Salt, excavated from a field at the Aral Tuz salt processing plant in Aral, Kazakhstan, in train carriages. In 1999, only 29 percent of the nation's households were using iodized salt. Now, 94 percent are.

PART SIX | On the Brink: Iodine Deficiency
In Raising the World's I.Q., the Secret's in the Salt

By DONALD G. McNEIL Jr.
December 16, 2006 | The NY Times | Map

ASTANA, Kazakhstan - Valentina Sivryukova knew her public service messages were hitting the mark when she heard how one Kazakh schoolboy called another stupid. "What are you," he sneered, "iodine-deficient or something?"

Ms. Sivryukova, president of the national confederation of Kazakh charities, was delighted. It meant that the years spent trying to raise public awareness that iodized salt prevents brain damage in infants were working. If the campaign bore fruit, Kazakhstan's national I.Q. would be safeguarded.

In fact, Kazakhstan has become an example of how even a vast and still-developing nation like this Central Asian country can achieve a remarkable public health success. In 1999, only 29 percent of its households were using iodized salt. Now, 94 percent are. Next year, the United Nations is expected to certify it officially free of iodine deficiency disorders.

That turnabout was not easy. The Kazakh campaign had to overcome widespread suspicion of iodization, common in many places, even though putting iodine in salt, public health experts say, may be the simplest and most cost-effective health measure in the world. Each ton of salt needs about two ounces of potassium iodate, which costs about $1.15.

Worldwide, about two billion people - a third of the globe - get too little iodine, including hundreds of millions in India and China. Studies show that iodine deficiency is the leading preventable cause of mental retardation. Even moderate deficiency, especially in pregnant women and infants, lowers intelligence by 10 to 15 I.Q. points, shaving incalculable potential off a nation's development.

The most visible and severe effects - disabling goiters, cretinism and dwarfism - affect a tiny minority, usually in mountain villages. But 16 percent of the world's people have at least mild goiter, a swollen thyroid gland in the neck.

"Find me a mother who wouldn't pawn her last blouse to get iodine if she understood how it would affect her fetus," said Jack C. S. Ling, chairman of the International Council for Control of Iodine Deficiency Disorders, a committee of about 350 scientists formed in 1985 to champion iodization.

The 1990 World Summit for Children called for the elimination of iodine deficiency by 2000, and the subsequent effort was led by Professor Ling's organization along with Unicef, the World Health Organization, Kiwanis International, the World Bank and the foreign aid agencies of Canada, Australia, the Netherlands, the United States and others.

Largely out of the public eye, they made terrific progress: 25 percent of the world's households consumed iodized salt in 1990. Now, about 66 percent do.

But the effort has been faltering lately. When victory was not achieved by 2005, donor interest began to flag as AIDS, avian flu and other threats got more attention.

And, like all such drives, it cost more than expected. In 1990, the estimated price tag was $75 million - a bargain compared with, for example, the fight against polio, which has consumed about $4 billion.

Since then, according to David P. Haxton, the iodine council's executive director, about $160 million has been spent, including $80 million from Kiwanis and $15 million from the Gates Foundation, along with unknown amounts spent on new equipment by salt companies.

"Very often, I'll talk to a salt producer at a meeting, and he'll have no idea he had this power in his product," Mr. Haxton said. "He'll say 'Why didn't you tell me? Sure, I'll do it. I would have done it sooner.' "

In many places, like Japan, people get iodine from seafood, seaweed, vegetables grown in iodine-rich soil or animals that eat grass grown in that soil. But even wealthy nations, including the United States and in Europe, still need to supplement that by iodizing salt.

The cheap part, experts say, is spraying on the iodine. The expense is always for the inevitable public relations battle.

In some nations, iodization becomes tarred as a government plot to poison an essential of life - salt experts compare it to the furious opposition by 1950s conservatives to fluoridation of American water.

In others, civil libertarians demand a right to choose plain salt, with the result that the iodized kind rarely reaches the poor. Small salt makers who fear extra expense often lobby against it. So do makers of iodine pills who fear losing their market.

Rumors inevitably swirl: iodine has been blamed for AIDS, diabetes, seizures, impotence and peevishness. Iodized salt, according to different national rumor mills, will make pickled vegetables explode, ruin caviar or soften hard cheese.

Breaking down that resistance takes both money and leadership.

