Round Table Discussion

The challenge ahead: iodized salt on every table for ever

Gregory Gerasimov ¹

Chandrakant S. Pandav ¹

Moulay Benmiloud ¹

François M. Delange ²

Charles Todd ¹ 

The history of the International Council for the Control of Iodine Deficiency Disorders (ICCIDD) is a remarkable example of what a nongovernmental organization with relatively small financial resources can do. With an overarching strategy and extensive network of members all over the world, it was able to mobilize international agencies and national government for IDD elimination. This success of the ICCIDD is also a personal accomplishment of its founder and former leader, Basil Hetzel. The Council showed itself especially efficient in advocacy: the goal of IDD elimination was accepted by the World Summit for Children in 1990 which was attended by 71 Heads of State, who signed a declaration on the provision of new goals for improved health and education for all children. By the end of 1999, more than 70% of the households in the world were using iodized salt, compared with possibly only 20% in 1990.

However, new challenges are ahead for the ICCIDD and its partners in the Global Network for Sustainable IDD Elimination founded in 2001. While progress has been impressive, and many nations have achieved high salt iodization coverage, in 36 countries less than half of the population uses iodized salt. In countries of Central and Eastern Europe and the Newly Independent States less than 25% of households consume iodized salt and iodine deficiency remains a public health problem. In these countries the full implications of iodine deficiency and its impact on human development have not been fully appreciated and the ICCIDD, with other members of the Network, must continue the advocacy process.

One should not forget that iodine deficiency is still not eliminated in many of the industrialized western countries either. There is a growing number of reports that the iodine intake in populations in the economically advanced parts of the world has fallen during the period in which most developing nations have been tackling the iodine deficiency problem. This is potentially dangerous not only for the people in these countries but for the whole global effort of IDD elimination. It arouses the suspicion of double standards, with universal salt iodization advocated only for the economically disadvantaged.

But the main challenge for the ICCIDD is the transition from running a campaign to sustaining its success. Sustained elimination of IDD means that from now on and for ever, every family table should have salt on it containing the optimal quantity of iodine. This is not an easy task. In the countries of the former Soviet Union iodine deficiency was once almost fully eliminated. It returned when salt iodization rates, once believed to be safely adequate, dropped dramatically. Complacency and lack of an efficient monitoring system were the main reasons for this relapse. Actions for maintaining success are not the same as those needed for achieving it, and they still need to be worked out. This is the new challenge for the ICCIDD. n

¹ ICCIDD Regional Coordinator for Eastern Europe and Central Asia, PO Box 24, Moscow 103001, Russian Federation (email: gerasimov@webiodine.com).

Ref. No. 02-0159

Eliminating iodine deficiency disorders in India

Chandrakant S. Pandav¹

An analysis of iodine deficiency disorder (IDD) elimination programmes all over the world shows that four elements contribute to their success: political commitment, administrative infrastructure, scientific leadership, and monitoring and evaluation. The International Council for the Control of IDD (ICCIDD) came into existence formally in 1986 but its members in India have been involved with these efforts in India since the early 1950s. India's experience with the four essential elements can be summed up as follows.

Political commitment. For the first 20 years of its existence, the National Goitre Control Programme (NGCP, launched in 1962 and renamed as the National Iodine Deficiency Disorders Control Programme (NIDDCP) in 1992) was a low priority. The turning point was in 1983, when Prime Minister Indira Gandhi was briefed by top scientists on the consequences of IDD and the availability of a cheap and cost-effective solution. She decided that this was not only a health problem but a national development problem. Almost overnight, the programme underwent a sea change, and the strategy of Universal Salt Iodization was adopted. Goitre control was on the Prime Minister's 20-Point Programme, and the private sector was invited to produce iodized salt. Members of ICCIDD have helped to make the authorities aware on a regular basis of the need for iodization.

Administrative infrastructure. For proper administration, it is essential to have a nodal point for the programme. For India this is the Adviser (Nutrition) and Deputy Assistant Director General (Goitre). Each state also has an IDD cell to act as its nodal point. Interaction with the Prime Minister raised resource allocation to Rs 200 million in the Seventh Five Year Plan.

