Preventing neural tube defects (NTDs) easily qualifies as a high-value opportunity to improve childhood survival
and health: the unmet need is significant (major preventable burden), the intervention is transformative (providing
sufficient folic acid), and delivery strategies (e.g., fortification) are effective in low-resource countries. Yet, NTD
prevention is lagging. Can public health surveillance help fix this problem? Critics contend that surveillance is largely
unnecessary, that limited resources are best spent on interventions, and that surveillance is unrealistic in developing
countries. The counterargument is twofold: (1) in the absence of surveillance, interventions will provide fewer
benefits and cost more and (2) effective surveillance is likely possible nearly everywhere, with appropriate strategies.

As a base strategy, we propose “triple surveillance:” integrating surveillance of cause (folate insufficiency), of disease occurrence (NTD prevalence), and of health outcomes (morbidity, mortality, and disability). For better sustainability and usefulness, it is crucial to refocus and streamline surveillance activities (no recreational data collection), weave surveillance into clinical care (integrate in clinical workflow), and, later, work on including additional risk factors and pediatric outcomes (increase benefits at low marginal cost). By doing so, surveillance becomes not a roadblock but a preferential path to prevention and better care.

Keywords: prevention; neural tube defects; spina bifida; surveillance; folic acid; health outcomes