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Can Africa meet the goal of eliminating iodine-deficiency disorders by the year 2000?
Festo P. Kavishe
The story of the control of iodine-deficiency disorders in Africa is one of success and provides the best example of how Africa can make rapid progress in the area of health and nutrition. It shows that Africa is moving rapidly towards the elimination of iodine-deficiency disorders by the year 2000 largely because of the availability of affordable, cost-effective technology and an unprecedented alliance among governments, the private sector, and international agencies. Following the impetus created by the 7987 regional meeting sponsored by WHO/UNICEF/International Council for the Control of Iodine-Deficiency Disorders (ICCIDD) and attended by 22 countries, and particularly after the 1990 World Summit for Children and the 1992 International Conference on Nutrition in which the elimination of iodine-deficiency disorders by the year 2000 was adopted as a feasible goal, progress towards universal salt iodation in Africa has been spectacular. By the end of 1995, there were iodine-deficiency disorder control programmes, using iodated salt as the long-term strategy, in almost all of the 50 countries in Africa where WHO estimates that iodine-deficiency disorder is a problem of public health significance. As of February 1996, it was estimated that more than 50% of the salt consumed in Africa was iodated, and that if the present efforts towards provision of iodation machinery and regulatory mechanisms are carried out to their logical conclusion, the mid-decade goal of universal salt iodation might be achieved by the end of 1996. The elimination of iodine-deficiency disorders in Africa may be a reality by the beginning of the next millennium. Major challenges to complete and sustained universal salt iodation still remain and require sustained advocacy, resource mobilization and monitoring, and evaluation.
Although Africa ranks third among regions of the world most affected by iodine-deficiency disorders, after the Western Pacific and South-East Asia, the toll of iodine-deficiency disorders in Africa is enormous. The estimated population at risk is 220 million, of whom 95 million are goitrous [1]. Each year about 3 million at-risk women become pregnant, resulting in about 15,000 foetal deaths, the birth of 30,000 cretins, and about 1 million brain-damaged children. Thanks to a combination of efforts over the last decade, the "iceberg" of iodine-deficiency disorders in Africa is now melting. As advocated by the 1990 World Summit for Children, the 1992 International Conference on the Assistance to the African Child (ICAAC), and the 1992 Global Plan of Action of the International Conference on Nutrition (ICN), the establishment of universal salt iodation programmes has been by far the leading approach, although in some countries targeted iodinated oil and iodination of water have been used as short-term stopgap measures.
Measuring success of iodine-deficiency disorder programmes
How do we measure success in nutrition programmes? By what criteria can we say that the iodine-deficiency disorder programmes in Africa are moving towards success? Success can be judged by three criteria.
The first criterion is the achievement of objectives in terms of both process (universal salt iodation) and outcome or impact (elimination of iodine-deficiency disorders). The major indicator of process is the proportion of salt that is iodated and consumed, as measured, for example, by the proportion of households consuming iodated salt or by the median urinary iodine excretion in a population. The indicators for outcome or impact show a reduction in the signs of iodine deficiency, such as reduced prevalence of goitre, improved function of the thyroid gland, or improved intelligence and hence improved educability of children.
The second criterion of success is the possibility of sustainability in technical and financial terms and especially in awareness through the triple-A cycle process of assessment, analysis, and action. This will require advocacy.
The third criterion of success is the establishment of complementary externalities, such as building up confidence and capacity to tackle other nutrition issues or improving the productivity of communities.
With varying speed, the iodine-deficiency disorder programmes in Africa are moving towards success as judged by all three criteria.
Status of salt iodation programmes in Africa as of February 1996
The 50 countries in Africa believed to have an iodine-deficiency disorder problem of public health significance can be divided into three groups according to the source of their salt. The largest group consists of 30 countries that import most of their salt. These countries can rapidly achieve universal salt iodation through regulation, as demonstrated by Burundi, Cameroon, and Nigeria. The second group contains 7 countries that obtain their salt from large refineries. The last group consists of 13 countries that have many small producers and that may have large refineries as well. The iodation of salt in the last two groups of countries benefits both these countries and the countries that import their salt. Table 1 gives the status of salt iodation programmes in the three groups of countries based on the latest available information from UNICEF Field Offices and iodine-deficiency disorder programme managers [2, 3].
