When Arnaud Laillou, a nutrition specialist with UNICEF, led a salt iodization study in 2014, he wanted to be sure that salt producers were not adding too much iodine.
Just four years earlier, UNICEF had stopped providing iodine to salt producers at the end of a decade-long, largely successful government-run iodization program.
Laillou was stunned to find that 90 percent of coarse salt and 40-50 percent of fine salt was now not iodized. And all of it was labeled as iodized.
“It was a real shock for us,” says Laillou of the findings of the paper that was published last year in the online journal Nutrients.
Serious public health problem
That paper said iodine deficiency in Cambodia had become “a serious public health problem” just years after the issue had largely been dealt with, and warned that poorer families and rural families were worst affected.
That was at odds with a study carried out three years earlier that showed salt producers were adding iodine, and that authorities were enforcing a 2003 subdecree that mandated iodization.
Iodine is essential to brain development and hormonal functions. If a pregnant woman is iodine-deficient, for example, her baby’s brain will not develop properly. The mineral is vital for brain development in children, too, and for proper hormone functioning in all ages. Iodine is so important that the World Health Organization has described iodine-deficiency as “the [world’s] single greatest preventable cause of mental retardation.”
Iodizing salt is widely regarded as one of the cheapest and most effective public health measures: it costs 2 cents per kilogram of salt.
Children hurt most
Iodine-deficiency, Laillou said, is particularly damaging for children.
“For example, Cambodia is investing a lot of money at the level of the Ministry of Education to improve the education of their children,” he said. “But having a lack of iodine in the brain, it decreases [their] IQ by 13 points.”
That, he points out, compares with the loss of three IQ points for a child who is not breastfed for the first six months of life.
In theory, adding iodine to Cambodia’s annual output of 80-100,000 tons of salt should be simple: close to 100 percent is produced by the SPCKK cooperative in the southern province of Kampot. SPCKK produces coarse salt, which it sells in bulk to middlemen who operate boilers that refine that into fine salt.
By law, SPCKK must iodize all of its salt output. But over the years several of the iodizing machines it was given have broken down, and SPCKK has not sourced spare parts. Now it has four working machines and that’s not enough.
And so, as SPCKK’s technical chief, Bun Narin told VOA, its workers often spray iodine by hand, a method that is at best imprecise.
“Large companies [outside Cambodia] use machines to monitor, whereas we are still using labor and so it’s not always accurate,” he said.
That is putting it mildly, given that Laillou’s research found 90 percent of the country’s coarse salt lacks any iodine. Despite that, SPCKK’s output is labeled as containing the mandated amount of iodine.
If boilers don’t test for the concentration of iodine in the coarse salt that they buy, and if, further along the production line, salt repackagers, like 57-year-old Koy Rithiya, don’t test for the concentration in the fine salt that they buy from the boilers and then add iodine where needed, the result is noniodized salt.
Which is exactly what has happened.
When Rithiya set up his business in Phnom Penh 15 years ago, he didn’t know he needed to add iodine; he started doing that a decade ago after being advised by UNICEF.
These days he uses an electronic monitor to test the concentration of iodine in the 500 kilograms of fine salt that he repackages each day, and adds iodine where needed to meet the mandated standard of 30-60 parts per million.
He doesn’t yet use the monitor to test his daily output of 400 kilograms of coarse salt; instead he relies on a test that merely shows whether iodine is present or not. That test, however, does not measure the concentration.
Rithiya reckons the problem of iodine-deficiency has emerged in part because some producers use expired iodine, “but also because some producers combine salt with iodine without correctly balancing it.”
“And some don’t bother to use it correctly,” he said.
A lack of enforcement
The report makes clear where the problem lies: on the production side is SPCKK, as well as some boilers and salt repackagers; on the enforcement side are the authorities for failing to ensure that producers follow the law.
The irony is that by 2010, the government’s program meant the health problems associated with iodine deficiency in Cambodia were largely a thing of the past. A decade earlier, nearly 1 in 5 primary school children had goiters, a condition where the thyroid in the neck swells up. Many adults did, too. By 2010, that was no longer the case.
But when iodine prices tripled after the 2011 Fukushima nuclear disaster in Japan, many salt producers in Cambodia stopped buying the additive, and the authorities failed to make sure they were iodizing. The result: a re-emergent public health issue that has, to date, remained largely invisible.
The situation, though bad, should start to improve. UNICEF is working with a government subcommittee to devise a certification standard for all producers, although that could take two years to implement.
Ven Keahak, who heads the subcommittee on salt iodization, says the new licensing system will mean producers “have to have a machine, iodine powder [in stock], a brand name, and salt with proper quality in order to get a license.”
“It’s a legal enforcement that the ministry has to conduct,” he said.
A lack of enforcement has been part of the problem, but Keahak would not comment on the failure of government agencies to apply the current law. He did confirm that no one has been prosecuted for failing to add iodine or for failing to monitor the system.
The difficulty for concerned Cambodians is that every bag of salt carries the logo stating that it is iodized. To deal with that, the Ministry of Planning will now test all salt brands and will place advertisements in newspapers to tell people which brands they can trust.
Until then, the failure to police the country’s salt output will keep damaging lives in what experts say was an entirely avoidable public health issue.