Salt for Freedom and Iodized Salt for Freedom from Preventable Brain Damage The All India Institute

1
Salt for FreedomandIodized SaltforFreedom
fromPreventable Brain DamageThe All India
Institute of Medical Sciences, New
DelhiICCIDDJune 2005
2
Ensuring freedom from preventable brain
damageSustainable Elimination of Iodine
Deficiency Disordersin India
Dr. Chandrakant S. Pandav Dr. Anil Kumar Dr.
Denish Moorthy Dr. K. Anand Dr. R. Sankar Dr.
M. G. Karmarkar
The All India Institute of Medical Sciences,
New Delhi Indian Coalition for Control of
Iodine Deficiency Disorders (ICCIDD)
3
Ensuring freedom frompreventable brain
damageTowardsSustainable Elimination of
Iodine Deficiency Disordersin India
4
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 modewith a
  vision for the nation
• -Dr. A. P. J. Abdul KalamPresident of
  India(Ignited Minds)

5
Outline of presentation

• What is iodine what is iodine deficiency?
• What are the consequences of iodine deficiency?
• How do we eliminate iodine deficiency?
• The Kangra Valley Study (1956 1972)
• New Evidence From Endemic Goiter to IDD (1962
  1983)
• What is the status of iodized salt coverage in
  India? (1998-99 2002)
• Changing status of legislation (1968-2005)
• Key issues in IDD
• Do we need Universal Salt Iodization?
• Why did consumption of iodized salt decrease?
• The way forward

6
1. What is iodine what is iodine deficiency?
7
What is iodine? - 1

• Nutrient needed in aminute quantity
  daily.Recommended daily intake150 µg
  (Micronutrient)
• Total quantity present in body is (15-20
  mg)mostly in thyroid gland

8
What is iodine? - 2

• Iodine Essential component ofthyroid
  hormones,which are needed for
• - Optimal mental physical development
• - Regulation of body metabolism (Generation
  utilization of body energy)

9
Iodine Daily requirements
WHO, UNICEF, ICCIDD Recommended iodine levels
in salt and guidelines for monitoring their
adequacy and effectiveness. WHO/NUT/96.13.
Geneva. 1996
10
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

11
Iodine deficiency Disease of the soil
Gradual leaching of iodine from soil due to
Floods
Melting of Glaciers
Rivers changing course
12
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

13
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
14
Goiter has been known since the days of Lord
Buddha and before
Earliest evidence of goiter 3000 BC
15
Importance of iodine inbrain development - 1

• 50,000 brain cells produced/secondin
  developingfetal brain
• 100 billion brain cells in adult
• One million billion connections between these
  brain cellsDetermine IQ

16
Importance of iodine inbrain development - 2

• 100 billion brain cells in adult
  humanComparable to the number of stars in the
  sky

17
Brain cell branching

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

18
Importance of iodine inbrain development - 4

• 90 of human brain development occurs between
  3rd month of pregnancy 3rd year of
  life(Critical period)

19
Importance of iodine inbrain development - 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 mothersget theirdaily requirementof
  iodine

20
Importance of iodine inbrain development - 6

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

21
Spectrum of IDD
Goiter
Cretinism
Spontaneous Abortions,Stillbirths,Birth Defects
Defects of Speech Hearing,Squint,Psychomotor
defects
Loss of 13 IQ points,Leading Cause of Mental
handicap
22
Iceberg of IDD
23
Effects on humansFetus

• Mortality
• Spontaneous abortions stillbirths
• Increased perinatal mortality
• Disability
• Birth defects
• Defects of speech hearing
• Psychomotor defects
• Cretinism

24
Effects on humansNeonate

• Mortality
• Increased neonatal mortality
• Morbidity
• Neonatal Goiter
• Neonatal Hypothyroidism(Decreased production of
  thyroid hormones at birth)

25
Effects on humansChildren adolescents

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

26
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
27
Effects on humans Adults

• Goiter its complications
• Hypothyroidism
• Impaired mental function
• Iodine induced hyperthyroidism (IIH)

28
Effects on all age groupsIodine deficiency
nuclear radiation

• Iodine deficiency leads toincreased
  susceptibility tonuclear 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

29
Effects on livestock

• Goiter
• Hypothyroidism
• Reproductive disorders
• Decreased productivity(Milk, meat, wool, eggs)
• Lower work output

Goiter in animal
30
3. How do we eliminateiodine deficiency?

