Iodine for all

The UPA government's decision to re-impose the ban on the sale of non-iodised salt is widely welcomed, especially because India has a low rating in the prevention of iodine deficiency disorders among the population.

T.K. RAJALAKSHMI in New Delhi

ON June 15, Union Minister for Health and Family Welfare Anbumani Ramadoss declared the re-imposition of the ban on the sale of non-iodised salt meant for human consumption. Considering that the majority of those suffering from iodine deficiency disorders (IDD) come from the backward socio-economic groups - National Family Health Survey (NFHS) II data substantiate this - where the element of choice is rather negligible, the decision of the United Progressive Alliance (UPA) government is evidently in the public interest. Scientific and empirical considerations seem to have prompted the decision. The ban perhaps recognises that Universal Salt Iodisation is a major step towards protecting a child's right to survival, growth and development. The only way, however, that the government can reach this salt to the populations that need it the most will be the Public Distribution System.

The ban on non-iodised salt had been lifted in September 2000 by C.P. Thakur, who was the Health Minister during the tenure of the National Democratic Alliance (NDA) government, for reasons not very clear. Most State governments had opposed the lifting of the ban, describing it as a step against the interests of public health. Consumer lobbies, however, insisted on the consumer's right to choose and argued that access to non-iodised salt should not be forbidden completely. It was opined that the role of the government should be confined to creating awareness about deficiency diseases. The official reason given by the NDA regime was that "matters of public health should be left to informed choice and not enforced through compulsion".

The UPA government, for its part, conducted a survey and found that there was no district or Union Territory that was free of iodine deficiency. Of the 312 districts that were surveyed by the Health Ministry, endemic iodine deficiency was found in 254 districts. The survey also debunked the myth that the prevalence of IDD was confined to the sub-Himalayan regions. What was of immediate concern was the revelation that there was a drop in the consumption of iodised salt after the ban was lifted.

Data from NFHS II (1998-99) showed that while 70 per cent of the population in India consumed salt with some amount of iodine, only 49 per cent used adequately iodised salt. This figure, according to Reproductive and Child Health (RCH) II survey (2002-03), fell to 37 per cent after the removal of the ban. The situation, the government felt, was of grave concern especially in the northeastern States and Uttar Pradesh where a substantial decline in the consumption of iodised salt was observed. The production of iodised salt dropped significantly in 2001-02 with the lifting of the ban and a hike in railway freight.

The Ministry of Health and Family Welfare and the United Nations Children's Fund (UNICEF) estimate that around 26 million children are born each year, of whom 13 million face the risk of IDD. Iodine deficiency is known to cause brain damage, stunting of growth, goitre, speech and hearing impediments, and depleted levels of energy in children. For pregnant women with IDD, the risks of miscarriage and stillbirth are high.

THE former Soviet Union is an example of the extent to which government policy can play a constructive role in public health. The International Council for Control of Iodine Deficiency Disorders, in a study of IDD in central and eastern Europe, the Commonwealth of Independent States, and the Baltic, found that the former Soviet Union had virtually eliminated endemic goitre and cretinism through a targeted distribution of iodine tablets among the vulnerable groups and through a well-placed system of monitoring. With the collapse of the Soviet Union, iodised salt production got interrupted in countries across the region barring the former Republic of Yugoslavia.

In India, it was in 1983 that a policy decision was taken to iodise salt meant for human consumption. This came to be known as the Universal Salt Iodisation programme. Interestingly, the private sector, which now accounts for nearly 97.5 per cent of the total salt production, was permitted and encouraged to produce iodised salt. The "elimination of goitre" was included in the Prime Minister's 20-point National Development Programme. From 0.3 million tonnes in 1983, iodised salt production rose to 4.1 million tonnes in 2003; in 2000 it touched a peak of 4.7 million tonnes. Three States namely, Gujarat, Tamil Nadu and Rajasthan, accounted for 96 per cent of the salt produced in 2003.

Among the South and South-East Asian countries, India fares rather poorly as far as the proportion of households consuming iodised salt is concerned. Bhutan tops the list with 95 per cent of its households consuming iodised salt and is closely followed by China at 93 per cent. Nepal, India and Myanmar feature at the lower rungs of the consumption ladder. A comparison between China and India of the percentage of newborns who are unprotected from IDD reveals that the figure is 7 per cent or 1.3 million children in the former, while in India it is 13 million or 50 per cent.

The re-imposition of the ban is also very much in consonance with the Tenth Five-Year Plan goals, which include achieving universal access to iodised salt, generating district-wise data on iodised salt consumption, and reducing the prevalence of IDD to less than 10 per cent by 2010.

The costs of iodisation are very low - in fact, less than 1 per cent of the purchase price. According to the Indian Coalition for the Control of Iodine Deficiency Disorders, the cost of iodine per person a year is 10 paise. It is the cost of packaging, branding and advertising the finished product that results in the increased price of iodised salt. Loose iodised salt - 70 per cent of the total iodised salt produced in the country is sold loose - is equally effective.

The iodised salt production capacity in the country is supposed to be adequate, as a part of the salt is exported. The majority of salt production is done in the small-scale sector.

Welcoming the move to reinstate the ban on the sale of non-iodised salt, R. Sankar, vice-president, Indian Thyroid Association, told Frontline that making available iodised salt to the population was a socio-economic goal as well. Negating fears of iodine-induced hyperthyroidism, he said that the thyroid gland was equipped to handle any additional load of iodine. "Iodisation of salt ensures that the human body gets its daily requirement of iodine," he said. Regarding the apprehension over costs, he said that there was a confusion between refined and iodised salt. Nearly 70 per cent of the salt produced in the country was crystal salt and its iodisation was not an expensive procedure. He also welcomed the Minister's suggestion of making iodised salt available through the PDS. "The government should absorb the retailer's margin, which is very high in this trade. It should also ensure that people get what they pay for," Sankar said.

The move to reinstate the ban should be followed by steps to ensure that iodised salt is made available to people at affordable rates, for the staple diet of most poor people in the country comprises chappatis, green chillies and salt.