Volume 20 Number 3, August 2004

In this issue

Towards USI: A Salt Industry Perspective

BY RICHARD L. HANNEMAN, PRESIDENT, SALT INSTITUTE; MEMBER, ICCIDD BOARD OF DIRECTORS

umanity as well as economics demands that we achieve our global public health goal of ensuring adequate iodine nutrition through universal salt iodization (USI). To avoid condemning millions of newborn infants each year to lives of mental deficiency requires a preventive strategy that is as simple technologically as it is affordable. In fact, we cannot afford not to fulfill the priority commitment of the 1990 World Summit for Children to virtually eliminate iodine deficiency disorders (IDD) throughout the world.

Many health challenges are manifest due to variations in genetics, prosperity, geography or other factors largely beyond our control. These health conditions vary from individual to individual. They are medical problems.

Iodine deficiency is different. Iodine is an essential nutrient. The body does not produce iodine; it must be ingested. Every human needs supplemental iodine. Eliminating iodine deficiency is a classic public health opportunity. Where diets are iodine deficient, providing supplemental iodine can be achieved most effectively on a population basis.

Fortification is the answer

Fortifying foods has been an efficient mechanism to combat nutritional deficiencies. We consume fortified foods every day: Vitamin D in milk; thiamin, niacin, riboflavin, iron and folic acid in cereals and bread; calcium in orange juice; Vitamin A in margarine. The list of fortified foods is long. We have been fortifying salt with iodine for eighty years. It has been the huge success in iodizing salt that led to the widespread use of food fortification today.

But why iodize salt? Surely there are other candidate foods. Cooking oils and drinking water have been iodized successfully and may be a preferred solution in certain locales. Salt is a superior food for iodization because it is also the least expensive option for fortifying a food. Iodide and iodate compounds are inexpensive. The process requires minimal capital investment and imposes low operating expense. Neither oil nor water can be iodized so cheaply. The preferred choice of salt, however, is for more reasons than the fact that it is the least expensive delivery mechanism.

Humans require iodine within a certain “safe and adequate” intake range, as is the case for virtually every nutrient. Thus, the choice of which food should be iodized assumes even greater significance. If food manufacturers were to indiscriminately fortify their products with all manner of “good” nutrients like iodine, ensuring micronutrient adequacy while avoiding excess consumption would be complicated. With salt, that problem disappears.

Every day every person everywhere in the world eats salt. All societies except a few remote and primitive ones have access to salt. Once traded ounce for ounce for gold, salt production using modern technology and transportation has made salt abundant and inexpensive.

Humans consume salt in a predictable 6–12 grams/day range. Except in a few societies like northern China and Japan, salt intakes are relatively predictable with 80–90% of the population clustered together. Medical studies have confirmed the stability of salt intakes within populations and over time. They are unchanged over the century since we discovered how to measure urinary sodium accurately.

Nor should this be at all surprising. Every species of livestock and poultry consumes salt in predictable amounts which is the basis for common use of salt as a carrier for trace minerals and medications to ensure animals’ health. Not insignificantly, iodine is among the most commonly used trace element to fortify animal salt.

Since intake levels are predictable, metering nutrient fortificants in salt is a simple mathematical exercise. Besides iodine, food salt is often fortified with fluoride in areas where drinking water is not fluoridated and with iron to combat anemia. Animal salt is fortified with still other micronutrients: cobalt, copper, manganese, molybdenum, selenium, iron, zinc, magnesium and sulfur. Salt is also used as a carrier to meter medications to livestock and poultry.

Unsurprisingly, public health agencies are in total consensus that iodizing salt ensures an achievable, affordable and, most importantly, predictable intake of iodine.

Iodizing salt is a simple technology

Adding iodine to salt is not “rocket science.” To dry salt is added either a dry mix or liquid drip or spray of potassium iodate or potassium iodide, with the addition of stabilizing additives, where needed. Obtaining the iodide or iodate is likely to be more difficult for salt manufacturers than actually applying it to the salt. Often, as well, it is a greater challenge to change product packaging to protect the iodate or iodide from humidity and other environmental degradation than to actually produce iodized salt. Any salt producer capable of delivering clean salt to consumers has the technical capability to iodize that salt.

