April 2023


How progress can silently slip away

The crisis in Sudan has led us to reflect on the ephemeral nature of progress.  A couple of months ago, the country was on the verge of improving iodine nutrition for its population; a new national law mandating iodization of salt needed only one final signature, plans to strengthen quality control were drafted, and engagement with salt industry was underway. Now it’s understandably the furthest thing from people’s minds.

While the situation in Sudan is an extreme example, similar situations existed or continue to exist in several other countries, impacting overall health and nutrition, including iodine nutrition. And while deficient iodine intake is not an immediately visible threat to health, it ’s a serious one.  Iodine deficiency during pregnancy can lead to lifelong damage, especially to the child’s developing brain.  So if a national salt iodization program falters, even just for a year, the consequences can be profound and long lasting.

Even in stable and economically satisfactory settings, nowadays, if you ask almost anyone about eliminating iodine deficiency, they likely won’t know anything about it, even though it’s one of the greatest public health successes.

It was an achievement that came about through a series of steps: Gathering scientific evidence; adoption of World Health Assembly resolutions; UNICEF’s setting an ambitious goal at the 1990 World Summit for Children, and donor support (including the Canadian, Dutch and US governments, and the Bill & Melinda Gates Foundation). At its heart was a powerful partnership involving UNICEF, WHO, governments, the salt industry, civil society (most notably Kiwanis International), IGN and other NGOs  (the Global Alliance for Improved Nutrition, Nutrition International) and donors.

But recently, WHO noted that by 2020, 21 countries were iodine deficient, and expressed concern about the status of vulnerable groups such as pregnant women.  Unlike polio and smallpox, iodine deficiency cannot be eradicated, but must be kept at bay through the perpetual salt iodization. Knowledge about the importance of iodized salt has slipped away. Policymakers and the public no longer understand its benefits, impacting demand, program implementation and performance. Diets are changing, with more reliance on processed foods that may not use iodized salt.  There is unnecessary confusion around the issue of reducing salt intake for other health reasons.

Even in countries where national status is adequate on average, significant population segments may face deficiency.  Monitoring systems in many countries are slipping, and financial resources to support programs have faded in the face of other challenges such as rising non-communicable diseases, but also larger societal problems such as instability, climate change, economic hardship, COVID-19 – and conflict, as we see in Sudan, Ukraine, and many other places.

It is difficult to address all these challenges, but in the midst of it, we must understand the need to perpetuate this technically simple and cheap intervention of adding iodine to salt.  We need to keep our attention on the possibility that this global problem of the past can quickly re-emerge. It’s crucial that governments include sustained adequate iodine nutrition as part of their national nutrition policies and broader fortification efforts, and that the salt industry continues its work to add iodine to salt, and that we explore new opportunities to reach everyone with adequate iodine nutrition.  Otherwise, we face the danger that this amazing achievement could silently fade away.