• What is iodine what is iodine deficiency? -
  Iodine is a micronutrient - Iodine deficiency is
  a disease of the soil
• What are the consequences of iodine
  deficiency? - Brain damage impaired physical
  growth in humans - Decreased productivity in
  livestock

31
Iodine deficiency disordersA public health
problem - 1

• Worldwide distribution

32
Iodine deficiency disordersA 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 possible

UNGASS United Nations General Assembly Special
Session on Children MDG Millennium Development
Goals
33
Our primary concern

• To ensure that
• Every population should
• Every mother child must
• Get their daily supply of iodine

34
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 requirementhas to be met
  daily, for all times to come
• Daily consumption of adequatelyiodized salt is
  a healthy habit

35
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 Indiaper person is
  10 gm
• Iodization of salt is a simple process
• Cost of salt iodization is 10 paise/person/year

36
Iodized salt The panacea for iodine deficiency
Promotion of Iodized Salt Consumption(Demand)
Salt production and iodization(Supply)
37
4. The Kangra Valley Study(1956 1972)

• What is iodine what is iodine deficiency? -
  Iodine is a micronutrient - Iodine deficiency is
  a disease of the soil
• What are the consequences of iodine
  deficiency? - Brain damage impaired physical
  growth in humans - Decreased productivity in
  livestock
• How do we eliminate iodine deficiency? - By
  daily consumption of adequately iodized salt

38
Legacy of The Legend Science Society
Prof. V. Ramalingaswami 8 August 1921 28 May
2001
39
Kangra
Himachal Pradesh
Kangra Valley Study Pioneer study conducted
inKangra District ofHimachal Pradesh, byProf.
V. Ramalingaswami
40
From evidence to program 1The Kangra Valley
study (1956-1972)
41
From evidence to program 2The Kangra Valley
study (1956-1972)

• 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

42
Kangra Valley study area
Dharamsala
From Pathankot
To Kulu
Zone AKI Salt
Zone BPlain Salt
Zone CKIO3 Salt
43
From evidence to program 3The Kangra Valley
study (1956-1972)

• Administrative Interventions
• Legislation (ban on sale ofnon- iodized salt in
  study area)
• Iodized salt distributed through government
  shops
• No price difference between iodized and
  non-iodized salt

44
From evidence to program 4.1The Kangra Valley
study (1956-1972)
Prevalence of goiter in zone A (KI salt)
40
40
30
Goiter prevalence in
20
19
10
8
1956
1962
1968
Intervention
45
From evidence to program 4.2The Kangra Valley
study (1956-1972)
Prevalence of goiter in zone B(Plain salt till
1962, then KI salt)
42
40
40
30
Goiter prevalence in
20
15
10
1956
1962
1968
Intervention
46
From evidence to program 4.3The Kangra Valley
study (1956-1972)
Prevalence of goiter in zone C (KIO3 salt)
40
40
30
Goiter prevalence in
20
15
10
5
1956
1962
1968
Intervention
47
From evidence to program 5The Kangra Valley
study (1956-1972)

• 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
48
5. New evidence From goiter to IDD(1962 1983)

• What is iodine what is iodine deficiency? -
  Iodine is a micronutrient - Iodine deficiency is
  a disease of the soil
• What are the consequences of iodine
  deficiency? - Brain damage impaired physical
  growth in humans - Decreased productivity in
  livestock
• How do we eliminate iodine deficiency? - By
  daily consumption of adequately iodized salt
• The Kangra Valley Study 1956 1972 - Provided
  scientific basis for NGCP

49
Scenario after Kangra Valley study

• National 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

50
NGCP activities (1962-1983)

12
51
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

52
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

• Subsequent surveys carried all over India

Iodine Deficiency Disorders A public health
problemin all states/UTs of India
53
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, 1994195-200
) Meta-analysis of 21 studies, 8 countries
54
Iodine deficiency learning disabilities

• Indian studies
• Intellectual assessment of school children
  fromseverely iodine deficient villages
• Mehta M, Pandav CS, Kochupillai N. Indian
  Pediatr 198724467.
• Developmental lag in pre-school children
  ofgoitrous mothers.
• Upadyaya SK et al. Indian Pediatr 198320259
• Intellectual and motor development in school
  children from severely iodine deficient region -
  Sikkim
• Sankar R, Pandav CS, et al. Indian J Pediatr
  199461407-414