Around the world, the majority of salt is produced in huge salt refineries or scientifically managed solar saltworks. But most salt makers are very small businesses; though numerous, they collectively produce only a minority of the 210 million tons of salt consumed each year for a myriad of purposes. Globally, the vast majority of producers use primitive technologies. These businesses don’t prepare business plans or use spreadsheets to manage their operations. Often they operate at a scale sufficient to support a single family. These small salt makers are relatively unsophisticated; many have never heard of iodine or its role in preventing brain-damaged children.

That salt can be produced using technologies available for millennia imposes special challenges to achieving USI. Were salt an expensive man-made chemical rather than an inexpensive natural mineral, the relatively few, and highly sophisticated, producers would be easy to identify and educate (or compel) to iodize salt. That is not the world in which we live. Salt is not expensive. Salt producers need no sophisticated understanding of geology, chemistry or meteorology. Barriers to entry into these subsistent operations of salt production are low. If the climate is conducive to salt making, anyone with a beach or frontage of a saline lake can make salt with minimal capital outlay. This type of producer is common and just as commonly unable to make high quality salt, unable to make significant quantities and usually unable (or uninterested) to market their product in protective packaging. But they do put salt in commerce, competing with the cleaner, iodized and packaged salt. For these small companies, cleaning and drying this crude salt and packaging it into small plastic bags is often more challenging than actually adding volatized potassium iodate to the salt.

As a national salt industry modernizes, accompanied by effective government regulations for food safety and increased consumer demand for purer iodized salt, these smaller, less sophisticated operations either modernize or are closed. Thus modernization is intertwined in the very process of implementing and sustaining USI. Pursuing this modernization process depends on all three “partners”: the salt companies themselves, but also government regulators and the consuming public.

Partners needed to achieve USI

The world’s organized salt industry has entered into partnership with government public health agencies, committed medical and nutrition experts and civic organizations like Kiwanis International to focus energy and attention on the virtual elimination of iodine deficiency disorders. Many smaller salt producers in IDD-challenged nations are also banding together to become full partners in the campaign for USI. Support from public health regulators and civil society has made possible enormous strides in educating and supporting salt producers to advance towards USI. In many countries with endemic IDD, national coalitions have been created; more are being organized — and many more will need to be organized in order to achieve and sustain our goal. These coalitions can assist the salt industry deliver the needed iodized salt. But their role should not be limited to the most common task to date as providers of technical assistance to salt makers. Rather, the need is for governments and civil society to create an educated public demanding iodized salt and creating a competitive commercial marketplace where iodized salt can compete fairly.

Salt companies are like any other business: they thrive when they satisfy a consumer need; they disappear when they don’t. If consumers are unaware that iodized salt is healthy for them and their children, the lack of demand undermines the quest for USI. If consumers are unaware that iodized salt is available or can be made available, they won’t know to insist on buying the fortified product. These problems can be addressed through public education to create a demand-pull for iodized salt.

If consumers are unaware that the salt they buy is iodized because ineffective regulations of food quality render label declarations meaningless, they will lose faith in a package that declares itself containing fortified salt. If a properly labeled package of iodized salt bears too high a price premium because imported potassium iodate faces high import tariffs and multiple taxes, consumers may conclude that the theoretical health benefits for their families are outweighed by the very real burden on their family food budgets.

If, on the other hand, consumers demand “healthy” iodized salt, packages clearly and reliably distinguish between iodized salt and non-iodized salt, and governments cooperate by not burdening iodized salt with taxes that create a significant price differential, then, and only then, will we be able to realize our goal of universal salt iodization and, with it, the end of the scourge of iodine deficiency disorders.

In North America, fortifying salt with iodine costs about 5¢ per person annually. Costs will vary since there are only a few worldwide suppliers of potassium iodate, but the price premium for iodized salt can and should be trivial. Price should not become a barrier to consumer acceptance. On the other hand, imposition of salt taxes has a rich legacy. Salt is an easy target to tax and, thus, a reliable revenue source because everyone needs it. But excessive tax levies, like the notorious gabelle in France, can produce serious consequences like the French Revolution.

