Despite widespread knowledge that folic acid early in pregnancy can reduce the incidence of neural tube defects such as spina bifida, effective distribution of this vitamin remains an important global health challenge. Particularly in developing countries, folic acid deficiency abounds. In Nicaragua, neural tube defects occur with an almost fivefold higher incidence than in the United States. To reduce these high rates, the Nicaraguan Ministry of Health passed a law last July mandating national fortification of rice—a staple—with folic acid. The new legislation was a consequence of efforts led by my former classmate Payam Bokhoor and me over the course of a year through a volunteer organization we belonged to at UCLA, called Project Nicaragua.
Student-run Project Nicaragua aims to improve the quality of treatment of patients with spina bifida. Since 2005, members have been making regular summer visits to Nicaragua’s primary neurosurgical hospital, Hospital Lenin Fonseca, where they have delivered necessary resources to the poverty-stricken hospital, including neurosurgical drills, neurosurgery textbooks, soap, gloves and diapers. When I joined the organization last year, I wondered why Nicaragua had such a high incidence of spina bifida in the first place, and so I proposed a journal club to my friend Payam to help us better understand this question. I never imagined our work would lead to a change in national policy.
As a part of our journal club meetings, Payam and I assigned specific discussion topics each week and invited Project Nicaragua members to study these topics as well as share their findings with the group. We learned a great deal about the major causes of neural tube defects. Moreover, through data I collected from Nicaraguan pediatrician Dr. Mejía Baltodano, we were able to determine that folic acid deficiency is the primary cause of these defects in the country.
Our team’s later meetings served to elucidate the potential solutions to this problem. With the support of our mentor, Dr. Onyebuchi Arah, an expert in epidemiology and global health, we proposed the fortification of rice with folic acid as a measure to control the epidemic.
Although the Nicaraguan Ministry of Health has offered folic acid supplements to pregnant women seeking prenatal care, the supplements often reach them too late. The neural tube of a developing embryo closes around the fourth week of gestation, but national surveys showed that on average pregnant women receive prenatal care and the accompanying supplements between the third and fourth month of pregnancy. To make matters worse, even though the Ministry of Health recommends 400 micrograms of folic acid before conception, public health education on the importance of folic acid is poor and distribution of supplements is unreliable.
Fortification of rice, which is consumed by 98 percent of the Nicaraguan population, provides a cheap and effective strategy for the national distribution of folic acid. It also circumvents the challenges of distributing supplements and educating the public. Fortunately, the fortification of rice will add only 1 to 2 percent to the cost of rice in the country, very inexpensive when one considers that the program is expected to decrease the incidence of neural tube defects by at least 60 percent.
In my effort to advocate for rice fortification, I contacted Dr. Antonio Largaespada, the former director of nutrition for the Ministry of Health. He was impressed by how carefully we had studied the problem. In June 2009, he organized a conference on the topic at UNAN Managua, a major university in the capital, inviting me to speak about the rice fortification proposal. Present at the conference were representatives from the Ministry of Health, faculty and administrators from the university and a representative from an American nongovernmental organization called PATH that fortifies rice.
At the conclusion of about a week and a half of additional advocacy efforts, Payam and I met with the university’s academic vice rector, Dr. Gustavo Siles, and our Nicaraguan collaborator, Dr. Antonio Largaespada, and together we crafted a letter to the Nicaraguan Minister of Health petitioning national fortification of rice with folic acid. The ministry ultimately considered the proposal worthwhile, and about one month later, the law was passed.
Looking back, I still find it remarkable that a single well-intentioned question could prove so powerful when the answer is passionately pursued.
The following members of Project Nicaragua also merit special recognition for their contributions to this project: Samuel Choi, Iman Zahedi, Ravi Menghani, Allyn Auxiliadora Ly, Cynthia Gutierrez, and Najib Ussef.
