Meeting of the Partnership on
Sustained Elimination of Iodine Deficiency

In the 1920's, iodized salt was introduced in the markets in the USA and Switzerland to combat what now is known as IDD, and it proved safe and effective in reducing iodine deficiency. Salt iodization was started in 1950's in severely iodine deficient countries of the Andes, although not all these efforts were sustained. Salt iodization was also introduced in China, India and Viet Nam during this time, but the targeted supply in these countries limited their effectiveness. 

At the 1990 World Summit on Children, Heads of State and Government endorsed the global goal of virtual elimination of iodine deficiency disorders by the year 2000. In a joint policy statement in January 1994, UNICEF and WHO recommended that all edible salt in a country should be iodized if IDD was a public health problem. This strategy has become known as "Universal Salt Iodization", or USI. In virtually all the 130 countries where the problem has been acknowledged, USI now has become the accepted national public nutrition policy. 

Five regional salt producers meetings were held from mid 1999 onwards. In several regions, they witnessed the initiation of regional salt producer associations. During these meetings, action plans were formulated to accelerate USI from collaborative efforts of national public-private-civic alliances. New information and data was uncovered of key gatekeepers in edible salt production and trade for human and animal consumption, and of the proportions of reported salt production being iodized. Specific obstacles in USI were identified, and ideas for their correction formulated. The meetings held in Kiev, Ukraine (Sep 1999), Bogota, Colombia (Nov 1999), Mombasa, Kenya (Feb 2000), Accra, Ghana and Dubai, UAE (both Apr 2000) were crucial opportunities for initial and renewed interactions of salt producers and traders with public sector officials, representatives from civic groups, UN and bilateral agencies, and international experts. 

Also, the participation in at Salt2000 by the group was significant and at a high level. UNICEF's Executive Director, Ms Carol Bellamy, and the Dutch Minister for Development Cooperation, Mrs Evelyne Herfkens, joined the Chairman of Salt2000 in giving presentations at the festive Opening Ceremony. Throughout the 4 days, lessons and results from ongoing national programs based on salt iodization were presented and discussed from various angles. Presentations of the history of USI strategy development, the end-of-decade status of USI in the world, investments and accomplishments in salt industry, and ways to sustain the success were given in a special plenary session. A series of posters were shown in the Exhibition Hall. 

Thus, the USI strategy for global elimination of iodine deficiency became a central theme of the Symposium. From the many inputs of persistent collaboration and mutually supportive work by a global partnership from public, private, civic, agency and scientific origins, Salt2000 became a magnificent milestone in the progress to protect humankind against the devastation of iodine deficiency. Engagement by chief salt executive officers was public testimony of the way in which leading salt industries now have embraced the global elimination goal by accepting ownership in applying the USI strategy.

Taking advantage of the participation at Salt2000 by so many Partnership leaders, the Salt2000 Chairman, Mr Floris A. Bierman, and the MI Executive Director, Mr M.G. Venkatesh Mannar jointly hosted a Roundtable to explore a policy and mechanism for further collaboration in the sustained elimination of iodine deficiency. Members at the Table included CEO's of salt industry, high-level officials of UNICEF, World Bank and WHO, executive leaders of civic and scientific groups such as Kiwanis International, ICCIDD and PAMM, directors of major iodine industries in the world, and senior bilateral agency officers. 

The purpose of the Roundtable is to explore a common policy and a mechanism for further collaborative work to achieve and sustain the global goal. Participants were encouraged from the results already achieved and cited by the Chair: Application of USI provides access to iodized salt in 70% households worldwide; Investments in USI have reached over US$1.5billion; The impact of improved iodine nutrition on the learning capacity of children is estimated at 750-800 million additional IQ points each year. 

