by Valerie Gregg

ighteen days after conception, the neural tube closes like a zipper around the embryonic spinal cord and brain. If folic acid levels are low, the tube may not close completely. If a hole is left arou nd the spinal cord, the result is paralyzing spina bifida. If the hole is near the top of the tube, the result is fatal anencephaly. In the United States, about 4,000 pregnancies a year are affected by neural tube defects. Rates are highest in northern Ch ina and in the southeastern United States. The reason why, says Godfrey Oakley, is folic acid deficiency.

Godfrey Oakley is the folic acid ambassador 24 hours a day.

At restaurants, on airplanes, at weddings, and on the street -- wherever he meets a woman of child-bearing age, he inevitably asks: "What do you know about folic acid?"

The only way to conduct a public health campaign with limited funding is to live the message, day in and day out, says Oakley, former director of CDC's Division of Birth Defects and Developmental Disabilities. It took five years of dogged persistence f or Oakley to see the data on folic acid's preventive effects against spina bifida and anencephaly translate into good policy.

"Opportunities for primary prevention that are as simple as this are rare," says Oakley, now visiting professor of epidemiology at RSPH. "It was a no-brainer. The science was the best kind there is -- randomized, controlled trials showing hands-down th at giving women folic acid supplements before they become pregnant drastically reduces the risk of neural tube birth defects. The solution was so easy, so inexpensive, and so proven to work. Just get folic acid added to all grains labeled 'enriched' and a ll women are covered. But it took the FDA five years to do it."

In 1991, after years of smaller, observational studies, a randomized, controlled trial showed that synthetic folic acid supplements prevent one-half to three-fourths of neural tube birth defects. The federal Food Additive Law had not been changed since 1943. In 1996, the FDA gave the nod to add synthetic folic acid to all grain products.

The nutrition and medical communities spent the time in between debating whether women should receive extra folic acid from natural food sources or synthetic vitamins added to grains. Some also feared that too much folic acid would mask pernicious anem ia among the elderly.

Oakley spent much of that time speaking and writing on the benefits of folic acid supplements. He published editorials about folic acid in major medical journals like JAMA, the NEJM, and Pediatrics. He also recrui ted the March of Dimes to the cause.

"I felt like I was repeatedly ramming my head into a wall for five years," says Oakley. "Meanwhile babies were continuing to be born with preventable defects that put them in wheelchairs for life. But we kept our eyes on the prize of healthy kids, and it's finally paying off."

Although he retired from the CDC in 1998, Oakley's work is not done. With Emory colleagues at Grady Memorial Hospital, he is seeking ways to get the word out to lower-income women. A recent study showed that only 4% of pregnant patients at Grady were t aking multivitamins with folic acid before they became pregnant. He continues to write editorials in major journals calling for more public education on the benefits of folic acid. He's also carrying on an international e-mail campaign to add it to the fo od supply around the globe.

Here's his advice to public health professionals who want to see research become public health policy. "Find someone on the outside to lobby for your cause. You have to work the system. You have to be a policy entrepreneur. It can be very hard to get t he politics and the logic heading in the same direction. The greatest frustration is to see that people could be saved at the stroke of pen, and to have others drag their feet."

Although Oakley won't be content until neural tube defects are a thing of the past, he has made tremendous progress. Last fall the CDC's Morbidity and Mortality Weekly Report reported that median blood folate levels had tripled among women in the United States.

For his efforts, Oakley was named "Man of the Week" by Peter Jennings on NBC News in 1996. This year, he received the Extra Mile Award in New Zealand, and the Governor of Oklahoma named Sept 13 and 14 Godfrey Oakley Days.

Godfrey Oakley