Action on Fluorosis in Saurashtra, Gujarat

INREM Foundation

Fluoride Knowledge and Action Network

Presentation in NDDB,

January 2

2014

I) Fluorosis situation in ground: previous action and learning

II) Concerted India – wide action on Fluorosis as a network

III) Collaboration of NDDB with Fluoride Network

Parts of presentation

I) Fluorosis situation in ground: previous action and learning

Millions suffering in India

Juvenile crippling is increasing

The real Fluoride picture is much more widespread than this

Source: CGWB, 1999

10 states are highly affected and 24 states report cases

Estimated 65 million are exposed to high fluoride in drinking water

Fluoride intake around 10 mg/ day or more from

water and food. Water standards are 1 mg/l

Deficiency of Calcium and other minerals such as Magnesium, Vitamin C. Decreases Iron absorption

Factors causing Fluorosis

The (mal) Nutrition link

Fluorosis affects intake and absorption of Calcium and Iron .

In turn, Nutrition deficiency of Calcium, Vitamin C and antioxidants makes Fluorosis more severe

Vulnerable sections being malnourished areas, women and children

Fluorosis

Malnutrition

As people understand

People misunderstand Fluorosis as ‘Va’

Also, doctors mis-diagnose as Arthritis

Dental stains taken as Tobacco or from poor hygiene

Crippling is taken as hereditary or local curse

Testing of drinking water

Steps in Detection

Testing of food – nutrition & fluoride

Dental & skeletal fluorosis surveys

Blood and urinary fluoride testing

X-rays of fore-arm & affected limbs

Approach to Tackle Fluorosis

• Minimize intake of fluoride through water and food

• Increase intake of Calcium and ways of absorbing Calcium

• Reduce Fluoride action within body through better nutrition

• Use indicators of fluorosis vulnerability to target interventions

• Longer term action on social determinants of fluorosis

Domestic water filtration

Community water filtration

Rain water harvestingProtecting safe water sources

a) Pharma supplements of Ca, Mg, Vitamin D3 and Zinc

b) Natural food rich In Calcium, Magnesium, Vitamin C: Amla (dried

form and tablets), Soya, Til-Chikki, Cassia Tora (Puvadiya, Chakora)

c) Ayurvedic and Herbal foods which help in better absorption of

nutrients and detoxification of fluoride

We can use the following Nutrition programme for Fluorosis:

The best approach is to stress on local food sources and traditions as far

as possible. Also fortification (flour, oil, water) using local food materials

rich in nutrients is important

Amla tabletsCalcium, Magnesium supplements

Dried AmlaTil Chikki

Nutrition enhancement

Green leaves

For this we need ….

People knowing the meaning of ‘safe water’ and ‘good nutrition’

Information being available to people

Better communication of ideas helps in changing people’s behaviour

Children being the main messengers and change agents, and

women acting on it

May-2010 Dec-2012

Impact of Safe water and Nutrition Intervention in Jhabua, MP

Fluorosis

Mitigation

Centre (FMC)

Training

Doctors / ASHA

NGOs / PRIs

Potters

Research

Impact of mitigation

Upscaling/Absorbment

Health Service

Diagnosis

Counselling

Periodic checkup

Technologies

Locally made filters

Nutrition enhancement

Communication

Mass level

Doctors

Periodicals

Teachers

Local institution for convergence – Fluorosis Mitigation Centre

Learning from experiences on the field

Combined approach of safe water and nutrition can help in

prevention and cure of fluorosis– Convergence is needed

Local context is needed based on local information on water sources and dietary habits - Customization of mitigation to local needs

Children and women are most important for communication of fluorosis – Good communication in schools and women’s groups

II) Concerted India – wide action on Fluorosis as a network

Fluoride Knowledge and Action Network

Formed for all of us to work together on Fluoride and Fluorosis in India

Consists of subject experts, govt bodies, NGOs, academic and research bodies, institutions, philanthropic trusts, CSR, industry

Formed in October 2013 with an initial meeting of members in New Delhi

The seeding institutions

INREM Foundation: Secretariat for the network. Located in Anand,

Gujarat. Works on policy research, field innovation and community engagement in the subject of natural resource management with focus on Water quality and health, Hydrology and river basin management, Water and Livelihoods and Policy& Governance issues.

