Salt for freedom

Salt for Freedom

and

Iodized Salt for

Freedom from Preventable Brain Damage

The All India Institute of Medical Sciences, New Delhi

ICCIDD

June 2005

* The All India Institute of Medical Sciences, New Delhi* The All India Institute of Medical Sciences, New Delhi

##

Indian Coalition for Control of Iodine Deficiency Disorders (ICIndian Coalition for Control of Iodine Deficiency Disorders (ICCIDD)CIDD)

Dr. Chandrakant

S. Pandav*#

Dr. Anil Kumar#

Dr. Denish

Moorthy#

Dr. K. Anand*

Dr. R. Sankar#

Dr. M. G. Karmarkar#

Ensuring freedom from preventable brain damage

Sustainable Elimination of Iodine Deficiency Disorders

in India

Ensuring freedom from preventable brain damage

Towards Sustainable Elimination of

Iodine Deficiency Disorders in India

Vision for the Nation

“With our resources and the money we spend,

we could easily accomplish three times what we do,

in half the time we normally take,

if we were to operate in mission mode with a vision for the nation”

-Dr. A. P. J. Abdul Kalam

President of India

(“Ignited Minds”)

Outline of presentation1.

What is iodine & what is iodine deficiency?

2.

What are the consequences of iodine deficiency?

3.

How do we eliminate iodine deficiency?

4.

The Kangra Valley Study (1956 –

1972)

5.

New Evidence: From Endemic Goiter to IDD (1962 –

1983)

6.

What is the status of iodized salt coverage in India? (1998-99; 2002)

7.

Changing status of legislation (1968-2005)

8.

Key issues in IDD

9.

Do we need Universal Salt Iodization?

10.

Why did consumption of iodized salt decrease?

11.

The way forward

Presenter

Presentation Notes

Please add page numbers to this OUTLINE OF PRESENTATION

1. What is iodine &

what is iodine deficiency?

What is iodine? -

1• Nutrient needed in a

minute quantity daily. Recommended daily intake:

150 μg (Micronutrient)

• Total quantity present in body

is (15-20 mg) mostly in thyroid gland

What is iodine? -

2

• Iodine: Essential component of

thyroid hormones,

which are needed for:

-

Optimal mental & physical development

-

Regulation of body metabolism

(Generation & utilization of body energy)

Iodine : Daily requirements

Age Group Iodine Requirement (µg/day)

0 –

11 months 50

12 –

59 months 90

6 –

12 years 120

>

12 years 150

Pregnant & Lactating Women 200

[WHO, UNICEF, ICCIDD: Recommended iodine levels in salt and guidelines for monitoring their adequacy and effectiveness. WHO/NUT/96.13. Geneva. 1996 ]

Sources of iodine

• Food is the main source of iodine– Meat, fish & dairy products

– Vegetables, cereals

• High amounts in sea fish & seaweeds

• Sea salt is a poor source of iodine

Iodine deficiency –

Disease of the soil

Melting of Glaciers

Floods

Rivers changing course

Gradual leaching of iodine from soil due to:

Iodine deficiency : A disease of the soil

SOIL EROSION

: WATER, SOIL

Environmental iodine deficiency

Low Availability : PLANTS Iodine poor feeds & of iodine

fodders, goitrogens

Effect on animals

: LIVESTOCK Clinical & Reproductive disorders,

Decreased productivity

Effect on people

: HUMANS

Health & Socio - economic impact

2. What are the consequences of iodine deficiency?

1. What is iodine & what is iodine deficiency?

-

Iodine is a micronutrient

-

Iodine deficiency is a disease of the soil

Goiter has been known since the days of Lord Buddha and before

Earliest evidence of goiter: 3000 BC

Importance of iodine in brain development -

1

• 50,000 brain cells produced/second

in developing fetal brain

• 100 billion brain cells in adult

• One million billion connections between these brain cells:

Determine IQ


2

100 billion brain cells in adult human

Comparable to the number of stars in the sky

Brain cell branching

• Diminished brain cell branching due to iodine deficiency• Diminished branching Less connections Lower IQ


4

90 % of human brain development occurs between 3rd

month of pregnancy & 3rd

year of life (Critical period)


5

• Deficiency of iodine during this critical period of development results in permanent brain damage

• This brain damage can primarily be prevented by correcting iodine deficiency before & during pregnancy

• This makes it vital that all expectant

& lactating mothers get their

daily requirement of iodine


6

• Iodine deficiency is single most common cause of mental handicap worldwide

• It is totally preventable

Spectrum of IDDGoiter

Loss of 13 IQ points,

Leading Cause of Mental handicap

Cretinism

Spontaneous Abortions,

Stillbirths,

Birth Defects

Defects of Speech & Hearing,

Squint,

Psychomotor defects

Iceberg of IDD

1% - 10%

Cretinism

5% - 30%

Some brain damage

30% - 70%

Loss of energy due to hypothyroidism

Effects on humans: Fetus

Mortality

• Spontaneous abortions & stillbirths• Increased perinatal

mortality

Disability• Birth defects• Defects of speech & hearing• Psychomotor defects• Cretinism

Effects on humans: Neonate

Mortality

• Increased neonatal mortality

Morbidity

• Neonatal Goiter• Neonatal Hypothyroidism

(Decreased production of thyroid hormones at birth)

Effects on humans: Children & adolescents

• Goiter• Hypothyroidism• Retarded physical development• Impaired mental function (13 IQ points)

