Imposing iodine

The ban on non-iodised salt, reimposed this May, is criticised as being based on generalisations made by the authorities.

LYLA BAVADAM In Mumbai

"I UNDERSTAND that the government is planning to ban the sale of all non-iodised salt in the country with effect from August 15, 2005. This is apparently in order to fight cretinism. The proposed measure of the government is akin to killing a fly with a hammer. Cretinism is present in any significant number of people only in certain very limited regions of our country. Not only is iodine not required for adults but also it can be positively harmful for people above the age of 40 years."

This succinct opinion is from a letter written by Susheel Somani last July to the Secretary, Ministry of Health and Family Welfare, in New Delhi. Somani, a resident of Mumbai, has been battling the ban on common salt ever since it was proposed in 1997. The reason for his fight is his personal experience with iodised salt consumption and that of his wife, Kumkum.

The iodised salt debate has been on since 1998 when the government first issued a notification banning the sale of non-iodised salt. In 2000, consumer lobbies won their case for a citizen's right to choose and the Centre lifted the ban. Six years later, it has been re-imposed via another notification, which came into effect on May 17. With the ban in operation, anyone guilty of selling non-iodised salt for human consumption will be prosecuted under the Food Adulteration Act; the irony that common salt has no additives and thus cannot technically be considered adulterated seems to have escaped the authorities.

The ban is operational all over the country except in Maharashtra. A stay order has been obtained from the Bombay High Court until June 30 based on a petition filed by two Gandhian organisations - the Rashtriya Yuva Sangthan, the SarvSeva Sangh - and Kumkum Somani. Their plea is for the right to choose between iodised and non-iodised salt for reasons related to health and economic conditions. The High Court heard it along with a similar petition filed by small-scale salt manufacturers.

However, opinion is sharply divided on the matter of informed choice. Studies (including National Family Health Survey II data) show that the majority of those suffering from Iodine Deficiency Disorder (IDD) come from underprivileged socio-economic groups, whose choices would be based on pricing rather than health concerns. The medical world is particularly divided on this issue. The Indian Medical Association's (IMA) secretary-general Dr. Vinay Aggarwal, said: "The IMA is firm on the necessity for iodisation of salt. There should be no choice between non-iodised and iodised salt. If you give a choice people will choose non-iodised salt since it is cheaper. At least 70 per cent of our population is in villages and has no primary health care facilities. They are the ones who have nutritional deficiencies and need iodine-fortified salt."

The Mumbai chapter of the IMA disagrees with the Delhi branch. At a meeting, Mumbai IMA President Dr. Sunita Kshirsagar was amazed that the issue of iodised salt had been raised again, saying she thought it had been resolved in 2000. Now, as then, the Mumbai IMA champions the right to choose. The members took a decision to form an independent inquiry commission to investigate the circumstances for reimplementing the ban. They were also unanimous in their opinion that iodine given indiscriminately to the population is risky.

Dr. S. M. Sadikot, consulting endocrinologist at Mumbai's Jaslok Hospital, was emphatic when he said: "First let us show how major a problem IDD is in our country before we make it compulsory. Until it is proved that IDD is widespread in India consumers should have a choice. Apart from a few papers, I am yet to come across peer reviewed research published in international journals that proves that IDD is widespread in India."

Just how widespread is IDD in India? A report of the Directorate of Health Services, Mumbai, claims that 70 million people suffer from goitre (nodule growth on the thyroid) and IDD, 2.2 million suffer from cretinism, 6.6 million have mild neuro-deficiencies and another 200 million are at risk of IDD. The same document also gives the number of goitre cases as 54 million. The Nutrition Foundation of India, a non-governmental voluntary agency that describes itself as "dedicated to the upliftment of the nutrition status of Indians", said that iodine deficiency accounts for about two million children with cretinism. It estimates that a further 40 million children in endemic areas are at risk. Government surveys by the Indian Council of Medical Research indicate that IDD is higher in 13 States and Assam, Andhra Pradesh, Uttar Pradesh and Rajasthan are the worst hit. An estimated 64 million Indians suffer from IDD, with people in the sub-Himalayan tracts being the worst affected.

The iodisation programme began in the Kangra Valley in Himachal Pradesh in the 1950s after studies showed that goitre was endemic to the region. Most studies show the regional nature of IDD. There is none that proves that IDD is rampant in the country. In the same manner, the remedy should also be implemented region-wise and not imposed on the whole country, say those who oppose the ban.

There is no doubting the empirical data that link goitre, cretinism, defects in speech and hearing, brain damage and psychomotor malfunction with iodine deficiency. But it is important to note that the thyroid is affected by more than just iodine. This detail has to be factored into the research on IDD. The thyroid is particularly sensitive to environmental pollutants. Endocrinologist Dr. Anoop Misra, Director, Diabetes and Metabolic Disorders at Fortis Hospitals in Delhi, says autoimmune diseases are the most common cause of hypothyroidism in Delhi. A former Professor of Medicine at the All India Institute of Medical Sciences, Dr. Misra is emphatic about the clear-cut segregation between reasons for IDD in rural and urban areas saying these differences should be established before iodised salt is made mandatory.

Dr. R.K. Anand, consulting paediatrician at Jaslok, spoke similarly about the causes of cretinism. All the children he has seen with cretinism or hypothyroidism were cases in which the disease was genetically inherited rather than because of iodine deficiency. Anand is pro-choice in the salt debate and is wary of compulsory iodisation. He said: "All iodised salt packets should carry the warning Take under advice of doctor only."

General malnutrition also affects the thyroid. A study by the Maharashtra Health Department said that higher levels of goitre cases were noticed in areas of severe malnutrition. Sadikot said: "Most people eating a normal diet don't need iodine additives." Sadikot quotes studies in Japan and the United States that showed that the number of people with thyroid disorders "increased by ten times in two to three years after eating iodised salt." He says iodised salt packages should carry a health warning.

