手机版
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 withUnicef, 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 's laboratory. "The number was zero percent."
哈萨克斯坦的阿斯塔纳--当瓦伦蒂娜·席瑞科娃（Valentina Sivryukova）听到一个哈萨克小学生如何形容别人愚蠢时，她觉得她的公共服务信息宣传成功了。那个孩子对另一个人嗤之以鼻地说："你怎么搞的啊！你脑子缺碘还是怎么啦？"
席瑞科娃女士是哈萨克慈善机构全国联盟主席，她闻听此言喜上眉梢。这意味着多年来提高公众认识碘盐防止婴儿脑损伤的努力起效了。一旦这项活动取得成果，那么哈萨克斯坦全国人民的智力水平就有了保障。
实际上，哈萨克斯坦这个亚洲内陆国家为各国提供了一个范例，它表明即使幅员辽阔的发展中国家也能在公共卫生方面取得一个显着的成功。1999年，哈萨克斯坦全国只有29%的家庭使用加碘盐，而现在这个数字是94%.预计明年（2007）,联合国会正式宣布哈萨克斯坦不再是缺碘的国家。
但这个转变并非一帆风顺。公共卫生专家表示，虽然往食盐中加碘是全世界最简单和最有效的健康措施，但哈萨克的这一运动不得不克服许多地方普遍存在对碘的质疑。每吨食盐需要添加两盎司的碘酸钾，成本为1.15美元左右。
全球大约有20亿人，即全世界三分之一的人口摄碘量极低，包括中国和印度的数亿人在内。研究显示，缺碘是智力发育迟缓的一个主要但可预防的因素。尤其是孕妇和婴儿，即便只是中度缺碘，也会导致智力降低10到15个智商（IQ）点，这削弱了一个国家发展不可估量的潜力。
最明显和最严重的后果是残障性甲状腺肿、呆小病和侏儒症。虽然这些疾病只发生在极少数通常住在山区的人身上，但全世界16%的人至少都有轻度甲状腺肿--即颈部的甲状腺肿大。
1985年，为了支持加碘运动，全世界350多位科学家组成了控制碘缺乏病国际理事会（the International Council for Control of Iodine Deficiency Disorders）,杰克·林（Jack C. S. Ling）是该理事会主席，他说："如果母亲知道缺碘会影响胎儿的发育，哪怕倾家荡产，她也要买到碘。你看看有哪个母亲不这样做呢？"
1990年，世界儿童问题首脑会议（World Summit for Children ）提出，到2000年消除碘缺乏。随后，林教授的组织和联合国儿童基金会（Unicef）、WHO、吉瓦尼斯国际（Kiwanis International）、世界银行（ World Bank ）以及加拿大、澳大利亚、荷兰、美国等外国援助机构共同努力。
就在公众毫无察觉的情况下，他们取得了惊人的进步：1990年，全世界25%的家庭使用加碘盐。而现在，这个数字是66%.
但近来这项努力无法得以继续。到了2005年，消除碘缺乏的目标还没有实现时，捐赠人开始失去兴趣，而转向AIDS、禽流感和其他更受到关注的威胁。
而且，所有这类运动的花费超出预期。1990年预测的费用为7500万美元--这比消灭脊髓灰质炎（小儿麻痹症）的花费要便宜许多，后者已经耗费了40亿美元。
根据碘理事会的执行主任哈克斯顿（David P. Haxton）介绍，从那以后的实际费用大约为1.6亿美元，包括吉瓦尼斯国际捐助的8千万美元和盖茨基金会捐助的1.5千万美元，以及不知名的捐款，全都被盐业公司用于购买新设备。
哈克斯顿说："这种事情经常发生：当我在会议上和某个盐商谈论加碘的事，他往往并不知道自己的产品有这种影响力。他会对我说，'你干嘛不早点告诉我��？我当然会做的。我立刻就会这么做的。"
像日本等许多地方，人们通过食用海鲜、海藻得到碘，还可以从生长在高碘土壤里的蔬菜或食草动物那里得到碘。但即使像美国和欧洲等地的发达国家，仍旧需要通过加碘盐来补充碘。
