World Health Assembly Resolution for Preventing Micronutrient Deficiencies and Associated Neural Tube Defects — The Power of Partnerships

A Birth Defects Insights Blog

by Vijaya Kancherla, PhD, Chair, Public Affairs Committee, Society for Birth Defects Research and Prevention

Wheat growing in a field

A companion webinar discussing the way forward will take place May 2, 2024. For more information or to register, click here.

On May 29th, 2023, at the 76th World Health Assembly (WHA), member nations unanimously adopted the resolution entitled: Accelerating efforts for preventing micronutrient deficiencies and their consequences, including spina bifida and other neural tube defects, through safe and effective food fortification. This resolution comes thirteen years after the 63rd WHA resolution which provided recommendations on birth defects surveillance, research, prevention, and clinical care aspects to WHA member nations. Both resolutions have brought attention to birth defects globally. Through the WHA resolutions, countries are made aware of the issues related to birth defects, and recommendations are provided on addressing inequities and gaps in surveillance, research, and prevention, while improving the clinical care and quality of life of those affected, no matter where one is born or resides.

The Society of Birth Defects Research and Prevention (BDRP) published a resolution ten years ago supporting mandatory fortification of staple foods with folic acid and recommendations aiming to achieve global total prevention of folate-sensitive spina bifida and anencephaly globally by the year 2024. On this 10th anniversary of the Society’s resolution, the goal has not been achieved yet. Another global push for the cause comes from the 76th WHA resolution.

The success of the 76th WHA resolution on food fortification with micronutrients was a direct result of well-organized and strategic advocacy by multiple organizations invested in global nutrition and maternal and child health. Typically, WHA resolutions can take many years to be introduced and passed by the assembly. However, the food fortification resolution was passed in just two years. The push behind this success is the powerful partnership between academia, the medical community, patient advocacy groups, governmental and non-governmental organizations, civil society organizations, professional scientific societies, and policy makers. This blog presents a case study and the roadmap for how a WHA resolution related to birth defects prevention came to be adopted, and how partnerships worked effectively to build the momentum and reach the goal in a short span of time.

The Global Alliance for Prevention of Spina Bifida-F (Folic acid-preventable spina bifida) (GAPSBiF) was seeded with a conversation over tacos in Austin, Texas in 2015. Dr. Godfrey Oakley (BDRP member and Director of the Center for Spina Bifida Prevention at Emory University), and two neurosurgeons, Dr. Jeff Blount (Children’s of Alabama in Birmingham) and Dr. Bermans Iskandar (University of Wisconsin), connected in Austin while attending a research conference. Dr. Oakley invited Dr. Blount to lunch and discussed the willingness of pediatric neurosurgeons becoming leaders in science-based advocacy for food fortification with folic acid to prevent neural tube defects associated with maternal folate insufficiency. Passionate about preventing birth defects, they continued discussions on building a larger partnership to make an impact. The first set of partners consisted of the Center for Spina Bifida Prevention at Emory and a group of neurosurgeons, led by Drs. Jeffrey Blount and Gail Rosseau (George Washington University). Neurosurgeons perform the life-saving spinal closure surgery for spina bifida as soon as the baby is born, so they see the condition and its serious impact on the baby and family up close. With the knowledge that food fortification with folic acid effectively prevents many cases of spina bifida, and that there are thousands of preventable spina bifida cases around the world, GAPSBiF initiated its work for primary prevention with great zeal. Also, many countries where there is a high prevalence of spina bifida lack enough neurosurgeons to treat spina bifida cases promptly after birth, which leads to death of the baby or life-long health complications and disability. These neurosurgeons deeply valued primary prevention where possible as a solution. With BDRP members Dr. Godfrey Oakley and me, Vijaya Kancherla (birth defects epidemiologist and faculty at Emory University Rollins School of Public Health), the neurosurgeon team initiated strategizing prevention efforts, and founded GAPSBiF in 2019.

Drs. Blount and Rosseau, through their leadership, expanded GAPSBiF by bringing together clinical, nutrition, and public health communities. The group grew over the next few months, opening the opportunity for many stakeholders to join the advocacy effort, largely conducted through bi-weekly Zoom meetings. The number of national and international members soon exceeded the expectation, reaching over 100. The Zoom meetings included clinicians not only from neurosurgery, but outside the field (e.g., pediatricians, urologists, general surgeons), patient organizations (International Federation for Spina Bifida and Hydrocephalus), epidemiologists, health policy and public health professionals, civil society, nutrition organizations, and public health students. Meetings lasted for an hour discussing actionable plans, and everyone went to work on the cause until the next meeting. There was a deep interest, a sense of purpose, and each member had a role to play.