Scientific leadership. ICCIDD members have been involved in conducting research on different IDD for the last 40 years. The formation of the Council as an international NGO in India has facilitated the creation of a "home base" located in the country's premier health institute, the All India Institute of Medical Sciences. This serves as the training and resource centre for field surveys, training in measuring iodine levels in salt and urine (to track progress towards IDD elimination), information dissemination, technical expertise and monitoring and evaluation of activities. State-level workshops for IDD workers have been conducted from time to time to review progress, identify bottlenecks, learn from their own and others'experience, and modify programmes accordingly.

Monitoring and evaluation. India has a system in which food inspectors collect salt samples and send them to laboratories for analysis. In New Delhi, ICCIDD has established a system for regularly enlisting the schools in monitoring the programme (1). ICCIDD has also forged collaborative partnerships with a network of NGOs such as the Voluntary Health Association of India, and the Bharat Scouts and Guides, which carry out activities all over the country. In addition to providing technical support, ICCIDD has conducted independent evaluations of the Universal Salt Iodization Programme in New Delhi (2, 3), Madhya Pradesh (4), Sikkim (5–8) and Kerala (9).

The ICCIDD has played a major role in the IDD elimination programmes of many countries, especially those in southern Asia. The "5 Cs of ICCIDD" — commitment, cohesiveness, collaboration, credibility and continuity — have become not only an ideal but a reality. Their multidisciplinary team includes experts in public health, epidemiology, biostatistics, health social sciences, health economics, salt technology, medicine, endocrinology, biochemistry, and psychiatry. They have worked to establish partnerships between the stakeholders, who include the technical groups, the media, the legal experts and the salt industry.

As a result there has been a tremendous increase in iodized salt production: from 0.2 million tons in 1983 to 4.6 million tons in 2001. Coverage with adequately iodized salt is now 49%, according to a survey completed in 1999. But that means the glass is only half full. To reach and sustain 100% coverage is necessary and possible, but only when civil society is determined to make the effort. n

1. Pandav CS, Sachdeva I, Anand K, Pandav S, Karmarkar MG. Using government schools to monitor iodine content of salt at household level in Delhi. Indian Journal of Pediatrics 1999;66:179-83.

2. Pandav CS, Kochupillai N, Karmarkar MG, Ramachandran K, Gopinath PG, Nath LM. Endemic goiter in Delhi. Indian Journal of Medical Research 1980;72:81-8.

3. Pandav CS, Mallik A, Anand K, Pandav S, Karmarkar MG. Prevalence of iodine deficiency disorders among school children of Delhi. National Medical Journal of India 1997;10:112-4.

4. International Council for Control of Iodine Deficiency Disorders (ICCIDD). Independent survey evaluation of Universal Salt Iodisation (USI) in Madhya Pradesh. New Delhi: ICCIDD; 1996.

5. Sankar R, Rai B, Pulger T, Sankar G, Srinivasan T, Srinivasan L, et al. Intellectual and motor functions in school children from severely iodine deficient region in Sikkim. Indian Journal of Pediatrics 1994;61:231-6.

6. Sankar R, Pulger T, Bimal R, Gomathi S, Pandav CS. Iodine deficiency disorders in school children of Sikkim. Indian Journal of Pediatrics 1994;61:407-14.

7. Sankar R, Pulger T, Rai B, Gomathi S, Gyatso TR, Pandav CS. Epidemiology of endemic goiter in Sikkim. Journal of the Association of Physicians of India 1997;45:936-40.

8. Sankar R, Prabhakar S, Sheshadri MS, Pulger T, Rai B, Gomathi S, Pandav CS. Clinical study of neurological cretinism in Sikkim. Neurology India 1997;45:244-9.

9. IDD Study Group. Tracking progress towards elimination of iodine deficiency disorders in Kerala. New Delhi: ICCIDD. Forthcoming 2001.

¹ Additional Professor, Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India (email: cpandav@now-india.net.in).

Ref. No. 02-0156

The alliance to eliminate iodine deficiency is impressive but not yet sufficient

Moulay Benmiloud¹

Basil Hetzel explains the role of the International Council for Control of Iodine Deficiency Disorders (ICCIDD) in the global combat against iodine deficiency disorders, since its creation in 1995 (see pp. 410–413). As a long-time member of the executive of ICCIDD I can confirm his statements on its positive impact, especially in the developing countries of Africa and Asia where the risk of IDD risk is most severe. Indeed, the ICCIDD has been an important catalyst for the concerted activities of the global partnership of WHO, UNICEF, the World Bank, the international salt industry, the Kiwanis clubs and other bodies. These activities have led to worldwide use of iodized salt for IDD prevention.

