Events

Copenhagen Consensus gives top grades to Micronutrient Interventions

An Interview with Dr. Susan Horton

Over two years, more than 50 economists have worked to find the best solutions to ten of the world’s biggest challenges. [In May 2008] an expert panel of 8 top-economists, including 5 Nobel Laureates, sat down to assess the research.
The result: A prioritized list highlighting the potential of 30 specific solutions to combat some of the biggest challenges facing the world.
Combating malnutrition in the 140 million children who are undernourished reached the number one spot, after economist Sue Horton of Wilfrid Laurier University in Canada made her case to the expert panel.

Dr. Susan Horton is the lead author of the Copenhagen Consensus Challenge Paper on Hunger and Malnutrition along with Harold Alderman and Juan A. Rivera.

- Copenhagen Consensus Press Release, May 30, 2008

In July 2008, Lucie Bohac, Coordinator of the Network for Sustained Elimination of iodine Deficiency had the opportunity to interview Dr. Horton about the results of the Copenhagen Consensus. Here Dr. Horton meets Venkatesh Mannar, President of the Micronutrient Initiative.


How well aware were the panelists of iodine?
I don’t think anyone asked me specifically about iodine; probably the most interested party was Jagdish Bhagwati who is from South Asia. South Asian Economists tend to be more aware of the importance of nutrition than their North America colleagues. He asked very insightful questions. One of his questions referred to the challenges of simultaneous undernutrition/ over nutrition such as is found in India, where malnutrition and increasing rates of diabetes are both a challenge. 

How would you state the results of the Copenhagen Consensus in terms of the benefits of micronutrient interventions?
In terms of cost/benefit ratios there isn’t anything with such a high rate of return. There are hardly any other development priorities with such a high ratio as iodine. The estimated ratio is 30 to 1. And there is hardly anything else that you can invest in that gives you that kind of rate of return, because it’s so cheap to add the iodine and yet the economic consequences are so negative if in-utero children aren’t exposed to adequate iodine levels.

What differentiates the USI strategy to combat IDD from other micronutrient strategies and is this particular distinction part of the success factor? Is that what gives us such a great ratio of cost to benefit?
Salt has just turned out to be a really great vehicle. That’s also why there has been so much work done on the double fortified salt – salt carrying other nutrients. It was something that tended to be centrally processed, covering not 100% of households but probably 90 or so percent, the technology is really easy, the amount of iodine really small so it doesn’t discolor the salt or change the taste, people don’t notice and its thus it can be considered nearly an imperceptible intervention. Because of this salt iodization could be continued indefinitely, purchasers would be paying only slightly more, so it’s really like almost a perfect vehicle. The only issue now is with emphasis on decreasing salt usage because of what it does to hypertension, so you have to take that into account.
I know that an issue which the salt industry is particularly concerned about because salt iodization is not a promotion of an increase in salt usage but rather saying that the salt that is available for human consumption should be iodized. There is definitely work in public awareness that still needs to be done. Also, because adding of iodine is tightly controlled, it’s easy to adjust the levels, so if less salt is consumed that can be adjusted for.

How does Cost/Benefit differ from other economic comparisons?
Cost-effectiveness compares one health outcome across different health interventions. DALYs use a formula to include not only deaths averted but morbidity issues into a common measure. The advantage of this is that you don’t have to make assumptions into the worth of a human life and thus is very convenient for use in the health sector. Still, because it’s dealing with morbidity and mortality, it doesn’t allow you to compare health outcomes with other forms of investments such as education, water etc.
For the Copenhagen Consensus, challenge papers used cost/benefit. In the case of iodine, cost/benefit was not a challenge because outcomes could be thought of in dollars, in terms of the increase in productivity. It was more challenging with interventions such as Vitamin A where the issue is averting child mortality and thus one needs to get into what the cost of a human life is in order to come up with a benefit cost ratio.

Is the case for iodine deficiency less powerful because normally economic models don’t take into account the still births and premature abortions that aren’t normally calculated like the lives saved after birth?
No, because the case of cognitive benefits is so strong, so overwhelming, I think that says it all. People are more and more concerned about cognitive benefits thus it’s becoming a stronger and stronger case.