LOSS OF IQ : IMPLICATIONS

The Intelligence Quotient (IQ) score of children living in an iodine deficient environment is nearly 13 IQ points less than those living in iodine sufficient environments

IMPLICATIONS OF LOSS OF IQ

Poor scholastic performance

Frequent failures / grade repetitions

Absenteeism / Dropouts

Impact : Retarded social & economic growth

Effects on humans: Adults

• Goiter & its complications

• Hypothyroidism

• Impaired mental function

• Iodine induced hyperthyroidism (IIH)

Effects on all age groups: Iodine deficiency & nuclear radiation

• Iodine deficiency leads to increased susceptibility to nuclear radiation

• When there is iodine sufficiency, the thyroid gland does not take up

radioactive iodine

• Therefore, in iodine deficient

populations, it is critical to have

effective universal salt iodization

Effects on livestock

• Goiter

• Hypothyroidism

• Reproductive disorders

• Decreased productivity

(Milk, meat, wool, eggs)

• Lower work outputGoiter in animal

3. How do we eliminate iodine deficiency?

1.


-


-


2.


-

Brain damage & impaired physical growth in humans

-

Decreased productivity in livestock

Iodine deficiency disorders: A public health problem -

1

Worldwide distribution

Iodine deficiency disorders: A public health problem -

2

• High risk groups: -

Pregnant & lactating women

-

Pre-school children

• Elimination of IDD: -

is an important developmental &

social goal for governments (UNGASS 2002; MDG –

2015)

-

is possibleUNGASS: United Nations General Assembly Special Session on Children

MDG: Millennium Development Goals

Our primary concern

To ensure that:

• Every population should&

• Every mother & child mustGet their daily supply of iodine

Iodine consumption on daily basis for all times to come

• Daily requirement of iodine per person is 150 µg –

fits on the tip of hair !

• Lifetime requirement for 70 years is 5 gms – one teaspoonful !

• However, this daily requirement has to be met daily, for all times to come

• “Daily consumption of adequately iodized salt is a healthy habit”

Vehicle for iodine : Salt• One food item consumed every day,

by everybody in fixed quantities

• Rich or poor, urban or rural area, man or woman, child or adult

• Average daily consumption in India per person is 10 gm

• Iodization of salt is a simple process

• Cost of salt iodization is : 10 paise/person/year

Iodized salt –

The panacea for iodine deficiency

Salt production and iodization

(Supply)

Promotion of Iodized Salt Consumption

(Demand)

4. The Kangra Valley Study (1956 –

1972)

1.


-


-


2.


-


-


3.


-

By daily consumption of adequately iodized salt

Prof. V. Ramalingaswami8 August 1921 –

28 May 2001

Legacy of The LegendScience & Society

Kangra

Kangra Valley StudyPioneer study conducted in

Kangra District of

Himachal

Pradesh, by

Prof. V. Ramalingaswami

Himachal

Pradesh

From evidence to program –

1 The Kangra Valley study (1956-1972)

Study design Community based Prospective controlled trial

Study area Kangra Valley, Himachal

Pradesh Divided into 3 zones –A , B , C

Study period 1956 -

1972

Study duration 16 years

Study population 1,00,000 School age children

Outcome variable

Goiter prevalence among school age children



• Baseline survey in 1956

• Salt distributed to three zones– Zone A : Salt + Potassium iodide– Zone B : Plain salt– Zone C : Salt + Potassium iodate

• 15 gms of salt/person/day– So as to ensure 200 µg of iodine/person/day

• Salt produced by Hindustan Salts Ltd. at Sambhar lake (Rajasthan)

with UNICEF assistance

Kangra Valley study area

From Pathankot

To Kulu

Dharamsala

Zone A

KI Salt Zone B

Plain Salt Zone C

KIO3

Salt



Administrative Interventions

– Legislation (ban on sale of non-

iodized salt in study area)

– Iodized salt distributed through government shops

– No price difference between iodized and non-iodized salt


4.1 The Kangra Valley study (1956-1972)

10%

20%

30%

40%

Prevalence of goiter in zone A (KI salt)

1956 1962 1968

40%

19%

8%Goi

ter

prev

alen

ce in

%

Intervention



Prevalence of goiter in zone B (Plain salt till 1962, then KI salt)

10%

20%

30%

40%

1956 1962 1968

40%

15%

Goi

ter

prev

alen

ce in

%

Intervention

42%



10%

20%

30%

40%

Prevalence of goiter in zone C (KIO3

salt)

1956 1962 1968

40%

15%

5%Goi

ter

prev

alen

ce in

%

Intervention



Conclusions

• Iodine supplementation in the form of adequately iodized salt on a regular and continuous basis reduces goiter prevalence

Recommendations

• Establish a National Goiter Control Programme (NGCP)

As a result, National Goiter Control Program established in 1962

5. New evidence: From goiter to IDD (1962 –

1983)

1.


-


-


2.


-


-


3.


-


4.

