For a Few Pennies More

Salt Fortification with Iodine

Television transcript

By: Television Trust for the Environment

Date: 2004

Source: Television Trust for the Environment. "For a Few Pennies More." Lifeonline, 〈http://www.tve.org/life-online/index.cfm?aid=1127〉 (accessed November 4, 2005).

About the Author: Television Trust for the Environment (TVE) in an independent non-profit organization dedicated to raising global awareness of the environment, development, human rights, and health issues through television broadcasts. TVE was set up in 1984 with the support of the Worldwide Fund for Nature, the United Nations Environment Program, and Central TV.

INTRODUCTION

In the 1980s, Kodyat B. Djokomoelyanto, an Indonesian physician and hormone expert, investigated the problem of iodine deficiency among the people living on the slopes of Mount Merapi, one of the region's most active volcanoes. It is not uncommon for the soil in volcanic areas to be deficient in iodine, which may have serious implications for the health of those living there. Djokomoelyanto found cretinism, a condition marked by bulging eyes, a low hairline, and stunted growth, among many individuals here and treated them with iodine-infused oil. This program looks at one of his patients, Kahmidi, who went on to marry and have two healthy children after his treatment.

Djokomoelyanto's work highlighted the problem of iodine deficiency and the solution. But it is easier to supplement salt with iodine than to give individuals iodine treatment. The program "For a Few Pennies More" reveals that the iodized salt program is not being properly put into practice in the Mount Merapi area. Researchers looked at families where the children had goiter, a swelling of the thyroid gland that is a hallmark of iodine deficiency. When the salt they used was analyzed, it had had little or no iodine in it. The salt producers, although obliged to add iodine by law, were cutting costs by leaving it out. This was a false economy, since the World Bank shows that lack of nutrients, such as iodine, can lead to a drop in gross domestic product of up to 5 percent. People lacking iodine miss out not just on work productivity, but on quality of life. The program highlights the need to enforce the iodized salt legislation at a national and local level, for the sake of the health and happiness of the people.

PRIMARY SOURCE

COMMENTATOR: Mount Merapi on the island of Java … Merapi is Indonesia's most active—and dangerous—volcano. But despite the danger, the slopes below Merapi are intensively farmed. Java's volcanoes have created some of the most fertile agricultural land on earth. With 120 million people, Java is the world's most densely populated island. Yet it's self-sufficient in food—the fertile soil allows farmers two to three harvests a year with little or no need for fertilizer. But in spite of this natural abundance, there's a vital ingredient missing from Java's soil. It's only needed in minute quantities—but for millions of Indonesians it can mean the difference between health and happiness or a life-time of handicap and misery….

Dwi Asnawan is three years old. But he cannot yet walk or talk. He's sick because he's not getting enough iodine in his food. Iodine is a trace element usually present in tiny amounts in soil and water. Because it's missing from his parents' land, his food is also missing it. This morning two other children suspected of having the same problem have come to this clinic—which specializes in iodine deficiency disorders. Dr Untung is director of the clinic.

DR UNTUNG (translation): Iodine deficiency kills children. The most serious damage happens in the womb and in the first three months of life. Without iodine, children suffer from a range of illnesses we call Iodine Deficiency Disorders—or IDD. There may be 3 million children here with IDD, and we don't have the money to do expensive lab tests, so we have to rely on visual observations like this….

COMM: Dwi's mother Mahmuda has had a swelling on her throat since her early teens. It's a strong sign of lack of iodine. Iodine is needed by the thyroid gland—normally invisible—to make hormones needed to control vital bodily functions. When there's not enough it has to work harder and expands, producing this tell-tale swelling, known as goitre. So it's no surprise that her child is also unwell. All three mothers have come from the village of Sengi at the foot of Mt. Merapi. While goitre's the best known sign of iodine deficiency, the most serious damage goes unseen. It takes place in the months before and after birth. Damage done at this stage of a child's development is irreversible. In areas where iodine deficiency is endemic a high proportion of babies are born seriously underweight. And there are many stillbirths. Mahmuda's neighbour Sryani is about to go into labour.

SRYANI (translation): Those with goitre are generally weak and in poor health … you sometimes see people with swollen limbs … but the worse thing is when children are sick.

COMM: With three of her neighbours' children sick, Sryani feels her unborn child is at risk. An extreme effect of iodine deficiency is cretinism. Cretins suffer from severe and irreversible mental and physical retardation. They're usually very short and may be partially deaf.

DR UNTUNG WIDODO, Director of IDD Research Centre, Borobudur (translation): How old are you? Eh? How old?