A program outline for national coalitions

Balance is the key to building an effective partnership to achieve USI. Energy is needed; that’s certain. Someone must take the lead, but success demands collaboration with every partner making a unique contribution. If the enterprise is unbalanced, it can behave like an automobile engine with cylinders misfiring, or a car with a flat tire, or even worse, with a locked wheel, going around in circles. There’s not enough energy to risk wasting it in a go-it-alone campaign for USI.

A balanced program must address the three major elements: the technology to produce iodized salt, the consumer demand for iodized salt and a marketplace that ensures iodized salt can compete fairly.

Salt producers

Producers, to restate the point, exist when they satisfy their customers and would-be customers. Customers always want to pay the least amount possible for the product they want. If they do not distinguish a quality difference among available salt products, they will likely choose the least costly product. So the challenge is to instill in consumers an appreciation of the health benefits of consuming iodized salt. That should be an easy case to make. The benefits are compelling. The costs of iodine deficiency are visible (goiters and cretinism); more importantly, they are well documented in terms of mental impairment, the massive loss of potential IQ and the sacrifice of economic productivity. Often, iodized salt is also a “white” salt compared to its less pure competitors; the purity is an obvious selling point. And iodized salt must be packaged to protect the potassium iodate; those packages are attractive and can contain important consumer education messages. Producers must:

  1. Have access to technical assistance on simple process improvements to iodize salt (and package their product if they are not already doing it).
  2. Make a commitment themselves to invest in these improvements (in some cases, perhaps, governments could assist in encouraging cooperative ventures by smaller producers or subsidizing loans for the improvements).
  3. Make a firm commitment to complying with government requirements with regard to providing iodized food salt.

Concerned citizens

Concerned citizens — medical and nutrition specialists, educators, civic groups and every other conceivable community organization — should take the lead in creating consumer demand. Schools need to teach students the debilitation of iodine deficiency, perhaps equipping their charges with test kits to use at home (which will educate their parents). In India, the Boy Scouts have also mobilized youth. Endocrinologists, dietitians and nutrition experts need to add their credible voices in a rising chorus hailing the benefit of iodized salt. Food manufacturers, marketers and retailers; restaurants and cafeterias need to proclaim, truthfully, their use of iodized salt. The media should provide public service advertisements and special news programming to highlight the benefits of dietary iodine and its source, iodized salt. Housewives and other food customers should be made to feel that access to properly iodized salt is not only possible, but it is healthier for themselves and their families to consume only iodized salt and to seek out retailers who will provide it to them. In short, marketplace dynamics and incentives need to be considered and harnessed. We need carrots more than sticks. Concerned citizens must:

  1. Demand iodized salt in the marketplace and refuse to purchase non-iodized salt.
  2. Insist on government enforcement of regulations against those who cannot or will not provide it.
  3. Food manufacturers will need to reformulate any products whose aesthetic appeal may be compromised by use of potassium iodate (and/or work with governments for narrow exemptions for such products as dill pickles which may be impacted but whose exemption would represent an insignificant contribution to the entire diet).

Food manufacturers

Food manufacturers will need to reformulate any products whose aesthetic appeal may be compromised by use of potassium iodate (and/or work with governments for narrow exemptions for such products as dill pickles which may be impacted but whose exemption would represent an insignificant contribution to the entire diet.

Governments

Government must play its role too. Government must lead the effort. A major part of government’s role is to provide “sticks” to supplement the carrots of consumer demand for iodized salt. This is not as straightforward as many believe. In the past, some governments have assumed that salt produced within their borders was “theirs,” ignoring the fact that the salt is actually owned by the salt makers who only produce it to satisfy market demands. Respecting this distinction is crucial. But just because governments do not “own” the salt, they cannot ignore their very real responsibilities as the rule-enforcers that enable salt makers to provide consumers with iodized salt.

Governments can aid in technology transfer for producers. Governments can contribute to consumer education. Both are good. Neither is enough.

The unique and central role for governments is to police the marketplace, to ensure that iodized salt can compete. This sounds elementary and we may think it a simple task. It is neither. Creating an effective food regulatory program, of which enforcement of iodized salt regulations is a small subset, is a complex challenge. It requires political courage. It won’t be easy. But it is essential.