The Kangra Valley Study: 1956 –

1972

-

Provided scientific basis for NGCP

Scenario after Kangra Valley studyNational Goiter Control Program (NGCP)

launched at the end of Second Five Year Plan (1962)

Aims

: 1) Initial survey to identify endemic areas

2) Production & Supply of iodized salt to endemic areas

3) Impact assessment surveys after five years

Approach

: District specific program

NGCP activities (1962-1983)

Salt iodization plants established in public sector

Rajasthan:

5

Gujarat:

3

West Bengal:

4

Estimated need/year 1.00 million tons (100%)

Production Capacity / year 0.38 million tons ( 38%)

Actual production / year 0.15 million tons ( 15%)

}12

NGCP: Low priority

• Goiter: -

is painless

-

not a cause of death -

has been perceived as a

cosmetic problem only -

socio-cultural norm

in some groups

• Therefore, NGCP received low priority from the viewpoint of government as a national public health program,

and also from the population

New epidemiological evidence: 1962-1983

• Delhi study : Endemic goiter in Delhi, 1980• Extra Himalayan foci of IDD reported• 1984 –

86 : ICMR multicentric study

- 14 districts in 9 states

(outside traditional “goiter belt”)- Goiter Prevalence : 21%- Endemic cretinism: 0.7%

Iodine Deficiency Disorders : A public health problem

in all states/UTs of India

• Subsequent surveys carried all over India

Presenter

Presentation Notes

ICMR study states: AP, Assam, Bihar, Gujarat, MP, Maharashtra, Manipur, TN, UP

Iodine deficiency & learning disabilities

Global studies

School age children living in iodine deficient

environment, on an average, have 13 I.Q.points less than those living in iodine sufficient

environment(Bleichrodt N, Born M Ph. A meta-analysis of research on iodine and its relationship to cognitive

development. In: Stanbury JS (ed). The damaged brain of iodine deficiency – Cognitive behavioral,

neuromotor, educative aspects. New York: Cognizant Communication Corporation, 1994:195-200 )

Meta-analysis of 21 studies, 8 countries

Iodine deficiency & learning disabilities

Indian studies

1.

Intellectual assessment of school children from

severely iodine deficient villages

Mehta M, Pandav CS, Kochupillai N. Indian Pediatr 1987;24:467.

2.

Developmental lag in pre-school children of

goitrous

mothers.

Upadyaya SK et al. Indian Pediatr 1983;20:259

3.

Intellectual and motor development in school children from severely iodine deficient region -

Sikkim

Sankar R, Pandav CS, et al. Indian J Pediatr 1994;61:407-414

All studies point to impaired intellectual and physical development, and reduced psychomotor performance due to iodine deficiency

Iodine Deficiency = Goiter = Visible Swelling

No Pain, Cosmetic problem

Cretinism: A rare event= LOW PRIORITY

Brain DamageLack of Energy - hypothyroidism

Learning Disability, ↑Deaths

Child Development & Child Survival

Human Resource Development

= HIGH PRIORITY

The hourglass of IDD

Historic view

1962-1983

Current view

1984 onwards

Universal Salt Iodization

• In 1983, Government of India took policy decision to iodize all salt meant for

human consumption –

Universal Salt Iodization (USI)

• Private sector was permitted and encouraged to produce iodized salt

• “Elimination of goiter”

was included in Prime Minister’s 20-point National Development Program

6. What is the status of iodized salt coverage in India?

1.


-


-


2.


-


-


3.


-


4.


1972

-


5.

New evidence: From endemic goiter to IDD (1962-1983)

Salt iodization -

1 Progress after declaration of USI *

Variables 1962 –

1983 1984 –

2003

No. of Salt iodization plants 12 859

Production Capacity(in million tons)

0.038 12.2

Estimated requirement/year(in million tons)

0.1 5.0

Actual Production(in million tons)

0.015 4.1

Actual ProductionRequired Production

15% 82%

Production: in Public Sector 100% 2.5%

Production: in Private Sector,including cooperatives

0% 97.5%

* Universal salt iodization (USI) proposed by Government of India in 1983

Salt iodization -

2 Progress from 1985 –

2003

Production of iodized salt in India (Million Tons)

0.3

1985

2.5

1990

3.7

1995

4.7

2000

4.5

2001 2002

4.2

2003

4.1

1

2

3

4

5

Ban lifted

Presenter

Presentation Notes

59

Salt production in India (2003)

StateSalt produced

(% of total)

Gujarat 71

Tamilnadu 16

Rajasthan 9

Andhra Pradesh 2

Maharashtra 1

Others 1

Total 100

Source: Annual Report (2003 –

2004), Salt Department, Govt. of India

}96

Production of Refined Iodized Salt

0

20

40

60

80

100

Gujarat

Tam

ilnadu

Rajasthan

Others

Refineries Refined IodizedSalt

RefineriesRefined Iodized Salt

Gujarat Tamilnadu Rajasthan Others Total

Number of refineries 26 (65%) 7 (17%) 2 (5%) 5 (13%) 40 (100%)

Production of refined iodized salt

1083 (81%) 182 (14%) 60 (4.5%) 6 (0.5%) 1331 (100%)

%

Production of Unrefined Iodized Salt

010203040506070

Gujarat

Tam

ilnadu

Rajasthan

Others

Salt Iodizationunits

UnrefinedIodized Salt

Salt IodizationunitsUnrefinedIodized Salt

Gujarat Tamilnadu Rajasthan Others Total

Number of iodization units

300 (36.6%) 74 (9%) 297 (36.2%) 148 (15.2%) 819 (100%)

Production of unrefined iodized salt

1722 (61.7%) 392 (14%) 550 (19.7%) 125 (4.6%) 2789 (100%)

Presenter

Presentation Notes

62

State wise production of refined & unrefined iodized salt

State Refined salt production

Unrefined salt production

Gujarat 1083 (81%) 1722 (61.7%)

