A Statement prepared as part of the continuing advocacy to encourage collaboration between public and private sectors in the field of elimination of micronutrient malnutrition. PAMM has been a leader in attempting to pull elements of these sectors together in joint ventures.

David P Haxton

January 14, 1993

Government must establish national goals for the nation and standards for food products and for processing and quality control, but food is essentially a product of the market: produced by individual farmers; processed and marketed in the private sector; and consumed there. For national efforts virtually to eliminate micronutrient malnutrition, this point is central to success.

For national efforts virtually to eliminate micronutrient malnutrition, this point is central to success.

It is well known that the most efficient method of assuring adequate intake of iodine in the human diet over time at acceptable cost to large populations is through the production and marketing of iodized salt, a product of the market. It is bought and sold in market places in villages, towns and cities all over the world in every country every day. For the most part, the mining, processing, packaging and marketing of salt is in the hands of private entrepreneurs.

It is natural, therefore, that ICCIDD (International Council for Control of Iodine Deficiencies) initiated the idea of a creative alliance with producers at the Seventh World Salt Symposium in Kyoto. As a consequence of the goal of elimination of IDD set by the Global Summit on Children, demand for iodized salt is on the increase. A significant push by private industry through usual marketing channels would reduce the period required for global coverage. Most of the action required to assure adequate supplies appropriately iodized must be taken at national level between governments and industry.

To demonstrate the mutually supportive roles of private producers and government action, ICCIDD and the Government of Botswana, with support from UNICEF, ILSI (International Life Sciences Institute), CIDA (Canadian International Development Agency), and WHO held a workshop comprised of representatives of government, communications specialists and private industry from 7 southern Africa countries. The discussions revealed that the role of government to establish the ground rules and assure a level playing field would allow private producers to produce a quality product at acceptable prices and to assure adequate iodization both for domestic consumption and also for export.

In short, at the Global Summit on Children the political leaders of the world accepted the recommendation of scientists that IDD could be eliminated. The followup Montreal Conference of senior government officials to End Hidden Hunger said that it should be done. Alliances between private producers of salt and government organs responsible for public health and food protection must accept the obligation to see that it gets done.

During 1992, progress was made in creating and extending the alliance of partners required to reach the goal of virtual elimination of IDD in this decade. Some additional milestones:

a. the Botswana conference has stimulated interest in holding similar workshops in Central America, Europe, Philippines, China, SAARC region, Middle East.

b. a meeting in Dakar of producers and government officials from West African nations agreed on steps to accelerate iodization in the private sector, including salt produced abroad.

c. a number of Governments have elevated the priority of elimination of IDD. (Indonesia tripled its budget). Most have stated intentions to encourage private salt producers to assure a quality product at a fair price for the entire population.

d. ICCIDD is discussing with major producers of salt, such as Akzo, Morton, Dampier, Cargill Inc., Campagnie de Salins du Midi et des Salines de l'est. the production of iodized salt and to offer it as a regular product for sale through their massive marketing networks.

e. A report by ICCIDD - UNICEF - WHO clearly shows the seriousness of IDD in Europe. It calls for mutually supportive actions by industry, science and government to address the issue on the continent. The report by Prof. Burgi and others on salt iodization in Switzerland concludes: "Iodization of salt has proved a highly cost effective preventive measure in Switzerland"

f. A meeting in PAMM, Atlanta, brought together the Carter Center, US CDC, Emory University, ICCIDD, IVACG, INAG, UNICEF, WHO, USAID, IDRC and the ICFSN in Netherlands with representatives of multi national industry leaders from Canada, Europe, and North America. The major conclusion: alliances between public health and private producers were welcome and would be most effective at national level and can work to eliminate micronutrient malnutrition.

But it is not alone in the production side that progress is recorded. Nor is progress in the private sector the only advance made during the year.

Bolivia and Bhutan are very close to being able to report "no new cases". Both used iodized oil injections to protect people while quality iodized salt production increased to penetrate to markets in all villages. In Ecuador alliances with the private sector with major emphasis on social communications and the agriculture sector have been key elements in success.

More development agencies recognize that IDD is pervasive. CIDA was early to recognize the need for aggressive action to eliminate IDD through bilateral efforts, UNICEF, and ICCIDD. Its support of the massive undertaking in Bangladesh is comprehensive covering survey costs; equipment design and production, training needs, quality assurance, research, evaluation and monitoring.