All studies point to impaired intellectual and
physical development, and reduced psychomotor
performance due to iodine deficiency
55
The hourglass of IDD

• Iodine Deficiency Goiter
• Visible Swelling
• No Pain, Cosmetic problem
• Cretinism A rare event
• LOW PRIORITY
• Brain Damage
• Lack of Energy - hypothyroidism
• Learning Disability, ?Deaths
• ? Child Development Child Survival
• ? Human Resource Development
• HIGH PRIORITY

Historic view1962-1983
Current view1984 onwards
56
Universal Salt Iodization

• In 1983, Government of India tookpolicy 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
  Ministers 20-point National Development Program

57
6. What is the status of iodized salt coverage in
India?

• What is iodine what is iodine deficiency? -
  Iodine is a micronutrient - Iodine deficiency is
  a disease of the soil
• What are the consequences of iodine
  deficiency? - Brain damage impaired physical
  growth in humans - Decreased productivity in
  livestock
• How do we eliminate iodine deficiency? - By
  daily consumption of adequately iodized salt
• The Kangra Valley Study 1956 1972 - Provided
  scientific basis for NGCP
• New evidence From endemic goiter to IDD
  (1962-1983)

58
Salt iodization - 1Progress after declaration of
USI
Universal salt iodization (USI) proposed by
Government of India in 1983
59
Salt iodization - 2Progress from 1985 2003
5

• Production of iodized salt in India (Million Tons)

4.7
4.5
4
4.2
4.1
3.7
3
2.5
2
1
0.3
1985
2001
2002
1990
1995
2000
2003
Ban lifted
60
Salt production in India (2003)
96
Source Annual Report (2003 2004), Salt
Department, Govt. of India
61
Production of Refined Iodized Salt

62
Production of Unrefined Iodized Salt
63
State wise production ofrefined unrefined
iodized salt
64
Indian Scenario Use of iodized saltNational
Family Health Survey 2(1998-1999)

71
Adequately iodized salt contains 15 mg iodine/kg
salt at household level (15 ppm)
65
Consumption of adequately iodized saltaccording
to socio - economic status in India (NFHS-II,
1998-99)
Inadequate
Inadequate
Inadequate
22
50
64
Adequate
Adequate
78
Adequate
50
36
LOW SES
MEDIUM SES
HIGH SES
66
Use of Iodized Saltat Household Level North
East
91
88
84
80
79
70
NFHS 2, 1998-99
67
63
59
59
57
55
DLHS - RCH, 2002
52
47
Mizoram
Meghalaya
Manipur
Arunachal
Assam
Sikkim
Nagaland
67
Use of Iodized Saltat Household Level North
91
89
87
80
75
71
NFHS 2, 1998-99
64
53
53
DLHS - RCH, 2002
24
Haryana
J K
Punjab
Delhi
Himachal
68
Use of Iodized Saltat Household Level Heartland
57
57
NFHS 2, 1998-99
49
49
47
47
42
36
DLHS - RCH, 2002
32
25
5
5
Bihar
Chhatisgarh
Jharkhand
M.P.
U.P.
Uttranchal
69
Use of Iodized Saltat Household Level - South
56
NFHS 2, 1998-99
43
39
DLHS - RCH, 2002
35
30
28
27
23
21
22
A. P.
Kerala
Tamil Nadu
Karnataka
Orissa
70
Use of Iodized Salt atHousehold Level - West
60
56
54
NFHS 2, 1998-99
46
45
42
38
DLHS - RCH, 2002
24
Goa
Gujarat
Rajasthan
Maharashtra
71
(No Transcript)
72
(No Transcript)
73
(No Transcript)
74
Estimated percentage of households consuming
adequately iodized salt
UNICEF-2003
75
Burden in India China
76
India China
Iodized salt coverage lt80
Iodized salt coverage gt80
77
SummaryUse of Iodized Salt at Household Level

• India is performing poorly as compared to other
  countries in South East Asia Region
• In general, there has been a gradual decrease in
  iodized salt coverage at the household level
• Alarming situation in UP, Uttaranchal
• Kerala Goa improvement afterstate-level
  partnership activities
• Poor performance by salt producing states
  National Repercussions(Gujarat, Tamilnadu,
  Rajasthan)

