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             The I.D.D.(Iodine Deficiency Disease) Scene in Pakistan

About Dr Zahid Masood Khan

After a long, slow struggle toward ending the devastating mental and physical effects of iodine deficiency, the pace of progress has quickened and the goal of virtually eliminating IDD is in sight. Salt iodization is on target in most affected countries, and the global effort to conquer this problem is reaching its final, defining phase. The history of this effort is a lesson in what can be accomplished when scientists, development experts and political leaders work together to focus attention and spur action on a specific health measure.

We have learned a great deal about communication and mobilization. We have also begun to apply this knowledge to the creation of partnerships with industry and other stockholders who can wipe out IDD entirely and forever by the year 2000. Scientists were the first to sound the wake up call and then on the campaign was taken up by UNICEF and WHO. Progress has certainly been made, but much more needs to be done.

Clearly, the scientific and technical aspects of the campaign are critical. It is essential to monitor health progress through surveillance, screening and laboratory work and to assure the quality of the iodized salt product through manufacture, transportation and storage. But it is equally important to assure the quality of the entire process, particularly the communication and training required to convey to everyone the importance of ingesting minute amounts of iodine on a regular basis. Any relaxation of iodine use would allow IDD to return.

Selling the world on iodized salt is not like marketing some brand name. It is not about boosting market share or getting most people to buy it. It is about saving the brain of every child-- preserving normal growth by protecting against brain damage. Nor is universal salt iodization simply a matter of passing laws, telling people to make it and take it.

We have come to understand that partnerships help. People learn, practice and adopt new behaviors indirectly through their interaction in groups as much and perhaps even more than they do as individuals directly exposed to messages. This is one reason program planners are increasingly concerned with creating close ties, or partnerships, with societal groups that influence the people they want to reach.

Another reason for working with partners is the success of the business communication process of turning potential competitors into partners through negotiation. By finding areas of common interest, collaboration and profitability, a number of companies can work together to grow and thrive. In a world where government and industry are mutually dependent, creating " win-win " situations has become an effective development strategy as well as an enlightened business practice.

Ecuador & Pakistan:
To show how partners work together in real programs, this guide cites examples of social mobilization, primarily from Ecuador and Pakistan. These countries offer two perspectives on social mobilization, one over the past decade, the other a work in progress.

Ecuador: In 1984, Ecuador's Ministry of Health began to build an integrated program against iodine deficiency that has overcome technical, geographical, language and bureaucratic barriers to protect almost all of its five million Andean population against iodine deficiency. Since salt is produced by a small number of large producers in Ecuador, many argue that advocacy with decision makers, discussion with industry, regulatory action and monitoring should have been enough.Working with just a few producers, Ecuador was able to subsidize iodized salt for a few years until consumer demand was enough to pass the cost on to the consumers. However, because those most at risk were also the most difficult to reach, these " supply side " activities had to be matched with " demand side " work.

With international and bilateral support from the government of Belgium, Ecuador followed a social marketing strategy backed by considerable advocacy work that helped to involve agencies and influential people at every level. This sort of extensive advocacy at the international, national, provincial and community levels was coupled with a " problem-solving " management style.

As the program proceeded, partners were found to provide needed resources, to accomplish specific tasks, and to overcome obstacles. Planning was decentralized and program promotion put in the hands of provincial training teams with ready telefax communication to the sources of power and resources in the capital. The provincial teams involved local leaders and rural school teachers and enlisted the support of other relevant individuals and organizations. this is an example of social mobilization or good social marketing, whichever term you prefer.

Advocacy and alliance-building helped gather strength for the IDD program in Ecuador by essentially asking everybody to pull in the same direction. After ten years of continuing reassessment and revision, Ecuador's program was declared to have virtually eliminated iodine deficiency in 1994.

Pakistan: In comparison to Ecuador, Pakistan has many more salt producers, a less well developed road infrastructure and an uncontrolled iodized salt price. Pakistan is also more heavily populated, and its IDD program started from a much lower percentage of iodized salt consumption in 1994: 2% as compared to 50% in Ecuador.