Rajasthan 60 (4.5%) 550 (19.7%)

Tamilnadu 182 (14%) 392 (14%)

Others 6 (0.5%)125 (4.6%)

Total 1331 (100%) 2789 (100%)

Presenter

Presentation Notes

ADD after 62 – this slide becomes 63

Indian Scenario: Use of iodized salt National Family Health Survey –

2

(1998-1999)

Iodized Salt Consumption at Household Level % Value

Adequate iodine in salt 49

Inadequate iodine in salt 22

No iodine in salt 29

Total 100

} 71%

Adequately iodized salt: contains 15 mg iodine/kg salt at household level (15 ppm)

Consumption of adequately iodized salt according to socio -

economic status

in India (NFHS-II, 1998-99)

LOW SES MEDIUM SES HIGH SES

36%50%

78%

64%50%

22%Inadequate InadequateInadequate

Adequate

Adequate

Adequate

Use of Iodized SaltUse of Iodized Salt at Household Level at Household Level ––

North EastNorth East

Meg

halay

a

63%55%

Naga

land

67%70%NFHS –2, 1998-99

DLHS - RCH, 2002

Mizo

ram

91%

52%

Man

ipur

88%

59%

Arun

acha

l

84%

57%

80%

59%

Assa

m

Sikk

im

79%

47%

Delhi

89%80%

J & K

53%

24%

Punjab

75%

64%NFHS – 2, 1998-99

DLHS - RCH, 2002


NorthNorth

Himac

hal

91%87%

Harya

na

71%

53%

Bihar

47%

25%

Chhati

sgarh

57%

36%

47%

Jhark

hand

32%

NFHS – 2, 1998-99

DLHS - RCH, 2002


HeartlandHeartland

57%

42%

M.P.

U.P.

49%

5%

49%

5%Uttra

ncha

l

27%

A. P

.

28%35%

Orissa

30%

Kera

la*39%

56%

Tamil N

adu*

21% 22%

NFHS – 2, 1998-99

DLHS - RCH, 2002

Use of Iodized SaltUse of Iodized Salt at Household Level at Household Level --

SouthSouth

Karn

ataka

43%

23%

Goa*

42%

54%56%

Gujara

t

38%

Rajasth

an

46%

24%

NFHS – 2, 1998-99

DLHS - RCH, 2002

60%

45%

Mah

aras

htra

Use of Iodized Salt at Household Level -

West

Progress with salt iodization in Iran

90

50

72

88

0

10

20

30

40

50

60

70

80

90

100

1994 1995 1996 1997

Progress with salt iodization in Vietnam

2532

83

49

61

73 75 78 79 80

0

10

20

30

40

50

60

70

80

90

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Progress with Salt Iodization in China

9080

70

40

0

20

40

60

80

100

1995 1997 1999 2002

Coverage rate of Iodized Salt meeting standards

Estimated percentage of households consuming adequately iodized salt

Bhut

an95%

China

93%

Vietn

am

77%

Thail

and

74%

Bang

lades

h

70%

Indo

nesia

65%

Nepa

l

63%

India

50%

Myanm

ar

48%UNICEF-2003

Burden in India & China

Country Newborns Unprotected in millions (%) per year

India 13.0 (50%)

China 1.3 ( 7 %)

India & China

Iodized salt coverage <80%

Iodized salt coverage >80%

Summary: Use of Iodized Salt at Household Level

1) India is performing poorly as compared to other countries in South East Asia Region

2) In general, there has been a gradual decrease in iodized salt coverage at the household level

3) Alarming situation in UP, Uttaranchal

4) * Kerala

& Goa

–

improvement after

state-level partnership activities5)

Poor performance by salt producing states: National Repercussions

(Gujarat, Tamilnadu, Rajasthan)

7. Changing status of legislation (1968 –

2005)

1.


-


-


2.


-


-


3.


-


4.


1972

-


5.

New evidence: From Endemic Goiter to IDD (1962-1983)

6.

What is the status of iodized salt coverage in India?

(1998-99; 2002)

Changing status of legislation

Iodized Salt brought under revised PFA Act1987

Sale & storage of non-iodized salt banned1997

Central Government decides to lift ban on

sale of non-iodized saltMay 2000

Ban on sale of non-iodized salt liftedSeptember 2000

Policy decision taken for Universal Salt Iodization1983

Iodized salt brought under PFA Act1968

Presenter

Presentation Notes

The story of IDD has only been science and policy – missing part is the societal perspective- what does the societal perspective involve? A time, person and place description of the key actors in the matter;what was the issue that transpired over the last year

Withdrawal of the ban

• Government of India withdraws ban on sale of non – iodized salt for human consumption (13th

September 2000)

• Reason given by Government of India: “Matters of public health should be left to

the informed choice, and not enforced through compulsion”

Before May 2000: All States (29) & UT (6) had the ban in place except

Andhra Pradesh & Maharashtra (Partial ban) Kerala (No ban)

Scenario after lifting of the ban

After lifting of the ban,

large quantities of non-iodized salt available

for human consumption

in Gujarat -

the major salt producing state

Ban remained in place 27 states & UTs

Ban partially remained in place

Andhra Pradesh, Maharashtra

Ban lifted & then reinstated Orissa

Ban lifted Gujarat, Arunachal

Pradesh

No ban Kerala

8. Key issues in IDD

1.


