factors" (FATMA) and Regional Target Project sponsored by Assessorato per la difesa dell'ambiente, Regione Autonoma Sardegna.
REFERENCES
Table 1. Urinary iodine excretion, expressed as mean ± SD and median, and goiter prevalence in Central-Southern Sardinia.
| Area | Number of | Prevalence of | Urinary Iodine Excretion | |
|---|---|---|---|---|
| (Districts) | subjects | Goiter | Mean ± SD | Median |
| Nuoro | ||||
| Ulassai | 59 | 46 | 99 ± 85 | 68 |
| Desulo | 140 | 61 | 96 ± 73 | 73 |
| Baunei-Triei | 174 | 57 | 68 ± 44 | 56 |
| Ierzu | 186 | 16 | 98 ± 80 | 71 |
| Sedilo | 98 | 54 | 40 ± 35 | 30 |
| Oristano | ||||
| Scano | 81 | 37 | 61 ± 29 | 56 |
| Samugheu1 | 58 | 25 | 50 ± 42 | 32 |
| S. Lussurgiu | 113 | 35 | 64 ± 58 | 46 |
| Paulilantino | 116 | 56 | - | - |
| Cagliari | ||||
| Carloforte | 283 | 28 | 81 ± 50 | 67 |
| Cagliari City | 443 | 19 | 92 ± 58 | 78 |
Historically, Bhutan had some of the world's most severe iodine deficiency. A survey in 1983 described a mean national goiter prevalence of 64.5%. The government responded with a vigorous IDD elimination program. A recent publication (Iodine Deficiency Disorders: The Bhutan Story, 1992, published by the Directorate of Health Services, Ministry of Social Services, Royal Government of Bhutan) describes the progress on follow-up to that year. The present article offers some highlights.
The severity of IDD in Bhutan has been described previously in the Newsletter (1(1):12, 1985 and 5(2):9, 1989). The overall goiter prevalence was around 60%, ranging from 41% to 85% among different areas. In the western region, nearly 50% of those surveyed had urinary iodine levels less than 25 mg iodine per gram creatinine, and the incidence of elevated TSH's on screening for neonatal hypothyroidism was around 10%. All districts had cretins, and in some the incidence reached 10%.
All of Bhutan's salt is imported, chiefly from India. Iodized salt had been tried in the 1960's but had been found unacceptable to the population. In 1985 a salt iodization plant was opened at Phuntsholing on the border with India. All salt reaching the country is processed in this plant.
The IDD control program consists of components, as follows:
Salt iodization - The Food Cooperation of Bhutan is responsible for distribution of salt throughout the country. The government regulates the distribution and requires that all salt pass through the iodization plant.
Iodized oil administration - Fifty-four thousand injections were administered during 1988-91 along the southern border because competing non-iodized salt was available to the population. It is not anticipated that further oil injections will be necessary as the community has now been educated to the importance of iodized salt.
Monitoring - Salt is required to contain 60 ppm of iodine at the factory, 25 ppm at retail, and at least 15 ppm at the household or consumption level. Field kits are used in the primary health care system and all basic health units are required to test a minimum of 60 samples quarterly and send reports to headquarters.
Evaluation - Regular impact evaluations are carried out.
Education - Community education is recognized as essential to a successful program and is a major area of government focus.
The 1991/92 nationwide survey
Thirty clusters in the north and an additional 30 in the south were included, as recommended by WHO/ICCIDD/UNICEF methodology. A total of 1581 women and 1443 children (about 50 women and 45 children per cluster) were examined in the northern area and 988 women and 992 children (about 30 of each per cluster) in the south. Total goiter prevalences among women were 18.5% in the north and 45.9% in the south. Among children aged 6-11, they were 18.4 in the north and 33.5 in the south.
The program set up Method A for determining urinary iodine from the ICCIDD manual (IDD Newsletter 9(4):40, Nov. 1993) described elsewhere in this issue of the Newsletter, and samples were crosschecked by Dr. Dunn in the ICCIDD Urinary Iodine Reference Lab in Charlottesville. Median urinary iodine excretions were approximately 25 mg/dl in the north and 24 in the south. Less than 6% of children had urinary iodine concentrations below 5 mg/dl.