78
7. Changing status of legislation(1968 2005)

• What is iodine what is iodine deficiency? -
  Iodine is a micronutrient - Iodine deficiency is
  a disease of the soil
• What are the consequences of iodine
  deficiency? - Brain damage impaired physical
  growth in humans - Decreased productivity in
  livestock
• How do we eliminate iodine deficiency? - By
  daily consumption of adequately iodized salt
• The Kangra Valley Study 1956 1972 - Provided
  scientific basis for NGCP
• New evidence From Endemic Goiter to IDD
  (1962-1983)
• What is the status of iodized salt coverage in
  India? (1998-99 2002)

79
Changing status of legislation
Iodized salt brought under PFA Act
1968
Policy decision taken for Universal Salt
Iodization
1983
Iodized Salt brought under revised PFA Act
1987
Sale storage of non-iodized salt banned
1997
Central Government decides to lift ban onsale of
non-iodized salt
May 2000
September 2000
Ban on sale of non-iodized salt lifted
80
Withdrawal of the ban
Before May 2000All States (29) UT (6) had the
ban in place except Andhra Pradesh Maharashtra
(Partial ban) Kerala (No ban)

• Government of India withdraws ban on sale of non
  iodized salt for human consumption (13th
  September 2000)
• Reason given by Government of IndiaMatters of
  public health should be left to the informed
  choice, and not enforced through compulsion

81
Scenario after lifting of the ban
After lifting of the ban,large quantities of
non-iodized salt availablefor human
consumptionin Gujarat - the major salt producing
state
82
8. Key issues in IDD

• What is iodine what is iodine deficiency? -
  Iodine is a micronutrient - Iodine deficiency is
  a disease of the soil
• What are the consequences of iodine
  deficiency? - Brain damage impaired physical
  growth in humans - Decreased productivity in
  livestock
• How do we eliminate iodine deficiency? - By
  daily consumption of adequately iodized salt
• The Kangra Valley Study 1956 1972 - Provided
  scientific basis for NGCP
• New evidence From Endemic Goiter to IDD (1962
  1983)
• What is the status of iodized salt coverage in
  India? (1998-99 2002)
• Changing status of legislation (1968 2005)

83
Key issues in IDD

• National vs. Multinational
• Consequences of excess iodine
• Cost of iodine
• Cost of iodized salt

84
Issue 1 National vs Multinational - 1

• 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

85
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

86
National vs. Multinational - 3

• Conversion of iodine to potassium iodatedone 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

87
Issue 2 Consequences of excess iodine 1

• 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.

Iodide goiter has not been reported from salt
iodization programs
88
Issue 2Consequences 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 (gt40
  years)

Increased incidence of IIH is transient, minimal
and self limiting
89
Issue 3Cost of iodine for salt iodization
Cost of iodine for salt iodization is 10
paise/person/year(¼ cents/person/year)
90
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
91
Issue 4Price 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

92
Community perception about iodized salt
Iodized Salt
Refined Salt
Packaged Salt
Branded Salt

High Priced Salt
Iodized Salt
93
The reality
IODIZATION
Phoda salt
0.25 1.00 Rs./Kg
Crystal salt
1.50 2.00 Rs./Kg
Powdered salt
2.00 4.00 Rs./Kg
Refined salt
gt 4.00 Rs./Kg
94
Price of iodized salt throughPublic Distribution
System (PDS)in some Indian states - 1
Source Annual Report (2003-2004), Salt
Department, Govt. of India
95
Price of iodized salt throughPublic Distribution
System (PDS)in some Indian states - 2
Source Annual Report (2003-2004), Salt
Department, Govt. of India
96
Total Monthly Per Capita Consumer Expenditure
(MPCE) on salt per person
Consumer expenditure on salt is negligible lt0.5
Reference period of 30 days Source National
Sample Survey Round 55 NSS Report No.
545,Household Consumer Expenditure in India
1999-2000 Key Results
97
Universal salt iodization Myths facts -1
98
Universal salt iodization Myths facts - 2
99

