FLUOROSIS – A Big Human Tragedy Still Largely Unattended

This paper was presented in 'Odisha Environment Congress, 2016' which had the focal theme 'Environment : Water, Sanitation & Hygiene

Bimal Prasad Pandia

INTRODUCTION

Fluoride is an important requirement of the human body. At the same time it is also a big threat. High fluoride causes a severe disease – fluorosis. Many underdeveloped and developing countries are grappling with high concentration of fluoride. India is fluorosis endemic country. Fluoride enters the body through various means but water is the primary carrier. High fluoride containing water and food causes fluorosis disease. In advanced stages fluorosis causes severe crippling of bones and joints and also leads to premature death. There are other social, economic and behavioural consequences of fluorosis. Fluorosis can be mitigated. But if not mitigated and allowed to advance then it cannot be cured. Fluorosis, being an untreatable disease, can only be mitigated through prevention and control. In recent period many studies and pilot programmes have found potentials of reversing fluorosis, especially in children.

Since, it is a preventable disease and is largely caused by poor water quality and poor awareness; there is a big need to attempt fluorosis mitigation and combat through planned and intertwined actions involving different aspects of it.

Current efforts of fluorosis combat have mostly been one dimensional as that has been largely stayed limited to provide safer water sources. Even that objective has not been fully met and other aspects stay unattended. There is a need to have a fresh look and without delay because it is a human rights violation and a serious crime against humanity if fluorosis is allowed to continue and spread, and the affected people are left unattended.

FLUORIDE MAY BE GOOD OR BAD, BUT FLUOROSIS IS SERIOUSLY BAD

The beneficial impacts and requirements of fluoride were discovered first. The history of identifying need for additional supply of fluoride dates back to the very beginning of 20^th Century. The story of fluoridation begins with a mystery staining of the teeth first described by dentist Dr. Frederick McKay in Colorado in 1901 and, independently in Naples in 1902 by Dr. J.M. Eager, an American dentist stationed in Italy (Mullen, 2005). Many studies found that water naturally fluoridated at 1ppm clearly benefited dental health. Such findings led to fluoridation, a process of adding fluoride in drinking water.  As per Mullen (2005), as many as 40 countries had artificial water fluoridation schemes in existence. Around 50 million people around the world receive water naturally fluoridated at a concentration of around 1 mg/litre. But much before beginning of artificial fluoridation, toothpastes started adding fluoride. Fluoride was added to toothpastes first in 1914 and continued thereafter. It was started after discovery that fluoride significantly decreases dental cavities (Denise, 2012).  In India water fluoridation has not been attempted but most Indian toothpaste makers started adding fluoride and also advertised such additions prominently in the 1970s and the decade thereafter.

The good effects of fluoride might have invited attentions first but the bad affects, in shape of fluorosis disease, have been widespread and too damaging. The Oxford dictionary defines fluorosis as ‘a chronic condition caused by excessive intake of fluorine compounds. Ingestion of excess fluoride, most commonly in drinking-water, causes fluorosis which affects the teeth and bones (WHO, 1993). In acute cases, affected person become crippled and may die premature.

The adverse affects of fluoride were first observed in the 1930s. The dental effects of fluoride naturally present in public drinking water were established during the 1930s and 40s by Trendley Dean and his colleagues at the US Public Health Service. In a series of epidemiological studies across the United States they demonstrated that as the concentration of fluoride naturally present in drinking water increased, the prevalence and severity of dental fluorosis increased and, the prevalence and severity of dental caries decreased (Lennon et.al. 2004).

Reddy (2015) has listed out beneficial and harmful effects of fluoride.

Beneficial and Biological effects of Fluoride:

Fluoride is mainly present in bones and teeth. The beneficial effects of fluoride in traces are overshadowed by its harmful effects caused due to its overconsumption. The Biochemical functions of the Fluoride are as follows.

1.       Fluoride prevents the development of dental caries by forming a protective layer of acid resistant fluoroapatite with hydroxylapatite of the dental enamel and prevents the dental decay by bacterial acids.

2.       Fluoride inhibits the bacterial enzymes thus reduces the production of acids.

3.       Fluoride is necessary for the proper development of bones. 4. Sodium Fluoride (NaF) inhibits the enzyme enolase of glycolysis.

