20 Years Later: The Legacy of an Oman Workshop

These women and a child at a wedding party in Oman likely benefit from Oman's wheat flour fortification program. Photo by Andrea Moroni/Flickr

These women and a child at a wedding party in Oman likely benefit from Oman's wheat flour fortification program. Photo by Andrea Moroni/Flickr

17 November 2016

Wheat. Grind it, mix it, and make some bread. This simple process has existed for centuries in the Mediterranean region, where bread is a staple food. However, in 1996, a regional fortification workshop in Muscat, Oman, sparked a big shakeup for that process. Following the five-day meeting, Oman became the first country in the region since 1978 to mandate adding iron and even folic acid to its flour. Within a decade, ten more countries would make decisions mandating fortification. This year, we celebrate the 20th anniversary of that memorable workshop by acknowledging its key players and partnerships.

One of the earliest fortuitous partnerships came a year before the meeting. Back then, Venkatesh Mannar, as Executive Director of the Micronutrient Initiative (MI), was trying to promote flour fortification in the region. This was a time when “very little was happening in the region. There was no information available [on fortification] and no coordination between health sectors.” Mannar, however, took a big step in changing that when he reached out to Anna Verster, then the World Health Organization (WHO) Regional Adviser for Nutrition, Food Security, and Safety. Luckily, she had the same idea in mind.

“You’ve come at a great time!” Mannar recalls Verster saying. In October 1995, Verster organized a technical consultation in Iran to develop guidelines for the control of iron deficiency in countries of the Eastern Mediterranean Region, Middle East and North Africa. The meeting included professors and doctors from Iran as well as nutrition and health experts from Bahrain, Egypt, Jordan, Morocco, Pakistan, Sudan, Syria, and Oman. These experts discussed strategies for control of iron deficiency and anemia and spoke about the feasibility of fortifying flour with iron and the success of existing programs. Together, they agreed that fortification was one of the key strategies to control iron deficiency. Soon after the meeting, Oman requested hosting a strategy workshop on fortification.

Omani government representatives, millers, and officials from 11 countries in the region took part a year later. By that time the collaborating partners had expanded to include UNICEF, the Canadian International Development Agency, and the Program Against Micronutrient Malnutrition. Workshop participants attended panels and collaborative meetings on fortification methods and evaluation, economics, and legislation. Participants even toured Oman’s largest wheat flour mill, which was fortifying flour on a trial basis.

Twenty years later, that experience still sticks out for David Alnwick, the UNICEF Senior Advisor of Micronutrients at the time.

“I recall…looking down into one single small hatch, perhaps just eight inches wide, which was used to add additives and improve all of the flour consumed in Oman and beyond,” said Alnwick. For him, it was something so simple, yet so important. “This was actually the entry point into the mouths of the entire population of that country.”

Another key takeaway of the workshop was gathering support for fortifying with folic acid.  Verster recalls Alnwick suggesting adding the nutrient, as he knew that the US Centers for Disease Control and Prevention (CDC) was involved in discussions on folic acid fortification of flour to reduce neural tube defects in the USA. At that time, no other country had implemented a national program of adding folic acid to flour to prevent these severe birth defects of the brain and spine.

“The Omanis immediately took that [idea] up and started!” said Verster, who is now a Senior Advisor for FFI.

Overall, Oman's incidence
of spina bifida
has experienced a 70%
reduction since flour
fortification was mandated.

Alnwick was shocked by the response. He was used to countries taking maybe a year or two to get on board. Deena Alasfoor, the Head of Nutrition for Oman’s Ministry of Health at the time, has a few suggestions as to why.

“At that point, the flour mill manager was well-oriented with fortification literature. He had the technical background and the logistics were not difficult,” said Alasfoor. "We had one flour mill that controlled more than 75% of the market. So if that person fortified, we would have covered a lot of ground.” Officials also made sure to use national media to inform the public about the workshop and build consensus for fortification.

Alasfoor added that the other important element was the corporation between the private sector and the government. “The government will push, but they cannot mandate something unless the private sector is ready technically and logistically to actually implement it.”

Oman was ready. On July 25, 1997, Oman gazetted a ministerial decree mandating the fortification of flour with 30 parts per million (ppm) of iron and 1.5 ppm- 2 ppm of folic acid. Alasfoor is especially proud of this action.

"It's not that Oman only influenced the decision to put folic acid into flour. But Oman also influenced the levels of flour fortification. During the workshop, we provided data on what percentage of flour people would get for each level of fortification."

Spina bifida prevalence in Oman has shown a steep decline as a result of fortification.  During its first year of implementation (1997-1998), spina bifida rates dropped from 2.11 per 1000 deliveries to 0.78 per 1000 deliveries. Overall, Oman's incidence of spina bifida has experienced a 70% reduction since flour fortification was mandated.

Nevertheless, the region still hit a few bumps before other countries agreed to implementation. Some people feared that fortification would cause an iron overload in people with blood disorders. At a 1998 fortification workshop in Beirut, Lebanon, Alasfoor remembers working to convince medical professionals to support fortification.  In fact, the report of that meeting includes an annex that concludes that there is no reason to believe that fortifying flour with iron will have any significant adverse impact on those individuals suffering from thalassemia. At the same time, it will have a significant and beneficial effect on the 150 to 300 million people in countries of the region who suffer from iron deficiency and its anemia, including those with thalassemia minor.

Despite such challenges, attendees from 16 countries at the Lebanon meeting recommended that the whole region adopt the standard derived from the Oman meeting. Furthermore, the MI initiated a flour fortification fund of $1 million for that region to support countries in initiating fortification. By 2001, WHO, UNICEF and MI held a review meeting to check up on the progress from various countries.

Countries such as Yemen, Kuwait, and Iraq passed fortification mandates by 2001. In 2002, Oman then held another meeting to discuss fortification of oil with vitamin A. In 2012, the CDC joined WHO, MI and the Global Alliance for Improved Nutrition (GAIN) to further improve wheat and flour fortification efforts at a workshop in Amman, Jordan.

Today, we can look back at the Oman workshop as the launching pad for this international agency collaboration and multi-sector country leadership in the Mediterranean.

“It was brilliant,” sums up Verster. “That was the first time we really talked about fortification in the region and [the first time] that a country actually invited us to come and talk about it. And they implemented what they were talking about!”

Recently, Verster concluded a strategy workshop for maize fortification in Africa in Dar Es Salaam, Tanzania. It’s still too early to tell what will develop from this latest strategy meeting. But Verster is optimistic.

“I hope,” said Verster, “that workshop will have as much effect as the one in Oman did.”