|The Prevention and Control of Iodine Deficiency Disorders - Nutrition policy discussion paper No. 3 (UNSSCN, 1988, 130 p.)|
|6. RECENT IODIZATION PROGRAMMES|
Schaefer (1974) provided a useful review of salt iodization programmes in Central and South America. By 1973 salt iodization legislation had been enacted in 16 of the 17 Central and South American countries in which iodine deficiency was recognized as a public health problem. He noted, however, the long delay between passage of the legislation and the actual installation of equipment and implementation of the law. Only in Guatemala was legislation followed by immediate implementation of a programme, and in this instance there were commercial factors involved in the possible threat to a national monopoly from suppliers outside Guatemala.
Nicaragua, with an overall goitre prevalence of 32 percent, had not up to 1973 passed legislation. Implementation of laws on salt iodization is still inadequate in Bolivia, Peru and Ecuador where endemic cretinism and a high incidence of endemic goitre are still evident. At the time of Schaefer's survey only a small part of Bolivia's salt supply, 25 percent of Peru's and 75 percent of Ecuador's were iodized.
In response to a questionnaire on the lack of effective implementation, the reasons given were found by Schaefer to be remarkably similar. They included the following.
1. The people, and especially the politicians, were unaware of the severity and magnitude of the IDD problem and their detrimental effects on health, especially in regard to the sequelae of cretinism, deaf-mutism, and other serious neurological defects. There was a failure to inform the public about the seriousness of the problem and its simple solution.
2. The most seriously affected populations usually lived in isolated rural areas where the level of social and economic development was very low. This meant that the problem carried little if any political weight.
3. The traditional system of salt production was not conducive to control, and governments did not provide adequate incentives to the small salt producer.
4. The national salt commissions and government health departments did not enforce the law. Common reasons were the lack of public-health personnel for control activities (although most control procedures do not in fact require technical personnel trained in public health) and heavy work loads.
5. There was a lack of cooperation between the industry and the public health officials or government enforcing agencies.
6. The price of iodized salt had increased by approximately 40-60 percent in some countries (but with simplified enrichment plants, the extra manufacturing cost per kilo of iodized salt was still infinitesimal).
7. The large number of salt-producing plants makes control difficult. This affects mainly Brazil, with nearly 190 plants, and El Salvador, with 37.
The 1973 Guaraja meeting of the Pan American Health Organization (PAHO) was devoted largely to a review of iodization programmes. In the discussion, the problems of cost, of awareness of the medical profession about prevention, and the need for pressure groups were all brought out. The issues raised were the social processes that influence change in health programmes.
The persistence of a high incidence of goitre and cretinism in Peru, Ecuador and Bolivia, caused by problems in implementing salt iodization programmes, led to reappraisal of the strategy. Successful demonstration of the value of iodized oil in the control of iodine deficiency and the prevention of goitre and cretinism in New Guinea (Mc Cullagh, 1963; Hennessy, 1964; Pharoah et al., 1971) suggested an investigation of the use of this alternative measure in a pilot study in several rural communities in Peru and Ecuador.
After two years, the feasibility and effectiveness of these programmes were shown by a sharp reduction in the incidence of goitre and the absence of cretinism among the children of the population injected with iodized oil, although both conditions occurred in the control group. It was concluded that iodized oil was a suitable public-health procedure in South America where salt iodization programmes could not be undertaken; and that the combination of salt iodization and iodized oil injection could provide an effective iodization programme for any region in South or Central America.
There is now an encouraging report (Arraya, 1986) of an iodized oil programme in 174 localities in Bolivia in 1985, when 99 834 people with a goitre prevalence of 69 percent were injected. As a number of communities were remote and difficult to reach, other public health measures including vaccination were administered. The impact of the programme is being evaluated in these communities, and it is planned to continue its activities in the areas not yet reached.