专家表示，碘的价格在降低。开支总是不可避免的成为公共关系战争。
在一些国家，碘化作用成为政府阴谋破坏生活必需品内的帮凶--盐专家认为这与美国二十世纪50年代保守人士强烈反对在水中添加氟化物的情况相同。
另一些国家，国内的自由主义者要求有选择无碘盐的权利，结果碘化盐几乎难以惠及穷人。一些不愿承担额外成本的小型盐商经常游说反对加碘盐。而担心失去市场的碘片剂生产商也反对加碘盐。
谣言自然四处流传：碘被说成是艾滋病、糖尿病、癫痫、阳痿和过敏的罪魁祸首。根据不同国家谣言工厂的不同版本，碘盐被描绘让泡菜爆炸、破坏鱼子酱或软化硬质奶酪。
冲破这种阻碍不仅需要资金还需要领导才干。
杰拉德·巴洛（Gerald N. Burrow）博士是耶鲁大学医学院前任院长，也是碘理事会副主席，他说："每年每人只需5美分，你就可以让整个人口变得比以前聪明。"
"这肯定对国家有益。但你需要一个有政治意愿做此事的政府。"
儿童发育不良的"丑闻"
二十世纪90年代，当碘化运动开始时，全球碘缺乏国家最集中的区域是中亚内陆的前苏联加盟共和国。
哈萨克斯坦，土库曼斯坦，塔吉克斯坦，乌兹别克斯坦、吉尔吉斯坦--随着前苏联的解体，所有这些国家遭遇了经济崩溃。上述整个区域，只有28%的家庭使用碘盐。
亚历克山大·佐夫（Alexandre Zouev）是哈萨克斯坦儿童基金会的首席代表，他说："随着整个体制的崩溃，之前的一切被全盘否定，食盐加碘只是其中之一。"
沙曼诺夫（Toregeldy Sharmanov）博士在1971至1982年期间曾担任哈萨克斯坦共和国的卫生部长，当时的哈萨克斯坦属于苏联。他表示，即使在当时，缺碘的问题也很严重，但他无法修改政策，因为那是莫斯科制定的。
"与俄罗斯同龄儿童相比，哈萨克的儿童发育不良。"他说，"但他们熟视无睹。这是一件丑闻。"
1996年，重点关注儿童健康的联合国儿童基金会在哈萨克斯坦成立了第一家办事处，筹备对5000户家庭的调研工作。调查发现10%的儿童发育不良，由此为国际援助开辟了通道。（发育不良的原因有多种，但碘缺乏是罪魁祸首。）
在相邻的土库曼斯坦，总统尼亚佐夫（Saparmurat Niyazov）是一个专制者，他规定所有的钟表上都必须刻有他的肖像，还把一周7天的名称前冠以其家人的名字。1996年，这位总统解决问题的方式就是直接宣布无碘盐为非法，而且规定商店每年以公费的方式给每位公民11磅碘盐。
在哈萨克斯坦，有民主信誉的总统纳扎尔巴耶夫（Nursultan A. Nazarbayev）自1991年以来执政至今。尽管已经受到批评，但他不会用法令来强制规定。"那种日子已经一去不返了，"哈萨克慈善联合会主席席瑞科娃女士说，"现在的企业已私有化。他们不会理睬总统的命令。"
不过重要的是，总统表示支持。但即便如此，当2002年议会开始讨论强制性加碘时，反对这项措施的强大游说队伍一下子形成了。
联合国儿童基金会在一份报告中透露，最初这个国家最大的盐业公司由于担心增加成本而不愿合作。同时，心脏病学家也担心这会鼓励人们使用更多的盐，所以极力反对加碘盐。沙曼诺夫指出，销售碘片剂的私人公司更是暗中作梗。
"这些公司在大众传媒上大肆宣传他们的产品，还宣称碘盐是有害的。"他一边说一边无奈地摇着头。
因此这位国家卫生部的部长沙曼诺夫 博士、席瑞科娃女士以及其他人制定了一个市场活动--这个活动大部分是由美国纳税人赞助的，钱通过美国国际开发署转交到联合国儿童基金会。
连环漫画的主角是一位戴头巾的十字军战士--碘人，讲述他从一个抓狂的老师手中营救一个反应迟钝的笨学生。连环画被分发到全国各地。
认被证过的含碘盐食品包装上的标志被设计成：一个圆圈中有一个红点和一条弧线。这个代表着一张笑容灿烂得连眼睛都找不到的笑脸。
席瑞科娃女士还介入当地妇女慈善网络。由于在前苏联所有国家中，人们对政府的建议都持怀疑态度，而民间组织却具有公信力。