Governments must convince salt producers they intend to level the playing field of the salt marketplace. With the promise that he faces likely penalties for his failure to produce iodized salt to meet legal requirements — and a conviction that his competitors face that same likelihood — producers are much more likely to do the right thing, confident they are not putting their businesses at risk. Businessmen want to be good citizens. But their livelihoods are at stake. Perhaps a government can survive if food regulations are insufficient or enforcement ineffective; producers know their businesses cannot survive.

Some salt businesses won’t survive anyway. Some smaller, less sophisticated producers may be unable or unwilling to make the process improvements required. A decision to close down non-complying producers entails political cost and risks for the government; all partners need to recognize that fact. The far greater good is achieved with universal salt iodization, but politics can often be local and the one disadvantaged individual will be vocal. Government regulators need courage — and vocal support from concerned citizens and the salt industry (see above).

Governments, then, must:

  1. Assume the leadership in forging a national coalition of producers and concerned citizens to partner with it in achieving USI. Too often, however, governments mistake their role in organizing the coalition and mistakenly treat their partners as less than equal.
  2. Enact legislation and regulations specifying minimum standards of food salt quality (some countries will include animal salt as well, since it can be substituted for human salt). This must include a standard concentration in the salt iodization (e.g. 30 ppm ± 10 ppm), and specifying standards for packaging and labeling. If a country imports salt, the regulations need to consider harmonization with its salt trading partners.
  3. Ensure enforcement of these laws and regulations. This may require establishing new bureaucracies or investing significantly in strengthening existing agencies to inspect salt production facilities and monitor the retail trade in salt. The integrity of this enforcement mechanism will determine whether the marketplace will be hospitable to the sale of iodized salt (and, thus, to its manufacture).
  4. Arrange, often with support from international agencies, for transitional technology transfer assistance to producers willing but otherwise unable to understand the necessity and type of process improvements that will be required.
  5. Consider possible tax credits or other subsidy mechanisms for producers to invest in process improvements.

6. Eliminate tariffs and discriminatory taxes on potassium iodate to minimize the added costs of producing and marketing iodized salt.

Towards USI

Pulling together, societies can achieve miracles. Iodizing salt isn’t that hard. It won’t take a miracle. It will take pulling together in a balanced team effort. A balanced coalition effort can produce surprisingly quick results. But a fast start is not all that is required.

Achieving iodine sufficiency will require more than a sprint. It’s even more than a marathon. Consider it, rather, a lifestyle change. It means daily exercise, not a burst of well publicized effort followed by a “return to normalcy.” We must establish conditions for sustainable USI.

The above steps, fine-tuned and localized by national coalitions of equal partners respecting and supporting each other, will produce a sustainable elimination of iodine deficiency. The salt industry desperately wants to be such an equal partner. We pledge to do our share: to produce a quality iodized salt product to meet consumer demand and in conformity with a regulated marketplace. This will be a “lifestyle change” for many companies. Some won’t survive. We accept that, knowing that those who can and will be able to produce iodized salt will contribute to a national “lifestyle change” of enhanced health and productivity that will lift our communities and our countries. Help us make it happen. ■

Measure of Progress in Myanmar

BY DAVID P. HAXTON, MEMBER, ICCIDD BOARD OF DIRECTORS

This is a summary of “Report on Progress Toward USI and Virtual Elimination of IDD in Myanmar” by David P. Haxton after a visit there in February 2003.

Background

Myanmar is governed by the State Peace and Development Council (SPDC) in which all executive and legislative authority resides. Most of the country is now open to foreign travelers which have helped to improve oversight of universal salt iodization (USI) operations in most places. The economy is agrarian with agriculture, forestry and fishing accounting for about 60% of GDP during 1997–1998, and two thirds of all employment. A wide range of products for domestic consumption and export includes rice, fish, cotton, rubber, pulses, teak, vegetables and edible oils. The industrial sector accounts for 11 percent of current price GDP. Foreign assistance for social and economic development is limited. No new foreign investment has been approved except for oil and gas. (1)

The Government and other authorities express serious commitment to achievement of USI and are proud of the ways in which they have been able to undertake the work with the limited physical and financial resources available. That said, the report concludes that there are elements of the national effort that demand priority attention and investment. These were brought to the attention of the Government at Ministerial level and to the management of UNICEF. Reports reviewed are of good quality and express what has been accomplished. However, they do not reveal completely the fragile infrastructure of the endeavor.