History has demonstrated that iodine deficiency can easily recur. Leaders at the Table should not let this happen. Salt iodization must remain the norm for all producers, and consumption of iodized salt must remain the established habit of all consumers. Guiding principles for the discussion therefore are:
. The national capacity to maintain USI policy should continuously be strengthened; 
. Elements of such national capacities include, but are not limited to: 
- Continued improvements of consumer education; 
- Constant renewal of policy advocacy; 
- Adequate resources and a transparent mandate for salt industry to continue iodized salt supplies; 
- National monitoring of iodized salt deliveries as well as impact on population iodine status. 
. To assist the national capacities, a global support system should watch over trends in salt production and trade (including international standards and regulations), and over national progress to USI and ID elimination. The system should facilitate responses to special situations where national progress is seen to stall or slide; 
. Education (via schools, health centers, retail outlets, etc) should constantly and consistently reinforce the understanding that salt iodization is necessary and forever; and finally, 
. We need better understand our respective roles and contributions, and continue our partnership work. 

Responses on the First Theme:
Accelerate and consolidate USI in countries 

William Johnston (Morton Salt): Morton's experience with iodization in North America dates back as far as the early 1920s. By the mid 1950s, IDD had disappeared from the USA. From 1995, Morton Salt has an ongoing partnership with Kiwanis International, in support of the Worldwide Service Project to combat iodine deficiency. Morton's business interests now also extend into Europe and Africa. For the future, the following three main areas need attention: (a) Consumer education, (b) Government support and (c) Local producer training support. 

Walter Becky (Morton Salt): In terms of consumer education, in societies without a mandatory law, the demand for iodized salt by consumers is as important as the supply push by producers. Creation of such a demand, however, takes many years. There now is need for more work on a recognized symbol or logo to identify adequate products. In the USA, slippage has occurred in iodine nutrition, which argues for action to intensify education especially of younger consumers. 

Gerard Dumonteil (Salins du Midi et de l'Est): As to government support, we also see a reduction in iodized salt penetration in Western countries. For instance in France, the belief is taking hold that foods should be natural while iodine is being perceived as a questionable additive. In addition, to cut on costs, mass merchants increasingly obtain cheaper, non-iodized salt for their supplies to food processors. The result in France has been slippage in the penetration of iodized salt from 60 to 40% in only four years, an enormous change with significant consequences for the population. We would like to jointly discuss and tackle the situation with the medical scientists and government to arrive at a constructive common policy agenda. In terms of local producer training, our company is active in Africa in Senegal and Madagascar. Together with Kiwanis we are involved in these countries in actions to improve the delivery by smaller producers of better, more conveniently packaged products, to ensure universal access of consumers to good quality iodized salt. We do this because the greater goal of ID elimination is more important than competition against other producers in the markets of countries where there is iodine deficiency.

Jan van Ingen (ESPA): Similarly as in North America, Europe realized the importance of iodine early. Like in the USA, we now see risks that earlier gains are being lost. Much of this has to do with consumer education. European producers have the technical ability to improve on actions to educate the consumers, for instance on the use of iodized salt for successful pregnancy. We realize that the promotion of iodized salt must be done carefully, and aim at increasing the share of consumption, rather than its actual amount. Western European producers are ready to help colleagues in other countries in training and technical skills. 

Floris Bierman (Akzo Nobel): From experience in The Netherlands, we have realized that it also is important to be well informed of changing food habits. Salt used by bread bakeries in our country has been iodized since the 1950s. Due to the decreased overall consumption of bread particularly by adolescent girls, we now have started to allow iodized salt in bread-replacing foods such as pastas and crackers. The knowledge of changes in food habits is important for our educational efforts, and for keeping national policy current. 

Carol Bellamy (UNICEF): The global achievement is extraordinary: 70% of the children in the world are being protected against brain damage through iodized salt in their nutrition. The challenge before us, of course, is to reach universal and also protect the remaining 30% of babies born, and this could be more difficult than reaching the 70% we have reached already. UNICEF wishes to particularly recognize the partnership that made this work. We wish to see this success as a means to re-ignite or accelerate actions by governments and the private sector in countries where ID continues to be a threat. The 10-year UN review of the accomplishments from the 1990 World Summit on Children will provide for such an opportunity. 