However, Hetzel's presentation overlooks the difficulties which have prevented us from fully reaching the goal of eliminating IDD by the year 2000. In this regard I can cite a few examples of defects in the global partnership, taken from my experience in Africa. Although not necessarily representative of the global picture, I believe they reflect inherent problems in multidisciplinary work involving many stakeholders.

Although great progress was noted in communication on IDD since the development of electronic means, much of the advocacy and technical publications still remain available only to minorities in ministries and universities. Lack of funds has hindered the ICCIDD from adopting a more aggressive attitude, and even the UNICEF and WHO country networks have had little direct access to field workers in the relevant health and salt industry sectors. Thus the participation of nationals is insufficient. National IDD committees, though a most welcome innovation, are not always functional, and suffer frequently from political instability.

Regional and subregional meetings organized by the continental task forces for IDD Control are useful but costly, and when far apart they do not facilitate an efficient re-evaluation of the programmes. These meetings, between national representatives and international sponsors, have provided the opportunity to redefine policies, but divergences on priorities and strategies occur between the global partners. A major line of division is between those who are more health-oriented and those who favour more industrial and commercial approaches. The resulting dissonance reduces the efficiency of the alliance, especially that of the ICCIDD which is financially weaker than other members.

A major handicap has been the slow development of an efficient monitoring system for country programmes. The supporting laboratory network is still dependent on a few national structures that were in place before the creation of ICCIDD. Field evaluation of iodine levels in salt is mostly quantitative and does not allow for adequate programme tuning. Urinary iodine measurement is available in only a few laboratories and is generally limited. This means that national capacity for sustaining the programmes is still fragile and there have been setbacks in Africa.

These shortcomings do not diminish the admirable accomplishments of the past 15 years. They should, however, remind the ICCIDD and its partners that the IDD problem is not solved. Greater cohesion in the global partnership is required, and the ICCIDD needs to keep a scientific watch over progress. n

¹ ICCIDD Senior Adviser, Agence Nationale pour le Développement de la Recherche en Santé, BP 062, Elmnouar, 31008 Oran, Algeria (email: benmiloud@elbahia.cerist.dz).

Ref. No. 02-0156

Iodine deficiency: a distinguished past, an uncertain future

François M. Delange²

Basil Hetzel provides an adequate overview (pp. 410–413) of the International Council for Control of Iodine Deficiency Disorders (ICCIDD). The importance of his own role in the creation and life of the Council is unquestionable and should be warmly acknowledged. The achievements of the ICCIDD are also the result of joint action by all its members, including its first chairman, John Stanbury, who already in 1954 published, with his colleagues, an outstanding study on endemic goitre (1), which has been an essential milestone for subsequent work on IDD.

ICCIDD is one among the hundreds of nongovernmental organizations dealing with health issues. Its special effectiveness appears to have been due mainly to the following characteristics.

First, as Hetzel points out, the Council was created at the initiative of thyroid scientists and public health professionals in order to tackle the specific problem of IDD. They were fully competent in this area and their objective was to bridge the gap between the knowledge available and the problems it could solve.

Second, the Council was conceived from the very beginning as a global partnership between the different stakeholders in the elimination of IDD. This took place some 15 years before such a partnership was established on a much larger basis between the major international organizations now involved. At least until recently, its Executive Group was largely international and multiethnic.

Third, during its early years the Council played a leading role in advocacy through UNICEF and WHO, which contributed to the decision by the 1990 United Nations World Summit for Children to commit itself to the goal of virtual elimination of IDD by the year 2000.

Fourth, in parallel and subsequently, it has played a determining role, frequently in direct collaboration with WHO and UNICEF, in science, technology and operational research for which it has a specific qualification, especially in the medical field. Examples are the side-effects of iodine supplementation (2, 3), normative values for variables defining the status of iodine nutrition (4, 5), laboratory methods (6), salt technology (7, 8), communication (9), and economic evaluation of IDD (10). Also, the majority of the experts involved in the production of the key documents establishing criteria for the elimination of IDD as a cause of brain damage (11–13) were members of ICCIDD.