The partners showcased many complementary strengths and voices, all powerful in successful advocacy efforts with a shared goal to accelerate the slow pace of prevention of spina bifida worldwide. Among the first steps taken to reach the goal was the July 2022 publication of a paper in The Lancet Global Health, to reach policy makers and influential change agents. This paper made an urgent call to action for food fortification with folic acid to prevent birth defects, save lives, and promote health equity. Partners worked tirelessly and penned many other simultaneous call to actions using different avenues, including a resolution by the International Society for Pediatric Neurosurgery, helping create the needed momentum; first, for introducing the resolution at the 75th WHA in May 2022, and then, for passing it in May 2023 at the 76th WHA — a record short span of one year. The Global Alliance for Surgical, Obstetric, Trauma and Anesthesia Care (G4 Alliance), an organization with previous experience in passing other successful WHA resolutions, played a key role in bringing advocates and policy makers under one roof, and providing a fertile ground for discussions about the food fortification resolution. The G4 Alliance and partners shared important experiential learnings. Another key voice and strength to the effort came from the International Federation for Spina Bifida and Hydrocephalus (IFSBH), the representative organization of people with spina bifida and hydrocephalus and their families worldwide. For over 45 years, IFSBH worked together with its members and partners from the public, civil and private sectors to advance actions on safe and effective food fortification. In addition to the global efforts and network, local chapters of IFSBH met with policy makers in their respective countries to advocate for the upcoming resolution at the WHA.

Partners at the Walk the Talk Event
GAPSBiF and G4 Alliance partners, including Vijaya Kancherla, participating in “Walk the Talk” event, promoting the food fortification resolution, at the World Health Assembly, Geneva, Switzerland, May 2022
Partners at the WHA side-event by G4 Alliance
World Health Assembly side-event by G4 Alliance, with partners, including Vijaya Kancherla, promoting the food fortification resolution for prevention of neural tube defects, Geneva, Switzerland, May 2022

The Colombian Ministries of Health and Foreign Affairs were major partners, and the engine for this effort at the WHA. Colombia not only sponsored the food fortification resolution at the May 2022 WHA, but also helped in developing the content to prepare its successful introduction at the WHA, and garnering support from 37 other member states (including Australia, Brazil, Canada, Chile, Ecuador, the European Union and its 27 member states, Guatemala, Israel, Malaysia, Paraguay, and the USA). Dr. Kemel Ghotme, a neurosurgeon from Colombia, and a member of GAPSBiF, served as a strong leader and advocate, pursuing every step of the resolution sponsorship by the Ministry of Colombia, and ensuring that it did not stall moving through various stages of the process. Regular consultations with the World Health Organization helped in drafting the text of the resolution. Concurrently, many individuals invested time and effort in promoting the draft resolution when it came for vote and bringing country champions onboard to support the process. This knowledge exchange and science diplomacy effort utilized top-down and bottom-up approaches, with partners from multiple disciplines, and corners of the world, contributing enthusiastically. Many NGOs and civil society organizations worked with Colombia to promote the resolution. Partners used their means and contacts to reach voting member country delegates all over the world, so the delegates were informed and voted favorably when the resolution came up for vote in WHA in May 2023.

The WHA resolution’s success also highlights a story of effective communication and coordination of multiple partners from public, private, and civic sectors. Various events were held ahead of the WHA vote as soon as the WHO Executive Board accepted the draft resolution in January 2023. Large organizations such as the Global Alliance for Improved Nutrition, Micronutrient Forum, Nutrition International, and Food Fortification Initiative, International Federation for Spina Bifida and Hydrocephalus, joined hands and were crucial partners. They formed multi-disciplinary teams and used international conferences to share the message. Every relevant opportunity was used to share about the resolution’s importance.