All resources for the activities come from the Government or from UNICEF. The latter provides the major portion at present in the form of technical assistance, reimbursable procurement, supplies and cash grants for travel, supervision and oversight. Most of the resources from UNICEF are a grant to it from KIWANIS International. ICCIDD Regional Coordinator has visited the country at regular intervals.

After many discussions with Government authorities at the Ministerial and field levels, and with UNICEF Officials; a review of the existing reports and documents; visits to processors, village markets, and field laboratories; the following are the conclusions and recommendations. They are in the general order of the guidelines in the ICCIDD, UNICEF, and WHO Assessment Guide (2).

Regarding the Product

General Comments

The supply of salt is sufficient to satisfy predictable national demand for the foreseeable future, based on population projections and potential to adjust to increased production needs. All salt is from the sea and salt beds and processing facilities are on or near a river which is a major form of transport in the country. Transport of salt is mostly by barge; some by rail; less by truck. The processed salt is distributed to wholesalers in strategic locations to supply the retail market.

There are 1600 salt bed operations in the country, mostly in the South along the large coastline and some in the West. They range from small family plots to larger holdings and are classified by size. All are private. It is reported that 80% of these small salt producers provide their salt to 110 salt refineries, all of which must have a license to operate and to produce iodized salt. All but 10 of the refineries are said to be in private hands. Some small salt pan owners sell to chemical plants; some of the product is boiled for home use; a good bit is what is called ‘border trade’ in the informal cross border exchanges with Bangladesh.

Together these are said to produce 280,000 tons of salt for a stated demand of 398,000 tons. Reports indicate that testing is regular, but the quality of testing needs verification by improved oversight and by comparison with a quality control standard. At present the quality of testing is not verified against a quality control standard. Increased oversight is an evident need.

Quality checks to assure compliance with standards are routine in the plants. Samples are collected and sent daily or weekly (depending upon the size and location of the plant) for quality assurance checks by local authorities. Iodization processes are primitive and lab facilities minimal and tenuous. The personnel are from the Myanmar Salt and Marine Chemicals Enterprise, an arm of the Ministry of Mines. These persons are supported by UNICEF with allowance for their travel and expenses. No plan to have this incorporated into the government budget is prepared as yet.

USI standards announced in Myanmar require the salt be iodized in the plant at 40–60 ppm. Household inspections are expected to find salt iodized at 15–30 ppm. The most recent household survey of year 2000 revealed that an average of 57% of households had salt that contained at least 15 ppm. Myanmar follows the guidelines for UIE of WHO, ICCIDD and UNICEF. Myanmar does not have a standard for the quality of salt. Laboratory equipment at factory sites and warehouse sites are minimal.

Salt harvesting, iodization and packaging use elemental and simple methods. Raw material is delivered to the processor by boat and off loaded by hand labor. Iodization of salt takes place in all plants by spraying with a manually operated sprayer during drying by motor driven centrifugal force. Loss of potassium iodate in the runoff is inevitable. It is reported that a study is under review to capture iodate in the runoff.

Production of iodized salt has increased at a remarkable rate from 1998 to now as a result of joint efforts of UN agencies, national authorities and private salt producers. Iodized salt production reached a total of 241,000 metric tons in March 2000, which covers 80% of household consumption of iodized salt and children’s dietary iodine intake. Visible goiter rate has significantly decreased as well as the risk of cretinism and mental retardation.
Bagging of salt is by hand labor. The product is then sealed into small (0.8 kilo) plastic bags, also using hand labor for sealing. Salt in the small sealed plastic bags are in turn shipped in larger polyethylene bags for shipment mostly by boat. Labels on the bags would protect the consumer and the producer and underscore the priority to prevent brain damage to children. The law would help establish standard quality assurance through the system.

The practice of repacking salt from sealed and labeled bags at retailer site should be stopped. To meet the goal, the salt actually reaching households needs to be iodized at appropriate levels, include the name of the processor, the fact that the product is iodized and the official logo.