Fifth, not being a funding agency, ICCIDD has played a modest role in the spectacular progress of implementing prophylactic programmes based on the use of iodized salt. However, most of the successful experience resulting from the use of iodized oil as vehicle for iodine supplementation has resulted from actions conducted by ICCIDD members (14, 15).

Sixth and finally, the next steps are to complete iodine prophylaxis in all affected countries and to evaluate the country programmes and their sustainability. The role of the Council in these activities still has to be worked out. n

1. Stanbury JB, Brownell GL, Riggs DS, Perinetti H, Itoiz J, Castillo EBD. Endemic goiter. The adaptation of man to iodine deficiency. Cambridge: Harvard University Press; 1954.

2. Stanbury JB, Ermans AM, Bourdoux P, Todd C, Oken E, Tonglet R, et al. Iodine-induced hyperthyroidism : occurrence and epidemiology. Thyroid 1998;8: 83-100.

3. Delange F, de Benoist B, Alnwick D. Risks of iodine-induced hyperthyroidism following correction of iodine deficiency by iodized salt. Thyroid 1999;9:545-56.

4. WHO and ICCIDD. Recommended normative values for thyroid volume in children aged 6–15 years. Bulletin of the World Health Organization 1997;75:95-7.

5. Delange F, de Benoist B, Bürgi H, and the ICCIDD Working Group. Median urinary iodine concentrations indicating adequate iodine intake at population level. Bulletin of the World Health Organization (in press).

6. Dunn JT, Crutchfield HE, Gutekunst R, Dunn AD. Methods for measuring iodine in urine. Wageningen: International Council for Control of Iodine Deficiency Disorders (ICCIDD); 1993.

7. Mannar VMG, Dunn JT. Salt iodization for the elimination of iodine deficiency. Wageningen: Micronutrient Initiative, ICCIDD, UNICEF, WHO; 1995.

8. Pandav CS, Arora NK, Krishnan A, Sankar R, Pandav S, et al. Validation of spot-testing kits to determine iodine content in salt. Bulletin of the World Health Organization 2000;78:975-80.

9. Ling JCS, Reader-Wilstein C. Ending iodine deficiency now and forever. A communication guide. Ottawa: International Council for Control of Iodine Deficiency Disorders (ICCIDD) and Micronutrient Initiative (MI); 1997.

10. Pandav CS. Yes. Worthwhile investment in health. Economic evaluation of iodine deficiency disorders control programme in Sikkine. Dehli: Oxford University Press; 1997.

11. WHO, UNICEF, ICCIDD. Indicators for assessing Iodine Deficiency Disorders and their control through salt iodization. Geneva: WHO; 1994 (document WHO/ NUT/94.6).

12. WHO, UNICEF, ICCIDD. Recommended iodine levels in salt and guidelines for monitoring their adequacy and effectiveness. Geneva: WHO; 1996 (document WHO/NUT/96.13).

13. WHO, UNICEF, ICCIDD. Assessment of the Iodine Deficiency Disorders and monitoring their elimination. Geneva: WHO; 2001 (document WHO/ NHD/01.1).

14. Dunn JT. The use of iodized oil and other alternatives for the elimination of iodine deficiency disorders. In: S.O.S. for a billion. The conquest of Iodine Deficiency Disorders. B.S. Hetzel, C.S. Pandav, editors. New Dehli: Oxford University Press; 1996; p 119-28.

15. Delange F, de Benoist B, Pretell E, and Dunn J. Iodine deficiency in the world : where do we stand at the turn of the century? Thyroid 2001;11:437-47.