Blood spot TSH assays of woman and children were taken and measured in the PAMM laboratory. About 20% of children had TSH concentrations greater than 5 mU/ml.
Regarding salt knowledge and practices, almost all of those questioned purchased their salt in Bhutan. About 75% purchased salt only one to three times per year, reflecting the distances people travel to obtain it and the consequent need for long storage. Only 23% in the north and 15% in the south knew why the government was promoting iodized salt. Ninety-five percent of 140 samples collected from homes in the south, and 97% of 146 samples in the north, contained at least 15 ppm of iodine, the legally acceptable level. Most of the unacceptable samples were from households that obtained salt less than four times a year. The report notes that cattle are fed iodized salt and that this will be another source for iodine in human nutrition. The study also noted that salt has frequently been stored in unsatisfactory containers, or near cooking fires. Salt is usually added to the cooking pot early in cooking, which may reduce the quantity of iodine finally consumed.
Current status of IDD control
The goiter rate is greatly improved since the 1983 study. The median urinary iodine level is excellent, and is considerably higher than that in the iodine sufficient United States, for example. The blood spot TSH levels are higher than usually found with this level of urinary iodine excretion, and it will be interesting to track these two parameters in the coming years. The report shows that adequately iodized salt is available in most of the country. However, most of the population is unaware of the importance of iodized salt, and its storage and use in cooking are not optimal.
Others areas of the program that need attention are the occasional breakdowns in iodization and distribution, a strengthening of salt monitoring and record keeping, and community level education.
The report makes several recommendations.
Finally, the Royal Government of Bhutan once again reaffirms its commitment to achieving the goal of virtual elimination of iodine deficiency in Bhutan by the year 2000. It is certainly well on the road to fulfilling its pledge.
Lessons for other countries
The report draws on Bhutan's experience to offer advice on several points, quoted directly from the report, as follows:
1. In planning a control program, it is important firstly to obtain quantitative data on the extent and severity of the IDD situation. As well as serving as a useful baseline against which to assess the impact of a program, this information can serve as a powerful tool for appraising government decision makers and attracting their support.
2. The program should be carefully planned out, based upon the severity of the problem and the resources available. If external assistance is required, the program should aim to phase it out as early as possible.
3. Those involved in planning and implementing the program should realize that it is a long-term undertaking. Certain components will eventually become unnecessary, while other components will continue indefinitely. Funding and staff allocations should reflect this.
4. Whenever possible, a multisectoral approach should be adopted. Because effective control of IDD involves the Health, Trade, Education Ministries as well as private and other sectors, it is important for representatives of each to be enthused and involved from the outset.
5. If possible, IDD control activities should be integrated into the existing programs and activities of the relevant sectors. Such an approach makes better use of scarce human and financial resources.
6. Ongoing monitoring and periodic evaluation should be used as tools for improving the program. Based upon the information which these provide, the program should be prepared to be flexible. For instance, it may prove necessary to increase the quantity of iodine added to the salt, if this route is being used, or to consider using iodized oil orally or by injection for particularly at-risk sectors of the population in certain circumstances. Or, incoming information may indicate that different educational methods and tools should be used.
Of course, these principles need to be adapted to the prevailing conditions if they are to prove relevant to local needs.
Conclusion
The report concludes as follows, again quoted directly:
The study reported in this booklet has shown that it is possible for a small nation such as Bhutan to make significant progress towards controlling iodine deficiency. During the past 10 years, Bhutan has seen the prevalence of iodine deficiency disorders dramatically reduced, and an encouraging increase in public awareness regarding the causes and prevention of IDD. Bhutan now has a program which is providing iodine in adequate quantities throughout the country, and a population whose understanding of IDD is slowly but steadily growing.
Of course, those working in public health programs in scores of countries are well aware that there are many factors which can reduce the effectiveness of these programs. Indeed, many programs which began well have now ceased to function at all.
However, if all concerned sectors cooperate in paying sustained attention to all aspects of the control program, it is fully possible for the progress made so far to be extended and maintained. In this way, IDD can be controlled not only to the year 2000, but indefinitely. Since this is now physically possible, many would assert that it is a crime to allow any child to be born a cretin, or for other forms of iodine deficiency to occur. Surely we owe future generations no less than a world where iodine deficiency disorders are virtually unknown.