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

IDD Survey – Sikkim

1987-89

Gotre Grades

41%52%

7%

GrI Gr II Gr III

IDD Survey – Sikkim

1987-89

Gotre Grades

41%52%

7%

GrI Gr II Gr III

IDD Survey – Sikkim

1987-89

Gotre Grades

41%52%

7%

GrI Gr II Gr III

IDD Survey – Sikkim

1987-89Prevalence of Endemic Cretinism – 3.5%

• 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.

Short stature

IDD Survey – Sikkim

1987-89

DD Survey – Sikkim

1987-89: Hearing Loss

High prevalence of high

frequency hearing loss in

apparently normal school age

children

T3

T4

TSH

IDD Survey – Sikkim

1987-89

Thyroid Function in Endemic Goitre

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

Population effect of iodine deficiency

The Evidence from Animal Studies

The Evidence from Animal Studies

The Evidence from Animal Studies

Obregon et al. Endocrinology

1991;129:2663-2673

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 EvidenceThe Kangra Valley Study

0

10

20

30

40

50

60

A B C

1956

1962

1968

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

“ 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