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Kul C. Gautam, UNICEF Deputy Executive Director: Sustainable Elimination of Iodine Deficiency: A Public Health Triumph in the Making

78th Annual Meeting of the American Thyroid Association

Check against delivery
New York, 7 October, 2007

It is a great privilege for me to be here among so many of the world’s leading thyroid specialists to exchange views and share our common interest in protecting the health and well-being of future generations from the scourge of iodine deficiency.
Nobody, no other professional group, is or ought to be as knowledgeable and concerned about the status of iodine deficiency – and its terrible consequences - than the world’s thyroid specialists.

So today I salute the American Thyroid Association for organizing this symposium.

Although it seems to have taken 78 years for ATA to convene this first-of-its-kind Symposium on Iodine Deficiency Disorders, we count on you to make this a continuing priority in the future.

As you all know so well, IDD is the single greatest cause of preventable mental retardation. Severe deficiencies cause cretinism, stillbirth and miscarriage. But even mild deficiency can significantly affect the learning ability of populations.

Scientific evidence shows alarming effects of IDD.  Even a moderate deficiency, especially in pregnant women and infants, lowers their intelligence by 10 to 15 IQ points, with incalculable damage to social and economic development of nations and communities.

Today over 1 billion people in the world suffer from iodine deficiency, and 38 million babies born every year are not protected from brain damage due to IDD. These 38 millions, or nearly 30 percent of the world’s newborns, come from families that are the least educated, most isolated and economically disadvantaged. 

The mark of a civilized society is how well it takes care of its most vulnerable and deprived communities. If we continue to fail to reach these newborns, we will be consigning them to an inter-generational cycle of poverty and injustice.

There are, of course, many problems in the world, and we cannot tackle them all. Some require huge investments that most countries cannot afford. Others require new breakthroughs in science and technology that we cannot forcefully accelerate.

But tackling the problem of IDD is among the most affordable and feasible propositions, with already existing and proven technology, and minimal financial investment. The solution as we all know, is to ensure universal access and consumption of small quantities of iodized salt.

If properly implemented, with the investment of only about 10 cents - a dime - per year per person for iodized salt, we can help prevent cretinism, stillbirth and miscarriage, and infant mortality due to iodine deficiency and save future generations from loss of learning ability.

Ladies and gentlemen,

Nearly a century ago it was learned that lack of iodine caused the swelling of the thyroid gland, commonly known as goitre. Research in Switzerland showed that 90 percent of school children in the city of Zurich suffered from goitre. Switzerland then became the first country in the world to introduce iodised salt in 1921 to combat goitre caused by IDD.

In the United States, it was revealed in 1918 that 30 percent of the men medically examined for war service in Michigan were found to have enlarged thyroid. Many of these men were declared unfit for military service.

  On the other hand, a study presented to the American Medical Association (AMA) convention in 1921 showed the successful prevention of goiter by iodide supplementation in a controlled study in school-children in Akron, Ohio.
  Both alarmed and encouraged by these studies, the Michigan State Medical Society launched one of the world’s first salt iodization campaigns in 1922.

In 1923, the year that ATA was founded, Michigan State Medical Society established a salt iodization committee as a public-private parnership, including physicians and representatives of the salt producers association.

A year later in 1924, six local salt companies began to put iodized salt on the shelves of Michigan’s grocers.

Later that same year, the Morton salt company began marketing iodized table salt nation-wide under the headline “Children protected against simple goitre are found to be superior in development”.

By 1932 iodized salt accounted for 90 to 95 percent of all sales in Michigan, and gradually in the rest of the country. A decade later the prevalence of goiter was reduced by over 75 percent.

Following the Swiss example, the rest of Europe too moved rapidly towards salt iodization – swiftly controlling goitre, cretinism, and mild forms of iodine deficiency.

In India the effectiveness of iodized salt was demonstrated in the 1950s, but other pressing priorities prevented developing countries like India from seriously addressing this problem.

As the consequences of IDD began to be better known by the public health community in the 1980s, international agencies like WHO and UNICEF began to press the case for iodization of household salt world-wide.

The fight for elimination of IDD has been at the heart of UNICEF since 1990 when we organized one of the largest gatherings of world leaders in history, “the World Summit for Children”.

Attended by 71 heads of State and Government and many ministers and senior officials, the World Summit adopted a Declaration and Plan of Action for the Survival, Protection and Development of Children. One of the key goals endorsed by that Summit was the virtual elimination of iodine deficiency disorders.  

This commitment was reaffirmed by another landmark Summit, the 2002 United Nations General Assembly Special Session on Children.
As a follow-up to these Summits, together with our partners including governments of developing countries, donors, other UN agencies,  non-governmental and professional organizations such as the ICCIDD, the Micronutrient Initiative, Kiwanis International, the Network for Sustained Elimination of IDD, and very importantly, private sector salt producers, UNICEF has supported programmes for the elimination of IDD through salt iodization in over 100 countries in the last two decades.