4.       Fluoroacetate inhibits aconitase of citric acid cycle.

5.       Fluoride prevents osteoporosis in adults particularly in post – menopausal women.

Harmful effects of fluoride:

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2.       Excessive intake of the fluoride above 1.5 mg/L in children causes mottling and discolouration of enamel, corroding of teeth. The teeth are weak and become rough with characteristic brown or yellow patches on their surface. These manifestations are collectively referred to as dental fluorosis.

3.       An intake of fluoride above 20mg/L is toxic and causes pathological changes in the bones. Hypercalcification, increased bone density and sclerosis of the bones of limbs, pelvis and spine. Even the ligaments of the spine and collagen of bones and tendinous insertions get calcified. Neurological disturbances are also commonly observed. These manifestations collectively constitute skeletal fluorosis.

4.       In the advanced stages, the individuals are crippled and cannot perform their daily routine work due to stiff joints. The knees angle in and touch one another. This condition is referred to as genue vvalgum or knock knee. This is due to the outward bending of distal portion of knee joint and inward bending of its proximal portion.

5.       In some cases, outward bowing of lower leg may occur. This condition is called as ganue varum or tibia vara.

6.       Sometimes knee joint bends backwards. This condition is referred to as genue recurvatum or back knee. This deformity is more common in women.

7.       Floride also affects the R.B.C cell wall. It is now known that when fluoride is ingested, it will also accumulate on the erythrocyte membrane, besides other cells, tissues and organs. The erythrocyte memberane in turn looses calcium content and becomes amoeboid. This is referred to as non-skeletal fluorosis.

Fluorosis disease can occur in three forms: (a) Dental fluorosis, (b) skeletal fluorosis, and (c) non-skeletal fluorosis. Acute cases of fluorosis lead to severe physical crippling. The late stages of skeletal and dental fluorosis are permanent and irreversible in nature and are detrimental to the health of an individual and the community, which in turn has adverse effects on growth, development & economy of the country (NHP, 2016).

All fluorosis cases can be identified through pathological examination of bone, blood, urine and serum. Dental and skeletal fluorosis, in advanced stages of affect, can be identified through visible physical symptoms as they significantly alter the tooth and bone textures and frames. Symptoms of non-skeletal fluorosis are not visible to naked eye. They are manifested through different ailments and symptoms. Studies have found that skeletal fluorosis complicates neurological functions, causes kidney ailments, reduces intelligence quotient (IQ), affects reproductivity,  interferes with thyroid gland function, increase diabetic problems etc. (Dey and Giri, 2015). Recent studies have shown that fluorosis also causes mental retardation (Sharma and Bapuji, 2015). Studies have suggested that fluoride might be associated with alteration in reproductive hormones level, infertility, Down’s syndrome, increased rate of congenital anomalies and cancers’ (Ghosh et.al, 2016).

Dr A. K. Susheela in 2016 has identified extensive diseases linked to Fluorosis. The linked diseases are:

1.       Dental fluorosis and extended effects in children with:

a.       Thyroid hormone deficiencies;

b.      Bone deformities; and

c.       Neurotoxicogical affects.

2.       Cardio-vascular diseases leading to high blood pressure, cholesterol and blood vessel blockages.

3.       Anaemia leading to non-absorption of nutrients and / or orally administered Iron and Folic acid tablet to correct anaemia in pregnancy and adolescent boys and girls.

4.       Renal failure leading to kidney dialysis or kidney transplant.

Other studies have found out that fluoride affects foetus, nerves, heart and may cause loss of appetite, nausea, pain in abdomen, intermittent diarrhea, muscular weakness, excessive thirst, etc. (Nemade et.al, 2002).

Recently, the bad impacts of fluoride have started far outweighing the good effects of fluoride. Fluorosis is emerging as a worldwide problem and endemic at least in 25 countries. It has been reported from fluoride belts: one that stretches from Syria through Jordan, Egypt, Libya, Algeria, Sudan and Kenya, and another that stretches from Turkey through Iraq, Iran, Afghanistan, India, northern Thailand and China. There are similar belts in the Americas and Japan (NHP, 2016).