"For 5 cents per person per year, you can make the whole population smarter than before," said Dr. Gerald N. Burrow, a former dean of Yale's medical school and vice chairman of the iodine council.

"That has to be good for a country. But you need a government with the political will to do it."

'Scandal' of Stunted Children

In the 1990s, when the campaign for iodization began, the world's greatest concentration of iodine-deficient countries was in the landlocked former Soviet republics of Central Asia.

All of them - Kazakhstan, Turkmenistan, Tajikistan, Uzbekistan, Kyrghzstan - saw their economies break down with the collapse of the Soviet Union. Across the region, only 28 percent of all households used iodized salt.

"With the collapse of the system, certain babies went out with the bathwater, and iodization was one of them," said Alexandre Zouev, chief Unicef representative in Kazakhstan.

Dr. Toregeldy Sharmanov, who was the Kazakh Republic's health minister from 1971 to 1982, when it was in the Soviet Union, said the problem was serious even then. But he had been unable to fix it because policy was set in Moscow.

"Kazakh children were stunted compared to the same-age Russian children," he said. "But they paid no attention. It was a scandal."

In 1996, Unicef, which focuses on the health of children, opened its first office in Kazakhstan and arranged for a survey of 5,000 households. It found that 10 percent of the children were stunted, opening the way for international aid. (Stunting can have many causes, but iodine deficiency is a prime culprit.)

In neighboring Turkmenistan, President Saparmurat Niyazov - a despot who requires all clocks to bear his likeness and renamed the days of the week after his family - solved the problem by simply declaring plain salt illegal in 1996 and ordering shops to give each citizen 11 pounds of iodized salt a year at state expense.

In Kazakhstan, the democratic credentials of President Nursultan A. Nazarbayev, who has ruled since 1991, have come under criticism, but he does not rule by decree. "Those days are over," said Ms. Sivryukova of the confederation of Kazakh charities. "Businesses are private now. They don't follow the president's orders."

Importantly, however, the president was supportive. But even so, as soon as Parliament began debating mandatory iodization in 2002, strong lobbies formed against the measure.

The country's biggest salt company was initially reluctant to cooperate, fearing higher costs, a Unicef report said. Cardiologists argued against iodization, fearing it would encourage people to use more salt, which can raise blood pressure. More insidious, Dr. Sharmanov said, were private companies that sold iodine pills.

"They promoted their products in the mass media, saying iodized salt was dangerous," he said, shaking his head.

So Dr. Sharmanov, the national Health Ministry, Ms. Sivryukova and others devised a marketing campaign - much of it paid for by American taxpayers, through money given to Unicef by the United States Agency for International Development.

Comic strips starring a hooded crusader, Iodine Man, rescuing a slow-witted student from an enraged teacher were handed out across the country.

A logo was designed for food packages certified to contain iodized salt: a red dot and a curved line in a circle, meant to represent a face with a smile so big that the eyes are squeezed shut.

Also, Ms. Sivryukova's network of local charity women stepped in. As in all ex-Soviet states, government advice is regarded with suspicion, while civic organizations have credibility.

Her volunteers approached schools, asking teachers to create dictation exercises about iodized salt and to have students bring salt from home to test it for iodine in science class.

Ms. Sivryukova described one child's tears when he realized he was the only one in his class with noniodized salt.

The teacher, she said, reassured him that it was not his fault. "Children very quickly start telling their parents to buy the right salt," she said.

One female volunteer went to a bus company and rerecorded its "next-stop" announcements interspersed with short plugs for iodized salt. "She had a very sexy voice, and men would tell the drivers to play it again," Ms. Sivryukova said.

Even the former world chess champion Anatoly Karpov, who is a hero throughout the former Soviet Union for his years as champion, joined the fight. "Eat iodized salt," he advised schoolchildren in a television appearance, "and you will grow up to be grandmasters like me."

Mr. Karpov, in particular, handled hostile journalists adeptly, Mr. Zouev said, deflecting inquiries as to why he did not advocate letting people choose iodized or plain salt by comparing it to the right to have two taps in every home, one for clean water and one for dirty.

By late 2003, the Parliament finally made iodization mandatory.

In Aral, Mountains Made of Salt

Today in central Kazakhstan, a miniature mountain range rises over Aral, a decaying factory town on what was once the shore of the Aral Sea, a salt lake that has steadily shrunk as irrigation projects begun under Stalin drained the rivers that feed it.

