# Our ongoing review of ICCIDD

The International Council for the Control of Iodine Deficiency Disorders Global Network (ICCIDD) advocates for and assists programs that fortify salt with iodine. Our preliminary work (writeup forthcoming) implies that even moderate iodine deficiency can lead to impaired cognitive development.

ICCIDD tracks iodine deficiency around the world and encourages countries with iodine deficient populations to pass laws requiring iodization for all salt produced in and imported to the country. ICCIDD also provides – and helps countries find – general support and assistance for their iodization programs.

In February, we wrote that we were considering ICCIDD for a 2014 GiveWell top charity recommendation. We’ve now spent a considerable amount of time talking to and analyzing ICCIDD. This post shares what we’ve learned so far and what questions we’re planning to focus on throughout the rest of our investigation. (For more detail, see our detailed interim review.)

ICCIDD has successfully completed the first phase of our investigation process and we view it as a contender for a recommendation this year. We now plan (a) to make a $100,000 grant to ICCIDD (as part of our “top charity participation grants,” funded by Good Ventures) and (b) continue our analysis to determine whether or not we should recommend ICCIDD to donors at the end of the year. Reasons we prioritized ICCIDD We prioritized ICCIDD because of our impression that iodization has strong evidence of effectiveness, cost-effectiveness, and room for more funding. The evidence of effectiveness for salt iodization is not fully straightforward – we plan to publish an intervention report with details before the end of the year – but multiple randomized controlled trials imply that reducing iodine deficiency in children leads to moderate (~3-4 points) gains in IQ. We have yet to find well-documented assessments of the cost of iodization, but the estimates we have seen most commonly estimate approximately$0.10 per person reached.

Although iodization rates have increased dramatically over the past 20 years, significant deficiency still exists. ICCIDD publishes a scorecard showing countries’ iodine status; many fall significantly below the benchmark of 100 µg of iodine per liter of urine.

Questions we hope to answer in our ongoing analysis

What would have happened to iodization programs in ICCIDD’s absence?

Because ICCIDD is an advocacy/technical assistance organization (it does not directly implement iodization programs but advocates that others do so), it is difficult to assess its impact.

ICCIDD has provided us with several examples of countries in which it believes it played an essential role (some of which we discuss briefly in our interim review page), but we have not yet investigated these cases sufficiently to form a confident view about what role ICCIDD played and how crucial its contributions were to the program.

What role does ICCIDD play relative to other organizations that work on iodization?

A number of organizations support government and private-sector salt iodization programs, especially UNICEF, the Global Alliance for Improved Nutrition (GAIN), and the Micronutrient Initiative.

We hope to better understand the roles each organization plays so that we can formulate a view about where donated funds are likely to have the greatest impact. (We’re considering the possibility that funds donated to any should be thought of as “supporting the international effort to support iodization” and that the important question is assessing the combined costs and impacts of all 4 organizations.)

We are also considering GAIN for a 2014 GiveWell recommendation. We do not expect our decision about GAIN to affect the likelihood of ICCIDD receiving a recommendation.

Program monitoring

Surveys to assess iodine consumption and status are completed more than once a decade in most countries, and are usually conducted by country governments or UNICEF. We have yet to analyze these surveys carefully enough to know whether or not they provide a reliable assessment of the track record of iodization programs: i.e., do iodization programs lead to a reduction in iodine deficiency?

Room for more funding

We have seen strong evidence that ICCIDD is funding constrained. It told us that its staff members have, over the past few years, consistently submitted requests for funds that are significantly higher than it is able to allocate. Additionally, ICCIDD lost what had been its largest funder in 2012. It has also shared an overall budget with us requesting significantly more funding than it has received in the past.

Nevertheless, we have two major questions about room for more funding:

1. Given iodization’s cost-effectiveness and track record, why haven’t others closed the funding gap? We have been told that the lack of funds may be due to “donor fatigue” (i.e., donors have supported iodization in the past and iodized a large proportion of the countries in need, so they no longer view it as a priority), but we have yet to investigate this question sufficiently to feel comfortable with our understanding.
2. Will ICCIDD’s future activities be as cost-effective as past attempts to increase iodization rates? One possible explanation for the lack of donor funds is that the countries that remain iodine deficient are particularly problematic. Were this true, it might be the case that donors are acting rationally because future efforts to iodize could be significantly more costly than past efforts.

Note that previously the Gates Foundation made a \$40 million grant to support universal salt iodization (USI) in 16 countries over seven years. That grant ends in March of 2015 and no extension of the grant has yet been scheduled.

• I think iodization is still extremely important. And it’s not just about IQ. I grew up in one of the ‘goiter belts’ (Southern Germany) in the 60s before iodized salt was common and many people had goiters. I was prescribed iodized salt in my teenage years because I was growing one as well.

One problem with this issue is, that some salt is now not only iodized, but also fluorinated which makes no sense: fluoride contributes to low iodine levels. That becomes a huge point for confusion for people. Plus there is a substantial push against fluoride in drinking water and supplementation.

Perhaps if this problem was more clearly explained then people would see the difference: that iodine supplementation in salt is good, but fluoride supplementation in salt is not a good idea.

Another aspect: where does the iodine come from? Does it come from industrial waste products, like the fluoride does?

Leaving all these questions and issues unanswered and undealt with will sooner or later contribute to lower donations to such an important cause.

• Toby Ord on August 1, 2014 at 6:04 am said:

Timothy,

That’s a great preliminary report. It is very important to know about any fortification opportunities given its high cost-effectiveness. I’m really looking forward to the final reports on ICCIDD and GAIN.

• Timothy Telleen-Lawton on August 6, 2014 at 12:55 pm said: