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."

    哈薩克斯坦的阿斯塔納--當瓦倫蒂娜·席瑞科娃（Valentina Sivryukova）聽到一個哈薩克小學生如何形容別人愚蠢時，她覺得她的公共服務信息宣傳成功了。那個孩子對另一個人嗤之以鼻地說："你怎么搞的啊！你腦子缺碘還是怎么啦？"

    席瑞科娃女士是哈薩克慈善機構全國聯盟主席，她聞聽此言喜上眉梢。這意味著多年來提高公眾認識碘鹽防止嬰兒腦損傷的努力起效了。一旦這項活動取得成果，那么哈薩克斯坦全國人民的智力水平就有了保障。

    實際上，哈薩克斯坦這個亞洲內陸國家為各國提供了一個范例，它表明即使幅員遼闊的發展中國家也能在公共衛生方面取得一個顯著的成功。1999年，哈薩克斯坦全國只有29%的家庭使用加碘鹽，而現在這個數字是94%.預計明年（2007）,聯合國會正式宣布哈薩克斯坦不再是缺碘的國家。

    但這個轉變并非一帆風順。公共衛生專家表示，雖然往食鹽中加碘是全世界最簡單和最有效的健康措施，但哈薩克的這一運動不得不克服許多地方普遍存在對碘的質疑。每噸食鹽需要添加兩盎司的碘酸鉀，成本為1.15美元左右。

    全球大約有20億人，即全世界三分之一的人口攝碘量極低，包括中國和印度的數億人在內。研究顯示，缺碘是智力發育遲緩的一個主要但可預防的因素。尤其是孕婦和嬰兒，即便只是中度缺碘，也會導致智力降低10到15個智商（IQ）點，這削弱了一個國家發展不可估量的潛力。

    最明顯和最嚴重的后果是殘障性甲狀腺腫、呆小病和侏儒癥。雖然這些疾病只發生在極少數通常住在山區的人身上，但全世界16%的人至少都有輕度甲狀腺腫--即頸部的甲狀腺腫大。

    1985年，為了支持加碘運動，全世界350多位科學家組成了控制碘缺乏病國際理事會（the International Council for Control of Iodine Deficiency Disorders）,杰克·林（Jack C. S. Ling）是該理事會主席，他說："如果母親知道缺碘會影響胎兒的發育，哪怕傾家蕩產，她也要買到碘。你看看有哪個母親不這樣做呢？"

    1990年，世界兒童問題首腦會議（World Summit for Children ）提出，到2000年消除碘缺乏。隨后，林教授的組織和聯合國兒童基金會（Unicef）、WHO、吉瓦尼斯國際（Kiwanis International）、世界銀行（ World Bank ）以及加拿大、澳大利亞、荷蘭、美國等外國援助機構共同努力。

    就在公眾毫無察覺的情況下，他們取得了驚人的進步：1990年，全世界25%的家庭使用加碘鹽。而現在，這個數字是66%.

    但近來這項努力無法得以繼續。到了2005年，消除碘缺乏的目標還沒有實現時，捐贈人開始失去興趣，而轉向AIDS、禽流感和其他更受到關注的威脅。

    而且，所有這類運動的花費超出預期。1990年預測的費用為7500萬美元--這比消滅脊髓灰質炎（小兒麻痹癥）的花費要便宜許多，后者已經耗費了40億美元。

    根據碘理事會的執行主任哈克斯頓（David P. Haxton）介紹，從那以后的實際費用大約為1.6億美元，包括吉瓦尼斯國際捐助的8千萬美元和蓋茨基金會捐助的1.5千萬美元，以及不知名的捐款，全都被鹽業公司用于購買新設備。

    哈克斯頓說："這種事情經常發生：當我在會議上和某個鹽商談論加碘的事，他往往并不知道自己的產品有這種影響力。他會對我說，'你干嘛不早點告訴我啊？我當然會做的。我立刻就會這么做的。"

    像日本等許多地方，人們通過食用海鮮、海藻得到碘，還可以從生長在高碘土壤里的蔬菜或食草動物那里得到碘。但即使像美國和歐洲等地的發達國家，仍舊需要通過加碘鹽來補充碘。

    專家表示，碘的價格在降低。開支總是不可避免的成為公共關系戰爭。

    在一些國家，碘化作用成為政府陰謀破壞生活必需品內的幫兇--鹽專家認為這與美國二十世紀50年代保守人士強烈反對在水中添加氟化物的情況相同。

    另一些國家，國內的自由主義者要求有選擇無碘鹽的權利，結果碘化鹽幾乎難以惠及窮人。一些不愿承擔額外成本的小型鹽商經常游說反對加碘鹽。而擔心失去市場的碘片劑生產商也反對加碘鹽。

    謠言自然四處流傳：碘被說成是艾滋病、糖尿病、癲癇、陽痿和過敏的罪魁禍首。根據不同國家謠言工廠的不同版本，碘鹽被描繪讓泡菜爆炸、破壞魚子醬或軟化硬質奶酪。

    沖破這種阻礙不僅需要資金還需要領導才干。

    杰拉德·巴洛（Gerald N. Burrow）博士是耶魯大學醫學院前任院長，也是碘理事會副主席，他說："每年每人只需5美分，你就可以讓整個人口變得比以前聰明。"

    "這肯定對國家有益。但你需要一個有政治意愿做此事的政府。"

    兒童發育不良的"丑聞"

    二十世紀90年代，當碘化運動開始時，全球碘缺乏國家最集中的區域是中亞內陸的前蘇聯加盟共和國。

    哈薩克斯坦，土庫曼斯坦，塔吉克斯坦，烏茲別克斯坦、吉爾吉斯坦--隨著前蘇聯的解體，所有這些國家遭遇了經濟崩潰。上述整個區域，只有28%的家庭使用碘鹽。

    亞歷克山大·佐夫（Alexandre Zouev）是哈薩克斯坦兒童基金會的首席代表，他說："隨著整個體制的崩潰，之前的一切被全盤否定，食鹽加碘只是其中之一。"

    沙曼諾夫（Toregeldy Sharmanov）博士在1971至1982年期間曾擔任哈薩克斯坦共和國的衛生部長，當時的哈薩克斯坦屬于蘇聯。他表示，即使在當時，缺碘的問題也很嚴重，但他無法修改政策，因為那是莫斯科制定的。

    "與俄羅斯同齡兒童相比，哈薩克的兒童發育不良。"他說，"但他們熟視無睹。這是一件丑聞。"

    1996年，重點關注兒童健康的聯合國兒童基金會在哈薩克斯坦成立了第一家辦事處，籌備對5000戶家庭的調研工作。調查發現10%的兒童發育不良，由此為國際援助開辟了通道。（發育不良的原因有多種，但碘缺乏是罪魁禍首。）

    在相鄰的土庫曼斯坦，總統尼亞佐夫（Saparmurat Niyazov）是一個專制者，他規定所有的鐘表上都必須刻有他的肖像，還把一周7天的名稱前冠以其家人的名字。1996年，這位總統解決問題的方式就是直接宣布無碘鹽為非法，而且規定商店每年以公費的方式給每位公民11磅碘鹽。

    在哈薩克斯坦，有民主信譽的總統納扎爾巴耶夫（Nursultan A. Nazarbayev）自1991年以來執政至今。盡管已經受到批評，但他不會用法令來強制規定。"那種日子已經一去不返了，"哈薩克慈善聯合會主席席瑞科娃女士說，"現在的企業已私有化。他們不會理睬總統的命令。"

    不過重要的是，總統表示支持。但即便如此，當2002年議會開始討論強制性加碘時，反對這項措施的強大游說隊伍一下子形成了。

    聯合國兒童基金會在一份報告中透露，最初這個國家最大的鹽業公司由于擔心增加成本而不愿合作。同時，心臟病學家也擔心這會鼓勵人們使用更多的鹽，所以極力反對加碘鹽。沙曼諾夫指出，銷售碘片劑的私人公司更是暗中作梗。

    "這些公司在大眾傳媒上大肆宣傳他們的產品，還宣稱碘鹽是有害的。"他一邊說一邊無奈地搖著頭。

    因此這位國家衛生部的部長沙曼諾夫 博士、席瑞科娃女士以及其他人制定了一個市場活動--這個活動大部分是由美國納稅人贊助的，錢通過美國國際開發署轉交到聯合國兒童基金會。

    連環漫畫的主角是一位戴頭巾的十字軍戰士--碘人，講述他從一個抓狂的老師手中營救一個反應遲鈍的笨學生。連環畫被分發到全國各地。

    認被證過的含碘鹽食品包裝上的標志被設計成：一個圓圈中有一個紅點和一條弧線。這個代表著一張笑容燦爛得連眼睛都找不到的笑臉。

    席瑞科娃女士還介入當地婦女慈善網絡。由于在前蘇聯所有國家中，人們對政府的建議都持懷疑態度，而民間組織卻具有公信力。

    志愿者們進入學校，請老師布置關于碘鹽的聽寫練習，并讓學生在科學課上測試自己家中拿來的鹽是否含有碘。

    席瑞科娃女士描述，有一個孩子得知自己是班級里唯一一個食用非碘鹽的人后，禁不住哭了起來。

    她提到，當時老師向這個孩子保證那絕不是他的錯。"孩子們很快開始告訴父母要買好的鹽。"她說。

    一名女性志愿者去了巴士公司，轉錄下這家公司的"下一站"報站通知，并把它穿插在碘鹽的宣傳短片里。席瑞科娃女士說："她的聲音很性感，男人們會告訴司機反復播放它。"

    即使是蟬聯多年冠軍而紅遍整個前蘇聯的英雄--國際象棋前世界冠軍卡波夫（Anatoly Karpov）也加入到這場戰役中。他在電視中向學生們建議："使用加碘鹽，你長大后就會成為像我一樣的大師。"

    佐夫先生透露，卡波夫尤其擅長對付那些持敵對態度的記者，當記者提及他為什么不主張讓人民自己選擇碘鹽或非碘鹽時，卡波夫的回答另辟蹊徑，他把這個問題比作每個家庭有權擁有兩個水龍頭，一個流出干凈水，一個流出臟水。

    到了2003年底，一會最終制定出強制加碘鹽的法令。

    咸海鎮里的鹽山

    今天，在哈薩克斯坦中部地區的咸海（Aral）鎮上隆起一座小型山脈。咸海（Aral）鎮是一個衰落的工業區，那里曾經是咸海（Aral Sea）的海岸。咸海是一個鹽湖，自從斯大林時代開渠灌溉農田項目開始后，鹽湖已逐漸萎縮。

    當車輛靠近后，那白色的尖峰就變成了一個由鹽構成的小阿爾卑斯山--那就是咸海塔茲（the Aral Tuz）公司的儲備。這里的鹽已經被開采了幾個世紀。現今，一條配有長長鐵軌的聯合開采機不斷啃噬著舊海床10英尺厚的鹽層，直到它被推行11英里回到鹽廠進行清洗和沉淀。進入到包裝車間之前，鹽下落通過一個斜槽，在傳送帶之間輸送的過程中，一個小泵噴灑出顆粒狀的白色碘霧。這個步驟就這樣簡單，因此要不是穿著實驗室白色工作服的婦女舀起樣品，我們就錯過了這一幕。

    價值1.5萬美元的水槽和噴霧器是聯合國兒童基金會捐贈的。該基金會還同時提供碘酸鉀。如今，咸海塔茲公司和另一個規模較小的競爭對手巴甫洛達爾鹽業公司（Pavlodar Salt）購買了他們自己的設備。

    當被問及兒童基金會報告中披露，咸海塔茲公司最初拒絕加碘的理由是擔心會損失7%利潤時，該公司總裁阿赫梅托夫（Ontalap Akhmetov）顯得有些茫然。"我只擔任了三年總裁。"他說道，"所以我對此一無所知。"他表示加碘的成本微乎其微："每噸只需幾美分。"

    哈薩克斯坦是幸運的。它的成功僅僅是政治和經濟條件正確組合的結果：政治上的支持、98%的識字率、提高天然氣和石油價格以便從經濟上推動前進。也許最為重要的是咸海塔茲公司生產了80%的食用鹽。

    許多國家正是缺乏這樣的組合，所以缺碘仍是一個健康危機。比如，鄰國巴基斯坦，在這個70%家庭使用無碘鹽的國家，有600多家小型的鹽商。

    馬納爾（Venkatesh Mannar）以前是印度鹽商，如今領導渥太華的微量營養素倡議行動，該倡議旨在向全世界缺乏碘、鐵和其他元素的食物中添加有營養價值的物質。馬納爾說： "如果一個國家有一個結構合理的食鹽體系，那么只需兩大型企業進行食鹽加碘工程。如果全是大量的小型企業，就開展不了這項工程。"

    現在哈薩克斯坦有了自己的法律，但席瑞科娃的志愿者們也沒有放松警惕。她們去市場購買鹽當場測試含碘量，以此推動這項運動的實施。政府培訓海關人員檢測進口食鹽，同時在一些地區設置圍欄防止人們私自挖掘鹽。兒童們仍然會收到小冊子和指導意見。

    專家們一直認為這個國家不大可能重新陷入到疏于管理的境地。哈薩克斯坦共和國前衛生部長沙曼諾夫表示，調查發現，消費者非常清楚碘的作用，而且那個紅白標志的影響力如此巨大，以至于食品生產商紛紛請求把它用到添加鐵或葉酸的食品上。加碘鹽產生了效果。1999年尋找發育不良兒童的調查中，從育齡婦女小樣本尿液檢測中發現60%達到碘次優水平。

    營養學院實驗室負責人奧斯帕諾娃（ Feruza Ospanova）說："我們剛完成一項還未公布的新研究。數據是零。"