Drive closer and the sharp white peaks turn out to be a small Alps of salt - the Aral Tuz Company stockpile. Salt has been dug here for centuries. Nowadays, a great rail-mounted combine chews away at a 10-foot-thick layer of salt in the old seabed, before it is towed 11 miles back to the plant, and washed and ground. Before it reaches the packaging room, as the salt falls through a chute from one conveyor belt to another, a small pump sprays iodine into the grainy white cascade. The step is so simple that, if it were not for the women in white lab coats scooping up samples, it would be missed.

The $15,000 tank and sprayer were donated by Unicef, which also used to supply the potassium iodate. Today Aral Tuz and its smaller rival, Pavlodar Salt, buy their own.

Asked about the Unicef report saying that Aral Tuz initially resisted iodization on the grounds that it would eat up 7 percent of profits, the company's president, Ontalap Akhmetov, seemed puzzled. "I've only been president three years," he said. "But that makes no sense." The expense, he said, was minimal. "Only a few cents a ton."

Kazakhstan was lucky. It had just the right mix of political and economic conditions for success: political support, 98 percent literacy, an economy helped along by rising prices for its oil and gas. Most important, perhaps, one company, Aral Tuz, makes 80 percent of the edible salt.

That combination is missing in many nations where iodine deficiency remains a health crisis. In nearby Pakistan, for instance, where 70 percent of households have no iodized salt, there are more than 600 small salt producers.

"If a country has a reasonably well-organized salt system and only a couple of big producers who get on the bandwagon, iodization works," said Venkatesh Mannar, a former salt producer in India who now heads the Micronutrient Initiative in Ottawa, which seeks to fortify the foods of the world's poor with iodine, iron and other minerals. "If there are a lot of small producers, it doesn't."

Now that Kazakhstan has its law, Ms. Sivryukova's volunteers have not let up their vigilance. They help enforce it by going to markets, buying salt and testing it on the spot. The government has trained customs agents to test salt imports and fenced some areas where people dug their own salt. Children still receive booklets and instruction.

Experts agree the country is unlikely to slip back into neglect. Surveys find consumers very aware of iodine, and the red-and-white logo is such a hit that food producers have asked for permission to use it on foods with added iron or folic acid, said Dr. Sharmanov, the former Kazakh Republic health minister. And the salt is working. In the 1999 survey that found stunted children, a smaller sampling of urine from women of child-bearing age found that 60 percent had suboptimal levels of iodine.

"We just did a new study, which is not released yet," said Dr. Feruza Ospanova, head of the nutrition academy's laboratory. "The number was zero percent."

ON THE BRINK

A Joint Attack on Many Perils of Africa's Young

By CELIA W. DUGGER

December 23, 2006, The NY Times

PONYAMAYIRI, Ghana - In this poor, dusty village of 550 people, four babies died of malaria in October, among them 11-month-old Yire Are. As word spread that the government would be handing out mosquito nets that prevent malaria, his uncle made sure he was there with his own children, their heads shaved in mourning.

"I came to claim a mosquito net," the uncle, Konyiri Doorkono, said firmly, his 3-month-old son clasped in his arms.

But when he and many of the village's families lined up beneath the spreading arms of a neem tree, they got much more. Children gulped down polio vaccine, vitamin A and deworming medicine. They howled at the prick of a measles shot.

They had joined a campaign to better children's odds of surviving past their fifth birthdays. It reached into even the most remote communities in Ghana over five days in November. Similarly monumental drives unfolded in eight other countries across Africa this year, with the mosquito nets alone expected to save the lives of 370,000 children over the next three years.

But while the world's leading public health officials praise this common-sense strategy to provide inexpensive, lifesaving doses of prevention to different diseases at the same time, it is far from simple to pull off. Getting an unwieldy collection of international organizations and charities to work together effectively is a major challenge.

In one measure of the difficulty, even as the Ghana campaign gathered steam, the board of the Global Fund to Fight AIDS, Tuberculosis and Malaria rejected a $46 million proposal to expand the approach to six more African countries.

An alliance of more than a dozen groups sponsored the proposal, but each of the six countries also submitted its own malaria application to the Global Fund, which controls most international malaria spending - and no one made sure the many requests did not overlap or conflict with one another.

"There were too many cooks," said Dr. Arata Kochi, who leads the global malaria program for the World Health Organization, whose experts helped draft the six-country proposal.