-


-


2.


-


-


3.


-


4.


1972

-


5.

New evidence: From Endemic Goiter to IDD (1962 –

1983)

6.


(1998-99; 2002)

7.

Changing status of legislation (1968 –

2005)

Key issues in IDD

• National vs. Multinational

• Consequences of excess iodine

• Cost of iodine

• Cost of iodized salt

IDD control program is a national effort

Contribution Made For Assessment & Tracking Progress:

- By national institutions

- With national support

- By national scientists

- Using national laboratories & equipments

Issue 1:National vs

Multinational -

1

National vs. Multinational -

2

• India is self-sufficient in production of common salt

• High quality salt iodization plants -

manufactured in India,

-

exported to other countries

• Technical assistance by national agencies

National vs. Multinational -

3

• Conversion of iodine to potassium iodate done in India

• Iodine imported: -

Less than 0.005% of all imports

-

Only 20% of total iodine imported is used for iodizing salt

-

Rest (80%) goes to industries (pharmaceuticals, medicare, dyes)

• Reason for import: No natural source of iodine in India

• Japan: -

Average intake is 3,000 g/day

-

Seaweed soup -

20 times the required amount

-

No side effects reported

• Pharmacological dose of iodine:

-

200,000

g/day

-

1300 times required amounts

-

can cause iodide goiter.

Issue 2: Consequences of excess iodine –

1

Iodide goiter has not beenreported from salt iodization programs

Issue 2: Consequences of excess iodine –

2

• Increased incidence of IIH (Iodine Induced Hyperthyroidism)

– Place: Severe iodine deficiency of long duration

– Intervention: Introduction of salt with high iodine content (100 ppm) in a short period of time

– Predisposing conditions: Pre-existing autonomous thyroid nodule or latent Graves Disease

– People: Commonly affects older age group (>40 years)

Increased incidence of IIH is Increased incidence of IIH is transient, minimal and self limitingtransient, minimal and self limiting

Issue 3: Cost of iodine for salt iodization

Total annual requirement of iodized salt in India for 1,000 million population @5kg/person/year 5 million tons

Iodine required for salt iodisation@30ppm (30gm/ton)

150,000 kg(150 tons)

Price of iodine @ Rs. 666/Kg,

Therefore total price for 150 tons Rs. 10 million

Cost of iodine/person/year 10 paise

Cost of iodine for salt iodization is 10 paise/person/year

(¼

cents/person/year)

Elimination of Iodine Deficiency Disorders YES -

A Worthwhile Investment in Health

This work was conducted as part of the INCLEN Training of Dr. Pandav at McMaster University, Canada, 1990-1991

Cost of iodine/person/year 10 paise

Cost benefit ratio(only health benefits)

1:3

If benefits related to education (13 I.Q points) & livestock (increased productivity & yield of eggs, milk, wool, etc) included, then:Cost benefit ratio

1:10

Issue 4: Price of iodized salt

Acts and Rules for Salt

• “Salt”

is declared as an item of food under Essential Commodities Act, 1955

• State governments have been authorized to administer the Act for

– Fixing the prices of salt– Its movement within their States,

if necessary

Community perception about iodized salt

Iodized Salt

Refined Salt

Packaged Salt

Branded Salt

High Priced SaltIodized Salt =

The reality

Phoda

salt 0.25 0.25 ––

1.00 1.00 RsRs./Kg./Kg

Crystal salt 1.50 1.50 ––

2.00 2.00 RsRs./Kg./Kg

Powdered salt 2.00 2.00 ––

4.00 4.00 RsRs./Kg./Kg

Refined salt > 4.00 > 4.00 RsRs./Kg./Kg

I

O

D

I

Z

A

T

I

O

N

State / UT PDS selling price/ kg.

Chhattisgarh Rs. 0.25

Gujarat Rs. 0.50

Tamilnadu Rs. 2.50

Rajasthan Rs. 2.50

Sikkim Rs. 2.90 (Loose iodized)

Price of iodized salt through Public Distribution System (PDS)

in some Indian states -

1

Source: Annual Report (2003-2004), Salt Department, Govt. of India

Price of iodized salt through Public Distribution System (PDS)

in some Indian states -

2

State / UT PDS selling price/ kg.

Arunachal

Pradesh Rs. 3.15

Tripura Rs. 3.50

Orissa Rs. 2.00 –

7.00

Goa Rs. 6.00 –

7.00

Himachal

Pradesh Rs. 7.50

Source: Annual Report (2003-2004), Salt Department, Govt. of India

Total Monthly Per Capita Consumer Expenditure (MPCE) on salt per person *

*Reference period of 30 days

Source: National Sample Survey Round 55; NSS Report No. 545,

Household Consumer Expenditure in India: 1999-2000 –

Key Results

Variable Rural Urban (In Rs.)

Salt Rs. 1.09 Rs. 1.38

All Food items Rs. 289 Rs. 411

Salt as a % of

All Food Items0.37% 0.34%

Total Consumer Expenditure

Rs. 486 Rs. 855

Salt as a % of Total Consumer Expenditure

0.22% 0.16%

Consumer expenditure on salt is negligible : <0.5%

Universal salt iodization – Myths & facts -1

Issues Myth Fact

MultinationalMultinational companies have a stronghold on iodized salt

• All the salt in India is produced, iodized, packaged and sold by national companies• All research on iodine and iodized salt is done by national scientists in national institutions

MonopolyThe large companies have a monopoly over the salt production

Most of the salt in India is produced by the medium and small-scale producers

Universal salt iodization – Myths & facts -

2

Issues Myth Fact

PriceIodization has lead to an increase in the price of salt

• Cost of iodine per person per year is 10 paise!• Iodization increases the price by about 50 paise!• Increased price is due to costs of packaging, branding & advertisement etc.