Arghyam: It is a public charitable trust located in Bengaluru. It strives to

support sustainable efforts that enhance equity in access to water for all. The initial support for the Secretariat for this network has been provided by Arghyam.

Apart from these institutions, several others have shown interest and participated in the Initiation meeting of the network

The Fluoride Knowledge and action Network is conceived as an open platform on the Fluoride and Fluorosis issue in India. It is forseen as a highly inclusive network with emphasis on both credibility as well as outreach and connectedness with communities

What are the initial network activities?

Enabling knowledge exchange

Regional Initiatives

Advocacy

PortalSocial mediaWorkshopsNewsletter Initiating state level

groupsSynthesizing state level white papers

Experiences from national fluorosis programmeCommunity water treatment experiencesState of Sector report for Fluoride and Fluorosis in IndiaWorking with Fluorosis Task force of ICMR

Apart from these, the network responds to specific opportunities from members and helps facilitate new initiatives

How the network can help us in Gujarat?

Experts are available on : technology such as filters and rainwater harvesting, for nutrition and health

Support is available on community based organizations on

experience from field

Policy efforts are ongoing within network to facilitate larger environment that helps good efforts like in Gujarat

III) Collaboration of NDDB with Fluoride Network

Collaboration of NDDB with Fluoride Network in Gujarat

Till Now

Initial discussions on Fluoride and Fluorosis in November 2013

Writing of a Gujarat Position Paper on Fluoride and Fluorosis by INREM in December

Agreeing to work together in Saurashtra on problem of Fluoride and Fluorosis

1. Helping to change people’s thinking and bring about mass awareness on Fluorosis for people and cattle

2. Building the capacity of people’s institutions such as Panchayat, Women’s groups, Anganwadis, Schools, PHC/CHCs, to work on Fluorosis in both detection and mitigation

3. Participate in development of solutions and promotion of these to people through people’s institutions

Suggested objectives of this collaboration

Overall Strategy

Strategy 1: Focus on one district such as Amreli and work for a year on all aspects of the problem

Strategy 2: Work in as many places as opportunity arises, but focus mainly on building awareness and giving messages to people

Some combination of these two strategies or mid-way can also be thought of

Self assessment and awareness of Fluoride and Fluorosis

Developing communication for people to understand in local language about Fluorosis and other water quality problems

Giving people ability to self assess basic symptoms

Simple testing of water quality by people and sample tested at main referral lab

Procedure for suspected Fluorosis cases to refer to PHC/CHC or veterinary authority

Demonstration effect of Filters and other water solutions

People will learn new habits by

demonstration

Local institutions such as Milk cooperatives, Panchayat, Schools, Anganwadis, Women’s centres, PHC, CHC , can be centres where solutions are demonstrated

Some examples are filters, rainwater harvesting,

Promotion of local nutrition self reliance through nutrition gardens

Good nutritious food change is a slow process

It requires ‘model’ farms where such nutritious food is grown

Nutrition gardens are now being developed across India for specific needs eg. Vision related, bone related, …

Fluorosis specific ‘Nutrition gardens’ can be promoted for Calcium, Vitamin C and related nutrient rich local foods

Cattle health during checkups for Water quality related problems

Fluorosis in cattle is not well documented

Regular cattle health checkups should include Fluorosis screening in Endemic areas

Screening and referral process can be developed for cattle for Fluorosis

Steps ahead

1. Deciding focal areas and preferred entry point institutions and approaches

2. Capacity building of local institutions by Fluoride Network

3. Developing a time plan for action and implementing through local institutions

Summary

Fluorosis in India is a serious problem requiring convergence of many actors

Fluoride knowledge and Action network is willing to collaborate with NDDB and provide support in Gujarat

Focussed Strategy needed for Saurashtra on building

people’s awareness, referral systems for better detection and creating model solutions for demostration and replication