However, it was observed that retailers in market places often empty the larger bags of iodized salt to repack the product into smaller unlabeled packages.

Laboratory processes and results need comparison for quality control with a recognized laboratory. Laboratory facilities and operations at production sites and wholesale outlets are bare minimum. No plan to replace equipment was evident. Plans for replacement of reagents is said to be in place. It is reported that 30,000 test kits are produced in Myanmar each year at the central Production Unit. This may not be sufficient for the massive testing required. More important, the test kit has never been evaluated against a quality control standard.

Recommendations

Progress in Myanmar is steady under very difficult and primitive conditions. The Ministry of Mines and UNICEF have brought ingenuity to the national effort. Greater vigor is needed to meet the best compromise between (a) the need for adequate personnel and facilities over time and (b) the need to support all of them with national resources. And the national investment is needed soon.

Myanmar can reach the level of appropriate salt iodization of 95% production for human consumption by the end of 2004, but urgent change is needed in quality monitoring and support to infrastructure.

The absence of a law regulating salt iodization may be a reason for absence of standards for salt. A law

Iodizing all salt is suggested. USI means all salt, for all human and animal consumption for all time in all of the country.

So far, producers, processors, wholesalers and retailers have not been enrolled as allies to take on efforts of advertising and public education. Myanmar has a long history of community collaboration and perhaps this important social asset can be found to be helpful.

Regarding the Processes

Comments

There is regular stated political commitment in many ways, but commitment to financial security of the national effort is precarious. The work of the staff in the Ministry of Health and the Ministry of Mines is solid and persistent. In addition, there is support from the Myanmar Medical Association. The salt producers and processors met were dedicated to elimination of iodine deficiency in the country.

There is a national committee, which is reported to meet regularly. The Minister of Health is Chairman and the Deputy Minister of Mines is Vice Chairman. With expansion of its membership to include educators, agriculturists, economists, communicators, producers and non-governmental organizations, additional efforts toward sustained iodine nutrition can be undertaken.

The Ministry of Mines operates a “Revolving Fund” created by UNDP, UNICEF and the Government of Myanmar with a grant from UNDP to initiate it. The idea was to purchase potassium iodate, import it, and sell it to producers with licenses to iodize salt, replenish the account accordingly, and subsequently, import potassium iodate in perpetuity.

The agreement stated that the Fund would sell potassium iodate to licensed producers at an established price. In practice the transaction is at an exchange rate lower than the price paid by UNDP (or UNICEF). It is said that this arrangement was to last for a short, interim period. It is not clear just how the Fund would be replenished to the original level unless the Ministry of Mines created a budget line to cover the difference. The price charged is what is called the official rate of exchange for national currency to US Dollars. The UNDP rate, attuned to market conditions and long used by UN agencies, meets with opposition from the Government, which has its own exchange rate. At present the Fund has an estimated shortfall of about 36% of needed capital.

Recommendations were made of alternative ways to correct this situation. That recommendation and others were proposed to be reviewed by the National Committee later in the year.

The financial support to the program is from development agencies, mostly from UNICEF. This is a national endeavor for the most part supported by the consumers when they buy iodized salt, but there are overhead costs of the government in oversight and quality assurance which need to be supported by a government commitment to do so. Inspectors, monitors, and laboratory workers need security and to work effectively require travel resources and support from national commitments. A revised investment plan was proposed.

An analysis of reporting over the past two years shows that delays are minimal and remedial actions are generally swift. This is due to the skill and dedication of the staff and the ability to travel and work, but the latter is supported from foreign sources and, thus, is not as secure as it ought to be.

Producers seem motivated and collaborative. It is important that officials cooperate to make things happen at the production and marketing level instead of expecting others to do the collaborating. Of the 1693 producers of salt, 1680 are in private hands, a very high percentage of which sell only to licensed processors. Of the processors, 100 are private and only 2 in public hands. The technical and operational details are similar, but the motivation is different and this needs to be taken into account in planning.

The national venture is seen as a “campaign” in the public information literature. An outside review of the communications efforts concluded that the communications were well planned and effective. It is evident that the message was regular, persistent and directed. That said, there is over emphasis on “goiter as the main problem” and “eliminate the deficiency” with under statement of the need to protect developing brains from nutritional insult. The emphasis is on elimination more than on sustained prevention.