Packaged vs non-packaged

salt

Iodized salt sold loose is not effective

• Loose iodized salt is equally effective• Over 70 percent of total iodized salt produced is sold loose

1.


-


-


2.


-


-


3.


-


4.


1972

-


5.


6.


(1998-99; 2002)

7.


2005)

8.

Key issues in IDD

9. Do we need universal salt iodization?


• Yes, USI is required for all times to come!• Because iodine deficiency is a disease of soil

• IDD is a public health problem Therefore, it requires public health solution

• The serious irreversible consequences of iodine deficiency (mental handicap)

may not be visible grossly

• Prevention (including health promotion & specific protection)

is better than cure (including early diagnosis & treatment,

disability limitation & rehabilitation)

“I would be hard-hearted enough to let the sick die if you can tell me how to

prevent others from falling sick”

-

Mahatma Gandhi

1.


-


-


2.


-


-


3.


-


4.


1972

-


5.


6.


(1998-99; 2002)

7.


2005)

8.

Key issues in IDD

9.


-

Yes, for all times to come

10. Why did consumption of adequately iodized salt decrease?

Why did consumption of adequately iodized salt decrease? -

1

Government of India lifts ban on sale of Non-iodized salt :

13 Sept., 2000

As a result, sense of complacency at State level

Increase in Rail Tariff –1st

April 2002

• Consequently, increase in movement of

iodized salt by road (especially from Rajasthan)

• Currently, No mechanism in place for monitoring quality of iodized salt transported by road


2

Disappearance of most common

visible effect of iodine deficiency i.e. goiter

Perception in people that :

-

iodized salt consumption is

NOT required anymore


3


4

Communication strategy

– DID NOT focus on mental handicap as a

consequence of iodine deficiency

– WAS NOT commensurate with seriousness of problem

both in terms of scale & frequency

1.


-


-

Iodine deficiency is a disease of the soil2.


-


-

Decreased productivity in livestock3.


-

By daily consumption of adequately iodized salt4.


1972

-

Provided scientific basis for NGCP5.

New evidence: From Endemic Goiter to IDD (1962-1983)6.


(1998-99; 2002)

7.


2005)8.

Key issues in IDD9.


-

Yes, for all times to come10. Why did the consumption of iodized salt decrease?

11. The way forward

The Dandi

March

FREEDOM FROM PREVENTABLE BRAIN DAMAGE

THROUGH DAILY CONSUMPTION OF

ADEQUATELY IODIZED SALT

Platinum jubilee of Dandi March(12th March – 6th April 1930-2005)

Towards the Elimination of Iodine Deficiency Disorders in India

The way forward : Sustained Political Commitment

• NIDDCP should be a priority National Health Program

of the Govt. of India

• Strategy for IDD elimination is universal salt iodization

• Increase & sustain 100% coverage of adequately iodized salt

Action:

1) Revitalize the National IDD Task Force

2) National Level meeting of Secretaries,

Directors of Health & Family Welfare &

Programme Officers in charge of IDD

3) Followed by State & District level

sensitization meetings

IDD Control Programme : MultiIDD Control Programme : Multi--pronged Strategypronged Strategy

Promotion of Consumption of

Adequately Iodized Salt Forever

Demand Pull

Supply Push

Regular

Reliable

Representative

State-level

Scientific Data

Data For Decision Makers

Sustained Political

Commitment

The way forward

IDD Control Programme : Multi-pronged Strategy



Supply Push

The way forward: Supply (Push)

Need to reinstate ban

Iodized Salt brought under revised PFA Act1987

Sale & storage of non-iodized salt banned1997

Ban on sale of non-iodized salt liftedSeptember 2000

Policy decision taken for Universal Salt Iodization1983

Iodized salt brought under PFA Act1968

Central Government drafts proposal to ban

sale of non-iodized salt

April

2005

Presenter

Presentation Notes

The story of IDD has only been science and policy – missing part is the societal perspective- what does the societal perspective involve? A time, person and place description of the key actors in the matter;what was the issue that transpired over the last year

Supply (Push)

Salt producers

Economic

incentives

Technical

Support

Social

incentives

Rail transport

Cheaper than road

Category B:

High priority

Exemption from

duty & tax

Social profit:

Welfare of children

Welfare of society

Quality

assurance

Better

iodization

techniques

Increased

yield of

quality salt

Presenter

Presentation Notes

Earlier 113 – now 114

• Continue with Priority for Rail movement for Iodized Salt :

Category B

• Reduce rail tariff for iodized salt

Supply (Push) –

Government -

1

Supply (Push) –

Government -

2

• Exempt Iodine for iodized salt

from import duty and sales tax

“Vaccine for optimum brain development”

Iodized salt exempted from VAT : Empowered Committee taken decision

Final notification to be issued

•Efforts to reduce price differentials between iodized & non-iodized salt

•More cost effective targeting of the PDS to address macro and micronutrient deficiencies

