"I lost four valuable years of my life to iodised salt," says Kumkum Somani, Mumbai-based writer and journalist. For four years, Kumkum suffered from very serious problems like severe skin irritation and eruption of boils, stomach cramps, depression, severe loss of weight, crippling fatigue and even near-blindness. A series of costly medical tests, diagnoses and medication failed to help. But once she gave up iodised salt, all her symptoms disappeared and soon she was leading a normal life.

Ganesh Easwar, Delhi-based advertisement executive, developed a skin irritation problem at the back of his neck that soon developed into ugly and pus-filled eruptions all over his body. Endless medical treatment across different schools of medicine (including steroid injections) later, he found relief when a homoeopath put him on a bland, salt-free diet. It was only accidentally that he found that the culprit was not salt, but the iodine in the iodised salt he had been consuming. Meanwhile, three years had already passed.

Back in 1996, Dr Francois Delange, Director of ICCIDD had said that any comprehensive claim of safety for I-salt would be a 'serious mistake'.

 •  Health or mere profiteering: Part I
 •  Iodised salt: Lesser known facts
 •  Pass the salt, please

Somani and Easwar are two of the best documented cases of iodine induced hyperthyroidism (IIH) in India, but they may not be isolated cases. According to well known endocrinologist from Mumbai's Jaslok Hospital, Dr Shaukat Ali Sadikot, "Thyroid malfunction goes up no less than ten times when the consumption of I-salt starts. It can manifest itself as either hyperthyroidism or hypothyroidism."

Sadikot says that most cases of IIH do not get detected at all, as the symptoms tend to be milder and more subtle – contiuous fatigue, depression, mood fluctuation, sleeplessness, mild skin problems and so on. "And since four out of five patients are women in the 40 plus age group, even serious symptoms are mostly ignored or suppressed with over the counter medication or dismissed as approaching menopause."

Dr Vijaya Venkat, well known nutritionist from Mumbai who runs the Health Awareness centre, takes a more comprehensive point of view. "Artificial supplements – iodine or anything else – can never be the basis for sound health. The human body craves natural and wholesome food – natural iodine present in organic food stuffs. Synthetic iodine only exhausts the endocrine and thyroid system in the body and disturbs its natural balance, " she says. At her centre, where Venkat treats all kinds of diseases not with medicine but with wholesome natural food and a natural lifestyle, the first thing she tells every patient is to revert to natural sea salt. "And I have seen all kinds of patients, irrespective of what kind of ailment they are suffering from, show a marked improvement afterwards."

According to Venkat, even if there is an iodine deficiency problem, it should be solved by making wholesome natural diet accessible to all, not through synthetic supplements. "And don't tell me it is impossible. It has been done in Britain," she says.

As a medical condition, IIH is very difficult to pin point. Somani's case was diagnosed as a spectrum of problems ranging from menopause to Hasimoto's disease. Even a thyroid level test, which did reveal thyroid malfunction, could not trace it back to iodised salt. In Ganesh's case, the diagnoses fluctuated over a range of skin problems from psoriasis to eczema. Both patients detected their real problem accidentally.

"Thyroid malfunction manifests itself in symptoms of different conditions which tend to get treated accordingly," says Dr A K Arun, Delhi-based homoeopath and member of the Medico Friends Circle. The real culprit hardly ever gets traced, he says. "I have come across some ten to twelve patients till date, but how many people are living with mild or severe manifestations of this condition without knowing it is anybody's guess," says Arun.

"Doctors are coming across increasing anecdotal evidence of the existence of IIH in the urban population," says Dr P Ravindra, Mumbai-based pharmaceutical technologist, "All around us, cases of thyroid disfunction in forty-plus urban women -- hypothyroidism especially -- are rising. Actually such cases have gone up sharply in the last decade. We have to raise the question if this has a connection with the intake of I-salt." Ravindra is associated with the Sada Namak Bachao Andolan, Mumbai.