There are varying opinions on the effects of too much iodine. According to the World Health Organisation (WHO), "on a population basis, the benefits of correcting iodine deficiency through universal salt iodisation vastly outweigh the risk of iodine-induced hyperthyroidism." This opinion relies on the prevalent medical belief that excess iodine is rejected by the body.

Calling this a dangerous generalisation, Sadikot said: "The body may or may not eliminate the excess iodine. Chances are that it will have some effect on the thyroid. We know this can happen so that is all the more reason for informed choice... Overdoses of iodine sometimes manifest themselves in vague and inconsistent ways. Patients report a general feeling of ill health. Four out of five people with thyroid dysfunction are women. Often unable to be specific about their complaints, they are dismissed as depressed or menopausal, and the problem remains untreated."

In 1998, when iodised salt was first made mandatory in the country, Kumkum Somani became a victim of excess iodine. From pus-filled boils, uncontrollable itching and griping stomach pains to depression, heavy-headedness and irritability, Kumkum's symptoms escalated rapidly. Her weight fluctuated wildly and sleep overpowered her during the day. One day she realised she could not even see the images on a cinema screen. Finally she narrowed her problem down to iodised salt. Within days of cutting this out of her diet her health stabilised.

Martindale: The Extra Pharmacopoeia, a complete reference of drugs and substances used worldwide and a touchstone for the medical world, states: "The toxic effects of continued administration of iodine are known to lead to mental depression, nervousness, insomnia, sexual impotence, myxoedema and goitre. Hypersensitivity... is characterised by headache, pain in the salivary glands, weakness, conjunctivitis, fever, laryngitis, bronchitis and [a variety of] skin reactions. Vomiting, metallic taste in the mouth, abdominal pain and diarrhoea are also known to occur.... Iodine given to the mother is also known to cause thrombocytopenia, which is hazardous to the foetus. Iodised salt should carry a compulsory warning in red, bold letters that its usage may lead to allergies and thyrotoxicosis."

No iodised salt packet carries any warning. Sadikot says, "When you make something compulsory, then you have to have checks and balances. The amount of potassium iodate [the compound used in iodisation] in the packet should be precisely indicated." Studies by the University of Massachusetts Medical Centre say hyperthyroid reactions are triggered only if a person has more than ten times the normal daily dosage of iodine. The WHO's recommended daily intake for people over 12 years is 150 mg, an amount so small that it could fit on a pinhead. The WHO has graded daily intake recommendations for 0-59 months, 6-12 years, above 12 years and pregnant and lactating women. Does this mean that iodised salt should be made available in graded packets according to user categories?

Questions also come up about potassium iodate, a volatile compound sensitive to heat and poor storage. Twenty per cent of it is lost in cooking. Another 20 per cent is lost from production site to household. Would the potency of the fortified salt decrease with time? Would this not minimise the therapeutic effect? In turn, would the salt have to be `over-iodised' to compensate for loss on the shelf? Will over-iodisation not have its own set of dangers? Because of its toxic nature potassium iodate has been replaced by potassium iodide in other countries. According to the Salt Commissioner's Office, iodate is used in India because of "its high stability under tropical conditions".

The recommended amount of potassium iodate is 15 ppm/kg at the time of spraying so that by the time the salt is consumed it is approximately 12 ppm/kg. The responsibility for this standardisation lies with the salt producer, the Salt Commissioner's office and the Food and Drug Administration. Small-scale manufacturers are unanimous in saying that agencies exercise no control over standards and twist the law. Furthermore, there is little awareness that special plastic packaging is required to preserve the iodised salt.

There appears to be a distinct commercial angle in the push for iodised salt. Viren Shah, a functionary of the Small-Scale Salt Manufacturers Association, is categorical in saying that the 1998 ban was revoked on the insistence of the WHO, which, he asserts, was influenced by large salt manufacturers. In May last year, small-scale salt manufacturers and officials from the Salt Commissioner's office were invited to a one-day meeting at Hotel Sea Princess in Mumbai. It was hosted by the United Nations Children's Fund (UNICEF) and its agenda was to persuade small-scale manufacturers to iodise salt. They were promised all facilities but none of the 60 or so manufacturers from the Palghar coast of Maharashtra agreed.

The manufacturers' main opposition is to the huge hike in salt prices as a result of iodisation. This has nothing to do with the actual cost of iodisation, which is just 0.9 paise a kilo. Their objection has more to do with the enforced packaging, and the subsequent marketing and competition with big brands. Earlier, the salt they sold was `loose' (that is, not branded). Iodised salt has necessarily to be packaged, both to preserve the iodine content and to prove to the authorities that it has been iodised. Once the salt is packaged and branded, the marketing war begins and this results in price rise, from Rs.2 that loose salt is available for to Rs.7 that iodised salt is sold for. Small-scale manufacturers are afraid that they will not be able to compete with the big, established brands and will lose their livelihood.

Nutritional alternatives to compulsory iodisation do exist. Nutritionist Vijaya Venkat is firm in her opposition to polished grains because the process destroys the natural iodine present in the outer husk. According to her, millets, pulses, cereals, jaggery, leafy vegetables, roots, milk, eggs, fish and even tap water all contain minimal doses of iodine that can be easily absorbed by the body. She says that the government should concentrate on providing a healthy balanced diet that includes clean drinking water instead of unnatural interventions.

By iodising a common food product such as salt the government is leaving people with no choice. When umbrella laws such as these are created, there should be something to substantiate them. But in the case of iodine there are no satisfactory answers to many questions. Instead an uneasy feeling remains that the ban on common salt is the outcome of generalisations made by the authorities and imposed on the public.