…Iodized Salt

Supply (Push) –

Government -

3

• Alliance with salt producers

– Good Manufacturing Practices

– Low Price , High Quality

– Active Assistance in obtaining International

ISO 9002 accreditation

(To be ready for WTO after Year 2005)

• External Independent Quality Assurance

Program

Supply (Push) –

Salt Industry

Presenter

Presentation Notes

Earlier 116


economic status



36%50%

78%

64%50%


Adequate

Adequate

Adequate


economic status



36%50%

78%

64%50%


Adequate

Adequate

Adequate

Adequately iodized salt production• Primarily from large scale producers•Remaining contribution from medium & small scale producers


economic status



36%50%

78%

64%50%


Adequate

Adequate

Adequate

Adequately iodized salt production

Primarily from large scale producers

Remaining contribution from medium & small scale producers

The challenge:

To adequately iodize 100% of salt

To sustain iodization of 100% of salt

Focus: Small & Medium scale salt producers

Supply (Push) –

Salt Industry Support Small scale salt producers

• Need to focus on small scale salt producers (Suppliers to Low Socio-economic Status)

• Potassium iodate subsidy in kind for 3 yrs -

Form revolving fund for purchase of

potassium iodate within this time• Initial assistance for repair and maintenance of

salt iodization plants• Technical & training support for:

-

Improving quantity & quality of common salt -

Maintenance of salt iodization plants

-

Establishing iodine monitoring laboratories• Ongoing external quality assurance for

iodized salt

Presenter

Presentation Notes

Add after 116

Small Scale Salt Producers: Supply of Iodized Salt

Small scale salt producers / Traders

Traders

No Iodization Iodized SaltManufacturers

KIO3 Subsidyfor 3 years

MicrocreditFinancing

Iodized Salt

MarketPublic Distribution System

Common Salt

Common Salt

Distribution

“Respond to Market Signal”

Non-iodized Salt




Demand Pull

Supply Push

The way forward: Demand (Pull)

Demand (Pull)

Community PerceptionMedia Education Legislation

(PFA Act, 1954)

Schools Physicians

Professional

OrganizationsAgriculture &

livestock

Traders

Consumer

Organizations

Disability

Groups

Demand (Pull)

• Intensify IEC with renewed focus on iodine & brain development

:

Iodine Quota & Intelligence Quotient• Education for All : Knowledge Power• India as a developed country• Regular Partnership with Media

Action

1)

Engage the services of a professional communication agency

2)

Consortium of Private iodized salt manufacturers to participate actively in this campaign

Personal meetings to promote use of adequately iodized salt

• People’s Representatives

• Political Party Office Bearers

• Policy Makers

• Producers of Salt & I-Salt

• Physicians

• Brochure (4 pages) -

Fact Sheet

-

Importance of IDD -

Current Status & Relevance of USI

Participation of frontline workers

Department of Education

School Principals

IEC,Mid Day Meals

Ministry of Health &

Family Welfare

ANM

IEC

Department of Women & Child Development

Anganwadi

Worker

IEC,Food

Supplement

Motivational Letter,20 Questions booklet on IDD,Flip Charts,Salt Testing Kits for Iodine

IEC Package:

Communication Challenges -

1Penetrate the system with key messages

• Schools : Loss of IQ, poor school performance, school drop out rates, employment opportunity

• Physicians : Daily consumption of adequately iodized salt is a healthy habit

• Professional associations’ advocacy• Agriculture & livestock :

giving iodized salt to livestock increases productivity

(milk, meat, eggs, wool & work output)


2

Value Addition

1)

Traders: Iodized salt -

a value added product

2)

Consumer organizations: value for money

3)

Disability Groups : Mental disability -

Totally preventable

(IMPACT, Other groups)


3

Communication Themes

• Iodine is important

• It prevents things we may not see: -

Mental handicap

-

Loss of 13 I.Q. points

• These are serious & irreversible

• IDD retards social & economic development


4

Community Perception

Why is the daily consumption of adequately iodized salt a good thing ?

• Things we are asking people to do…• They have to do for all times to come…• As a result of daily consumption of

adequately iodized salt, discussions on preventable brain damage will be

a lesson of history




Demand Pull

Supply Push

Regular

Reliable

Representative

State-level

Scientific Data

The way forward: Regular Reliable Representative Scientific Data

Regular, Reliable, Representative Scientific Data

• Surveys conducted by respective state governments in collaboration with AIIMS, UNICEF, MI, ICCIDD

• Kerala, Tamilnadu, Orissa, Bihar, Goa, Rajasthan

• Quantitative component: 30 Cluster Methodology

• Qualitative component: K A B P

(Knowledge, Attitude, Beliefs, Practices)

• Need for tracking progress to achieve sustainability

Presenter

Presentation Notes

Replace Kerala book with Tamilnadu

NFHS-3 (2005-2006)

• National Family Health Survey (NFHS-3) under process

• 110,000 families will be visited from all over the country

• Iodine in salt will be detected by salt testing kit (STK)

Our suggestion: Analyze 10% of salt samples by titration method

AIIMS / NIN can analyze these 11,000 samples by titration method




Demand Pull

Supply Push

Regular

Reliable

Representative

State-level

Scientific Data


Sustained Political

Commitment

The way forward: Sustained Political Commitment

Tracking Progress Towards Sustainable Elimination of IDD in

Kerala (2001)

Tracking Progress Towards Sustainable Elimination of IDD in

Tamil Nadu (2002 - 2003)