Despite these differences, Pakistan uses a " problem-solving " management style similar to that used in Ecuador. Because it is taking place today, Pakistan is making use of new thinking about alliance building. Recently, after a quickly achieved increase in iodized salt consumption from 2% to 17%, the market share of iodized salt in Pakistan began to drop. Planners quickly re-assessed the IDD program and revised their communication strategy to include more training and alliance-building activities. The IDD program has strengthened and widened its steering committee, revised messages for consumers, and involved well regarded social workers in support of iodized salt.

It should be noted that mid-course corrections, such as those made in Ecuador and Pakistan, are a sign of program strength, not weakness. The ability to identify problems, adapt messages to changing conditions, take advantage of new opportunities, and seek out new partners means that essential monitoring systems are in place. Message design relies on knowing the audience -- understanding the knowledge, attitude, beliefs, and practices of its different segments -- but without some trial and error, no one truly knows what message or combination of messages will fit best or what the best delivery system will be.

In Pakistan where education is highly valued, the IDD program has used endorsements of religious leaders and health workers to market iodized salt as a way of enhancing children's capacity for learning. Interpersonal contacts stressed the positive results of using iodized salt rather than the negative consequences of not using it.

On the other hand, an evaluation of television ads found that the picture of a weak and disabled child was the most effective element influencing viewers in Pakistan to start using iodized salt. Researchers concluded that the impact of the advertisement stemmed from the viewers fear of disorders caused by iodine deficiency, especially among children. Clearly we need to learn what motives people in different cultures and circumstances to change their eating habits, but we do not always have to paint a pretty picture.

Despite these caveats, marketing has tremendous strengths. Both commercial marketing and social marketing are geared to meet the needs perceived by the different groups of users, not just the needs of program heads. Making extensive use of audience segmentation, focus groups, pre-testing, and other formative evaluation methods, marketing is one of the most important tools we have to design messages and choose communication channels for particular target groups.

David Alnwick, Venkatesh Mannar
The Medical SPECTRUM
Vol.21 No.12 December 2000

The Problem and Its Solution
The IDD problem statement says iodine deficiency disorders are the single most common cause of preventable mental retardation and brain damage in the world. They cause goiters and decrease the production of hormones vital to growth and development. Children with IDD can grow up stunted, apathetic, mentally retarded and incapable of normal movement, speech or hearing. The visible effects of IDD (cretinism) account for only as much as 10% of the ramifications. At least 90% of IDD consequences remain hidden. IDD in pregnant women cause miscarriage, stillbirth and mentally retarded children.

* 1.6 billion people are at risk.
* IDD effects 50 million children worldwide.
* 100,000 cretins are born every year.

Iodine deficiency was once considered a minor problem, causing goiter, an unsightly but seemingly benign cosmetic blemish. However, it is now known that iodine deficiency is the most common preventable cause of mental handicap in the world today, constituting a threat to the social and economic development of many countries of the world including some in Europe.

These are effective and affordable technologies that will prevent iodine deficiency and the problems it causes. ICCIDD specialists, collaborating with development agencies, governments and institutions, can provide the technical assistance required to control IDD.

The Effects
On Individuals:              goiter, hypothyroidism, loss of energy. In pregnant mothers:     miscarriages, stillbirths and                                       mentally retarded children.
In Children:                   impaired mental and physical development, dropouts, mental retardation, physical                                                   deformities and cretinism.
On Society:                   lower productivity and higher demand on social services.

The solution is relatively simple. A teaspoon of iodine is all a person requires in a lifetime, but because iodine cannot be stored for long periods by the body, tiny amounts are needed regularly. In areas of endemic iodine deficiency, where soil and, therefore crops and grazing animals do not provide sufficient dietary iodine to the populace, food fortification and supplementation have proven highly successful and sustainable interventions. Iodized salt programs and iodized oil supplements are the most common tools in the fight against IDD.

Iodine is an essential element for thyroid function, necessary for the normal growth, development and functioning of the brain and body. Iodine deficiency is the single most common cause of preventable mental retardation and brain damage in the world.

The Medical SPECTRUM
Vol.21 No.12 December 2000

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