Ethics and Public Health Policy Universal Salt Iodization A Case Study Food Technology for Better Nutrition 30 Nov 2007 Nutrition Foundation of India Col R Sankar (Retd) MD, MNAMS, FICP Prof. C S Pandav, MD, FAMS, MSc
Ethics and Public Health Policy
Universal Salt IodizationA Case Study
Food Technology for Better Nutrition30 Nov 2007
Nutrition Foundation of India
Col R Sankar (Retd) MD, MNAMS, FICP
Prof. C S Pandav, MD, FAMS, MSc
Ethics, Morality, Values and Law
Iodine
Consequences of its deficiency
Benefits of correction of iodine deficiency - the evidence
Extent of the problem in India
National Programme
Ethics and Public Health Policy
Ethics
• Distinction between right and wrong
• Moral values
• Rights, duties and obligations
Societal norm: acceptable and unacceptable conduct
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
Ethics, Morality, Values, and Law
Ethics, Morality, Values, and Law
Laws uphold the values of society
Legal but unethical actions
Ethical but illegal actions
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
Principles of Biomedical Ethics
Quarantine
Resource allocation
New situations
Advances in medical science - Organ transplant
Life support systems
Changing social values - ethics related to femalereproductive behaviour
Principles of Biomedical Ethics
• 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 g
Iodine
• 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
Iodine Deficiency
Goitre with its complications
Hypothyroidism
Impaired mental function
Goitre
Juvenile hypothyroidism
Impaired mental function
Retarded physical growth
Neonatal goitre
Neonatal hypothyroidism
Abortions, Still births, congenital anomalies
Increased PMR, IMR
Neurological Cretinism
Myxoedematous Cretinism
Psychomotor defects
Iodine Deficiency Disorders (IDD)
Neonate
Child and Adolescent
Foetus
Adult
IDD Survey – Sikkim
1987-89
Total No.Studied %
No.of RBs 440 249 56.6%
No.of HHs 58,746 3,179 5.5%
Population 316,385 17,837 5.6%
IDD Survey – Sikkim
1987-89
• Goitre prevalence 54.0%
• Males 48.5%
• Females 59.5%
Goitre Prevalence
46% 54%
Goitre No Goitre
• Highest cretinism prevalence – 15% in
Changthang
• 194/249 RBs had one or more cretins
• In 13 RBs the cretinism prevalence was >10%
• 617 cretins studied 228 belonged to 99
families suggesting familial clustering
IDD Survey – Sikkim
1987-89
IDD Survey – Sikkim
1987-89
• 75 families had 2 cretins each 75x2 = 150
• 19 families had 3 cretins each 19x3 = 57
• 4 families had 4 cretins each 4 x4 = 16
• 1 family had 5 cretins 5 x5 = 5
Total 228
IDD Survey – Sikkim
1987-89
• 38/617 were cripples
• 49/617 were severely mentally retarded.
• Many could perform simple tasks.
DD Survey – Sikkim
1987-89: Hearing Loss
High prevalence of high
frequency hearing loss in
apparently normal school age
children
IDD Survey – Sikkim
1987-89
Goitre prevalence 54.0%
Cretinism Prevalence 3.5%
Median Urinary Iodine Excretion 70 ug/L
HH coverage of Iodised Salt 34%
• 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?
What is the social cost of Iodine deficiency
1.Intellectual assessment of school children from severely iodine deficient villages
Mehta M, Pandav CS, Kochupillai N. Indian Pediatr 1987;24:467.
2.Developmental lag in pre-school children of goitrous mothers.
Upadyaya SK et al. Indian Pediatr 1983;20:259
3.Intellectual and motor development in school children from severely iodine deficient region - Sikkim
Sankar R, et al. Indian J Pediatr 1994;61:407-414.
Iodine and its relationship to cognitive development
IDD is preventable – The EvidencePapua New Guinea Study
Untreated Treated
Births 534 498
Ch exam 406 412
Normals 380 405
Deaths 97 66
Cretins 26 7
115 + 16 (72)*104 + 24 (66)Development
quotient
167 (252)*250 (263)Infant mortality per
1000
98 (129)*188 (123)Perinatal mortality
per 1000
2837 + 542 (112)*2634 + 552 (98)Birth weight
TreatedNot treated
Effect of iodized oil given during pregnancy
Thilly CH et al. Bull Acad Med Bel 1981;136:389-412
IDD is preventable – The Evidence
Sikkim Study
0
10
20
30
40
50
60
70
80
90
1987 1991 1992 1993 1994 1995 1996 1997 1998 2005
IODISED SALT GOITRE PREV CRETINISM PREV
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
• n=4,09,923
• Goitre prevalence 21.1%
• Cretinism prevalence 0.7%
• DGHS Surveysb
• 275 districts surveyed
• 235 are endemic. These districts cover all states and Uts
a. ICMR Task Force Study 1989
b. WHO SEARO SEA/NUT/138,1997;pp1-8
133
85
75
6
3-5%
0-4%
0-4%
nil
80
70
60
29
Deoria
Gorakhpur
Gonda
Delhi
NCH per 1000 births
Cretinism %
Goitre %
Ethics and Public Health Policy : USI - An Indian Case Study
Ban withdrawn on sale of common salt for human consumption
- GOI, 13th Sept. 2000
Reason given:
On point of principle, compulsions in the matter of individual choice in undesirable
CONFLICT BETWEEN RIGHTS & NEEDS
Need of society for prevention
vs.
Rights of the individual case or contacts.
Widely accepted features of
communicable disease control
Current conflict :
Rights of individuals
Vs. Needs of communities
Use of Iodized Saltat Household Level – North East
63%
55%
67%70%NFHS –2, 1998-99
DLHS - RCH, 2002
91%
52%
88%
59%
84%
57%
80%
59%
79%
47%
47%
25%
57%
36%
47%
32%
NFHS – 2, 1998-99
DLHS - RCH, 2002
Use of Iodized Saltat Household Level – Heartland
57%
42%
49%
5%
49%
5%
UNIVERSAL SALT IODISATION: ISSUES INVOLVED- 1
Established fact 1:
Iodine Deficiency Disorders (IDD) is an important public health problem
Established fact 2:
IDD is effectively prevented by iodisation of salt
UNIVERSAL SALT IODISATION:ISSUES INVOLVED- 2
World experience :
Both iodised & non- iodised salt available in market - People opt for non-iodised salt
Reason : Ignorance & lower price
Community perception about
iodized salt
Iodized Salt
Refined Salt
Packaged Salt
Branded Salt
High Priced SaltIodized Salt =
The reality….
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 > 7.00 Rs./Kg
IODIZATION
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 government’s role is to
encourage greater production
UNIVERSAL SALT IODISATION:ISSUES INVOLVED- 3
IDD : Child survival & Child development
Human Resource Development
Rights of unborn child
Rights of animals
To prevent IDD - Provide iodine in some form
Simple, Physiological & Cost Effective route:
Universal Salt Iodisation
” In the field of Nutrition, as in Politics, the task
is to do what is possible without forgetting to
make possible what is necessary”
G H. Beaton & J M. Bengoa
Nutrition in Preventive Medicine
World Health Organization
Geneva, 1976