Why is the Indian government's public health programme fixated myopically on iodine, just one micronutrient among hundreds, when whole communities in the country are starving for lack of basic nutrition (food)? Have all the facts related to the health implication of iodine been made public? Who are the actual beneficiaries of the salt iodisation drive? How well has the issue been researched in the country?
Government 'awareness' programmes on iodisation of salt are unlikely to answer these questions, and yet they are too crucial to be ignored.
Nagpur based nutritional scientist and president of Academy for
Nutritional Improvement, Dr Shantilal Kothari, has researched the
compulsory salt iodisation issue since 1984. The Academy of
Nutritional
Improvement, a small self-funded body, collects and
makes public
nutritional information from public health laboratories
from
across the country. Related to this, the institute also runs campaigns and
mobilises public opinion. 11 people work at the Academy. Also, Kothari, along
with hyperthyroidism patient Kumkum Somani, is one of the voluntary respondents
in the Supreme Court case filed against the lifting of the ban on compulsory
iodisation. (Common Cause, a consumer organisation, filed the case in 2000.)
According to Kothari, the reasons for the renewed stress on compulsory iodisation have very little to do with public health. Not only are there specific political pressures at work behind this drive, he says, but facts of crucial importance have been hidden from the public, which makes the motives behind this drive dubious.
Health facts that were never revealed
Kothari says that the biggest myth being propagated under the iodisation programme is that iodised salt is a cure for all iodine deficiency. "Any standard medical text will tell you that lack of dietary iodine is just one of several causes of iodine deficiency," says he, producing a copy of Textbook of Medical Physiology, by Arthur Guyton and John Hall. According to this text, an average adult requires just 50 grams of ingested iodine per year or 1 mg per week, which can be easily ingested from a balanced diet not consisting of iodised salt. Green vegetables, whole grains and milk are rich sources of iodine. Natural sea salt also contains iodine (6-8 parts per million (ppm) as compared to 20 ppm in Tata salt, according to a report by the Department of Biochemistry, Nagpur University), a fact which has not been taken into account by policy makers.
The Guyton and Hall text also states that apart from low intake of dietary iodine,
other reasons for iodine deficiency include the congenital absence of
the deiodinase enzyme in the body or a blocked or heriditarily absent
peroxidase system, which make it impossible for the body to process
dietary iodine and secrete thyroid hormones. Also, excessive amounts of
goitrogens (found in polluted water and processed food, and can be
ingested through excessive consumption of vegetables like cabbage or
lady's finger) in the diet is another reason for iodine deficiency.
In all such cases, as also in the case of people with normal iodine levels, an arbitrary, one-size-fits-all dose of iodine force-fed by public policy runs the risk of actually doing more harm than good.
Excess iodine in the body (hyperthyroidism) raises the body's requirement of vitamins and cause a 'relative vitamin deficiency'. It can also increase the basal metabolic rate to '60 to 100 per cent above normal', which in turn has significant adverse effects on blood flow, heart beat, depression in hearth muscle strength, increase in arterial pressure. Appetite and food intake rise sharply, resulting in diarrhea. Other common symptoms of hyperthyroidism are muscle tremour, extreme nervousness, fatigue and psychoneurotic tendencies like anxiety complexes, paranoia and worry.
While there is a lack of comprehensive data on the incidence of iodine-induced hyperthyroidism (IIH) in India, there is well documented evidence that several developed countries from the West, among them USA, England, Italy, Germany, Japan, Switzerland and Australia, abandoned compulsory iodisation way back in the 1940s, after deaths were recorded in the US and England from hyperthyroidism. England's massive iodine deficiency problem was solved naturally through improvement in diet, and today, just 2 per cent of salt in the country is iodised.
Again, several African countries subjected to high doses of iodisation by Western experts suffered IIH outbreaks as late as in the 1990s. The most important case was that of Zimbabwe, where, in 1995, the incidence of IIH went up by 27 per cent after the recommended dosage of iodine was increased, and mortality from heart complications was reported.
Today, all over the developed world, both iodised and common varieties of salt are available in the market, with the choice left to the consumers.
