To iodise or not to iodise

But medical doctors had a different explanation for the high incidence ofcretinism and endemic goiter found in the Terai: severe iodine deficiency intheir diets.

According to V Ramalingaswami, former head of the Indian Council of MedicalResearch (ICMR), when he first began his research in the Kangra Valley inthe late 1950s and early sixties, it was common to see people withover-large goitres. Iodine Deficiency Disorder (IDD) was common in theHimalayan foothills, but later research showed that IDD footprint was allover India, including coastal Kerala.

Kalyan Bagchi, a noted nutritionist, recounts how with salt iodisation, theincidence of cretinism has come down in the Terai which was once describedas the “goitre belt of India”.

It is estimated that about 150 million people are at risk from nutritionaliodine deficiency in India. Studies conducted by Ramalingaswami, and laterby N Kochupillai of the All India Institute of Medical Sciences (AIIMS) inseverely-iodine deficient districts of U.P. show around 70 per cent goitreprevalence.

Kochupillai, who now heads the Endocrinology Department at AIIMS, refers toa frequent problem that teachers encountered in the hilly regions, that ofpoor educability among children.

Simple tests revealed low IQ levels in the children, along with mentalsluggishness and physical lethargy. Till the doctors zeroed in on the cause:irreversible brain damage in infants born of mothers who had insufficientiodine in their diets.

Iodine deficiency also resulted in stunted linear growth and mentalretardation in children, delay in secondary sexual maturation in adolescentsand early onset of heart disease in adults. Conclusive evidence which ledthe government to announce a national goitre prevention programme in themid-eighties and the universal iodisation of salt in 1992. At present, morethan 70 per cent households in India use iodised salt.

The recently-issued government notification to lift the ban on non-iodisedsalt, leaving it to the consumer to make the choice, threatens to unravelall that has been achieved through salt iodisation.

If the virtual disappearance of cretinism from Bhutan or Sikkim, and thedramatic fall in IDD all over the country, is making the governmentcomplacent enough to scrap the iodisation requirement, the medical communityfeels it is a step backwards, which will result in a reappearance of iodinedeficiency-related disorders.

Expressing their strong opposition to the move, the Indian MedicalAssociation emphasises that iodine deficiency is the most common preventablecause of mental retardation in India.

According to Seema Puri, senior nutritionist, Institute of Home Economics,New Delhi, it is virtually impossible to obtain iodine from natural sources.“If it’s a Vitamin A deficiency, we could say eat more green leafyvegetables. But with iodine deficiency, we can’t say eat a carrot and you’llget iodine. It has to be added to the food, and salt is the best medium.”In the Himalayan region, massive deforestation and resulting erosion haveleft the soil deficient in nutrients. So the small amounts of iodine inrainwater which falls on the top soil get washed away with soil erosion.

Those against salt iodisation argue that iodised salt is too expensive andthe poor will not be able to afford it. Branded names of salt are boughtonly in urban centres, neatly packed in polythene. In most of rural India,salt is still purchased by the kilo from the local grocer at prices as lowas Rs 2 a kilo. There is a possibility that some of this salt may not beiodised. But a team of doctors from AIIMS who recently picked up samplesfrom remote villages in UP and Bihar, found that though sold in open form,the salt was iodised.

Another argument is that excessive iodine in the diet could prove harmful.Both doctors and nutritionists agree that if excess iodine is consumed, itis eliminated by passing out through urine. Says Bagchi, salt is aself-limiting substance: it is not like sugar that children may gobble itup. The amount of iodine added to salt is very small, something like 15parts per million, so the likelihood of excessive iodine intake isnegligible.

In fact, adds Bagchi, we’re worried that in the case of older persons, thecampaign to cut salt from the diet to reduce hypertension, may lessen thesalt intake and thereby the iodine content in their diets.

Yet others believe in free choice: that the choice should be left to theconsumer. This is the most specious argument, since except for some informedpersons, very few read the small print on packaging or are going to askspecifically for iodised salt. Additionally, most salt in the country isconsumed in open form, where no labelling of any kind exists.

The argument of the swadeshi lobby is that small salt producers in Gujaratand Tamil Nadu are being wiped out, while big business drives up the priceof salt. There are some 6,000 salt producers in Gujarat and a similar numberin Tamil Nadu, who should be supported to modernise their salt-makingprocess to include iodisation, instead of jettisoning a major nationalhealth programme.

Some Sarvodaya leaders met the Prime Minister and threatened a second saltsatyagraha unless the compulsory iodisation of salt is lifted. Scientificevidence should be the guiding principle when socio-medical decisions withfar-reaching health and development consequences are taken.

But the health bureaucracy appears to have abdicated its responsibility inthis instance and the wheels have been set in motion to roll back one ofIndia’s most successful preventive public health programmes.