Though the proposal failed, Dr. Kochi called the combined campaigns "a winning strategy," and Dr. Richard Feachem, head of the Global Fund, described them as "spectacularly successful."

"Everybody is slack-jawed, aghast" at the rejection, said Mark Grabowsky, a public health doctor with the federal Centers for Disease Control and Prevention, who joined the Global Fund this year as a malaria program officer and who has long championed the marriage of measles and malaria in joint campaigns.

Dr. Feachem and Dr. Kochi say they hope that their organizations can improve their coordination.

"Malaria is a preventable child holocaust which occurs in Africa for no reason," Dr. Feachem said. "We can stop this. The Global Fund's role is finance, and we must work more closely with the W.H.O., the Red Cross and others to ensure that the money flows to those who can use it effectively on the front line."

Much of the challenge stems from the fact that each drive against a disease - polio, measles, malaria - has its own leaders, charitable groups and donors at the international level. Piecing them together in unified campaigns requires the logistical skills and diplomatic finesse of a skilled battlefield commander.

While public health officials know well the difficulties of mounting even individual campaigns, they say they have learned they can save more lives by piggybacking campaigns, particularly by adding malaria and distributing mosquito nets.

The need is great: malaria kills about 800,000 children a year in Africa. The W.H.O. estimates that only 3 percent of the most vulnerable African children under age 5 are covered by the insecticide-treated bed nets that can last four to five years. The cost for each net is $5 to $6.

Studies have also established that giving children vitamin A (2 cents per dose) boosts their immune systems and reduces deaths, while medicines to rid them of intestinal worms (also 2 cents) greatly improve their health and school attendance.

The push to give every child polio vaccine (15 cents a dose) has prevented some five million cases of paralysis worldwide since 1988, while inoculating children with measles vaccine (16 cents) has saved more than a million lives since 1999, according to the W.H.O.

The combined campaigns in Africa this year have made it possible to sustain gains from earlier measles and polio drives, while the net distributions promise a new payoff in reduced malaria deaths.

Dr. Grabowsky, who has devoted much of his professional life to measles, said the need for joint measles and malaria campaigns dawned on him gradually. In the late 1990s, on a visit to a mission hospital in Gulu, Uganda, he had an epiphany when a doctor there told him: "If you get rid of measles, we can close the measles ward. If you get rid of malaria, we can close the hospital."

In 2001, he was assigned by the C.D.C. to serve as an adviser to the Red Cross when the groups started the Measles Initiative, an effort to reduce measles deaths in Africa, along with the W.H.O., the United Nations Children's Fund and Ted Turner's United Nations Foundation.

As measles campaigns radically reduced measles deaths in country after country, Dr. Grabowsky worried that the undertaking would become a victim of its own success.

Why would a mother walk hours to get her baby immunized once measles was mostly gone? And what would happen if parents stopped flocking to campaigns? The answer was ominous: a resurgence of measles, an extremely contagious disease.

He had only to look at the 18-year slog to eradicate polio, which still has not wiped out that crippling disease. In northern India, more than two dozen polio-only campaigns in recent years have generated fierce resistance among some parents, who are mistrustful of the vaccine, fed up with the campaigns and angered that officials are not doing more to fight other diseases that kill their children.

In Africa, Dr. Grabowsky figured that parents would keep coming for measles vaccines if the campaigns also offered mosquito nets to prevent malaria, which routinely kills small children across the continent.

In 2002, the Red Cross, with a $50,000 grant from the Exxon Mobil Foundation, ran the first test of combined campaigns here in the impoverished, northwestern corner of Ghana, where one in five children dies before age 5. In the Lawra district, it got measles vaccines and nets to more than 90 percent of children under age 5.

Three years later, researchers returned and were startled to find the benefits had persisted. Most of the children still slept under the nets at night, when malarial mosquitoes bite.

Evaluations of combined campaigns carried out nationally in Togo in 2004 and in Niger last year also found soaring numbers of children under 5 sleeping under bed nets. But the surveys also discovered that more people owned nets than actually used them. In Togo, for example, more than 9 of 10 families with young children got a net, but only about 6 in 10 children had actually slept under one the previous night.

Unlike vaccines, which are effective once given, nets must be used regularly to work - and that means education and following up. The Red Cross has mobilized thousands of volunteers to help in the task.

Still, getting the nets to children is the first step, and this year more than 18 million nets were handed out in combined campaigns - far more than ever before.