• What is iodine what is iodine deficiency? -
  Iodine is a micronutrient - Iodine deficiency is
  a disease of the soil
• What are the consequences of iodine
  deficiency? - Brain damage impaired physical
  growth in humans - Decreased productivity in
  livestock
• How do we eliminate iodine deficiency? - By
  daily consumption of adequately iodized salt
• The Kangra Valley Study 1956 1972 - Provided
  scientific basis for NGCP
• New evidence From Endemic Goiter to IDD
  (1962-1983)
• What is the status of iodized salt coverage in
  India? (1998-99 2002)
• Changing status of legislation (1968 2005)
• Key issues in IDD

9. Do we need universal salt iodization?
100
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 problemTherefore, 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)

101

• 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

102

• What is iodine what is iodine deficiency? -
  Iodine is a micronutrient - Iodine deficiency is
  a disease of the soil
• What are the consequences of iodine
  deficiency? - Brain damage impaired physical
  growth in humans - Decreased productivity in
  livestock
• How do we eliminate iodine deficiency? - By
  daily consumption of adequately iodized salt
• The Kangra Valley Study 1956 1972 - Provided
  scientific basis for NGCP
• New evidence From Endemic Goiter to IDD
  (1962-1983)
• What is the status of iodized salt coverage in
  India? (1998-99 2002)
• Changing status of legislation (1968 2005)
• Key issues in IDD
• Do we need Universal Salt Iodization? - Yes, for
  all times to come

10. Why did consumption of adequately iodized
salt decrease?
103
Why did consumption of adequately iodized salt
decrease? - 1
Government of India lifts banon sale of
Non-iodized salt
13 Sept., 2000 As a result, sense of
complacencyat State level
104
Why did consumption of adequately iodized salt
decrease? - 2

• Increase in Rail Tariff
• 1st April 2002
• Consequently,
• increase in movement ofiodized salt by
  road(especially from Rajasthan)
• Currently,
• No mechanism in place for monitoring
  quality of iodized salt transported by road

105
Why did consumption of adequately iodized salt
decrease? - 3
Disappearance of most common visible effect of
iodine deficiency i.e. goiter Perception in
people that - iodized salt consumption is
NOT required anymore
106
Why did consumption of adequately iodized salt
decrease? - 4

• Communication strategy
• DID NOT focus onmental handicap as
  aconsequence of iodine deficiency
• WAS NOT commensurate with seriousness of
  problemboth in terms of scale frequency

107

• What is iodine what is iodine deficiency? -
  Iodine is a micronutrient - Iodine deficiency is
  a disease of the soil
• What are the consequences of iodine
  deficiency? - Brain damage impaired physical
  growth in humans - Decreased productivity in
  livestock
• How do we eliminate iodine deficiency? - By
  daily consumption of adequately iodized salt
• The Kangra Valley Study 1956 1972 - Provided
  scientific basis for NGCP
• New evidence From Endemic Goiter to IDD
  (1962-1983)
• What is the status of iodized salt coverage in
  India? (1998-99 2002)
• Changing status of legislation (1968 2005)
• Key issues in IDD
• Do we need Universal Salt Iodization? - Yes, for
  all times to come
• Why did the consumption of iodized salt decrease?

11. The way forward
108
The Dandi March
109
FREEDOM FROMPREVENTABLE BRAIN DAMAGE
THROUGHDAILY 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

110
The way forward Sustained Political Commitment

• NIDDCP should be a priority National Health
  Programof 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

111
The way forward
IDD Control Programme Multi-pronged Strategy
Regular Reliable Representative State-level
Scientific Data
Data For Decision Makers Sustained Political
Commitment
Promotion of Consumption of Adequately Iodized
Salt Forever
Demand Pull
Supply Push
112
The way forward Supply (Push)
IDD Control Programme Multi-pronged Strategy


Promotion of Consumption of Adequately Iodized
Salt Forever

Supply Push
113
Need to reinstate ban
Iodized salt brought under PFA Act
1968
Policy decision taken for Universal Salt
Iodization
1983
Iodized Salt brought under revised PFA Act
1987
Sale storage of non-iodized salt banned
1997
September 2000
Ban on sale of non-iodized salt lifted
Central Government drafts proposal to bansale of
non-iodized salt
April2005
114
Supply (Push)
Salt producers
Economicincentives
TechnicalSupport
Socialincentives
Rail transportCheaper than road Category BHigh
priority Exemption fromduty tax
Social profitWelfare of childrenWelfare of
society
Qualityassurance
Betteriodizationtechniques
Increasedyield ofquality salt
115
Supply (Push) Government - 1

