A Simple Matter of Salt: An Ethnography of Nutritional Deficiency in Spain

University of California Press

A simple, timely action in the 1920s—the iodization of ordinary table salt—would have made the writing of this book unnecessary. But people in iodine-deficient regions of Spain needlessly suffered until the early 1980s, and in many regions of the globe continue to suffer, the chronic and often degenerative consequences of endemic goiter and cretinism. These are the two most well-known manifestations of the set of diseases coming to be known as iodine deficiency disorders, or IDD. A nutrition deficiency disease, IDD is manifested in a wide spectrum of afflictions that iodized salt is effective in preventing.

While the iodization of salt is a simple matter, the reasons for the failure to adopt this measure are complex. It is my task here to contribute to our understanding of health systems and medical care by explaining the complex of reasons that account for such inaction or delay.

The number of victims needlessly afflicted with IDD in Spain over these sixty years is not, even in that country, small. Over this time span, we conservatively estimate at least 10 million Spaniards to have been at risk of IDD; 50,000 have been sufficiently afflicted to have sought treatment.1

But inaction and delay have much wider—indeed worldwide—implications. For the failure to take the preventive action here examined is, in respect to IDD and a host of other preventable diseases, repeated over and over again, year after year, in country

after country. According to the most recent United Nations estimate, 800 million people around the globe are at present at risk of IDD (Hetzel 1989). This "simple matter" has very large implications indeed.

We have long known how to prevent the conditions, endemic goiter and cretinism, discussed in this work. Likewise, we have long known how to prevent other nutritional diseases such as pellagra and scurvy, obesity, adult onset diabetes, or the heart disease associated with a high cholesterol diet. More recently, we have learned how to control infant diarrhea with an extraordinarily simple measure also involving salt, but we have managed to propagate that technique to only one-fourth of the world's parents in need of it. We have also long known how smoking is associated with lung disease and how poverty and teenage pregnancy are associated with low infant birth weight, retardation, and other birth defects. But, as in the case of iodine deficiency in Spain, using our knowledge of prevention straightforwardly and to maximum effect has not been easy.

Take the example of our own society. It is our paradoxical tendency to spend very large sums on therapeutic high-technology intervention while neglecting to take preventive action. While the case reported here happens to have taken place in another country, the lessons that can be drawn from it are more widely applicable. The lessons are applicable on a global scale.

Today's newspaper headline, as I write this introduction, offers an instance of these problems:

HOSPITALS OVERWHELMED AS POOR IN NEW YORK CITY SEARCH FOR CARE

At its roots [it is] a crisis of a public-health system that regularly produces advances in medical procedures but cannot adapt itself to meet the most basic health needs of the poorest and weakest. . . . The crisis will not be solved by more beds. Unless there is a concomitant expansion of other services we will simply perpetuate a system in which expensive hospital-based technological interventions are substituted for more appropriate primary-care services.2

Here at home in the midst of our greatest city, in a cultural context different from the one reported in this book, is the problem we examine: the misdirection and misapplication of high-technology medical knowledge at the expense of low-technology primary care and prevention. The result of such misapplication of knowledge and resources is needless affliction.

Compared to the dramatic applications and cost of high-technology therapeutics, matters having to do with "primary care" may seem uninspiring. Typically, they involve education, immunization, monitoring and social support, and dietary or behavioral adjustments. It is not the stuff of high drama. Nor are such matters likely to seem the answer when, as in the American case, an infectious, life-threatening disease such as AIDS befalls us. Yet we continue to learn only belatedly, after years of affliction, how crucial preventive measures can be. Indeed, in the case of AIDS, they, for the moment, offer the only hope.

Most often, such low-technology measures are the most effective means of preventing or limiting the spread of chronic, endemic, and nutritional diseases. These, as in the case of iodine deficiency and other kinds of easily preventable disorders, assail hundreds of millions routinely as a part of daily life. Whether for our own sake or for the sake of the vulnerable millions in the less affluent parts of the world, we need to understand better the obstacles to prophylactic thinking and prophylactic action. By analyzing a case history of endemic goiter and cretinism, this work seeks to contribute to that understanding.

In this work, I seek to explain inaction—the sixty-year delay in eradicating endemic goiter and cretinism in the village of Escobines and the parish of El Texu, a set of mountain communities in Asturias, a province of northern Spain. The knowledge gained in these mountain communities is set within the larger Spanish context and ultimately within a global context.

The case examined here illustrates, as I say, the wider phenomenon of inaction—the passive toleration of noninfectious, readily preventable diseases, chronic or endemic, that seem to exempt urban Westerners from their threat. Hence, this study is concerned with two larger issues: the diffusion of prophylactic techniques and knowledge and the generation of political will to employ that knowledge effectively.

There are many other conditions that merit the kind of attention given here to endemic goiter and cretinism, or IDD. Among these conditions are infant malnutrition, smoking, alcohol consumption, and overeating. What we learn of the twentieth century's passive toleration of IDD can help us understand these broader problems.

The iodine prophylaxis that at a mass level is capable of safely and effectively preventing endemic goiter and cretinism became feasible in the early 1920s. Knowledge of it came to the attention of the medical community, heads of state, and the American public during the peak years of the "prophylactic era"—from about 1920 to 1934. It was an era during which prophylactic programs were initiated in Switzerland and the United States and the virtues of iodine prophylaxis were widely discussed in popular literature as well as in professional journals.

Popularly, it was well known that Asturias and many other mountainous provinces of Spain had for many generations been afflicted by endemic goiter and cretinism, but it was during the prophylactic era that knowledge of these endemic disorders in Spain was inserted into the national and international medical record. The breadth...