Dissemination Workshop5th June 2003, Chennai

AdvocacyDemand Creation

Monitoring

Health Minister

Secy. Health

Panchayat Raj

Members

District Magistrates

AwarenessMonitoring

Activities Related to Supply Side

Increase in Iodized Salt Production

Capacity of TNSC

Salt & Iodized Salt Producers Meeting

Ensuring Quality, Accessibility. Availability, Affordability, Acceptability

of Iodized Salt

Linking Research to Policy & Program:

The Tamilnadu experience -

1

Linking Research to Policy & Program: The Tamilnadu experience -

2

• Quality iodized crystal salt distributed at Rs. 2.50/Kg through PDS

• Increase in distribution of iodized salt by ten folds through PDS

Year 2000 : 4,200 tons Year 2004 : 42,829 tons

• Distribution of iodized salt to Below Poverty Line (BPL) population:

Tamilnadu

: 3.5 million people Karnataka

: 2.0 million people

Andhra Pradesh

: 1.5 million people

Why should government facilitate the process of elimination of IDD?

• Health is socially desirable and better for people

than they realize

• Health is a ‘merit good’

– Government has the responsibility to protect

population health

– Individuals do not always make good choices,

especially when benefits are in the future

• Government’s intervention on iodized salt producers

(who are small in number as compared to the

entire population) benefits the entire population

• 1,000 iodized salt producers : 1,000 million people benefited

( ‘positive externalities’)

Tenth Five Year Plan (2002-2007) Annual Health Expenditure Outlays (approx.)

Program Rs. Crores

(%)

Pulse Polio (revised) 322 (25)

Immunization and its Routine Strengthening

286 (22)

Social Marketing and Free distribution of contraceptives

341 (26)

NACO 254 (20)

NPCB 89 (7)

National IDDCP 7 (0.5)

TOTAL 1298 (100)

* Source: Health Information of India 2003, CBHI, DGHS, MoHFW, GoI

AIDS

NPCB

Pulse Polio

Immunization

Contraception

IDD

and} (47)

Presently, NO consultant for IDD.

Express need to have full-time consultants under NIDDCP

to accelerate the program

Consultants in health programs

Pulse Polio303 consultants

Tuberculosis100 Consultants

Leprosy18 Consultants

Presenter

Presentation Notes

Earlier 137

• In the field of nutrition as in politics, the task is to do what is possible without

forgetting to do what is necessary

• Achieving optimal iodine nutrition through USI, provides this opportunity –

“Never before so much can be done For so many, For all times to come For so little, in such a short time”

Consumption of adequately iodized salt for all times to come




Demand Pull

Supply Push

Regular

Reliable

Representative

State-level

Scientific Data


Sustained Political

Commitment

To Reiterate the Next Steps

In summary…1.


2.

What are the consequences of iodine deficiency?3.


4.

The Kangra Valley Study (1956 –

1972)5.

New Evidence: From Endemic Goiter to IDD

(1962 –

1983)6.

What is the status of iodized salt coverage

in India? (1998-99; 2002)7.


2005)

8.

Key issues in IDD9.


10.

Why did consumption of iodized salt decrease?11.

The way forward

How Simple is Simple?

The Story of Iodine Deficiency &

Preventable Brain Damage

Sustainable Elimination of Iodine Deficiency Disorders in India

“Simple Goitre is the easiest of all known diseases to prevent…

It may be excluded from the list of human diseases

as soon as the society determines to make the effort.”

- Dr. David Marine, 1920(Pioneer in mass prophylaxis of endemic goiter)

Thus, The Story of iodine deficiency continues…

How Simple is Simple?How Simple is Simple?

Even man finds it difficult to be human !Even man finds it difficult to be human !

MirzaMirza GhalibGhalib

18th Century Poet18th Century Poet

" We ourselves sometimes feel that what we do is just a drop in the ocean,

But the ocean would be less because of that missing drop.“

- Mother Teresa

" We ourselves sometimes feel that what we do is just a drop in the ocean,

But the ocean would be less because of that missing drop.“

- Mother Teresa

Acknowledgements -

1

To the Global PartnershipDedicated to the Sustainable Elimination of

Iodine Deficiency DisordersAn Ancient Scourge of Mankind

The People of the affected countriesThe Governments of the affected countries

The Salt Producers of each country

Acknowledgements -

2

The International Agencies –

especially

The United Nations Children’s Fund

The World Health Organization

The World Bank

The Micronutrient Initiative

Kiwanis International

Acknowledgements -

3

The Bilateral Agencies –

especially

The Australian Agency for International Development

The Canadian International Development Agency

The Netherlands Ministry for Development Cooperation

The Swedish International Development Agency

The United States Agency for International Development

Acknowledgements -

4

The Global Network for Sustained Elimination of Iodine Deficiency

The International Council for Control of Iodine Deficiency Disorders

Thank You!

For further details, correspondence is invited at:For further details, correspondence is invited at:

Dr. C. S. PandavDr. C. S. Pandav Professor & Head, Professor & Head,

Center for Community MedicineCenter for Community Medicine All India Institute of Medical SciencesAll India Institute of Medical Sciences

AnsariAnsari NagarNagar New Delhi New Delhi –– 110029110029

Email: Email: [email protected]@iqplusin.org

Daily consumption of adequately iodized salt is a healthy habit

Towards Sustainable Elimination of IDD

Salt for freedom

Health & Medicine

Transcript of Salt for freedom