SIDA, in addition to support of ICCIDD has for years been in support of national programmes. The efforts in Tanzania show how assistance applied progressively, over a range of needs, leads to significant progress. A number of non government organizations in Germany support a range of activities in a number of places, most significantly in Ethiopia. The Netherlands supports training in food technology and other fields and in addition to direct country programme support has supported publications production through ICCIDD for a number of years.

Belgian assistance in training, in surveys and in national programme support has been significant in countries in Africa, and is a key to the outstanding progress reported in Ecuador. France is active in innovative approaches to iodization of drinking water in small rural villages in Mali.

The success of PAMM (Programme Against Micronutrient Malnutrition) in training and orientation in laboratory, surveillance, management, communications, and advocacy techniques is due to strong and significant support from UNICEF, UNDP, the US CDC, Emory University, The Carter Center and USAID and to its multi discipline professional approach to national team preparation.

The US Congress for the first time in history approved legislation with specific reference to IDD in the foreign aid appropriation. USAID announced a $50 million initiative to attack problems of IDD, vitamin A and iron. The World Bank is beginning to include support to elimination of micronutrient malnutrition in loans. It has also been a key factor in forming the Micronutrient Initiative, based at IDRC, with support also from UNICEF and UNDP.

The idea of working directly with private industry for a public health intervention is new to government officials, to development agencies and to private management, so it will take some orientation to take full advantage of opportunities. As confidence grows in the iodization of salt, a rather simple production process..both governments and private industry will see challenges to fortify other foods and to "double fortify" (salt with iodine and fluoride). Other food products can be fortified with vitamin A (sugar, tea, for example); and iron (flour).

Producers could be encouraged to: iodate salt to national standards; improve packaging; assist in demand creation; help in sustaining political commitment; provide technical and other support to national endeavors; help draft new legislation (as was done in Guatemala); consider multiple fortification of salt (as in Costa Rica); help to promote the goals of the Global Summit; encourage agriculturists to demand iodized salt for animals; collaborate with training in the country and abroad.

The importance of alliances to assure elimination of IDD can also be demonstrated in relation to "education for all." Investments in education in IDD countries are at great risk because of the direct relationship to iodine and brain growth; i.e., between "iodine quantity" and "intelligence quotient." For example, it is safe to suggest that if IDD were eliminated from China, it would reduce the global problem by one third. While the exact correlation of the numbers may lead to discussion, one can postulate that of the 30 to 50% of all newborns that suffer from thyroid disorders caused by lack of iodine in their mothers, most will suffer irreversible intellectual disability as a result. Studies (By G Maberly and others) show that in areas with mild to moderate IDD, schoolchildren have IQs that are on average 10 points below those in areas not deficient in iodine. If half of all children born in China each year are iodine deficient, the potential loss of IQ points adds up to some 60 million per year!!

As Madame Gao, of the Ministry of Health of China said recently, "Ignorance is not bliss." The consequences to investment in education and to development in iodine deficient countries is evident.

UNICEF has elevated the priority of IDD. The relationship of UNICEF with ICCIDD can prove even more beneficial by requesting the technical, scientific, and management advice in problem identification, programme design, monitoring, evaluation and social communications that may be required to start or to accelerate. UNICEF and others now look to PAMM as an essential resource for training of a national team to undertake the work.

The following list, adapted from a note prepared by Dr. Peter Greaves comprises reasonable targets to be reached in pursuit of the goal of elimination:

By 1993 all countries with a problem to have plans to address it as called for by the Global Summit on Children. All countries report on progress and formulate requests for additional assistance required. All countries begin arrangements to have mutually supportive ventures between private and public sector operatives. All countries secure a regular source of potassium iodate. Reimbursable procurement by public and private producers through UNICEF is possible. All countries make training needs known By 1995 all countries should have a functioning national IDD elimination unit, be embarked on a national and nation wide salt iodization programme and reporting regular progress. In the case of countries in SAARC, all citizens should have access to iodated salt as agreed by the Meeting of Ministers. All countries should have functioning epidemiological capacities or access to them at regional centers. Half of all countries should have monitoring and surveillance systems in place and monitoring of iodine levels in salt in markets should be routine. An international conference of producers, governments, UN and others could be held to review progress toward the goal of elimination. By 2000, virtual elimination of IDD. All countries should have a fully operative, sustainable salt iodization programme, even though iodized oil might still be needed in some areas. This can be done. If it can be done, it should be done. Our generation is the one that must do it. Further delay is unacceptable by any standard.