Case Studies: Jonathan Gorstein - Outline
Sam Clark |
Jonathan Gorstein - Abstract |
Jonathan Gorstein - Outline |
Anne Marie Kimbal |
Martina Morris |
Beth Rivin |
Bettina Shell-Duncan |
Clarence Spigner |
Joe Zunt |
Universal Salt Iodization to Prevent Iodine Deficiency Disorders
Ibu Kamudia was born on the Indonesian
island of Java severely iodine deficient. She suffered from the most pronounced
form of mental and physical retardation known as cretinism which was caused by a
lack of iodine in the diet of her mother during the first weeks of pregnancy.
Her entire life was one of virtual dependency on other family members and the
extended community, although she maintained a warm playfulness.
With the support of her local religious leader, Kamudia was able to get married in a traditional Javanese wedding ceremony to a farmer who was also born with severe cretinism. During their lifetime, the Indonesian Government introduced a policy that all salt intended for human consumption be iodized, and over the course of a few short years, their iodine levels became normal, although their mental retardation (caused before they were born), was irreversible
The increased iodine intake from the locally available salt did make them more energetic and communicative, and in their mid twenties they gave birth to two sons, who were born without any signs of iodine deficiency. Although salt iodization is a cost-effective intervention for which simple appropriate technological solutions are available, there are several barriers in ensuring that all salt in the country is iodized, primarily due to the traditional customs of salt harvesting which is done by poor salt farmers. The elder son of Kumidia, Rame, now attends college in Jakarta and is studying small business administration and hopes to use his degree to work with the thousands of small farmers scattered along the coasts of Indonesia to form into cooperatives to ensure that all of their salt is adequately iodized and will help prevent iodine deficiency in future generations.
1. Intro to topic
Iodine deficiency is the primary cause of
preventable mental retardation and brain damage, having the most devastating
impact on the brain of the developing fetus and young children in the first few
years of life. Iodine deficiency also increases the chance of infant mortality,
miscarriage and stillbirth. Most children born to iodine-deficient mothers
appear normal but have also suffered brain damage and loss in IQ points,
affecting their ability to develop to their full potential. These seemingly
normal children will later have difficulty learning in school and staying in
school. However, some children born to mothers
whose iodine deficiency is more pronounced can suffer from extreme physical and
mental retardation manifesting, and in the most extreme cases, cretinism. These
children, however, represent only the tip of the iceberg; in addition, in many
cases it is too late to reverse these effects.
Children who have suffered from less severe
deficiencies and who appear normal, but have lost 10 to 15 intelligence
quotient (IQ) points. All IDD can be prevented with just one
teaspoon of iodine - consumed in tiny amounts on a regular basis over a
lifetime – at very little cost.
An iodine deficient
environment requires the continued addition of iodine, which is most
conveniently and cheaply achieved by the addition of iodine (typically as potassium
iodate) to the salt supply.Most humans
eat salt in roughly the same amount each day.A decrease in salt intake can be readily met by increasing the iodine
content. Where a significant amount of processed food is consumed, it is
important that the salt used by the food industry in preparing such food is
iodised as well as the salt used in the home.
salt iodisation (USI) which ensures all salt for human and animal consumption
is adequately iodised has been remarkably successful in many countries.But sustainability of this successful
correction of iodine deficiency is now the challenge because iodine deficiency
may recur at any time even in industrialised countries. Since 1990 there has been tremendous
progress in increasing the amount of salt which is iodized in countries
throughout the world, as well as the proportion of households using salt which
contains adequate iodine levels to satisfy physiological requirements. At the
same time, there are significant problems, and in spite of the seeming
‘simplicity’ of the intervention, there are many subtle challenges to achieving
2. Why is this a priority?
and challenges of public-private partnerships
- Role of
legislation and enforcemen
- Mandatory vs. voluntary policies
- How does
pubic sector provide incentives to private sector
deficiency occurs when iodine intake falls below recommended levels. Iodine
deficiency is a naturally occurring ecological phenomenon that occurs in many
parts of the world. The erosion of soils in riverine areas due to loss of
vegetation from clearing for agricultural production, overgrazing by livestock
and tree-cutting for firewood, ensures a virtual absolute loss of iodine from
the soil. Consequently, the groundwater and foods grown locally in these areas
lack iodine. When iodine intake falls
below recommended levels, the thyroid may no longer able to synthesise
sufficient amounts of thyroid hormone. The resulting low level of thyroid
hormones in the blood (hypothyroidism) is the principal factor responsible for
the damage done to the developing brain and the other harmful effects known
collectively as the Iodine Deficiency Disorders.
critical period is from the twelfth week of pregnancy to the third year after
birth. Normal levels of thyroid hormones are required for optimal development of
the brain, and in areas of iodine deficiency, where thyroid hormone levels,
brain development is impaired. In its most extreme form this results in
cretinism, but of much greater public health are the more subtle degrees of
brain damage which affect the entire population. As a result, the mental
ability of ostensibly normal children and adults living in areas of iodine
deficiency is reduced compared to what it would otherwise be.In fact, iodine deficiency is the most
prevalent preventable cause of mental retardation and brain damage in the
3. What kind of evidence is needed to evaluate and address this case topic? What kind of
evidence is out there?
magnitude of IDD and coverage of iodized salt
of the biology of iodine, IDD and its consequences
necessary to have adequate dietary iodine to prevent brain damage in the fetus
and in the young infant when the brain is growing rapidly. Whether a national
programme is effective in providing an adequate amount of iodine to the target
population is reliably assessed by reference to measurements of salt iodine (at
factory, retail and household level) and urine iodine (measured in casual
samples from school children or households).
of salt and urine iodine thus provide the essential elements for monitoring
whether IDD is being successfully eliminated.These measurements must be carried out regularly according to systems
that include both internal and external quality control of factories in order
to ensure that all edible salt being produced is iodized, and that the iodine
levels are adequate.
estimated that in 1990, of its 191 Member States, 130 had a significant IDD
problem, with a total of affected population of 740 million – or 13 percent of
the world’s total population. While the struggle to
conquer the IDD started in the early years
of this century, it is the last decade that has seen the greatest progress.