It was, in fact, a breakthrough year. Combined campaigns, which included some combination of measles shots, polio drops, deworming pills, vitamin A and nets, were carried out in nine African countries spanning the continent, from Ghana in the west, to Ethiopia in the east, to Angola in the south.

But even when all the donors and charitable groups are pulling in the same direction, such campaigns are a daunting challenge. Each Wednesday, representatives of a dozen groups working on measles and malaria call a common phone number to coordinate this complex undertaking.

Here in Ghana, Unicef officials scrambled before the campaign to raise money for the mosquito nets. Britain and Japan paid for two million nets, enough to cover all children under age 2, though less than the hoped-for coverage of children under 5.

In the month before the campaign, the Ghanaian government, which embraced and executed the strategy, dispatched 70 container-loads of bulky nets across the country by truck, boat, tractor, bicycle and donkey cart.

The last nets arrived at the port of Tema, Ghana, only days before the campaign began on Wednesday, Nov. 1. "We were sweating it until Friday," said Dorothy Rozga, Unicef's Ghana representative.

As the campaign days dawned, squadrons of health workers zoomed off on motorbikes along pitted country roads, kicking up clouds of dust that enveloped the small, gray boxes of vaccine lashed to the backs of their two-wheelers.

Villagers waited stoically in the shade for the workers to arrive, then waited hours more with squirmy children on their laps for the medical elixirs.

In places like Ponyamayiri - a village with no electricity or telephones that is in a district with no hospital, doctor or ambulance - prevention is often all that stands between a child and death.

After the vaccines were given and the mosquito nets handed out, a villager led the way along a maze of sandy paths, through tall grass and millet fields, to the homes of children who had died in the previous couple of weeks.

In the heavy midday heat, 14-month-old Suonguno's family lay under a mango tree in a stupor of grief. The little girl had died of malaria two days earlier. She was buried beneath a fresh mound of red earth hard against the family home. One of her tiny white shirts lay on the grave.

Her name means Witch's Catch in the local language - and she was given it in memory of her father's four siblings who died in childhood of measles, mumps and dysentery. Her grandfather believed that evil spirits had claimed them. Now she, too, had been snatched away.

Her father, Manama Bejie, 37, a hardscrabble farmer who said he had only enough food to feed his family once a day, described his daughter's torment. She had developed a high fever. She cried and cried. She vomited bile. Her body was shaken by convulsions.

He took her to the clinic in Wechau, headquarters of the West Wa district, where he was told that she was anemic and that she needed a blood transfusion and laboratory work that could only be done at the regional hospital in Wa, more than an hour's drive away.

"We were going to go to Wa the next morning, but she died that night in her grandmother's arms," he said.

All too often, even those who try to reach the hospital do not make it. "They go back as corpses," said Dr. Erasmus Agongo, the health director here in the Upper West region.

Hoping to prevent suffering across Africa, the Global Fund itself has financed the purchase of nets for other combined campaigns in Angola, Niger, Rwanda, Kenya and Ethiopia.

The six-country proposal - for Benin, Liberia, Burkina Faso, Mali, Ivory Coast and the Central African Republic - was rejected because it was not well coordinated with the countries' malaria strategies and because it inadequately explained how infrastructure problems would be overcome, Global Fund officials said.

Dr. Feachem, the head of the Global Fund, said that he deeply regretted that the application did not meet the fund's standards and that he hoped that the applicants would reapply next year.

Dr. Kochi, who is trying to help fix the troubled global malaria effort at the W.H.O., said he would try to make sure that the organization's malaria team masters the art of winning grants from the Global Fund.

For now, the fund's rejection of the six-country net request will slow the momentum of combined campaigns. Even if the countries successfully reapply, the money will come too late for the measles campaigns next year in Burkina Faso, Liberia and Mali.

The groups organizing the campaigns hope to raise money for nets from rich countries and charitable groups. The United Nations Foundation, Sports Illustrated, the National Basketball Association's NBA Cares and the United Methodist Church are also turning to the public for donations through a Web site, www.NothingButNets.net.

Andrea Gay, an official with the United Nations Foundation, part of the measles-malaria alliance that submitted the six-country proposal, sputtered with frustration that the Global Fund had not come through.

"They agree we have a strategy to prevent malaria using nets and then they don't do anything," she said, soon after learning of the rejection. "They go back to their desks. Six countries could have had full coverage for children under 5. How many lives would have been saved?"

Copyright 2006 The New York Times Company