One such conference was the International Maternal Newborn Health Conference (IMNHC), held in South Africa, in March 2023. It was important to bring birth defects to the stage at this large international conference attended by governments, NGOs, civil society organizations, and other influential global leaders working on maternal and child health issues. A panel session was allocated at this conference, and a multi-disciplinary team of partners, including myself, could share about the upcoming resolution with attendees and delegates from over 95 countries. We could speak directly to Ministry delegates from most African and Asian countries. It was a timely conference, just a few months prior to the 2023 WHA, where the resolution would be brought to vote in Geneva, Switzerland. Another example of an event leading up to the WHA resolution was a large side-event conducted on May 23rd, 2023, in Geneva, Switzerland, right before the voting day at the WHA. This WHA side-event, titled “Fortifying the Future”, further strengthened the advocacy effort by receiving multi-sectorial support from member states attending the WHA. Attendees understood the potential beneficial impact of food fortification, and its positive effect on the prevention of spina bifida and other birth defects. The benefits were not only viewed from the public health and clinical angles, but also from children’s disability rights and patients’ rights perspectives. All these efforts bore fruit on May 29th, 2023, as the member nations unanimously adopted the resolution. The WHA proceedings were relayed live on the web, and many GAPSBiF partners, including myself, who could not be in Geneva in person, anxiously followed the voting period, and cheered from distance as the resolution was passed.

Partners at the Fortifying the Future event
“Fortifying the Future”, a side-event at the WHA, with partners promoting the adoption of the resolution on food fortification for prevention of neural tube defects and micronutrient deficiencies, Geneva, Switzerland, May 2023

It has been a several months now since the fortification resolution was passed by the WHA. While all the partners celebrated the resolution’s passage, the work has only begun. The next steps are to retain the interest shown by member nations to fortify staple foods with folic acid when they voted in favor of the resolution and push for policy for implementation of fortification in over 100 countries. Time is of the essence, as waiting and inaction means preventable cases of spina bifida continue to occur in most vulnerable populations. The partnerships that developed in 2019 and worked efficiently during the pandemic years to see the resolution pass, are still active and decisive in moving the fortification implementation agenda in countries worldwide. The direct impact of this effort and success is only measurable when the world averts every possible preventable case of spina bifida and other neural tube defects.

Map of the world showing countries with mandatory fortification of wheat flour, maize flour, and/or rice with folic acid in the year 2020.
Neural tube defects prevention in countries through mandatory fortification policy of wheat flour, maize flour, and/or rice with folic acid in the year 2020. Over 100 countries, mostly in Asia, Africa, and Europe, are yet to implement food fortification program to prevent neural tube defects globally. Reference: Kancherla et al. (2022) Birth Defects Research;114(20):1392–1403

March 3rd is the World Birth Defects Day. Many organizations are partnering to use their platforms to raise awareness for birth defects. One of the highlights of this year’s World Birth Defects Day promotion is to make the WHA resolution on food fortification a focus and use opportunities that serve as a reminder to countries to implement large-scale food fortification of staples with folic acid, and any other complementary programs (e.g., folic acid supplementation) recommended in the resolution to improve micronutrient status among women of reproductive age. Several BDRP members have directly and indirectly contributed to the resolution through their participation and research. On March 3rd, we pause to reflect on the journey, celebrate these partnerships and successes, and renew global commitment to action on preventing birth defects where possible, while also improving care for those living with these conditions.

A companion webinar discussing the way forward will take place May 2, 2024. For more information or to register, click here.

About the Author: Vijaya Kancherla, PhD, is an Associate Professor in the Department of Epidemiology at Emory University Rollins School of Public Health. She also serves as the Deputy Director of the Center for Spina Bifida Prevention at Emory University. Vijaya is the current Chair of the Public Affairs Committee of the Society for Birth Defects Research and Prevention. Her research is focused on birth defects epidemiology, covering topics such as surveillance, etiology, prevention, health care outcomes, and policy, both in the U.S. and internationally.
The Birth Defects Insights Blog series is published by the Society for Birth Defects Research and Prevention (BDRP). BDRP is a multidisciplinary society of researchers, clinicians, epidemiologists, and public health professionals from academia, government, and industry who study birth defects, reproduction, and disorders of developmental origin. BDRP convenes a robust scientific meeting annually in June where members and others share their research, gain new knowledge and continuing education, mentor the next generation of researchers in the field, and network. The Society publishes the peer-reviewed scientific journal, Birth Defects Research. Learn more at http://www.birthdefectsresearch.org. Find BDRP on LinkedIn, Facebook, Twitter, and YouTube.

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