TABLE 1. Status of salt iodation in countries in Africa believed to have an iodine-deficiency disorder problem according to source of salt as of February 1996
| Source of salt | % of salt iodated |
| Most salt imported | |
| Benin | 0 |
| Burkina Faso | ND |
| Burundi | 80 |
| Cameroon | 100 |
| Central African Republic | 20 |
| Chad | ND |
| Comoros | ND |
| Congo | ND |
| Cole d'Ivoire | ND |
| Equatorial Guinea | ND |
| Ethiopia | 80 |
| Gabon | ND |
| Gambia | ND |
| Guinea | ND |
| Guinea-Bissau | ND |
| Lesotho | 40 |
| Liberia | ND |
| Malawi | 40 |
| Mali | ND |
| Niger | 1 |
| Nigeria | 96 |
| Rwanda | 50 |
| São Tome and Principe | ND |
| Sierra Leone | 43 |
| Swaziland | 40 |
| Togo | ND |
| Uganda | 50 |
| Zaire | 50 |
| Zambia | 90 |
| Zimbabwe | 90 |
| Large refineries | |
| Algeria | 80 |
| Botswana | 90 |
| Egypt | 1 |
| Eritrea | 75 |
| Kenya | 98 |
| Namibia | 40 |
| South Africa | 40 |
| Many small refineries | |
| Angola | ND |
| Ghana | 15 |
| Libya | 90 |
| Madagascar | 80 |
| Mauritania | 100 |
| Morocco | ND |
| Mozambique | 40 |
| Senegal | ND |
| Somalia | 0 |
| Sudan | ND |
| Tanzania | 90 |
| Tunisia | ND |
| Yemen | 41 |
Source: ref. 2 and personal communication with UNICEF field offices. ND = No data available.
Three observations can be made from this table. First, countries in Eastern, Southern, and North Africa have made greater strides in iodizing their salt than countries in West Africa. This may be because of greater early awareness and regional strategies adopted in these countries. Second, there is a greater gap in information regarding the proportion of salt that is iodated in the salt-importing countries than in the other countries. Again the gap is mainly noticed in West Africa. Third, with the exception of Egypt, the seven countries with large refineries have progressed well towards achieving universal salt iodation, defined in this article as at least 80% iodation.
With the exception of Congo, Liberia, Mali, Niger, Togo, and Somalia, all other countries either have a salt iodation regulation or are in the process of developing one. The countries that have a law in effect are Burundi, Cameroon, Malawi, Nigeria, Rwanda, Zaire, Zambia, Zimbabwe, Kenya, Namibia, South Africa, Angola, Madagascar, and Tanzania. Most of the legal framework is in the form of regulations within the food and drug quality control laws. The impetus created by salt iodation programmes in Africa has in fact pressured some countries without food and drug quality laws, such as Ethiopia and Namibia, to start developing them. Some other countries, like South Africa, have had to revise theirs. Varying levels of iodine (40 100 ppm) have been included in the regulations. A major weakness in the salt regulations in Africa is that the ability to enforce them is low. However, compliance with the regulations has depended more on advocacy and the potential for legal action than on enforcement.
Has progress in salt iodation in Africa made any difference to the iodine-deficiency disorder situation?
Although extensive data are not available due to the weak monitoring systems, country-specific studies show that there has been some improvement in the situation according to both process and impact indicators.
Indicators of process
Two major indicators are pertinent here. One is the several-fold increase in the proportion of salt in Africa that is iodated, as shown by the number of countries presently iodating (table 1), compared with only two a decade ago. The second is evidence of consumption of the iodated salt, as measured both by the proportion of households consuming the salt and increased iodine urinary excretion. For example, studies in Tanzania indicate that after iodation machinery was installed in 1992 and legislation for iodation of salt was enacted in 1993, the proportion of households consuming iodated salt in the highly endemic areas steadily rose from zero before the programme to over 90% in some areas. In Kericho District, Kenya, the median urinary iodine excretion rose from a baseline of 15 g per 24 hours in 1972, when the first law to iodate salt was passed, to 90 g per 24 hours in 1994.
Impact indicators
In Kenya the prevalence of goitre in three districts (see FIG. 1. Trends in the prevalence of goitre in three districts of Kenya, 1964 1994. From ref. 4) declined rapidly after the introduction of legislation for the iodation of salt, confirming its impact on the reduction of goitre rates along with an increase in median urinary iodine excretion (see FIG. 2. Trends in the prevalence of goitre and in urinary iodine excretion (UIE) in Kericho District, Kenya, 1964-1994. From ref. 5). Similar examples are available in Cameroon, Tanzania, and Zambia. Preliminary results of a recent WHO/UNICEF/ICCIDD multicentre study in Nigeria, Cameroon, Zaire, Kenya, Tanzania, Zambia, Zimbabwe, and Botswana show that, indeed, the salt iodation programmes in these countries have had a major impact on both goitre prevalence and urinary iodine excretion.
Another example of impact is the effect of iodine supplementation on the intelligence of children in Malawi. This effect is comparable to that shown by meta-analysis of 18 iodine supplementation studies done outside Africa (see FIG. 3. Effects of iodine supplementation on the intelligence of children. From refs. 6 and 7). The potential to improve the intelligence of children through iodine supplementation has been a major advocacy tool to secure political commitment and mobilization of resources [8].
Factors responsible for progress in salt iodation programmes in Africa
International and national commitment
International and national commitment has been expressed in a number of forums and documents, especially the World Health Assembly (WHA) resolutions, the World Summit for Children (WSC), the International Conference on Assistance to the African Child (ICAAC), the International Conference on Nutrition (ICN), Better Health for Africa, and the African Regional Nutrition Strategy. This commitment has also been incorporated into the national programmes and plans of action emanating from the global initiatives.