• Continue with Priority forRail movement for
  Iodized Salt
• Category B
• Reduce rail tariff for iodized salt

116
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 decisionFinal notification to be
issued
117
Supply (Push) Government - 3

• 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

118
Supply (Push) Salt Industry

• 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

119
Consumption of adequately iodized saltaccording
to socio - economic status in India (NFHS-II,
1998-99)
Inadequate
Inadequate
Inadequate
22
50
64
Adequate
Adequate
78
Adequate
50
36
LOW SES
MEDIUM SES
HIGH SES
120
Consumption of adequately iodized saltaccording
to socio - economic status in India (NFHS-II,
1998-99)
Inadequate
Inadequate
Inadequate
22
50
64
Adequate
Adequate
78
Adequate
50
36
LOW SES
MEDIUM SES
HIGH SES
121
Consumption of adequately iodized saltaccording
to socio - economic status in India (NFHS-II,
1998-99)
Inadequate
Inadequate
Inadequate
22
50
64
Adequate
Adequate
78
Adequate
50
36
LOW SES
MEDIUM SES
HIGH SES
122
Supply (Push) Salt IndustrySupport 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 foriodized
  salt

123
Small Scale Salt Producers Supply of Iodized Salt
Small scale salt producers / Traders
Common Salt
Traders
Respond to Market Signal
Common Salt
Iodized Salt Manufacturers
KIO3 Subsidy for 3 years
Microcredit Financing
No Iodization
Iodized Salt
Non-iodized Salt
Distribution
Market
Public Distribution System
124
The way forward Demand (Pull)
IDD Control Programme Multi-pronged Strategy


Promotion of Consumption of Adequately Iodized
Salt Forever
Demand Pull
Supply Push
125
Demand (Pull)
CommunityPerception
Media
Education
Legislation(PFA Act, 1954)
Physicians
Schools
Traders
DisabilityGroups
ProfessionalOrganizations
Agriculture livestock
ConsumerOrganizations
126
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
• Engage the services of a professional
  communication agency
• Consortium of Private iodized salt manufacturers
  to participate actively in this campaign

127
Personal meetings to promoteuse of adequately
iodized salt

• Peoples 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

128
Participation of frontline workers
Motivational Letter, 20 Questions booklet on
IDD, Flip Charts, Salt Testing Kits for Iodine
IEC Package
129
Communication Challenges - 1

• Penetrate the system with key messages
• Schools Loss of IQ, poor school performance,
  school drop out rates, employment opportunity
• Physicians Daily consumption of
  adequatelyiodized salt is a healthy habit
• Professional associations advocacy
• Agriculture livestock giving iodized salt to
  livestock increases productivity(milk, meat,
  eggs, wool work output)

130
Communication Challenges - 2

• Value Addition
• Traders Iodized salt - a value added product
• Consumer organizations value for money
• Disability Groups Mental disability - Totally
  preventable (IMPACT, Other groups)

131
Communication Challenges - 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

132
Communication Challenges - 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 bea lesson of history

133
The way forwardRegular Reliable Representative
Scientific Data
IDD Control Programme Multi-pronged Strategy
Regular Reliable Representative State-level
Scientific Data

Promotion of Consumption of Adequately Iodized
Salt Forever
Demand Pull
Supply Push
134
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 component30 Cluster Methodology
• Qualitative componentK A B P(Knowledge,
  Attitude, Beliefs, Practices)
• Need for tracking progress to achieve
  sustainability

135
NFHS-3 (2005-2006)

• National Family Health Survey(NFHS-3) under
  process
• 110,000 families will be visitedfrom all over
  the country
• Iodine in salt will be detected bysalt testing
  kit (STK)