What is worse, some people might even be dying of IIH without knowing it. Studies on hyperthyroidism unanimously agree that it is a serious disorder 'that may in extreme cases lead to death, usually from heart associated causes' (Field Exchange, journal of the Emergency Nutrition Network, June 2006).

But in India, we may never find out. Unlike other countries where salt iodisation programmes have been run, both in the West and in Africa, there is no iodine level monitoring system in India. And in the absence of such a system, it is impossible to determine the exact extent of the prevalence of IIH in India.

So is I-salt actually making India sick instead of making it healthier?

Debate fraught with contraditions

Nothing can be said clearly in the absence of definitive and coherent data on the subject.

The entire debate on IIH in the country appears to be fraught with contradiction and confusion. While even the votaries of iodisation are forced to agree that I-salt causes IIH in 'some' people, they are inclined to downplay the issue by arguing that the cause of the masses should not be compromised for a 'few' individuals or for the sake of a 'few' people 'wanting to exercise their right to choose'. This, without data to prove that the numbers of such people are indeed 'few'. Some, like Dr Veena Shatrughna, of the National Institute of Nutrition, Hyderabad, have even gone to the extent of suggesting offhand solutions for those suffering from IIH. In a medical bulletin published last year, she said: "About hyperthyroid cases…yes we could ask for adverse drug (iodine) monitoring system…and propagate information that if the salt is left open…iodine levels come down to nil very soon. Maybe in 15 to 30 days (from 30 ppm to nil). Hyperthyroid cases can use this salt." (MCF bulletin Oct 2005-Jan 2006).

Dr Shridhar, quoted in the same bulletin, says, "Patients who know they are hyperthyroid could surely be legally spared some non-iodated salt from the surplus industrial sodium chloride available, even if the ban is well enforced. Those who do not know could suffer, of course, let us define this problem and see if there is a way to help such people get diagnosed and treated adequately – which we ought to have been doing anyway."

On the other hand, those opposing the ban on non-iodised salt are hesitant to make IIH one of the prominent issues in the debate, again because they have no data to prove that the problem is serious enough to merit that kind of attention. When asked to comment on the issue, Mumbai-based Gandhian activist Smita Shah confined her comment to the single sentence, "Yes, some people can't tolerate iodine", before passing on to other issues. Even Sadikot, while making the above mentioned comments about the health hazards of I-salt, told me that IIH was not 'a main issue' in the I-salt debate, and cautioned me not to get 'carried away'.

Again, international studies make out a case that IIH is a problem only with iodine deficient populations who have been supplied with I-salt – a problem that balloons and then gradually tapers over years. An ICCIDD study published in the IDD newsletter of February 1998, and the Field Exchange journal study referred to earlier both support this view. But there is no evidence to suggest that IIH does not affect non-iodine deficient populations. Actually, the case of Somani and Eshwar (Somani had taken a thyroid level test some years before starting to consume I-salt, which had registered normal), and the information given by the above-mentioned medical professionals makes a case for the opposite.

Need to admit ignorance

"The point is that we simply don't know," says Dr Shantilal Kothari. "We have to admit the fact that we do not know all the risk factors involved in I-salt, and that there is a crying need for systematic and comprehensive studies in this respect," he says. Iodisation should not be made compulsory till all the risk factors have been ascertained reliably and sufficiently, argues Kothari.

In 1996, Kothari had written to the ICCIDD asking if there was any assurance that extra iodine in diet was "not at all harmful irrespective of age, sex, natue of work, health status, environment, salt intake, iodine content of food etc." In his reply Dr Francois Delange, director, ICCIDD, said that an assertion making such a comprehensive claim of safety would be a 'serious mistake'.

Says Kothari, "What the ICCIDD and other bodies are refusing to understand is that it is just such a 'comprehensive claim of safety' that is being palmed off to the Indian public. So what are these bodies doing to prevent the 'serious mistake' which could end up making an unknown number of people sick?"

