In 2010, nine-year-old Kailash from Miyati village, Jhabua developed symptoms of skeletal fluorosis. Fluorosis, which affects millions of people in India, is a health issue caused due to high fluoride content in drinking water. Skeletal fluorosis is marked by deformed bones. It affected all aspects of Kailash's life including his education, physical functioning, social acceptance, etc.
Starting from the late 1980s and early 1990s, Dr Tapas Chakma and Dr Teotia, noted for their work on fluorosis, started noticing increasing cases of skeletal fluorosis among children like Kailash. Soon observations started coming in from across India on stunting and extreme forms of rickets in fluoride-affected areas which, coupled with high malnutrition in those places, was suspected to cause very early and serious forms of juvenile fluorosis. Many of these places were tribal pockets of central India, and Jhabua was one of them.
In 2010, INREM Foundation, a research institution probing societal issues concerning water, public health, agriculture and the environment was in the initial stages of developing a comprehensive approach to tackle fluorosis. A team of eminent doctors had concluded many of the fluorosis-related problems among people could be effectively addressed. Jhabua was an “open lab” for INREM.
In early 2011, people in two villages, Jasoda Khunji and Miyati in Jhabua district showed very high levels of blood serum, urinary fluoride, severe bone deformities and osteoporosis--conditions typical of fluorosis patients. People were drinking high fluoride water up to 8 mg/l, though the amount of fluoride in food was not significant enough to cause fluorosis. However, it was found that calcium consumption was very poor, up to 200-250 mg/day which is much less than the recommended daily intake of 800 mg/day. These important observations coupled with the fact that only water from deeper handpumps had high fluoride (to low fluoride content in shallow wells) offered some hints to INREM and the supporting scientists.
The scientific basis for action
Right from the 1930s when fluorosis was first detected in India, it was reasoned that the symptoms of the disease could be dealt with using better nutrition and clean water. It has often been pointed out that renal problems increase fluorosis affliction and that better renal health is essential in countering the disease. Further, good nutrition was often observed to reduce some forms of fluorosis.
Published research on fluorosis affliction shows a strong linkage between fluoride intake and bone afflictions that increase with calcium deficiency. Also, due to this linkage, calcium deficiency develops in patients; there is up to 40 mg of calcium requirement noticed for each ingested milligram of fluoride. Secondly, as reported by several authors, vitamin C plays a key role in developing better resistance to consumed fluoride in the body. Observations suggested that magnesium could help in both fluoride detoxification, as well as in calcium binding. Also, since these children were highly calcium deficient, experts thought that they might require a treatment similar to that of high rickets condition caused by vitamin D deficiency.
Developing a protocol for action
By mid 2011, a protocol for action was formed in terms of nutritional supplementation in Jhabua by INREM Foundation, comprising appropriate amounts of calcium supported by magnesium, vitamin D and zinc, along with vitamin C. Amla or Indian gooseberry, which is high in vitamin C was used--initially in the form sweet and salted candies, and later in a tablet form. Other food items chosen include til chikki or sesame with jaggery, which is high in calcium and magnesium.
Stopping fluoride from entering the body required two types of approaches. Where safer sources of fluoride were found close by, those were recommended, for example from shallow water sources such as dug wells. Where they were not found, a household fluoride removal unit was developed using the work of Dr Iyengar, IIT Kanpur, done in partnership with UNICEF in the late 1980s. Previous experience across India on the design of such filters and failures of these efforts were also looked into. It was understood that a good design was essential along with a close adaptation of the technology in people’s lives backed by constant maintenance.
Community action and behavioural change
Since a complete adoption of the suggested practice of consuming safe water and good nutrition was essential to the success of the programme, a close-knit communication programme was developed to bring the community towards better acceptance of the problem and on acting on it positively. This involved understanding the problem in change practices such as consuming water from a safer source, or using the household filter, or consuming nutritional supplements or suggested food, and solving problems in a participatory manner.
The INREM field team made weekly visits to each household to closely understand their problems and perceptions on fluorosis and whether a change in practices was being followed or not. Many changes in the programme, such as a modified filter, came about due to this process of close interaction and feedback from the affected community. People in Jhabua have used various versions of domestic filters over a period of six years due to this.
Promoting safe water sources among the community through simple field testing of water sources proved to be a very strong communication agent. The pink-yellow colour differentiator between safe and unsafe fluoride got translated as ‘lal-pila' locally for different water sources. This proved beneficial to better acceptance of safe dug well water by Miyati village people in early 2012.
INREM had been following the individual cases very closely for signs of improvement in symptoms and using these as cues for their own continuity of change practices and communicating the same to other families as a good practice. Observations were being made by local stakeholders such as parents, teachers, other children, and most importantly, their siblings and the children themselves. Following these observations, initial reporting of pain relief, increased vigour, attention, speech, and general signs of vitality were made.
Kailash was one such child who showed improvements by following the mitigation practices starting from the usage of the household filter and tablets and later using the dug well water and better food. Kailash not only recovered physically, but he can now ride a bicycle and grows and sells vegetables for a living. He walks seven kilometres a day to the nearby town of Thandla. More recently, he migrated to Gujarat and got engaged to be married. His recovery, apart from other observations, lends much credit to the mitigation efforts. INREM’s model of working has gradually expanded in the surrounding areas within Jhabua district and later in Alirajpur and Dungarpur.
These important messages coming out of the Jhabua experiences give hope to many people across India who are suffering from fluorosis and related symptoms. It also tells us to act quickly to improve the lives of the fluoride affected people.
This post is extracted from the attached policy brief. For more information on this issue, please visit the Fluoride Knowledge and Action Network's website. You can also write to Sunderrajan Krishnan and Vikas Ratanjee, and join FKAN on Facebook.