Because of a huge population, overwhelming dependence on groundwater and huge deposits of fluoride bearing geological formation; India is emerging as one of the biggest fluoride water bearing zone and one of the fluorosis affected region of the world. The world’s fluoride stores in the ground are estimated at 85 million tons. Out of which nearly 12 million tons are located in India (Roy, 2007). High levels of Fluoride are reported in 230 districts of 20 States. And it is growing. In 2001, Dr A K Susheela had found, from available data of that time, that  15 states in India are endemic for fluorosis (fluoride level in drinking water >1.5 mg/l), and about bout 62 million people in India suffer from dental, skeletal and non-skeletal fluorosis. Out of these; six million are children below the age of 14 years (Susheela and Bhatnagar, 2001). These many people being affected with fluorosis is significant. This affected population constituted 5.85 percent of total population of that time. This is a huge number.

FLUOROSIS AND RESPONSES OF THE GOVERNMENT

Government has a huge role and stake related to fluorosis. Article 21 of the Constitution of India is about ‘Protection of life and personal liberty’. The said article declares a fundamental right of the citizen that ‘No person shall be deprived of his life or personal liberty except according to procedure established by law’.

The Courts of India have clearly held that ‘right to life’ also includes ‘right to water’.  The Supreme Court has protected the right to clean and safe water as part of the right to a healthy environment in a spate of water pollution cases coming before it from the early nineties onwards (Kothari, 2008). In Andhra Pradesh Pollution Control Board V Prof M V Naydu, the Supreme Court did mention that ‘all citizens have the fundamental right to have access to clean and safe drinking water’ (Supreme Court of India, 1999).

While the Courts have strongly and conclusively held that every citizen has a fundamental right to clean and safe water, as enshrined under Article 21 of the Constitution of India; India is also a signatory to numerous important international commitments including commitment on right to water and sanitation. India is a signatory to the United Nations Resolution on Human Rights to Water & Sanitation. The said resolution recognises, “the right to safe and clean drinking water and sanitation as a human right that is essential for the full enjoyment of life and all human rights” (United Nation, 2010).

The central and state governments have obviously declared their intentions and commitments. The government of India is implementing a massive National Rural Drinking Water Programme (NRDWP). The programme’s objective is ‘to provide every rural person with adequate safe water for drinking, cooking and other basic domestic needs on a sustainable basis, with a minimum water quality standard, which should be conveniently accessible at all times and in all situations’ (Press Information Bureau, 2013). In a response to the Rajya Sabha on July 21, 2015; the Union Health Minister said that “Government of India supplements the efforts of the States by providing technical and financial assistance under the centrally sponsored National Rural Drinking Water supply Programme (NRDWP) for providing safe and adequate drinking water supply facilities in rural areas of the country. Further, 5 percent of NRDWP Funds are earmarked and allocated to those States facing problems of chemical contamination in drinking water. Up to 67 percent of the NRDWP fund allocated to States can be utilized for tackling water quality problems in rural areas. In addition, Government of India provides 3 percent NRDWP funds on 100 percent Central assistance basis to States for water quality monitoring and surveillance , which inter alia include taking up works relating to setting up of new or up gradation of district/sub-district water quality testing laboratories, providing chemicals and consumables to laboratories, providing field test kits/refills to Gram Panchayats etc. (Rajya Sabha, 2015).

Besides NRDWP, Government of India has started an exclusive programme on fluorosis prevention and mitigation, “National Programme for Prevention and Control of Fluorosis (NPPCF)”. The NPPCF which aims to prevent and control Fluorosis disease in the country has set the following objectives:

·         To collect, assess and use the baseline survey data of fluorosis of Ministry of Drinking Water Supply for starting the project;

·         Comprehensive management of fluorosis in the selected areas;

·         Capacity building for prevention, diagnosis and management of fluorosis cases.

The NPPCF, launched in year 2008- has already included 111 most affected districts of the country 09 in a phased manner.

While government is mandated by the Constitution, international commitments and also a self adopted proactive welfare approach to development; the non-government agencies too are playing quite important roles in bits especially on matters relating to right to water, right to life etc.

However, with all such declarations, commitments and launching of programmes; while the cause of fluorosis has got more focus the affect has hardly got much attention. Identification, treatment, relief and rehabilitation of affected people have hardly got any attention.