Conspicuous silences
According to Kothari, the biggest flaw in the Indian government's implementation of its iodisation programme is that while extensive advertisement and 'awareness' campaigns have been run on the benefits of iodised salt, no efforts have been made to educate the public on issues like the range of root causes for iodine deficiency and the health hazards of hyperthyroidism.
Apart from this, the basis on which the quantity of iodine in salt is decided is itself suspect. Kothari refers to a document on Recommended Iodine Levels in Salt and Guidelines for Monitoring their Adequacy and Effectiveness, issued jointly by the WHO, UNICEF and the International Council for Control of Iodine Deficiency Diseases (ICCIDD), which clearly states that "There is no level of iodine in salt that offers complete protection against some increase in the incidence of hyperthyroidism."
The same document also states that recommended iodine levels in salt have been made on two assumptions -- that iodine losses from iodised salt are 25-50 per cent and the average salt intake is between 5 to 10 gm per day per person. "These assumptions are too thin a basis for the implementation of an iodisation programme as comprehensive as ours," says Kothari.
The central government has also followed a policy of silence on the rampant profiteering in the iodised salt trade, which is dominated by large companies. While government advertisements cry themselves hoarse that the difference in price between iodised and non-iodised salt is 'nominal', in actuality the price difference is anywhere between two to three fold -- perhaps even more for some brands. This despite the fact that the cost of the iodine to be added to one kg of salt is just two paise, or Rs.0.02. "Pressure from iodisation has even sent up the price of common salt," says Dr Kothari. "Even today on the Gujarat coast, salt sells for Rs.0.15- 0.20 per kg, whereas in the cities it costs Rs.3," he adds.
This is in sharp contrast to pricing in developed countries like the USA and Australia, in both of which countries there is hardly any difference in price between iodised and non-iodised salts. In the US, natural sea salt is far more expensive than any refined table salt, iodised and non-iodised. "We in Indian are so lucky to have natural salt, healthy in abundance, and at very low prices at that," says Kothari, "but the government is bent upon forcing needlessly, and ridiculously expensive iodised salt on us."
Botched research, questionable data
The research conducted in the country before and after the implementation of the iodisation programme shows a host of lacunae, which makes its reliability as an argument in favour of iodisation somewhat suspect.
For instance, a government publication, The Story of Iodine Deficiency, says this, while describing a study undertaken in the Kangra Vally in Himachal Pradesh between the years 1956 and 1968: "After six years of iodisation, i.e., in 1962, a striking decrease in the prevalence of goitre was observable in Zone A (from 38 per cent to 19 per cent) and Zone C (from 38 per cent to 15 per cent), but no significant change in Zone B. (Zone B was supplied with non-iodised salt)"
But a table of figures on the same page show that in Zone B, the prevalence of goitre had fallen from 34 to 17 per cent among males and from 51 to 17 per cent among females during the time period stated, which is proportionate to the drop in goitre levels in the groups provided iodised salt. How, the question arises, can it be assumed that the drop in goitre levels happened due to iodised salt when the drop in the goitre level was almost equal in all three groups? The same document states just a few sentences later that "Following the successful Kangra Valley pilot study, the Government of India between 1962 and 65 installed, with the financial assistance of UNICEF, a total of 12 iodisation plants in different parts of the country."
This single decision by the government overlooked two crucial lacunae. Firstly, how can a single pilot study conducted in just one small valley justify the installation of as many as 12 iodisation plants, and that too all over the country? Why was no comprehensive study of the prevalence of goitre in different regions of the country undertaken before such a huge step was taken?
Secondly, and is classic governmental fait accompli style, the 12 plants were installed between 1962 and 1965 -- halfway through the 'successful' 12-year study.
An Indian Council of Medical Research (ICMR) document on the status of the National Goitre Control Programme, which covers the span from 1960 to 1984, shows that 35 districts out of a total of 83 districts in different parts of the country, in which the study had been undertaken, the supply of iodised salt had not commenced at all during the entire period of the study. In many other districts the supply had started as late as 1982, and in one district, in 1984. No re-survey of goitre status had been done in 62 districts.
Kothari says his analysis of various studies conducted by individual scientists and government bodies like the ICMR, the Ministry of Health's Directorate General of Health Services (DGHS) and a number of state governments on the prevalence of IDDs shows that research on the subject has failed to establish a credible connection between IDD prevalence and the consumption of iodised salt. In many areas, IDD prevalence appears to have risen after the commencement of iodisation.
