Micro Need Macro Problem

An aspect of global health I’m learning more about is the relationship between health and nutrition, an aspect that we, in the land of the large, all-you-can-eat buffets, and a multi-billion “dieting” industry, easily ignore, but obviously, for many of the world’s citizens, especially those whose developing minds and bodies need nutrition, is a major concern.  While the more wealthy world’s response to famine and imminent loss of life is well-tuned and historically many countries quickly provide food supplies when natural or man-made disasters occur, a more pernicious and poorly-addressed problem is chronic under-nutrition which leads to a wide range of specific deficiency diseases, increased susceptibility to infectious disease, and reduced ability to earn a living.  One under-recognized, yet apparently easily addressable, condition I now know something about is iodine deficiency.

Iodine is an essential element in the human diet as a key component of the thyroid hormones that are involved in regulating metabolism and cell development.  In fact, the body’s need is so great that the classic sign of iodine deficiency is enlargement of the thyroid gland (goiter) due to hyperproliferation of the tissue needed to make the hormones.  Iodine deficiency causes fetal and neo-natal mortality and congenital abnormalities, and if that’s not bad enough, causes impaired mental function in children and adolescents, and in adults it has been linked to decreased educatability, increased apathy, and loss of work productivity.  This complex of effects is know as iodine deficiency disease (IDD) (see a Lancet review by Zimmermann et al 2008).  Iodine is a naturally-occurring component of many foods, e.g., plants grown in iodine-containing soils or in sea food, but for most of the world’s population these sources are insufficient.  The good news is that in the early 1990s, the WHO/UNICEF, advocacy groups like the International Council for the Control of Iodine Deficiency Disorders (ICCIDD) and the Iodine Network (IN), governments, and salt manufacturers launched a campaign against IDD through the simple and inexpensive (cents per ton) public health measure of adding iodine to table salt.  Currently, about 70% of households have access to and use iodized salt with the result a remarkable decrease in IDD over the past 20 years.

The not-so-good news is that IDD is still a problem for many people in both the developing and developed world.  In 2008, UNICEF estimated that 2 billion people have insufficient intake of iodine, including one-third of all school-age children in many regions with the highest insufficiency occurring in Eastern Europe (52%), Eastern Mediterranean (48%), and Africa (41%) (Table 3, Zimmermann et al. 2008).  In the same report, the organization states that iodine deficiency is the leading cause of preventable mental retardation in the world and that 38 million children born at risk each year (UNICEF press release).  The goal for governments and public health advocates is universal iodization and involves getting salt manufacturers to add iodine and food processors and people to use it, so the solution is mostly a matter of political will, modest amounts of money, and PR (see Global Alliance for Improved Nutrition Universal Salt Iodization Program).

Unlike many global health solutions, the role of new technology is minimal, although there is a hole technology could fill.  To monitor and evaluate the success of iodization programs, one needs to measure the amount of iodine in the people at risk and the current process, while not technically difficult, requires samples to be collected in the field and analyzed at a central laboratory, subject to contamination and loss (see WHO Assessment Guide).  While I couldn’t find any specific guidance on the number of samples needed for adequate monitoring, I am guessing that a half a million may need to be analyzed each year (2 billion at risk and bi-yearly statistically-meaningful sampling).  Hence back in 2008, someone at the CDC and/or NIH swung into action and put out a single paragraph request for SBIR/STTR proposals to develop a rapid field test for urinary iodine (“Simple, reliable measures for field use would be a great help.” NIH Omnibus Solicitation 2008) and a small company in Ohio, the Institute of Bioengineering Technologies, Inc. (IBET) sent in a proposal, received Phase I and II funding, developed a prototype strip-type assay, and accepted my offer to help find collaborators for the field testing, funding for the scale-up to manufacturing, and customers and licensees, which I’m doing.  So for a relatively small investment of public funds and with luck and some private investment, public health agencies may have a better tool for eliminating IDD in a couple years.  Your tax dollars at work.

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