² Board member and former Executive Director of ICCIDD, and Regional Coordinator for Europe of ICCIDD, 153 avenue de la Fauconnerie, 1170 Brussels, Belgium (email: fdelange@ulb.ac.be).
Ref. No. 02-0158

Eliminating iodine deficiency: applause and questions

Charles Todd¹

Basil Hetzel must take much of the credit for the worldwide recognition of the importance of iodine deficiency as a major public health problem. By coining the term "iodine deficiency disorders" (IDD) in his seminal 1983 Lancet paper he transformed our understanding of the problem from the seemingly trivial "endemic goitre" to a wide range of conditions, with the fetus and young child especially vulnerable (1). The realization that adequate amounts of iodine are vital for normal brain development, and that deficiency leads to a general suppression of mental ability in affected communities, galvanized world opinion from the mid-1980s onwards into pressing for action. The results have been very impressive, and even though the goal of elimination as a public health problem by 2000 has not been achieved in all countries, hundreds of millions of people who were at risk a decade ago no longer are.

Hetzel's paper in this issue of the Bulletin (pp. 410–413) raises several important questions. First, do international nongovernmental organizations (NGOs) such as ICCIDD have a role in global advocacy and action on important public health issues? The answer must be a resounding "Yes" based on ICCIDD's own success. The work of the traditional players in global health issues, notably WHO and UNICEF, can undoubtedly be complemented by that of international NGOs such as ICCIDD. However, sometimes focus on a single issue can lead to a loss of perspective. For example, some IDD protagonists have advocated elaborate vertical monitoring systems for the world's poorest countries, where access to basic primary health care services is very limited. In any given country, the fight against IDD must be seen in the context of the other important causes of the burden of disease and the overall resources available.

Second, is there a role for partnerships with private industry in tackling public health problems? Many public health workers are traditionally wary of the private sector as interested only in profit, remembering for example the role played by infant formula manufacturers in undermining breastfeeding in many developing countries in the 1970s, with disastrous consequences for babies in poor households. The recent successes in tackling IDD, though, have in large part been due to the successful partnership between the international agencies and NGOs, national authorities and the salt-producing companies. In Southern Africa this partnership has resulted in iodized salt being on hand in nearly all households, even in the remotest areas.

The next question follows on directly from the last: given the growing evidence for the harmful effects of high levels of salt consumption, should salt still be promoted as the vehicle for iodine supplementation? Indeed, some health workers regard the salt industry in the same way as the tobacco industry, only interested in promoting more salt consumption at the expense of public health (by increasing the prevalence of hypertension). Furthermore, iodization of salt might serve to encourage even higher levels of consumption. This issue has proved particularly controversial in Europe, and is one reason why that region now lags behind the rest of the world in the rate of progress towards eliminating IDD. Another is resistance to universal salt iodization as contrary to the notion of freedom of choice. It is important that those advocating universal salt iodization do not encourage increased salt consumption, and that they emphasise that iodine is an essential nutritional requirement.

Finally, there is the question of whether we should be in such a hurry to eliminate IDD, given the recognized danger of an increased incidence of hyperthyroidism following the introduction of iodine supplementation (2). This has proved particularly controversial in poor developing countries where there may be extremely limited access to treatment for hyperthyroidism, but it is just those communities, in which iodine deficiency is so severe, that will benefit the most from supplementation. What is important is to provide physiological amounts of iodine. Early recommendations for Africa called for a standard level of 100 parts per million (ppm) of iodine (as potassium iodate) in all salt for human consumption. This level proved far too high for many countries. Following reports of increased hyperthyroidism in the Democratic Republic of the Congo and Zimbabwe, WHO, UNICEF and ICCIDD carried out a special study in seven African countries and subsequently lowered the recommended level of salt iodization to 20–40 ppm (3). Regrettably, the evidence base for the initial recommendation had been weak, and it was only through close monitoring of the impact of salt iodization that the danger was uncovered. n

1. Hetzel BS. Iodine deficiency disorders (IDD) and their eradication. Lancet 1983;ii:1126-9.

2. Stanbury JB, Ermans AE, Todd C, Oken E, Tonglet R, Vidor G, et al.. Iodine-induced hyperthyroidism: occurrence and epidemiology. Thyroid 1998;8:83-100.

3. WHO/UNICEF/ICCIDD. Recommended iodine levels in salt and guidelines for monitoring their adequacy and effectiveness. Geneva: World Health Organization; 1996. Unpublished document WHO/NUT/ 96.13.

¹ Regional Health Adviser, Delegation of the European Commission to Zimbabwe, P O Box 4252, Harare, Zimbabwe (email: ctodd@healthnet.zw).

Ref. No. 02-0157