It is important to reach farmers and others with domestic animals in order that they recognize the need for iodine nutrition for their animals and perceive the benefits to be derived. In addition, the food processing industry should be enrolled as an ally with insistence that iodized salt be used in the processing of foods.

The ICCIDD/UNICEF/WHO Guidelines suggest a minimum of ten programmatic indicators of which at least eight must be at a high level of performance to suggest sustainable good iodine nutrition. The Myanmar national effort is advanced on some of these.

Recommendations

The political commitment needs translation into a law protecting the population from the dietary deficiency. This law would protect the population; codify standards; and provide the necessary regulatory procedures.

It is vital that priority action be taken to assure national financial support to the operations of the endeavor, to the oversight responsibilities, and to the management and operation of the Revolving Fund.

The National Committee is a positive element of the endeavor. However, it is noted that elements of society are not represented, among whom: agriculture and food processors; educations and learning systems; information and communication channels; religious and other non-governmental organizations.

The Revolving Fund needs an audit and reorganization to remain viable. Subsidies might be considered for a period to offset current operating costs. However, the subsidies should be those of the government, perhaps, supplemented by a change in sales prices. Once on a sound financial footing, the Fund might consider financing other needed activities like replenishment of supplies and equipment for laboratories, foreign travel for national orientation.

It is important that the communications effort be redesigned to focus on the protection of brains not the mere elimination of goiter. In addition, plans are needed to incorporate public education into the venture. Penetration of the education system is needed to assure a generational transfer of knowledge of the dangers of IDD and the values of iodine sufficiency.

USI achievement requires iodization of all salt for human and animal consumption. The food processors need to become full partners in the endeavor.

Progress in Human Nutrition

Observations

The Ministry of Health through its outreach network and the National Nutrition Center are in charge of monitoring the network of small but effective laboratories and the dedicated staffs are assets. The MOH undertakes surveys and reports regularly. Laboratory facilities are an established national network; they are not elaborate, but functional. That said, however, the reviewer concludes that the situation is tenuous since it is almost totally dependent upon foreign assistance and it was difficult to find plans to replace the foreign support once it concludes. The laboratories are basic and lack plans for replacement parts and supplies except as provided from abroad.

The Ministry of Mines is active in oversight and management. The technical support of its professionals is significant.

Regular surveys to date show steady progress in median urinary concentration. Additional surveys at regular intervals are said to be planned. The Government would welcome additional support for surveys for the next few years.

Recommendations

In short, the national effort is remarkable given the circumstances. It has accomplished much for the protection of the people. The ingenuity of the workers and the dedication to the task are inspiring. However, the financial commitments of the government to this effort need urgent and high level attention. In the long run, the effort will be financed from sales of iodized salt with modest government investment for oversight and analysis. The published standards need to be checked against a quality control standard from abroad. The Government should consider seeking technical collaboration from abroad for (a) improving quality assurance processes and standards, (b) confirming procedures against quality control standards and (c) information exchange on ‘state of the art’ laboratory management. ■

REFERENCES
  1. Situation Analysis of Children and Women, UNICEF Myanmar, 2003.
  2. ICCIDD, WHO, UNICEF Iodine Deficiency Disorders Elimination Guide.

Towards IDD Elimination in Tibet — Then and Now

BY MU LI, M.D. AND CRESWELL J. EASTMAN, M.D.

AUSTRALIAN CENTRE FOR CONTROL OF IODINE DEFICIENCY DISORDERS (ACCIDD);
INSTITUTE OF CLINICAL PATHOLOGY AND MEDICAL RESEARCH (ICPMR), WESTMEAD HOSPITAL;
THE UNIVERSITY OF SYDNEY, SYDNEY AUSTRALIA

Background and Introduction

Over the past two decades China has made significant progress in its efforts to eliminate IDD. The goal of elimination, established as part of China’s National IDD Elimination Program (NIDDEP), is largely achievable within the allocated timeframe. The 1997 Chinese National Surveillance Study revealed impressive provincial aggregate figures for both iodized salt coverage, as well as satisfactory urinary iodine levels throughout the country. However, control of IDD in Tibet was clearly lagging behind the efforts and achievements of most other Provinces in the People’s Republic of China (PRC). While iodine supplementation in Tibet had been initiated, many years ago, on a small scale through iodized oil supplements and the establishment of a “Tea Brick Factory” to iodize tea, the results were poor. The Qualified Iodized Salt Coverage Rate was only 6.2 per cent (6.2%), and other indicators available for Tibet were 29% for palpable goiter, and 55 ug/L for the median urinary iodine level for school children when this project commenced.