UNICEF’s legendary former Executive Director, James Grant popularized the cause of universal salt iodization by always travelling with a salt testing kit in his pocket. Whenever he met Kings, Presidents, Prime Ministers or Governors and Mayors, whether in formal State Banquets or private dinner parties, he would always ask his hosts to pass the salt and inquired if the salt was iodized. Of course, most leaders would not know.

He would then take out his testing kit and test the table salt right then and there to show the leaders if it was iodized. He used these occasions to educate and convince the leaders on the importance of salt iodization, which left a lasting mark, and often an instant commitment, by the leaders to commit national resources for universal salt iodization.

As a result of such high level advocacy, and practical support to salt manufacturers on the ground, progress has been tremendous.
From the early 1990s to 2005, the percentage of households in the developing world using iodized salt increased from less than 20 percent to about 70 percent. As a result, the number of people who consume iodized salt in the world increased from less than 1 billion to nearly 4 billion people.

Some 84 million newborns are now protected every year from brain damage caused by iodine deficiency. And hundreds of millions of children are performing better in school, and succeeding in life.

Universal salt iodization is a great equalizer. Rich and poor, old and young, male or female – all need and use salt.

As IDD affects brain development, and ultimately people’s learning ability and productivity, we should look to elimination of IDD as not only a social but also an economic programme with great potential for combating poverty.
 Based on careful review of scientific evidence – much of it provided by ICCIDD - WHO and UNICEF have recommended that elimination of IDD through Universal Salt Iodization (USI) is a safe, cost-effective and sustainable strategy to help ensure sufficient intake of iodine by all individuals.

 I am often asked, how much did it cost to reach the additional 3 billion people in the last 15 years or so? I would guess, less than $1 billion in terms of external assistance.

 Surely, if any private corporation could reach 3 billion people and get them to buy their product, they would consider an investment of just $1 billion to be a great bargain. Indeed, most large corporations spend much more than that in their advertising budget alone.

The cost effectiveness of iodized salt intervention has been confirmed by leading economists at the World Bank and by a group of prominent economists who came up with the Copenhagen Consensus, confirming that investment in combating micronutrient malnutrition, including through universal salt iodization is one of the best bargains in development.  

The World Bank estimates that each dollar dedicated to IDD prevention yields a productivity gain of $28. Indeed, it is now widely accepted that IDD elimination is one of the most cost-effective programme interventions in the areas of health, hunger and malnutrition.
 According to WHO, the number of countries where iodine deficiency is a public health problem has been reduced by 50 percent over the past decade from 110 countries in 1993 to just 54 in 2004.

 Some countries have made spectacular progress in the use of iodized salt. For example, between 1995 and 2005, Cambodia increased the percentage of households consuming iodized salt from 7 per cent to 73 per cent; Mali from 1 per cent to 74 per cent, Sri Lanka from 7 per cent to 90 per cent; Mexico from 28 per cent to 91 per cent; and Kazakhstan from 20 per cent to 92 per cent.

 Unfortunately, not all countries have made such progress. The poorest performers are countries in the CEE/CIS region – including Russia and Ukraine; in South Asia- including Afghanistan and Pakistan; and in Africa, countries such as Ethiopia and Sudan.

 But today globally, the more severe manifestations of IDD have disappeared from most part of the world and for most countries the clinical manifestations of iodine deficiency are becoming rare. 

With adequate iodine intake from salt iodization programmes, the risk of intellectual impairment has been dramatically reduced.
These achievements represent perhaps one of the greatest public health accomplishments of this century, which may have an impact as significant as that of the eradication of small pox or polio.

Yet the story of the great progress and remaining challenges in salt iodization is not very widely known, I would bet even among members of the ATA.

I hope this Symposium will help to rectify that.

Dear friends,

The history and evolution of the global effort to eliminate IDD, including universal salt iodization, is fascinating, with many lessons applicable to other public health efforts. 

The business of producing, distributing, selling and taxing salt has been a source of great historical events – of revolutions and wars, construction of huge infrastructure projects and protection of the health and well-being of millions – even billions – people. 

I would commend to you a fascinating book, entitled “Salt – A World History”  by Mark Kurlansky. It gives one the impression that the whole of human civilization has been revolving around salt.

The great Greek poet Homer called salt a divine substance. Plato described it as especially dear to the Gods.

Mahatma Gandhi started a salt march that eventually led to the overthrow of the British Empire, not just in India but well beyond.

Some of the greatest public works projects in history, including the building of the Great Wall of China, and the Erie Canal, were funded through salt revenues.

Rights of government to tax and control salt were apparently one of the key elements leading to the American Revolution and the Civil War in this country.

So our epic struggle to ensure universal salt iodization, to eliminate the scourge of iodine deficiency, and to protect human health and enhance human potential might indeed be the greatest historical contribution of this divine substance.