Our suggestion Analyze 10of salt samples by
titration method AIIMS / NIN can analyze
these11,000 samples by titration method
136
The way forward Sustained Political Commitment
IDD Control Programme Multi-pronged Strategy
Regular Reliable Representative State-level
Scientific Data
Data For Decision Makers Sustained Political
Commitment
Promotion of Consumption of Adequately Iodized
Salt Forever
Demand Pull
Supply Push
137
Linking Research to Policy ProgramThe
Tamilnadu experience - 1
Advocacy Demand Creation Monitoring
Activities Related to Supply Side
Dissemination Workshop 5th June 2003, Chennai
Increase in Iodized Salt Production Capacity of
TNSC
Health Minister
Secy. Health
Tracking Progress Towards Sustainable Elimination
of IDD in Tamil Nadu(2002 - 2003)
Salt Iodized Salt Producers Meeting


Panchayat Raj Members
District Magistrates
Tracking Progress Towards Sustainable Elimination
of IDD in Kerala (2001)
Ensuring Quality, Accessibility. Availability,
Affordability, Acceptability of Iodized Salt
Awareness Monitoring
138
Linking Research to Policy ProgramThe
Tamilnadu experience - 2

• Quality iodized crystal salt distributedat Rs.
  2.50/Kg through PDS
• Increase in distribution of iodized saltby 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

139
Why should government facilitatethe process of
elimination of IDD?

• Health is socially desirable and better for
  peoplethan they realize
• Health is a merit good
• Government has the responsibility to
  protectpopulation health
• Individuals do not always make good
  choices,especially when benefits are in the
  future
• Governments intervention on iodized salt
  producers(who are small in number as compared to
  theentire population) benefits the entire
  population
• 1,000 iodized salt producers 1,000 million
  people benefited( positive externalities)

140
Tenth Five Year Plan (2002-2007)Annual Health
Expenditure Outlays (approx.)
(47)
Source Health Information of India 2003,
CBHI, DGHS, MoHFW, GoI
141
Consultants in health programs
Pulse Polio 303 consultants
Presently, NO consultant for IDD.Express need to
havefull-time consultantsunder NIDDCPto
accelerate the program
Tuberculosis 100 Consultants
Leprosy 18 Consultants
142
Consumption of adequately iodized salt for all
times to come

• 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

143
To Reiterate the Next Steps
IDD Control Programme Multi-pronged Strategy
Regular Reliable Representative State-level
Scientific Data
Data For Decision Makers Sustained Political
Commitment
Promotion of Consumption of Adequately Iodized
Salt Forever
Supply Push
Demand Pull
144
In summary

• What is iodine what is iodine deficiency?
• What are the consequences of iodine deficiency?
• How do we eliminate iodine deficiency?
• The Kangra Valley Study (1956 1972)
• New Evidence From Endemic Goiter to IDD(1962
  1983)
• What is the status of iodized salt coveragein
  India? (1998-99 2002)
• Changing status of legislation (1987 2005)
• Key issues in IDD
• Do we need Universal Salt Iodization?
• Why did consumption of iodized salt decrease?
• The way forward

145
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146

• How Simple is Simple?
• The Story of Iodine DeficiencyPreventable
  Brain Damage
• Sustainable Elimination ofIodine Deficiency
  Disorders in India

147

• Simple Goitre is the easiest of all known
  diseases to preventIt may be excluded from the
  list of human diseasesas soon as the society
  determines to make the effort.
• Dr. David Marine, 1920
• (Pioneer in mass prophylaxis of endemic goiter)

How Simple is Simple? Even man finds it difficult
to be human ! Mirza Ghalib 18th Century Poet
Thus, The Story of iodine deficiency continues
148
" 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
149
Acknowledgements - 1

• To the Global Partnership
• Dedicated to the Sustainable Elimination of
  Iodine Deficiency Disorders
• An Ancient Scourge of Mankind
• The People of the affected countries
• The Governments of the affected countries
• The Salt Producers of each country

150
Acknowledgements - 2

• The International Agencies especially
• The United Nations Childrens Fund
• The World Health Organization
• The World Bank
• The Micronutrient Initiative
• Kiwanis International

151
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

152
Acknowledgements - 4

• The Global Network for Sustained Elimination of
  Iodine Deficiency
• The International Council for Control of Iodine
  Deficiency Disorders

153
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154
Daily consumption of adequately iodized salt is a
healthy habit
Towards Sustainable Elimination of IDD
For further details, correspondence is invited
at Dr. C. S. PandavProfessor Head, Center
for Community MedicineAll India Institute of
Medical SciencesAnsari NagarNew Delhi
110029 Email cpandav_at_iqplusin.org
Thank You!