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PART 1
DAMAGE ASSESSED, PROGRESS RECORDED
This report offers a global overview of vitamin and mineral deficiency,
of the progress being made against it, and of the challenges that lie
ahead if the world is to bring under control a public health problem that
prevents as many as a third of the world's people from reaching their
physical and mental potential.
To accompany this Global Progress Report, individual Damage Assessment
Reports are also being issued for 80 developing countries. These nation-by-nation
audits draw on latest information to present the most comprehensive picture
to date of the toll being taken by vitamin and mineral deficiency (VM
deficiency). The findings, for countries that are home to approximately
80% of the world's population, are set out in the tables on pages 36 to
39.
A summary makes sombre reading:
- Iodine deficiency is estimated to have lowered the intellectual capacity
of almost all of the nations reviewed by as much as 10 to 15 percentage
points.
- Iron deficiency in the 6-to-24 month age group is impairing the mental
development of approximately 40% to 60% of the developing world's children.
- Vitamin A deficiency is compromising the immune systems of approximately
40% of the developing world's underlives and leading to the deaths of
approximately 1 million young children each year.
- Iodine deficiency in pregnancy is causing almost 18 million babies
a year to be born mentally impaired.
- Folate deficiency is responsible for approximately 200, 000 severe
birth defects every year in the 80 countries for which Damage Assessment
Reports have been issued (and perhaps as many as 50, 000 more in the
rest of the world). The deficiency is also associated with approximately
1 in every 10 deaths from heart disease in adults.
- Severe iron deficiency anaemia is also causing the deaths of more
than 60, 000 young women a year in pregnancy and childbirth.
- Iron deficiency in adults is so widespread as to lower the energies
of nations and the productivity of workforces - with estimated losses
of up to 2% of GDP in the worst affected countries. "Vitamin and mineral
deficiencies, " says the World Bank "impose high economic costs on virtually
every developing nation. "
- In practice, vitamin and mineral deficiencies overlap and interact.
Half of children with VM deficiency are in fact suffering from multiple
deficiencies - adding up an immeasurable burden on individuals, on health
services, on education systems, and on families caring for children
who are disabled or mentally impaired.
A 'new' problem
This assessment of the world-wide damage being infiicted establishes
the starting point of this report - that we are here dealing with a global
problem of enormous importance that is as yet little recognised.
In large part this is because VM deficiency is a 'new' problem in as
much as its true scale and consequences have only recently been discovered.
For several decades it has been known that micronutrient deficiency -
the lack of key vitamins and minerals -brings anaemia, cretinism and blindness
to tens of millions of people. But the news of the last decade is that
these manifestations are but the tip of a very large iceberg. Levels of
mineral and vitamin deficiency that have no clinical symptoms, and that
were previously thought to be of relatively little importance, can and
do impair intellectual development, cause ill health and early death on
an almost unthinkable scale, and condemn perhaps a third of the world
to lives lived below their physical and mental potential.
Today it is known that these 'moderate' or 'mild' levels of vitamin and
mineral deficiency are extremely common in almost all countries; perhaps
40% of the developing world's people suffer from iron deficiency; probably
15% lack adequate iodine; and as many as 40% of children are growing up
with insufficient vitamin A. Indeed so ubiquitous is vitamin and mineral
deficiency that it debilitates in some significant degree the energies,
intellects, and economic prospects of nations.
The implications of thesefindings are obviously far-reaching. Most fundamentally,
as UNICEF Executive Director Carol Bellamy has said, "We have to leave
behind the old thinking and act in the light of new knowledge: it is no
longer a question of seeking out symptoms of severe deficiency in individuals
and treating them. It is a question of reaching out to whole populations
to protect them against the devastating consequences of even moderate
forms of vitamin and mineral deficiency. "
Solutions
But if it is clear that VM deficiency represents a much greater problem
than was imagined even a decade ago, it is also clear that for once the
world is confronted by a problem for which there are available and affordable
solutions.
In summary form those solutions are:
Fortification: Adding vitamins and minerals to foods or condiments that
are regularly consumed by a significant proportion of the population -for
example flour, sugar, salt, margarine, cooking oil, and sauces. The cost
of fortification can be as little as a few cents per person per year.
Supplementation: Reaching out to vulnerable groups (particularly children
and women of childbearing age) with vitamin and mineral supplements in
the form of low-cost tablets, capsules and syrups. A vitamin A capsule,
for example, is effective for up to 6 months and costs as little as 2
cents; a three-month supply of iron tablets costs 20 cents.
Education: Informing the public about the need for supplements or fortified
foods, and about the kinds of foods that can increase the intake and absorption
of vitamins and minerals. In some cases this might also involve assisting
communities to grow and consume a wider variety of foods (Panel 1).