A request for support in the effort to eliminate IDD in Tibet was submitted to WHO by the Tibet Bureau of Public Health (TBPH) in June 1998. WHO responded positively by asking Professor Cres Eastman to convene a workshop in Beijing in November 1998 to develop a plan for this project. The major elements of the proposed plan were: conducting an IDD epidemiological survey to obtain baseline data, developing a health education and social mobilization program, strengthening laboratory monitoring capability and facilities, implementing an iodized oil supplementation program, and providing training for health personnel from county to provincial level. Each element of the proposal has been examined in detail and a plan developed and agreed upon.

A feasibility study was conducted in Tibet in May 1999, by a multi-disciplinary team representing all stakeholders and led by Professor Cres Eastman, to independently confirm the magnitude and severity of the IDD problem in Tibet and to better define the support to be provided for the IDD elimination project.

At the conclusion of this mission the Feasibility Study Report presented to WHO confirmed the vast dimensions of the IDD problem in Tibet and recommended the immediate implementation of a scripted intervention strategy. This Report, and all of the recommendations contained therein, were accepted by the WHO/WPRO in Manila.



Iodized salt production in Lhasa Salt Factory, Tibet
The Report stated: “Considering the status of the IDD control program and current prevalence of IDD in Tibet it is accepted that the target of elimination of IDD by the year 2000, the proposed achievable goal in most parts of China, cannot be achieved in Tibet. An achievable goal, with more realistic targets and timeframe, is by the year 2003 (in 4 years time) 85% of the population of Tibet will consume qualified iodised salt and will have satisfactory levels of UIE, being a median level >10 ug L. To achieve these targets it will be necessary to commence immediately an oral iodised oil supplementation program directed to the most vulnerable segments of the population. This supplementation program can be scaled down over the next five years as the iodized salt production, distribution and uptake is scaled up and reaches the target of at least 85% population coverage. The ultimate long-term solution for control of IDD is through universal salt iodisation”.

The Australian Government, through AusAID, provided in excess of A $2,000,000 to fund the Iodine Deficiency Disorders (IDD) Elimination Project in Tibet. The project has been managed by WHO/WPRO and implemented by the Institute of Clinical Pathology and Medical Research (ICPMR) from Westmead Hospital in Sydney, Australia. The project was overseen by three committees. The Project Management Committee in Tibet was chaired by the Vice Governor of the Tibet Autonomous Region (TAR) Government responsible for culture, education and health. The Scientific Advisory Committee was co-chaired by Professor Chen Zupei, the ICCIDD Regional Coordinator for China and East Asia and the head of the Chinese IDD Expert Group and Professor Cres Eastman, the ICCIDD Regional Coordinator for Asia Pacific Region and the International Adviser for the China National IDD Elimination Program. Professor Eastman was also the chairperson of the Project Coordinating Committee, based at ICPMR. Dr. Mu Li has coordinated these management inputs and has largely overseen the project implementation in Tibet.

The Goals and Outcomes of the Project

The Project aimed at providing a sustainable solution, through Universal Salt Iodization (USI), for the elimination of IDD in Tibet. The short to medium term goal of the project has been to provide iodine to the most vulnerable groups in the community, namely, women of childbearing age (WCBA) and children less than 2 years of age. This transitional strategy is being achieved largely through a targeted distribution program of iodized oil capsule (IOC). The long term goal of the project is the provision of iodine to the whole Tibetan population through the implementation of USI. This strategy is in keeping with the national policy of the Peoples Republic of China for IDD elimination. The project commenced with an official launching ceremony in Lhasa on 18th May 2000.

The project consists of five major components addressing demand, supply and monitoring of iodine uptake by the community. These components are: