Delegates at the 76th World Health Assembly (WHA), the annual meeting of the World Health Organization, unanimously passed a resolution in 2023, urging countries to adopt food fortification practices to prevent severe birth defects. The resolution, adopted under the umbrella of the United Nations Decade of Action on Nutrition (2016–25), promises to address large-scale micronutrient deficiencies and avert preventable birth defects including spina bifida and other devastating disorders.
The resolution that passed last year, was the result of extensive advocacy by the Global Alliance for Prevention of Spina Bifida-F (GAPSBIF), led by co-founder Gail Rosseau, MD ’85, who serves as clinical professor of neurological surgery at her alma mater the George Washington University School of Medicine and Health Sciences (GW SMHS). Along with fellow neurosurgeon and GAPSBIF co-founder Jeffrey Blount, MD, MPH, from the University of Alabama-Birmingham, the group implemented a global campaign to raise awareness of the devastating disease, promoting passage of a resolution calling for folic acid fortification of staple foods.
“There are an estimated 214,000–322,000 pregnancies worldwide affected by spina bifida or anencephaly each year, these are neural tube defects where the spinal cord itself doesn’t close properly during the first month of gestation. As a result, children are born with cognitive, motor, and neurological deficits,” explained Rosseau.
“It is a preventable condition in the vast majority of cases, yet, until just recently, only a small percentage of countries have adopted folic acid and micronutrient fortification policies in their food supply systems,” she added.
Often referred to as “hidden hunger,” deficiencies in essential vitamins and minerals, specifically folate, iron, vitamin A, and zinc, affect 50% of all preschool aged children and 67% of all women of reproductive age worldwide. These deficiencies can cause devastating birth defects, blindness, fragile immune systems, and even death during childbirth. Iodine deficiency, still prevalent in many countries, impairs brain development in children, undermining their ability to learn and their eventual earning potential and productivity.
In nearly two-thirds of spina bifida cases, however, just a small amount of folic acid, also known as vitamin B9, in the diet could prevent the condition. By simply adding essential vitamins and minerals to staple foods and condiments, such as wheat and maize flours, rice, cooking oil, and salt, countries can have a significant effect on the incidence of these disorders.
Food fortification, or the practice of increasing the content of one or more vitamins or minerals to improve the nutritional quality of that food, is one of the most cost-effective public health interventions available. Walk through any grocery store in much of the industrialized world and you can spot dozens of products featuring micronutrient fortification to ward off disease. In the early 1920s, iodized salt was introduced to treat and prevent goiter. Vitamin D was added to milk in the early 1930s to reduce rickets in children. And, in the mid-1940s, Grand Rapids, Michigan, became the first community in the world to add fluoride to tap water following studies showing reduced rates of cavities among schoolchildren.
“The GAPSBIF group was relentless in advocating for children and families globally,” said Timothy Singer, MD, MS, a pediatrician trained in global health who put his practice on hold to complete an additional residency in neurological surgery at GW SMHS. “It started with a few dozen people on an email list. One by one, they strategically reached out to folks, figured out who had a connection here and who had a connection there to bring attention to folic acid fortification, country by country, and ultimately to the WHA.”
Their successful advocacy included stakeholder mapping, presentations to the executive committee of the WHA in Geneva, a social media campaign, and articles in nearly a dozen peer-reviewed journals, including a major review in the May 2022 edition of the Lancet Global Health.
“This resolution will accelerate the pace of global prevention of severe and fatal birth defects, support equitable food fortification in all countries, and assist countries in reaching their 2030 Sustainable Development Goals on child mortality and health equity,” the GAPSBIF authors wrote in the journal.
Joining the campaign calling for action were specialists from around the world, including pediatricians, urologists, nutritionists, epidemiologists, and other medical professions, as well as a number of non-governmental organizations.
The breakthrough occurred when the government of Colombia offered to serve as the primary sponsor of the resolution, and then reached out to other national representatives through their permanent mission at the WHO. “It was amazing,” Singer said. “Within a matter of months after that, there was a huge wave of global support.”
Ultimately Australia, Brazil, Canada, Chile, Ecuador, the European Union, Israel, Malaysia, and Paraguay joined Colombia to bring resolution to the floor of the assembly at the WHA.
“This began as an effort by surgeons who wanted to deliberately and strategically identify a surgical condition for which enlightened policy by the WHO could decrease or eliminate a global scourge,” Rosseau explained. “The successful passage of this resolution, and the inclusive advocacy efforts it represents, encourages our collaborators to continue to work together to highlight what must be done to reduce the unmet burden of surgical conditions worldwide.”
Now, Rosseau and the GAPSBIF team are working with ministries of health around the world to push for folic acid fortification policy implementation. The group acknowledges that success will not be easy as it will require overcoming years of delayed action. However, there is reason to have hope, as the authors wrote in their Lancet paper.
“These hurdles have resulted in more than four million preventable cases of spina bifida and anencephaly globally in the 30 years since the British Medical Research Council’s landmark trial publication providing unequivocal evidence on folic acid. There are sufficient, high-quality data on the safety and effectiveness of fortification for policymakers to swiftly implement fortification.”
“As countries around the world now change their practices, we should see rates of spina bifida and anencephaly finally begin to come down,” predicted Singer. “We anticipate significant benefits to children, families, and ultimately nations.”