Progress has been particularly fast in Asia and Africa. There is an increasing
number of countries in which a significant proportion of households are using
adequately iodized salt, including several countries that consistently rank
very low on performance of other health indicators.
and tools to assess iodine status in the population
and monitoring systems to measure the iodine content in salt
- The role
of different partners in monitoring, e.g. Government, producers, civil
- Use of
information to modify program dynamics and implementation
4. How does institutional capacity affect the problem
and the process?
successful national salt iodisation programme depends on the implementation of
a set of activities by various sectors:
- government ministries (legislative
and justice, health, industry, agriculture, education, communication and
- salt producers, salt importers and
distributors, food manufactures;
- concerned civic groups;
- nutrition, food and medical
scientists and other key opinion makers.
the channels of communication and maintaining commitment and co-operation
across these various groups is perhaps the greatest challenge to reach the goal
of Universal salt Iodization (USI) and ensure the sustainable control of IDD. The salt producers and distributors are the main agents to ensure that IDD is eliminated. Protecting the consumers requires a framework to be in place that will ensure the distribution of adequately packaged, labelled, iodised salt and the setting of this framework is the main responsibility of the government.
Ensuring a demand for the product and understanding the reason to insist on only iodised salt is a shared responsibility of
the private salt marketing system, the government and civic society. The
establishment and maintenance of such an alliance and all of the associated
programme elements will determine the success and sustainability of the
programme. Two major policy questions
emerge here. First, who is responsible for the marginal cost of adding iodine
to salt – consumers or the Government, and secondly, is it appropriate for the
Government to exert pressure on small-scale producers who are much less likely
to ‘comply’ with mandatory iodization, not for a lack of commitment, but rather
for a lack of adequate resources.
multidisciplinary orientation required for a successful programme poses special
difficulties in implementation. Experience indicates that particular problems often arise between health
professionals and the salt industry – with their different professional
orientations. There is need for mutual
education about the health and development problems of IDD and the problem of
the salt industry in the continued production of high quality iodised salt.
Such teamwork is required for sustainability to be achieved.
a strong belief that the additional cost of salt iodisation to salt production
(less than 5 cents [US] per person per year) should eventually be borne by an
educated community. This will greatly
assist sustainability, but as a public good is this the right approach among the
poor and marginal segments of society who make decisions based on absolute
- Focus on
issue of small-scale farmers
of interest when Government workers have financial stake in salt companies
5. Population vs. individual level outcomes
Iodine deficiency affects the entire population and if
present during pregnancy may lead to permanent consequences. The treatment of thyroid disease exacerbated
by iodine deficiency is extremely expensive, and imposes a major burden on the
health system. Given the cost-effectiveness of IDD prevention through salt
iodization, most countries (including those in the industrialized world) have
opted to focus on prevention of IDD at the population level.
6. Ethical issues
The impact of iodine deficiency on a
population is pronounced and in many cases, irreversible. The mental
deficiency associated with IDD has an immediate effect on child learning
capacity, women’s health, the quality of life of communities, and economic
productivity. Thus the potential of a whole community is reduced by iodine
deficiency. There is little chance of achievement, and underdevelopment is
perpetuated. Indeed everybody may seem to be slow and rather sleepy. The
quality of life is poor, and ambition blunted. The community becomes trapped in
a self-perpetuating cycle.
the main issues that has been debated in the international nutrition community
regarding IDD is whether the improvement of iodine status, and the prevention
of IDD is a public good that should be subsidized by the Government, or whether
the costs should be passed onto consumers.
issue which has emerged is associated with the important role of all salt
producers in USI programs. There has been a particularly challenging obstacle
of bringing all small-scale producers on board in countries with long
coastlines, as there are literally thousands of artisanal seasonal salt
producers who harvest small quantities of salt and then sell it unprocessed
(and un-iodized) directly to local markets, thus creating a supply of
non-iodized salt for retailers and consumers. If the Government requires these
farmers to only sell iodized salt, many will not have the capacity and will be
forced out of business Larger factories
will come in and dominate the markets. In order to address this problem, it has
been critical to identify appropriate models for ‘organizing’ small farmers,
such as though co-operatives so that they can remain viable and also contribute
to the progress towards USI.
- Who pays
for a public good?
a precedent for food fortification when adequate nutrition is considered
as a basic human right
Video: For A Few Pennies More (2000; 24min)
The importance of nutrition, and
specifically iodine in the diet of poor people, is the unusual topic of this
segment, set in Java , Indonesia. An estimated two billion people around the
world are at risk from this medical problem. Goiters, cretinism, stillbirths,
underweight babies, lower IQs-these are some of the consequences of iodine
deficiency. The World Bank estimates that up to 5% of global GDP is lost
because of the lack of micronutrients like iodine.
*Available through the Center for Advanced
Studies in International Development (CASID) http://www.isp.msu.edu/casid/video.html
Bleichrodt N. and Born M. A Meta-analysis of Research on
Iodine and Its Relationship to Cognitive Development.The Damaged Brain of Iodine Deficiency, J.-B. Stanbury (ed).Cognizant Communication Corporation, New
York, 1994, pp 195-200.
WHO, UNICEF, ICCIDD. Global prevalence of iodine
deficiency disorders. MDIS Working Paper # 1. 1993.