One of the most pressing challenges of our times is to make globalization work for all people.  And one way to move closer towards that goal is for governments, the United Nations system, private sector enterprises, a professional organization like ATA, and civil society groups to forge partnerships around specific goals, and then work with creativity and determination to achieve them. 

Partnerships have been crucial to turning the tide against IDD.  Among the many partners who have been most active in the global campaign for USI, I would like to acknowledge the strong support of the Canadian CIDA, US-AID, the Bill and Melinda gates Foundation, the Kiwanis International, ICCIDD and the Micronutrient Initiative. These organizations along with key private sector partners, UN agencies and the World Bank have forged a uniquely effective partnership.

Former U.N. Secretary General Kofi Anan singled out the USI/IDD work as a model of public/private partnership for development.

We now need to further strengthen this partnership to extend and sustain IDD elimination permanently into the future.   

 But despite the huge progress made – there is still much left to do to ensure that every child is protected from the world’s major cause of preventable brain damage.  There are still some 38 million children born every year at great risk of lifelong brain damage associated with iodine deficiency. 

We owe it to them, and the future of our world, to ensure that they are born healthy and grow up with every chance to realize their full human potential.

This great public health and nutrition effort requires the favorable blending of three essential ingredients:

- impeccable science with proven results in public nutrition
- full participation of the private productive sector in which the delivery process is lodged
- persistent monitoring and review of sustained progress and public reporting.

 The remaining challenges to achieve sustainable elimination of iodine deficiency can be grouped into four areas in which ATA and members of other thyroid associations around the world could take important roles. 

- 1. Advocacy and political commitment.  Please help us secure government and industry commitment to USI which is so essential for sustained progress for elimination of IDD. This commitment must be periodically renewed through continuing advocacy. 

As an example of your exemplary advocacy, I noted that early this year ATA wrote to President George W. Bush, requesting him to ensure adequate availability of potassium iodide for protection of young people against developing thyroid cancer in the event of a terrorist attack and massive release of radioactive iodine.

To support your case, you cited the example of the nuclear accident in Chernobyl that resulted in thousands of cases of thyroid cancer in children.

But cancer is only the tip of the iceberg. Even after 20 years, widespread iodine deficiency in the vicinity of Chernobyl and other parts of Belarus, Russian Federation and Ukraine is leading to a whole generation of children growing up potentially brain-damaged.

We believe that universal iodization of all the salt for human and animal consumption is one of the most essential responses in a Chernobyl like situation. We would like to see ATA become a strong advocate and watchdog of USI for elimination of IDD.

- 2. Improved regulatory action.  While voluntary iodization is beneficial in individual situations, only mandatory iodization will ensure universal access and use. We also need regulations to stop cross border trade in non-iodized salt.

The respected voice of ATA and other worldwide thyroid associations could be very helpful in this regard.

Sound technical and scientific evidence are essential to advance the regulatory and strategic guidance for the elimination of iodine deficiency. 

Although iodine deficiency is not considered a public health problem in the US, it is important to increase awareness of adequate iodine nutrition, particularly during pregnancy and lactation, among US women.

ATA’s recommendation for iodine supplementation during pregnancy and lactation period to ensure normal brain development of American children, is therefore an important reference. We will hear more about that from Dr Elizabeth Pearce. 

- 3. Monitoring programmes and iodine status.  A regular, effective monitoring system to verify iodine levels in salt, and iodine status of the population, is instrumental for a successful programme. 

Today, approximately 70% of the table salt sold in the US is iodized. However, it is estimated that household table salt accounts for only about 15 per cent of daily salt intake in the US, and the salt used in processed foods may not be iodized. 

The US National Health and Nutrition Examination Survey (NHANES) showed that although iodine intakes have decreased by 50% since the early 1970s, the US remains iodine sufficient, but there are concerns about the increased proportion of low urinary iodine values among women of child bearing age.

There is a need for a national and systematic assessment of iodine status in different US populations and for routine monitoring of food iodine content. ATA can play a helpful role in this regard.

4. Forming National Oversight Committee.   Success of the global IDD programme depends on national efforts at the political, scientific, private, professional and civic society levels.  A good way to assure such participation and action is through a national oversight committee in each country with the active partnership by civil, private sector, scientific, professional, communications and policy people. 

History tells us that when no national entity like this is put into place, all good efforts may wax and wane. Therefore, we would like to see ATA and its affiliates worldwide championing for an oversight mechanism in each country to ensure USI for elimination of IDD.

Dear friends, 
In 1978, one of UNICEF’s great leaders, Harry Labouisse, our Second Executive Director said, in the names of WHO and UNICEF that “It ought to be a crime that one more child be allowed to be born mentally handicapped when we know how to prevent it!”  This statement was right then and is still right today.

I hope that ATA through its members and affiliates worldwide will be a staunch advocate for universal salt iodization to combat IDD, and thereby help create a world that is truly fit for all our children.

Thank you.




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