ETHICS AND PUBLIC HEALTH POLICY

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• ETHICS AND PUBLIC HEALTH POLICY

The Universal Salt Iodisation in India
A Case Study
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Universal Salt Iodisation in India

• Ethics and Public Health Policy
• Iodine and consequences of deficiency
• Extent of the problem
• Why universal salt iodisation
• Issues
• Is IDD a public health problem!
• USI and small salt producers
• USI and cost of salt
• Mandatory Vs Voluntary

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• Ethics
• Distinction between right and wrong
• Moral values
• Rights, duties and obligations

Societal norm acceptable and unacceptable conduct
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Ethics, Morality, Values, and Law

• Ethics and Morality
• The moral values of society are the basis of many
  of our laws
• Community standards are also influenced by social
  values
• Health-related social values - remarkable change

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Principles of Biomedical Ethics

• Respect for autonomy
• Human dignity and freedom
• Nonmaleficence
• primum non nocere first do no harm
• Beneficence
• Principle of doing good
• Justice
• Fairness, equity and impartiality

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• Quarantine
• Resource allocation
• New situations
• Advances in medical science - Organ transplant
• Life support
  systems
• Changing social values - ethics related to female
• reproductive
  behaviour

Principles of Biomedical Ethics
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Iodine

• Iodine is a trace element
• Is an essential micronutrient
• All vertebrates extract iodine, concentrate it
  and secrete it in hormonal form
• Thyroid hormones are iodinated molecules of
  tyrosine
• Iodine is an essential component of the thyroid
  hormones
• This is the only confirmed role for iodine
• It is present in the body in minute amounts
  15-20 mg i.e., 0.02 x 10-3 of body wt
• The daily requirement is 150 µg

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Iodine Deficiency

• Iodine is sparsely distributed over the surface
  of earth
• Iodine is a water soluble element
• Over millions of years, it has been leached from
  the upper crest of earth
• Glaciations, heavy rain on sloppy ground,
  repeated flooding

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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
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Iodine Deficiency Disorders (IDD)
Foetus
Abortions, Still births, congenital
anomalies Increased PMR, IMR Neurological
Cretinism Myxoedematous Cretinism Psychomotor
defects
Neonate
Neonatal goitre Neonatal hypothyroidism
Child and Adolescent
Goitre Juvenile hypothyroidism Impaired mental
function Retarded physical growth
Adult
Goitre with its complications Hypothyroidism Impai
red mental function
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Endemic Goitre

• Goitre
• Any enlargement of the thyroid gland
• Endemic goitre
• is defined as the presence of generalized or
  localized thyroid enlargement in 5 percent or
  more of the school age children (age range 6-12
  years).

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Population effect of iodine deficiency
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What is the social cost of Iodine deficiency

• Are children from an iodine-deficient area who
  are not manifestly cretins still at risk of
  having impaired mental and motor development?
• Is the so called normal iodine-deficient
  population undamaged and really normal?

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Iodine and its relationship to cognitive
development

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

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Global Prevalence of IDD
a 192 WHO Member States b Based on population
estimates for the year 2002 Source WHO Global
Database on IDD, 1993-2003.
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Is IDD a Public Health Problem in India?
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Iodine Deficiency Disorders in India

• High prevalence of goitre and cretinism in the
  Himalayan, sub-Himalayan terai.
• ICMR study 1986a
• 14 districts from 9 states
• n4,09,923
• Goitre prevalence 21.1
• Cretinism prevalence 0.7
• DGHS Surveys
• 275 districts surveyed
• 235 are endemic. These districts cover all states
  and Uts
• ICMR Task Force Study 1989
• WHO SEARO SEA/NUT/138,1997pp1-

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IDD in Tamil Nadu
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Iodine Deficiency DisordersRajasthan
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Why Iodise Salt?

• Salt is consumed by all
• Intake is more or less constant
• Technology used to iodise salt is simple
• Iodisation is inexpensive
• Does not change the colour or taste

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Effectiveness of Salt Iodisation The
EvidenceThe Kangra Valley Study
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Production of Iodidsed Salt in India
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Iodised salt is expensive!
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Community perception about iodized salt
Iodized Salt
Refined Salt
Packaged Salt
Branded Salt

High Priced Salt
Iodized Salt
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The reality
IODIZATION
Phoda salt
0.75 1.50 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
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Cost of Salt Iodization Crystal iodised salt in
loose
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Cost of Iodised Salt

• Cost of iodisation is a small fraction of the
  sale price of iodised salt
• Packaging, transportation and trade margins are
  the main causes of cost increase

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Salt iodisation negatively impacts small salt
producers
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Salt production in India (2003)
96
Source Annual Report (2003 2004), Salt
Department, Govt. of India
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Salt production in India 1980 to 2003
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Salt production in India 1980 to 2003
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Salt production in India 1980 to 2003
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Mandatory Vs Voluntary Question of Choice
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Indian Scenario Use of iodized saltNational
Family Health Survey 2(1998-1999)

71
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Consumption of adequately iodized saltaccording
to socio - economic status in India (NFHS-II,
1998-99)
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50
64
Adequate
Adequate
78
Adequate
50
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LOW SES
MEDIUM SES
HIGH SES
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Use of Iodized Saltat Household Level North
East
91
88
84
80
79
70
NFHS 2, 1998-99
67
63
59
59
57
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DLHS - RCH, 2002
52
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Mizoram
Meghalaya
Manipur
Arunachal
Assam
Sikkim
Nagaland
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Use of Iodized Saltat Household Level Heartland
57
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NFHS 2, 1998-99
49
49
47
47
42
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DLHS - RCH, 2002
32
25
5
5
Bihar
Chhatisgarh
Jharkhand
M.P.
U.P.
Uttranchal
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Why Should Government Take Lead?

• Health Mandate Responsibility to protect
  population health. Individuals often cannot make
  good choices when the benefit is preventive or in
  the future. Health is a Merit Good.
• Market Maker USI has Positive externalities when
  benefits accrue not only to consumers, but to
  society as a whole, then governments role is to
  encourage greater production

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Salt Iodization Programme in India
Kangra Valley Study 1956
NGCP Launched 1962
Private Sector invited to produce IS 1983
Iodized Salt brought under revised PFA Act 1987
Sale storage of non-iodized salt banned 1997
Ban on sale of non-iodized salt lifted May 2000
Proposal to ban sale of non-iodised salt May
2005
Ban on sale of non-iodised salt May 2006