UNICEF will continue supporting national actions to eliminate iodine deficiency, as a partner among all the entities. UNICEF will continue giving support for monitoring of progress in countries and prevent reversal. Sustaining the success in countries is part of UNICEF's agenda for the future. Also, UNICEF wishes to see the global partners also challenge industrialized countries to report on their iodine nutrition.

Nettles Brown (Kiwanis International): Kiwanis members have transferred more than US$ 29 million to fund USI projects in more than 75 countries. Kiwanis with their influence and connections will continue to support the creation of consumer demand, the renewal of political commitment and the establishment of national alliances for oversight and public reporting of the state of human iodine nutrition. Kiwanis will continue to raise money and raise their voices in support of achieving the goal and sustaining it. 

Graeme Clugston (World Health Organization): WHO since many years is committed to seeing the sustainable elimination of IDD. WHO collaborates closely with UNICEF and ICCIDD, NGOs and other partners, and Member States. A key mechanism for WHO is the World Health Assembly and its regular reporting function through the Ministries of Health. Progress towards the global elimination of IDD has been reported 2-3 yearly, and the most recent report dates from 1999. Resolutions on basis of these reports are a key instrument to urge governments and member states toward more action and mobilize agency support. For WHO, the global elimination of IDD is as important as the global victory over smallpox and soon, the eradication of polio. 

WHO sees several key issues. First, reach the un-reached: In 15 countries with an IDD problem, there are no programs in place yet and in another 15, action needs to be improved because the problem isn't being adequately addressed. Second, monitoring must be strengthened as the key element that underpins the other actions in all countries. This should include an assessment of population iodine status as the only way to see if the elimination effort is successful, connected to iodized salt monitoring to ensure that iodine levels are safe and adequate. Monitoring systems in countries need to feed into reporting globally, regionally and to countries. Advocacy needs to be an ongoing effort: To governments, industry, NGOs, international agencies, and the public. The infrastructure in countries will need continued support, including the capacity for planning and evaluation, for laboratory analyses, for legislation, and for national surveys at regular intervals.

WHO is pleased to play its full part in the global efforts with UNICEF, ICCIDD, MI, Kiwanis, PAMM and the salt industry. The success of this global partnership will help reinforce WHO's normative and standards setting role in support of member states. WHO hopes for substantial progress to be reported next by 2005 to the World Health Assembly. 

Responses on the Second Theme:
Continue the partnership to support sustained national capacity

Zhihua Dong (China National Salt Corporation): The Government of China accords great importance to IDD control, through universal supply of iodized salt from an agreed-upon national salt monopoly. From the efforts of CNSC in the national salt iodization project, we report almost 90% coverage in China with iodized salt. China is ready to tackle the issues of sustainability, including the education of consumers via schools and health centers. CNSC will make special efforts through its 750,000 outlets all over the country to reach the large population. The CNSC will continuously work to improve its management of production and delivery of the product, and its education of its customers.

R. Prakash (Salt Commissioner, India): Based on long-standing government commitment to salt iodization, India has continued to make progress toward elimination of iodine deficiency. Many support actions have been helpful, including direct support for small salt producers, regular and widespread holding of partnership meetings, and production and dissemination of advertising and promotional materials. Iodized salt now reaches almost 80% of the population, and the government is anxious to bridge the gap to universal. For many producers, consistent access to potassium iodate at a reasonable price is problematic, and India is looking for support to solve this. In the national strategy, a "mission approach" at State level was found most effective and many states are emulating successful examples from others. A remaining challenge is to reach some 8,000 small producers to iodize edible salt, but India hopes to be successful in a few years. 

Basil Hetzel (International Council for Control of Iodine Deficiency Disorders): Salt2000 comes at a significant moment in time and this certainly is a great moment for ICCIDD. The term IDD was introduced in 1983 following a successful intervention study in Papua New Guinea in the 1960s. It is incredibly satisfying to see the fate of this new concept, which replaced the old term goiter. Goiter didn't figure in any priority of agencies because it did not convey the importance of iodine for brain development. 