Unprecedented interagency, public, and private sector collaboration
The use of iodated salt to combat iodine-deficiency disorders on a long-term basis seems to have struck a consensus chord in all agencies and sectors of government. As a result, intersectoral and interagency collaboration has been excellent. UNICEF has been the major supplier of the iodation machinery, with technical, advocacy, and resource involvement of other UN agencies, such as WHO, the World Bank, ACC/Subcommittee on Nutrition (SCN), United Nations Development Programme (UNDP), UNU. FAO, and World Food Programme (WFP). Other agencies involved include the Micronutrient Initiative (MI), Programme Against Micronutrient Malnutrition (PAMM), and USAID/Opportunities for Micronutrient Interventions (OMNI). Bilaterals. particularly the Swedish International Development Authority (SIDA) and the Canadian International Development Agency (CIDA), have been supportive, as have governments, particularly those of Canada, the Netherlands, Italy, and Sweden. The major stimulator of action and interagency collaboration has been the International Council for the Control of iodine-Deficiency Disorders (ICCIDD), a non-governmental organization established in 1985 solely dedicated to the global elimination of iodine-deficiency disorders.
A unique feature of the management of iodine-deficiency disorder programmes in Africa was the formation by ICCIDD of the African IDD Control Task Force in 1987 and the promotion of multisectoral National Councils for the Control of iodine-Deficiency Disorders (NCCIDDs), which have greatly facilitated interagency collaboration and in many countries are living models for the control of micronutrient deficiencies in general. There has also been a strong collaboration between the public and private sectors that is unprecedented in public health intervention in Africa.
Intensive capacity-building
In all regions and in most countries of Africa, training and advocacy workshops, seminars, and meetings have been held. In addition, a series of consultancies initiated by ICCIDD has resulted in a better understanding of the iodine-deficiency disorder situation and built up national human resource capacity.
Strong networking
Through the efforts of ICCIDD, a distinct network of individuals, consultants, and institutions interested in the elimination of iodine-deficiency disorders has been formed. This programme-driven network effectively links up issues of research, training, and programmes. Although international databases have developed as a result of this networking, a major challenge is to encourage African countries to access these databases.
Major challenges in salt iodation programmes
The major challenge now is to build on the success achieved so far and provide that final push in every country through both public and private sectors to achieve and maintain universal salt iodation. The challenges may be grouped into three categories.
Completing the unfinished business
To complete the iodation of all salt for human and animal consumption, we must ensure that all salt-producing countries, including those exporting to Africa, iodate their salt. We must also ensure that all countries where iodine-deficiency disorder is a problem of public health significance enact and enforce salt iodation regulations.
Accelerating the momentum
The success in intersectoral and interagency collaboration, networking, and capacity-building needs to be maintained. Strong advocacy efforts must continue to keep the iodine-deficiency disorder agenda active and ensure continued political commitment and resource allocation.
Monitoring, evaluation, and verification
Monitoring should be at the factory as well as the retail level. Monitoring for compliance is very important, since excessive levels could cause thyrotoxicosis and inadequate levels would be ineffective. After a decade of implementing a process to eliminate iodine-deficiency disorders, the time has come to demonstrate that the efforts and resources used have indeed had an impact. Although some examples are given in this article, there is a need to strengthen the monitoring, evaluation, and verification mechanisms to show impact on a larger scale. For example, in 1995 Cameroon requested international verification of the elimination of iodine-deficiency disorders, and the preliminary results of the recent WHO/UNICEF/ICCIDD multicentre study verified that iodine-deficiency disorders are about to be eliminated in Cameroon. If more countries strengthen their monitoring mechanisms, verification of elimination should be possible.
Both process and impact need to be monitored. For process monitoring, the use of the iodated salt field test kits would play a crucial role. It should be stressed here that when the field test kits are purchased, two or three recheck solutions should be requested for every 10 test solutions ordered. It should also be clearly stated that the kits are to be used to test for iodate. The acidic recheck solution is needed to neutralize the alkalinity of most salt produced in Africa in order to give a colour change. The alkalinity is due to naturally present carbonates or magnesium or to free flow agents that are added to fine salt.
Sustaining elimination beyond the year 2000
The year 2000 is only four years away. While present efforts should continue to be directed towards achieving the elimination goal, plans should be begun to sustain the elimination beyond the year 2000. The year 2000 is too close to continue to be the magic cut-off year adopted by WHO in the 1978 Alma Ata Declaration on Health for Ail.
This analysis may seem too idealistic to be true, especially when viewed against Africa's deteriorating trend of protein-energy malnutrition. The author has taken the perspective of a half-full rather than a half-empty glass. Certainly, there is evidence that the glass is filling up. How fast this will happen will depend on continued advocacy and allocation of resources. When something is working, there is a tendency to assume sustainability or to try to look for faults to mend instead of reinforcing the successes. This is precisely the moment to increase efforts to enhance the system for the elimination of iodine-deficiency disorders to achieve sustained elimination. The effort must not be fatigued by success.
