Salt Fortification: Simple Solution: But is it?
A friend of mine sent me an article to read by Ramaiah et al. (2000). My friend favours the use of salt fortification but that left my mind thinking. Is it worth it, definitely- it can eliminate a disease! Is it simple: yes- just add it to salt! Is it feasible, hmm... perhaps not!
For starters the articles are pretty old (> 8 years) and therefore their immediate effect/ lessons learnt from them would be of questionable relevance. Like the Ramaiah article points out that there was good compliance in rural areas (over 70%) in people who received the drugs. The problem there was that 30% of people were not covered and of the rest 58% (which implies 70% of the people who were given drugs) took the drugs. So in case we can decrease that 30% by a margin and add to it some educational campaigns, we can go a long way. And as I can recall a near 85% coverage is enough for eradication.
I was encouraged by the fact that rural areas had higher compliance than urban areas as I thought rural areas will be the ones with max problem. However the article points it out well that the disease burden is higher in urban areas. The study it uses was done in 1986 though, 23 years from now, situation may have changed since then; need a more recent estimate for this urban/rural divide.
I agree that mass drug administration (MDA) of di-ethyl carbamazine (DEC) takes a longer time and also has problems of side effects and compliance which shall not be the case with salt fortification. But let me add an ethical side to it. Use of iodine in salt or of fluoride in water, are both cases of addition of naturally existing substances. People and critics can therefore not say much against it, as they ingest this item in regular quantities every day from natural sources.
A drug on the other hand is not something that you consume on an everyday basis. You take it only when you are ill, and therefore you can pressure a person to take a drug even for treatment, let alone on a prophylactic scenario. Then you can say, that this fortification will be done only in areas where there filariasis is endemic. The Ramaiah article states 18 states/UTs or 412 million people are infected (almost 40-50% of the Indian population). That would imply two types of salt, one fortificated in endemic areas (half of India) and the other normal.
If you do implement a dual strategy it falls in achieving its objective because of the high amount of migration and also people willing to cross districts to get normal unmedicated salt if they may so desire. Next up is the problem with people who are willing to take the salt, they can argue why all year long when I can make do with once annual drug ingestion exercises. Of course chronic exposure to low dose DEC could be more harmful than single high dose – at least in people's perspective. These motivated people might then also migrate towards using normal salt.
Then is the case of policy, presently iodized salt is being sold in India and it is illegal to sell uniodized salt. Suppose we plan to make such a policy to implement fortification of salt with DEC in the whole of India. But before that, why would we need such a policy? Firstly, Government of India doesn't make salt, private companies do. Yes the private sector has a social responsibility but not at the cost of their market. So until you enforce some laws, salt companies will not pick up using DEC in salt. Suppose one company does pick up this, all those consumers wanting unmedicated salt will switch allegiance to other companies, thereby decreasing sales of the company. You can argue that there will be a section of population that would want medicated salt and so start buying this company's salt. For any company, when it comes to making a decision about whether to keep loyal customers against getting new customers, they will always favour the former: keep your customers.
This was the reason why iodized salt was not working in India as there was no law to enforce it. Therefore, until you have a blanket ban on sale on unmedicated salt, there is no way to ensure that fortification of salt would meet its purpose.
Here it is worthy to point out that the use of medicated salt is also favoured because it would take much less time for us to eliminate filariasis. But that is only possible if say everyone in the country uses medicated salt for that one year simultaneously. Therefore a ban becomes all the more a necessity to get such quick remedial action on way. Without a ban, you may fortify 70% of the salt sold in markets, it reaches to 60% of people and 50% of them consume it; how different is this from MDA then.
But not just benefits, when enforcing a blanket ban or a strategy so radical so as to influence everyone in a country, the drawbacks and side effects are necessary. Yes DEC is good for people that may have filariasis, but what is more important is the fact that DEC should not be harmful in any given way to anyone in the country. Suppose someone is allergic to DEC, where would that person go if all the salt in the country is fortified. It then amount to forced feeding of the whole country with something the experts think is good for the people.
Also does fortification of salt with DEC spell some problems for other sectors or public health endeavours? Iodized salt could become a problem, given that people will start first recognising DEC as a problem of forced feeding, and then iodine. This may lead to setbacks in the goiter control programme. Also if the salt is already fortified with DEC, the place for MDA would be little. People compliance would decrease as they are already taking the drug in salt. And if the salt fortification did not work, then you are left with a depleted intervention (MDA) with little people confidence in DEC...
Just some thoughts of an overworked brain, I guess most of these things must have been discussed already and addressed in policy papers. I still have to go through them and shall write a more informed post later.
The article:
Ramaiah, K. D., Das, P. K., Appavoo, N. C., Ramu, K., Augustin, D. J., Kumar, K. N., et al. (2000). A programme to eliminate lymphatic filariasis in Tamil Nadu state, India: compliance with annual single-dose DEC mass treatment and some related operational aspects. Trop Med Int Health, 5(12), 842-847.