ICCIDD became established in 1985 in an inter-country meeting organized by UNICEF and WHO. It is a multi-disciplinary network with over 500 members from 94 countries, recognized as the expert group on all aspects of IDD. ICCIDD is concerned about sustainability and sees program monitoring, especially of urinary iodine excretions, as critical. This technique allows for an assessment of the problem of deficient as well as excessive iodine intakes. We now find that up to 25% of the populations in a number of countries are getting too much iodine, and this imposes risk of iodine-induced hyperthyroidism in the iodine-deficient population. Monitoring of iodine excretion, therefore, needs to complement monitoring of salt iodine. ICCIDD has worked closely with UNICEF and WHO since 1985. A recent example is the joint report in 1999 on the remarkable progress achieved globally. Further reports are required on a 2-yearly basis to inform the present global partnership. As in the past, ICCIDD will be glad to continue collaborating with UNICEF and WHO, in consultation with the salt industry and Kiwanis, MI, PAMM, NGOs and bilateral agencies. The near opportunity of global IDD elimination is tantalizing. We cannot escape the need for monitoring iodine intake through urine analysis of schoolchildren and pregnant women, however. ICCIDD is available to assist as advisors and assure sustainability. 

Milla McLachlan (World Bank): Our analysis of World Bank supported programs in China, Indonesia and Madagascar confirms the importance of a strong legislative infrastructure and of monitoring, including self-regulation by the industry. In addition, education needs to occur to stimulate consumer demand. The Bank continues its interest to work with partners in areas where IDD still is a major public health problem, particularly the Central Asian Republics where the situation calls for a special partnership arrangement and quick action. We would also like to play our part in larger scale testing of salt fortified with iodine and iron. The Bank is awareof, and salutes the efforts of the partnership organizations in the global achievements, and it will continue its ongoing sponsorships for MI and ICCIDD. The Bank feels it critically important that the role of organized industry in achieving the elimination of IDD should be strengthened. 

Carol Bellamy (UNICEF): The role of the salt industry indeed is key, not only in the production and supplies of good quality salt everywhere, but also in the ways to keep and grow the markets in amounts and quality. From this Roundtable discussion, UNICEF hopes that we could form a small group to explore how we could build some efficient way of monitoring the progress towards bridging the 30% gap, and towards a situation of sustained national elimination. 

Glen Maberly (Program Against Micronutrient Malnutrition): From the speeches by leaders and the artistic performances in the Opening Ceremony this morning, all of us must be moved. What remains to be tackled is of course the protection of an additional 20 million babies each year who now are born in areas quite seriously deficient, plus another 20 million babies in the developed world who are born in situations that we need to watch very carefully. What the small group proposed just now should attack is the need that alliances such as the one around this Table should be strengthened nationally to oversee progress. In the past, such national alliances have been dominated somewhat by the scientists or the public sector, and they need to be transformed to a national watch from balanced inclusion of others. Second, there is the need for a salt production and trade watch. From experience in, for instance, the Philippines we know that sometimes populations are swamped from outside by shipments of salt that enter markets without proper oversight. And thirdly, we need to build a responsive network to deal with national identification, communications and other issues as they arise. A responsive network should be put in place with a strong enough leadership role of the salt industry. From this Roundtable meeting and the ensuing work of the small group, a focal point could emerge that can draw upon, and be representative of all partners.

Final remarks

Venkatesh Mannar (Micronutrient Initiative): MI offers its support for getting a small group together to work on a plan outline for the future. We will be in touch with partners for people to work in the small group, and we could then discuss how the group might move forward. 

Floris Bierman (Salt2000 Foundation): On behalf of my colleagues, we certainly wish to continue collaborating with all partners at the Table. We understand the needs for a national watch and a production/trade watch, and a response mechanism. We have discussed this among ourselves and we will have a person from Europe and of our American colleagues join the small group.

In conclusion, it is good to look back and be encouraged by the great achievements. It is essential to also look at the future, however, and recognize priority for consumer education, government support and local producer training. The small group needs to take these into account for action and progress towards the ultimate ideal of sustained IDD elimination through universal salt iodization. We, from salt industry, will certainly participate. 

June 15, 2000