Kothari had also asked for permission to undertake a feeding experiment to monitor the effect of extra-dietary iodine, which was turned down by the ICCIDD without assigning any reason. "How can we come to any point of understanding on the IIH issue when there is no baseline data and no monitoring?" asks Ravindra. He says that there is no reason why IIH should not be as seriously prevalent in India as it was found to be elsewhere in the world where it has been monitored. "The question is why it is not being monitored in India," he asks.

When asked to comment on why no comprehensive study was being undertaken on IIH in India, Sadikot complains of the lack of transparency in the manner in which the entire iodisation programme is being carried out, noting that the entire iodisation show is being run by a few doctors at AIIMS. "There is no real public debate, and no one apart from this select group is being consulted. We would like to see the reports on the basis of which this thing is being carried out." Sadikot says he wants to see what kind of medical journals have published those reports, and what kind of peer reviews they have received. "We want to know that if one of these doctors presents a paper in some country abroad, who is paying for it. Some iodine company?"

"There are no funds in the right places. Hence studies which should be carried out are not being done," alleges Venkat.

Is the right dosage reaching the people?

One question that the Ministry of Health has been evading is, is there a viable way to ensure that the right doses of iodine reach the people?

The answer is no. Says assistant salt commissioner, Jamnagar, P Venu, "Branded iodised salts, like Tata, contain anything between 40-60 ppm, of iodine, which is three to four times the recommended dosage." Venu himself is a patient of hyperthyroidism, but rues the lack of information on the subject. "Doctors tell me that the number of cases of hyperthyroidism are growing, but are unable or hesitant to attribute a reason," says he. Venu authored the article Iodised salt: The lesser known facts in India Together, in July 2006.

According to experts a highly impractical number of careful handling norms, packaging and sealing criteria are required to ensure that the quantity of iodine in salt is just right. A UNICEF booklet on the subject says that the salt has to be tested every hour at iodisation plants, once a week at wholesale depots, once a month at retail outlets and as often as possible in households. And salt found to contain more or less than the exact amount of iodine is to be discarded. The quality of plastic used in packaging, the way a packet of salt has been sealed, all affect the iodine content of the salt.

One might raise questions about whether such monitoring is being done in India or whether it is at all possible, but Kothari goes one step ahead and hits the nail on the head: "It is not as if no one knows that such strictures are impossible to carry out, in India or anywhere else. Actually no one is willing to admit that iodisation itself is a highly impractical prospect. These are only roundabout ways of saying so."

Wanted: Public debate and education

While it is nobody's case that iodised salt should be pushed out of the Indian market, what concerns most people's groups is the one-sided way in which iodisation is being imposed on the people of India. Doctors, activists and others involved in the campaign against compulsory iodisation unanimously agree that despite an overwhelming amount of evidence at various levels, the government has simply refused to pay attention to objections raised by different pro-people groups. The biggest problem confronting these groups today is the stubborn wall of apathy and silence erected by the Ministry of Health. "We have sent so many representations to the health ministry, but have received no response whatsoever. Even when we asked for information under the RTI, we were given inadequate information. Objections to that also fell on deaf ears," says Ravindra.

"Dr N Kodupillai, the brain behind the iodised salt programme….refused to believe me when I told him that iodised salt causes allergies which lead to itching, boils and hyperthyroidism," says Kumkum Somani. "Finally, what is the basis of the Indian iodisation programme," asks Sadikot, "No scientific data to prove that IDD exists, no iodine level monitoring system, no data on whether iodised salt is actually helping, not even the guarantee that the people are getting the right kind of iodised salt. We demand that the health ministry come into the public and answer questions."

The entire I-salt issue has become a holy cow of sorts," says Venu. "There is a coterie of some five doctors from AIIMS, some people from the department of public health and some UNICEF people who are running the whole show. One word of criticism, and you are labeled anti-poor," he says.

Finally, the only answer to the entire issue appears to lie in greater education. Till date, the debate on iodisation has remained confined to select, mostly urban groups. Perhaps by taking it to the wider public, enough pressure be mounted on the state mechanism to break its silence and finally listen to some home truths. (Concluded)