志愿者们进入学校，请老师布置关于碘盐的听写练习，并让学生在科学课上测试自己家中拿来的盐是否含有碘。
席瑞科娃女士描述，有一个孩子得知自己是班级里唯一一个食用非碘盐的人后，禁不住哭了起来。
她提到，当时老师向这个孩子保证那绝不是他的错。"孩子们很快开始告诉父母要买好的盐。"她说。
一名女性志愿者去了巴士公司，转录下这家公司的"下一站"报站通知，并把它穿插在碘盐的宣传短片里。席瑞科娃女士说："她的声音很性感，男人们会告诉司机反复播放它。"
即使是蝉联多年冠军而红遍整个前苏联的英雄--国际象棋前世界冠军卡波夫（Anatoly Karpov）也加入到这场战役中。他在电视中向学生们建议："使用加碘盐，你长大后就会成为像我一样的大师。"
佐夫先生透露，卡波夫尤其擅长对付那些持敌对态度的记者，当记者提及他为什么不主张让人民自己选择碘盐或非碘盐时，卡波夫的回答另辟蹊径，他把这个问题比作每个家庭有权拥有两个水龙头，一个流出干净水，一个流出脏水。
到了2003年底，一会最终制定出强制加碘盐的法令。
咸海镇里的盐山
今天，在哈萨克斯坦中部地区的咸海（Aral）镇上隆起一座小型山脉。咸海（Aral）镇是一个衰落的工业区，那里曾经是咸海（Aral Sea）的海岸。咸海是一个盐湖，自从斯大林时代开渠灌溉农田项目开始后，盐湖已逐渐萎缩。
当车辆靠近后，那白色的尖峰就变成了一个由盐构成的小阿尔卑斯山--那就是咸海塔兹（the Aral Tuz）公司的储备。这里的盐已经被开采了几个世纪。现今，一条配有长长铁轨的联合开采机不断啃噬着旧海床10英尺厚的盐层，直到它被推行11英里回到盐厂进行清洗和沉淀。进入到包装车间之前，盐下落通过一个斜槽，在传送带之间输送的过程中，一个小泵喷洒出颗粒状的白色碘雾。这个步骤就这样简单，因此要不是穿着实验室白色工作服的妇女舀起样品，我们就错过了这一幕。
价值1.5万美元的水槽和喷雾器是联合国儿童基金会捐赠的。该基金会还同时提供碘酸钾。如今，咸海塔兹公司和另一个规模较小的竞争对手巴甫洛达尔盐业公司（Pavlodar Salt）购买了他们自己的设备。
当被问及儿童基金会报告中披露，咸海塔兹公司最初拒绝加碘的理由是担心会损失7%利润时，该公司总裁阿赫梅托夫（Ontalap Akhmetov）显得有些茫然。"我只担任了三年总裁。"他说道，"所以我对此一无所知。"他表示加碘的成本微乎其微："每吨只需几美分。"
哈萨克斯坦是幸运的。它的成功仅仅是政治和经济条件正确组合的结果：政治上的支持、98%的识字率、提高天然气和石油价格以便从经济上推动前进。也许最为重要的是咸海塔兹公司生产了80%的食用盐。
许多国家正是缺乏这样的组合，所以缺碘仍是一个健康�；１热�，邻国巴基斯坦，在这个70%家庭使用无碘盐的国家，有600多家小型的盐商。
马纳尔（Venkatesh Mannar）以前是印度盐商，如今领导渥太华的微量营养素倡议行动，该倡议旨在向全世界缺乏碘、铁和其他元素的食物中添加有营养价值的物质。马纳尔说： "如果一个国家有一个结构合理的食盐体系，那么只需两大型企业进行食盐加碘工程。如果全是大量的小型企业，就开展不了这项工程。"
现在哈萨克斯坦有了自己的法律，但席瑞科娃的志愿者们也没有放松警惕。她们去市场购买盐当场测试含碘量，以此推动这项运动的实施。政府培训海关人员检测进口食盐，同时在一些地区设置围栏防止人们私自挖掘盐。儿童们仍然会收到小册子和指导意见。
专家们一直认为这个国家不大可能重新陷入到疏于管理的境地。哈萨克斯坦共和国前卫生部长沙曼诺夫表示，调查发现，消费者非常清楚碘的作用，而且那个红白标志的影响力如此巨大，以至于食品生产商纷纷请求把它用到添加铁或叶酸的食品上。加碘盐产生了效果。1999年寻找发育不良儿童的调查中，从育龄妇女小样本尿液检测中发现60%达到碘次优水平。
营养学院实验室负责人奥斯帕诺娃（ Feruza Ospanova）说："我们刚完成一项还未公布的新研究。数据是零。"