In Arunachal Pradesh, for instance, it rose from 30 to 38 per cent after iodised salt was made available in 1965. In the East and West Champaran districts of Bihar, it rose from 40.3 in 1960 to 64.5 and 51.2 respectively in 1979. I-salt supply had started in 1964, as per an ICMR document. In the Chandni Chowk and Kalkaji areas of Delhi, the prevalence rate dropped from 55.2 and 54.7 per cent respectively in 1980 to 29 per cent in 1986. And iodised salt supply started only in 1989! The biggest surprise comes from Assam, which was a non-endemic state (with a prevalence rate lower than 10 per cent) till 1969, but suddenly turned endemic within a decade, with prevalence rates as high as 65.8 in Dibrugarh in 1984-85.
Government data appears to be highly unreliable and incomplete, along with evidence of manipulation and even withholding of information. For instance, crucial information, like the year of commencement of iodised salt supply, is not mentioned in the case of many states, including Assam, which makes it impossible to evaluate or analyse the data with any degree of reliability. In the case of Arunachal Pradesh, DGHS surveys of 1960, 1969 and 1982 show uniform figures of 30.0, 38.0 and 26 (with varying decimal figures) in all ten districts of the state! In Adilabad and East Godavari districts of Andhra Pradesh, studies conducted by the state government and DGHS in the year 1985 show widely different results.
Added to all this is the fact that none of these studies takes into account the presence of goitrogens and other causes of iodine deficiency, without which a case in favour of I-salt does not hold water.
In the January 2006 bulletin of the Medico Friends Council, Dr Veena Shatrughna, deputy director of biochemistry at the National Institute of Nutrition (NIN), Hyderabad, said that while a 2003 institute report covering 40 districts all over the country showed that the prevalence rate of IDDs had come down since I-salt supply began (the proposed ban on non-iodises salt is premised on this), no simple correlations could be made because the goitrogen factor had not been taken into account. The present director of NIN, Dr B Sesikeran, did not respond to repeated queries.
Another serious lacunae in all the studies is that no distinction has been made between the two types of goiter physiological (natural) and pathological (as a disease), which raises the suspicion that the prevalence and seriousness of the disease is overestimated. Also, there is no evidence to suggest that the lifting of the ban in 2000 has raised the iodine deficiency levels in Indian diet. The WHO's 2002 Iodine Deficiency Status Report puts India in the 'optimum' consumption zone, with consumption ranging from 100-190 micrograms per day as against a requirement of 150 microgrammes.
Unholy haste?
The body that was most aggressively against India's decision to lift the ban on non-iodised salt in the year 2000 was the ICCIDD an organization funded by WHO and USAID. USAID, a US government-run agency, is particularly known for following an aggressive and corporate-driven 'development' agenda in Third World countries. The iodisation programme in India was led by scientists from AIIMS, under the banner of the Indian Coalition for Control of IDDs, which has the same abbreviation as that of the international body.
Notably, some of the scientists, for instance Dr Chandrakant Pandav and Dr Madhu Karmarkar, have connections with the international ICCIDD and hence may share views with the body. Pandav was the South East Asia regional coordinator of ICCIDD. Also, the ICCIDD newsletter of August 2000 shows that this body was instrumental in the filing of the public interest litigation with the Supreme Court of India against the lifting of the ban. The case was originally filed by Common Cause, and later, Dr Danish Moorti, a member of the Indian ICCIDD became a petitioner. The case remains pending before the Supreme Court.
Clearly, the government iodisation programme does benefit the bigger I-salt manufacturers. But Kothari sees a larger connection. "The entire iodisation programme is part of a corporate ploy to shift emphasis from food and nutrition issues and the Right to Food campaign to micronutrients," he alleges. "Iodisation is not the end of the salt-fortification story," says Kothari. He says that it may be followed by fortification with iron, zinc, copper, and what not. He notes that Union Health Minister Ambumani Ramadoss has already talked about iron fortification in the future, and zinc fortification may already be in the pipeline. "With every added fortification, the price of salt will rise, and the beneficiaries will be the big players in the global and national trade in salt and micronutrients," Kothari predicts.