OLD MAN: I'm 66.

DR UNTUNG: Do you have children?

OLD MAN: Nah.

DR UNTUNG: Are you married?

OLD MAN: No, no I'm not married.

DR UNTUNG: Don't you want to?

OLD MAN: No.

COMM: Goitre and cretinism are only the most visible sign of the far wider, more devastating impacts of iodine deficiency. IDD can seriously damage the brain, slowing mental responses and impairing intelligence levels. Even moderate IDD can lead to a drop of 10 to 20 points in the IQ performance of sufferers.

DR UNTUNG (translation): Children suffer most—they're slower and less intelligent. Then as adults they will be weaker and unable to work as well … and they'll be less productive and won't have the same quality of life. In fact it's like losing a huge part of your life, never getting the chances you should have had.

COMM: Where people lack the iodine their bodies need there are untold stories of lost opportunities in life. But for Kahmidi, who suffers from severe cretinism, life changed completely 20 years ago. A distinguished endocrinologist came to Sengi, and took a personal interest in him.

PROFESSOR DJOKOMOELYANTO: When I saw him he was so lonely under the tree. He doesn't work at all. But he was classified as an endemic cretin.

COMM: Giving iodine supplements can't reverse existing brain damage but it can revitalize sufferers.

PROFESSOR DJOKOMOELYANTO: Next year … when I came back there he was so different in appearance and he decided to marry somebody. It seems that he married a woman, a taller woman, who was also classified as an endemic cretin.

GINAH & KAHMIDI (Translation): Before I got that injection I couldn't use my brain … I couldn't understand anything.

He just couldn't use his brain.

And it wasn't only my brain I couldn't use…. I just couldn't do anything.

He couldn't do anything.

But the injection made me feel stronger. That's when I decided I wanted a wife…. It was the iodine treatment that did the trick.

COMM: Women with IDD are particularly vulnerable—and are more likely to have stillbirths, miscarry, or have low birth-weight babies with permanent brain damage or cretinism.

GINAH (translation): When we got married, I was so happy…. Now we were like everyone else…. But to be honest … I was worried that if I had a baby, I wanted it to be normal like other people's babies….

COMM: Professor Djokomoelyanto also injected Ginah with the iodised oil, to increase the chance that any children she and Kahmidi had would be normal. Soon, Ginah and Kahmidi did conceive, and to their great relief and joy, they had a son AND he was entirely normal. Their son, Rame, is now 18 and well above average intelligence. The doctor who treated his parents decided to sponsor Rame's education. Rame is the first member of his family ever to attend university. He's majoring in chemistry—for a particular reason….

RAME (translation): If I get to become a good scientist I'd like to find ways of helping people like my Dad. I hope no more generations are being born in the future having to suffer like my Dad did. When I was a kid I used to dream of discovering some kind of cure to make him normal … of course I know now that that's not possible. Since I was a kid I wished my Dad could be as tall as other kids' Dads … and think normally and talk normally with other people.

QUESTION: Was Kahmidi ever badly treated by other villagers because of his condition?

GINAH (translation): No he was always well treated and the villagers were very understanding. In fact his father loved him better than his other children because of his condition.

Because my husband can't speak properly, we've developed our own special language in the family. So if outsiders can't understand what he's trying to say, we do—even if he uses the wrong words….

RAME (Translation): Who did you say is having a baby?

GINAH: It's Syrani up the road.

RAME: Ah…. How are her tomatoes doing?

KAHMIDI: They're good!

RAME: Why don't we grow tomatoes too then?

KAHMIDI: We do…. We're growing them ourselves too!

RAME: What? Those that came in the plastic bag?

KAHMIDI: Ha ha ha!

RAME: You're having me on! You didn't grow them yourself! (laughing)

KAHMIDI: We bought them from a neighbour who needed cash. No we didn't grow them.

KAHMIDI: I want my sons to get good jobs so they can be "real" people. I'm proud of them!

COMM: Rame's family's story is vivid proof that all that's needed to end the scourge of IDD is a consistent dosage of iodine—provided it's given soon enough and in the right quantities….

COMM: Across the world, vast areas of land don't contain enough iodine—and a billion people remain at risk from IDD. Treating entire populations with regular iodine supplements—in the way that Kahmidi and Ginah were—is impractical. A simpler option is to fortify salt with small amounts of iodine. Salt is an ideal carrier because everyone needs it in fairly constant daily doses. In conjunction with many governments UNICEF has long advocated the universal iodisation of salt. In Indonesia, salt producers are legally obliged to add iodine to salt. This salt factory on Java's northern coastline is typical of Indonesia's many salt producers, adding the specified amount of iodine. It's added through a dispensing nozzle before being thoroughly mixed in. But, if, officially, most of the salt in Indonesia is already being iodised, why are so many people still suffering from IDD?