Disease control: Continuing efforts to control diseases like malaria,
measles, diarrhoea, and parasitic infections can also help the body to
absorb and retain essential vitamins and minerals.
These are the methods that have largely brought the problem under control
in the industrialised nations (Panel 9). They are now so inexpensive that
they could control VM deficiency world-wide. "Probably no other technology
available today, " says the World Bank, "offers as large an opportunity
to improve lives and accelerate development at such low cost and in such
a short time ".
As this report shows, each of the available solutions involves its own
complexities and difficulties; none is a complete solution in itself and
all need to be pursued simultaneously and according to the particular
contours of need and opportunity in each country. But so serious is the
problem, and so affordable the solution, that not to act decisively against
it would be to make a mockery of other, more difficult, development targets.
Targets
In May 2002, the General Assembly of the United Nations agreed that control
of key vitamin and mineral deficiencies should be one of the global development
goals to be achieved in the early years of the new millennium. Specifically,
the UN has called for the virtual elimination of iodine deficiency by
2005; the elimination of vitamin A deficiency by 2010; and a reduction
of at least 30% in the global prevalence of iron deficiency anaemia by
2010.
The struggle to achieve these goals is already underway. Throughout the
1990s, international agencies have been working with governments, national
institutions, and the private sector to fortify foods, improve diets,
and extend the outreach of vitamin and mineral supplements. In that time,
some remarkable advances have already been made. These achievements, and
the main lessons to be taken from them, are also summarised in these pages.
The main burden of this report however, is that the goals will not be
achieved, and the impact of vitamin and mineral deficiency will not be
substantially reduced, without a more ambitious, visionary, and systematic
commitment to putting known solutions into effect on the same scale as
the known problems.
In particular, experience to date suggests that dynamic national alliances
-involving governments, the private sector, health and nutrition professionals,
academics and researchers, civil society and international aid agencies
- are the means of unlocking this potential.
In order to galvanise such partnerships, it will first be necessary to
create a higher level of awareness of the problem; for one of the main
brakes on progress is that VM deficiency remains an issue whose scale
and severity is not yet fully appreciated by politicians, press, and public
in most nations of the world.
This Global Progress Report on vitamin and mineral deficiency, and the
accompanying Damage Assessment Reports for 80 individual nations, are
a contribution towards that end.
Achievements
Alongside the Damage Assessment Reports for individual countries, the
Micronutrient Initiative and UNICEF have also issued National Protection
Audits in an attempt to begin tracking, nation-by-nation, the progress
made in putting solutions into effect. Where possible, the National Protection
Audits record the progress made since 1990 and assess the current status
of efforts to control VM deficiency.
A summary of what has been achieved over the last decade:
- The global prevalence of iodine deficiency has been halved from 30%
to less than 15%. This has been brought about, above all, by a sustained
effort to add iodine to two- thirds of the world's household salt. As
a result, approximately 70 million new-borns a year have been protected,
in some degree, against mental impairment.
- More than 40 developing countries are now reaching two-thirds or more
of their young children with at least one high-dose vitamin A capsule
every year. Coverage with the necessary two-doses is much lower (Panel
2), but the effort to date is estimated to be saving the lives of more
than 300, 000 young children a year and, over time, preventing the irreversible
blindness of hundreds of thousands more.
- An international movement to fortify all wheat flour with iron and
folic acid (as in the United States and Canada) is beginning to gather
momentum. Indonesia, Jordan, Nigeria and South Africa have recently
acted, bringing to 49 the total number of countries with flour fortification
laws.
- Many more developing countries have begun the process of fortifying
other staple foods and condiments with essential vitamin and minerals
-from salt, sugar and margarine to cooking oil and soy sauce.
- In addition to these advances, there are signs that the seriousness
and urgency of the VM deficiency issue is beginning to be more widely
realised. In 2002, for example, a new $70 million Global Alliance for
Improved Nutrition (GAIN) was launche -i with the support of the Bill
and Melinda Gates Foundation, the Micronutrient Initiative, and the
aid programmes of Canada, Germany, the Netherlands and the United States
(Panel 12).
Many of these achievements stem from the resolutions made at the World
Summit for Children held by the United Nations in 1990, and are a tribute
to the power of international goals and commitments and to the subsequent
efforts made by a great many individuals and organisations. Nonetheless,
with almost a third of the planet affected in some degree by a problem
for which a clear solution beckons, anything less than rapid progress
would be unconscionable. This report therefore turns next to the distance
that still has to be travelled, and to the lessons from the last decade
that must guide the efforts of the next.
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