A CRIMINAL NEGLECT STILL PERSISTS

There are many aspects of fluorosis mitigation where lack of actions or inadequate actions or faulty actions by different stakeholders, most prominently by the government, have resulted in continuance of a criminal neglect.

The first such neglect starts with a clear absence of identifying fluorosis affected people and maintaining a database. Any status cannot properly be assessed without a good database. Unfortunately, neither the Central government nor the state governments have started maintaining a complete and correct database of fluorosis patients. In fact, the NPPCF itself hasn’t also made it an objective. The best it comes close by is its objective to ‘, assess and use the baseline survey data of fluorosis of Ministry of Drinking Water Supply for starting the project’. But the problem is that, the ministry Ministry of Drinking Water Supply and Sanitation (MDWS) does not keep any database on ‘fluorosis’. MDWS only conducts water quality tests for government created sources and identifies the water sources having fluoride level of 1.5mg per litre. This is a big stumbling block for a frontal attack on fluorosis and is showing in non-coordinated and non-serious approach to implementation of numerous government programmes. The government does not have any idea of how many people are already affected with dental, skeletal or non-skeletal fluorosis. It only refers to number of habitations identified by the Management Information System (MIS) of MDWS as fluoride affected and draws an estimation of ‘people at risk’.

In absence of a clear database, such estimation can be useful only if they are reliable. Unfortunately, the MDWS database cannot at all be relied upon. For example, referring to the MIS of MDWS, union Health Minister replied to Rajya Sabha on February 24, 2015 that 55,269 people of 279 habitations in Odisha (Rajya Sabha, 2015). This is a big understatement and hugely contradicts information declared and stated elsewhere by the government sources. In reply to a similar question, the government had informed to Rajya Sabha on December 19, 2011 that 475 habitations of Odisha are fluoride affected  (Rajya Sabha, 2011). This means, number of affected habitations in 2015 decreased from 2011 number. It showed such a trend because the MIS of MDWS assumes that a habitation becomes safe if government provides a safe source of water in that habitation. Such kind of assumptions is highly erroneous and does a disservice to the intention of eliminating fluorosis. For example, as back as in 31.12.2010, government of Odisha had identified 905 habitations of Nuapada district alone as fluoride affected. The government had further stated in that report that 426 of those habitations have already been provided with safe water sources. That means only 410 habitations were left as affected habitations. Following similar estimations governments have arrived at lesser number of affected habitations in later years. In context of fluorosis, such an approach is full of many hazards. That is evident from new cases of fluorosis emerging from so called safe habitations. And hence, governments must give emphasis on proper identification of fluorosis affected persons and not rely on information of fluoride affected habitations.

Government’s efforts have largely stayed limited to creation of infrastructures for safe water supply only.  The other aspects of fluorosis have hardly been dealt with. Even the NPPCF has failed to give emphases on its other important objectives, i.e. Comprehensive management of fluorosis in the selected areas; and Capacity building for prevention, diagnosis and management of fluorosis cases.

Had the NPPCF achieved its objectives, India would have a clear database of fluorosis patients, at least in the 111 districts included in the programme. The NPPCF has hardly made any progress. The NPPCF has allocated Rs 4,415 crore allocated under the programme, different districts have spent only 1,615 crore. In other words only 36.6 percent of allocated money was spent. The chart below provides state-wise figures of spent and unspent share out of allocations made under NPPCF in the above period.

States like Odisha, Bihar, Chhattisgarh and Madhya Pradesh have fared the worst in fluorosis combat programme. Odisha has spent only 23.4 percent of 115.86 crore rupees allocated to it.

The NPPCF has failed to achieve its objective to identify fluorosis affected people because of it has failed to create the infrastructures and put in place the resources required.  As per  NPPCF guidelines (MHFW, 2014), any suspected case of fluorosis can be confirmed  after retrieval of a clinical history, by the following tests:

·                Any suspected case with high level of fluoride in urine (>1mg/L).

·                Any suspected case with interosseous membrane calcification in the forearm confirmed by X-ray Radiograph.

·                Any suspected case, if kidney ailment is prevailing, serum fluoride need to be tested, besides urine fluoride.