       Part 2

DR UNTUNG: Hello Mahmuda!

MAHMUDA: Hello.

DR UNTUNG: Can we go inside?

MAHMUDA: Yes please come in.

DR UNTUNG: He's not still crying is he? I'd like to take a look at the salt you're using.

MAHMUDA: Sorry about the mess in here.

DR. UNTUNG (Sync): Let's take a look at this salt then…. If the salt is good, it will turn deep blue. Just look at this … this is not good at all. It has absolutely no iodine in it. It says on the pack that it's iodised—but it's not! You're being cheated!…

COMM: … The successful experience of many other countries confirms that iodising salt is by far the most effective way to combat IDD—but it needs to be properly enforced. As a result, most people here aren't getting enough iodine supplements. Dr Untung is outraged….

COMM: As a result of sub-standard salt being sold as iodised, untold numbers of children will never have the chance to live their lives to the full. Back in the village of Sengi, Sryani has had her baby, a normal healthy boy.

Dr UNTUNG: All this adds to the problem of development in our country. IDD is a simple problem which we know how to fix—cheaply and effectively. But for the relative cost of just a few pennies we haven't done it. Instead our country is being held back with a much more serious and costly problem.

KAHMIDI: Even though I'm poor, short, and ugly, and let's face it, my wife isn't exactly pretty,… it doesn't matter, because we are proud to have two good strong and healthy children….

SIGNIFICANCE

The problems of iodine deficiency are well known. The thyroid gland needs iodine to make hormones that influence growth and mental functioning. Iodine deficiency makes the thyroid swell because it has to work harder. The enlarged thyroid is easily recognizable as a condition called goiter. Women with goiter are vulnerable to miscarriage or to producing babies with brain damage.

Food fortification refers to the addition of nutrients to a food, whereas supplementation means the addition of nutrients to a food that already contains smaller amounts of that nutrient. Salt has been fortified with iodine in the United States and most other developed countries since the early 1900s. Other fortifications or supplementations include iron, niacin, and B vitamins added to flour and rice, milk with vitamins A and D added, and infant formulas fortified with iron.

The World Bank says that iodine deficiency is one of many vitamin and mineral deficiencies that impact the output and quality of life in developing countries. To address these problems, they advocate a mixture of education, distribution of supplements, and the fortification of common foodstuffs, like salt, or water. These solutions have proven to be effective and inexpensive. What is missing is robust adherence to legislation on fortification by industry, as seen in the Mount Merapi example, and awareness of the problem among the population.

Meanwhile, the World Health Organization (WHO) is committed to the elimination of iodine deficiency. WHO says that the problem affects 740 million people a year in 130 countries and is the single greatest cause of preventable brain damage in fetuses and infants. WHO plans to monitor the iodine status of vulnerable populations and investigate the quality of iodized salt. The current campaign is building on some success, for the number of countries with iodized salt has increased from forty-six to ninety-three in the period 1990–1998.

UNICEF (United Nations Children's Fund) also campaigns against iodine deficiency. It is working with the public, salt producers, and decision-makers, pointing out the toll that inaction will exact on a nation's health. In 2003, UNICEF organized a salt testing experiment involving children in Uzbekistan, which showed that 55 percent of samples were iodized. This is not good enough, but it is better than the 19 percent that a similar experiment revealed in 2000. UNICEF says that neither the Russian Federation nor Ukraine is going to be able to eliminate iodine deficiency in the near future. Lost productivity as a result of children born with iodine deficiency will cost the Federation about 1.3 billion Euro. Only 30 percent of Ukrainian households are consuming iodized salt. There is, as "For a Few Pennies More" points out, still much more to be done.

FURTHER RESOURCES

Web sites

UNICEF. "Iodine Deficiency." 〈http://www.unicef.org/ceecis/iodine_deficiency〉 (accessed November 4, 2005).

World Bank. "Enriching Lives: Overcoming Vitamin and Mineral Malnutrition in Developing Countries." 〈http://www.worldbank.org/html/extdr/hnp/nutrition/enrich.htm〉 (accessed November 4, 2005).

World Health Organization. "World Health Organization Sets Out to Eliminate Iodine Deficiency Disorder." 〈http://www.who.int/inf-pr-1999/en/pr99-wha17.html〉 (accessed November 4, 2005).