Even though cognitive impairments is more ephemeral than a physical manifestation of illness?
That’s true but, with globalization and increasing integration, you need educated workers to be able to participate in the market economy, in the global economy. You need it for the social benefit it provides, to allow you to participate in society, because if you don’t have education, you can’t participate, and at the same time it has a direct consequence on your economic living standard. 

Is there a way to create a link with cognitive impairments averted with educational achievement and GDP?
That’s actually not a particularly difficult challenge. I’ve had to do that myself with iron. For iron what you do is link a series of studies together to make the inferences, and luckily for iron, we’re now getting some longitudinal studies of iron completed. When you get these types of studies the information is very clear. We read, for instance, of the Institute of Nutrition of Central America and Panama(INCAP) studies where the kids get supplemented and 25 years later, we can see that some are taller and some are shorter and some are more likely to have jobs and all of those types of things. So if you have longitudinal studies, it really helps to validate the assumptions if you have to link together a series of cross-sectional studies. For iodine we don’t have those longitudinal studies, because iodine has mostly been used to fortify and not to supplement, and so it’s harder to find control groups.

In the labour market, are health outcomes in the developing world the greatest factor?
This is a hard question but no, I would say education is still the most important thing and, even in agriculture education is important because if you want to adopt new technology, education of the farm workers, being literate, has a dramatic effect. Yes, health is important but it’s harder to measure that than a person’s education. There’s definitely a correlation with health but not as strong an effect as you see with education. Clearly health feeds into education. We know kids who are malnourished and kids who are unhealthy miss years of school and don’t complete as much school, but the health effects are probably a little more indirect.

Over the past few years we have seen that as USI programs have matured and have been shown to be  sustainable, people begin to get ” IDD fatigue” and either think that the problem has been solved or start to forget about the need to maintain iodine nutrition . After all, it’s a deficiency, so if it isn’t maintained…
…you become victims of your own success. I think in vitamin A the same thing is happening because they’re finding it difficult to get above 70% coverage. Then some countries slip back and don’t continue their efforts and others come in, and the result is that the aggregate hasn’t gone up.
Folic acid is now going the same way and it’s having dramatic effects. Perhaps that’s one way of doing it; you use the success in other new fortifications and remind people of the story of iodine. Four countries have now instituted folic acid research programs and you can track the effect on neural tube defects and neuroblastoma. It’s just like iodine, it’s so cheap and yet the effects can be dramatic. Perhaps people should use that as a reminder.

What are the implications of the results for policy makers and is there any suggestion that the Copenhagen Consensus has swayed policy makers?
It normally takes a while for new research to make its way up to policy makers so at the moment we’re in the phase of trying to disseminate it. The participants of the challenge papers, such as myself, are making presentations, but the Copenhagen Consensus is also doing some follow up. They’ve asked the authors of the top six challenge papers to write articles that are really aimed at policy makers, involving not only the absolute numbers – the cost/benefit ratios – but also how you can implement the results in your own country. The plan is to take the papers not only to governments, but foundations, NGOs and use them that way.
This is also a good news story for Canada. Although there is a lot left to do, Canada has been one of the leading countries. A lot of the science is done here, Stan Zlotkin and the Sprinkles program, the work in double fortified salt, the research that I’m doing, and the Micronutrient Initiative’s work. CIDA has been really important for putting substantial funding into this. 

Are there any recommendations you’d like to make to the Network for its advocacy efforts in support of USI?
All the aid agencies right now are so concerned with results-based management and iodine is perfect because you have evidence where there is an economic cost/benefit ratio. Try and use that and formulate it so that people in results-based management can use it. It’s a little bit difficult because it sounds like you’re trying to defend an existing policy and people forget the immediacy of it. But it’s important that you don’t slip back.
Thank you Dr. Horton.

Dr. Horton is also Vice President Academic of Wilfrid Laurier University in Waterloo, Canada. She is an economist whose area of specialization is health and labour market issues in developing countries.
During the 2008/09 academic year she will work as Visiting Scientist with the Micronutrient Initiative in Ottawa, Canada. For more on the implications of the Copenhagen Consensus and Iodine, please see Copenhagen Consensus: Implications for Iodine in the August edition of the ICCIDD Newsletter (www.iccidd.org) which can be found at Iodine Network website (www.iodinenetwork.net).  
For more information about the Copenhagen Consensus or a copy of the Challenge Paper please visit www.copenhagenconsensus.com .