The above stipulations make it clear why there are so few cases of fluorosis have been identified officially. While this is a big bottleneck in fluorosis combat, the non-skeletal fluorosis has been neglected even more. That is more complex and doctors often diagnose those as other ailments. Ingole points out at gross inadequacy of fluorosis teaching in medical courses as another reason for lack of proper attention and treatment of fluorosis affected people or population exposed to fluoride threats. He mentions that ‘fluorosis is a neglected entity in community as well as amongst medical fraternity. Text books may not offer detailed coverage of fluorosis. The minds of medical students are not being impressed upon with the fluorosis epidemiology, clinical effects and prevention’ (Ingole, 2016).

OTHER NEGLECTED ASPECTS OF FLUOROSIS

Fluorosis is of course a disease. But it is not a health problem alone. It has far wider human resource, social and economic consequences. Many studies have found that fluorosis affects level of education and vice-versa.

Many studies have found that fluorosis affects intelligence and education. Connett and Blank (2016) informed that a total of 57 studies around the world have investigated the relationship between fluoride and human intelligence and over 40 studies have investigated the relationship of fluoride and learning/memory in animals. Of the 57 human studies as many as 50 studies have found that elevated fluoride exposure is associated with reduced intelligence quotient (IQ). The studies on animal have shown similar high relation. All 45 experiments on animals have found that fluoride exposure impairs the learning and/or memory capacity of animals. There is another kind of relation of education and fluorosis. Shah and Indu (2004) found that cases of fluorosis were reduced when education reached high among male and female both. They concluded that education makes better awareness, so people might be taking better care of themselves.

Any discussion on fluorosis mostly starts and concludes with water or fluoride affected water. But, food and nutrition also plays a major role in mitigating or enhancing fluorosis. Cornet (2013) found that nutrient deficiencies enhance fluoride toxicity. Krishnan and Indu (2016) convincingly declared that condition of juvenile fluorosis is unique in that it is a mix of both high Fluoride entering the body, as well as Malnutrition. A good nutrition helps in mitigation and control of fluorosis while the opposite happens if there is lack of nutrition or if food intake is friendly to invite fluorosis. Level of income and other social existence have a direct bearing on nutrition or type of food intake. Thus, there is a big need to have a look at the nutrition aspects of fluorosis.

Fluorosis has impacted or potentials to impact, mostly adversely, many other aspects related to a human being’s relation with society. Many studies have tried to assess impact on fluorosis on marriage, reproductivity, differential gender impacts, differential impacts on caste, income loss, productivity loss etc. Rao (2001) had published a very short but significant small feature in Times of India on December 16, 2001. It featured an unfortunate case of a fluoride hit reason where people are not being able to get married. Studies have also found out that fluoride might be associated with alteration in reproductive hormones level, infertility, Down’s syndrome, increased rate of congenital anomalies and cancers’ (Ghosh et.al, 2016).

Fluorosis ruins individuals, families and the economies financially. Unfornately, those aspects have not been studied or focused with seriousness. Krishanan (2010) informs that estimations of social cost of diseases such as fluorosis often neglect a larger section. Such estimations mostly consider (a) medical cost, such as cost on medicine and cost on medical advice; and (b) wage loss, if unable to work. But, many other aspects which are closely intertwined with daily existences remain neglected such as: (a) impacts on livestock’s productivity (b) cumulative labour loss in society, (c) impact on village gross domestic product, and (d) intangible costs on social stigmas etc.

Relief, treatment and rehabilitation of fluorosis affected people is another aspect that has been completely neglected. It is accepted that fluososis when advances too much is non-curable. But recent studies by Krishnan and Indu (2016) have found out that fluoride toxicity can be reduced in early stages and especially among the children. They did an intensive intervention with 25 children in Jhabua district of Madhya Pradesh with a combination of fluoride free water along with nutrition high in calcium, magnesium and vitamin C. Their intervention found that there was a recovery of bone deformities in five children and many improvements in others.

CONCLUSION

The current fluorosis focus is mostly limited to create safer water sources. It conveniently ignores that such a creation is not sufficient to mitigate fluororosis and provide relief to affected people. A problem like fluorosis needs a planned, intensive and integrated approach. The approach must include identification, mitigation, relief, rehabilitation and compensation. Somehow, such an approach is found largely missing in India and Odisha. There is a need to amend such mistake. Any continuation of that mistake is a violation of Article 21 of the Constitution of India and undermining of India’s national and global commitment.

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