Salt. Nepal. Evokes images of caravans, wealth and success stories. But it used to also remind us of goitre and cretinism.
Iodised salt may not be a glamorous subject, but Nepal's 28-year-old salt iodisation programme has been considered one of the most successful in Asia. Goitre and cretinism, caused by an iodine-deficient diet, used to be endemic. In parts of Gorkha and Rasuwa district, up to 80 percent of the inhabitants once had goitre or suffered from severe iodine deficiency. But three decades after launching a campaign to iodise salt, Nepal has beat this problem. The achievement cannot be quantified in dollars and cents, but if one could put a price tag on raising the intelligence level of a population then Nepal will have gained billions of dollars over the past three decades with its iodisation programme.
Now, this success is under threat. India, from where almost all of Nepal's salt is imported, decided last year to lift the central government ban on non-iodised salt and leave the decision to iodise or not up to state governments. In many parts of India you can now buy plain sodium chloride without iodine.
This becomes a problem for Nepal because despite the efforts of the partially state-run Salt Trading Corporation, Indian salt trickles through the open border and is widely retailed, especially in the tarai. Matters will worsen next year, when private organisations will once again be allowed to import and distribute salt. Health specialists say past experience has shown that when this happens, it is difficult to monitor levels of iodine.
Iodine is essential for normal growth and development in humans. Iodine deficiency causes under-production of the thyroid hormone, a condition called hypothyroidism. People who suffer from hypothyroidism have a depressed metabolic rate, which among other things means improper assimilation of vital nutrients. When the deficiency is serious, as it inevitably is if a modern lifestyle does not include iodised salt, it causes goitre and what has traditionally been called cretinism. Iodine Deficiency Disorder, to give it its proper name, comprises psychomotor defects, impaired mental functions and slow cognitive development. Pregnant women, foetuses, infants, and children are always at higher risk of developing IDD.
Given a daily intake of 10 grams of salt, standard in most parts of the world, an iodine concentration of 15ppm (parts per million) satisfies physiological requirements. This is minute amount-a teaspoon of iodine over a lifetime, but it keeps you healthy.
New Delhi's policy shift on iodised salt in India has already started affecting Nepal, with substandard salt making its way here. Settlements along Nepal's southern border with India were always vulnerable to substandard salt. The Nepal Micro-nutrient Status Survey 1998 (NMSS) showed that half the salt consumed in the tarai had either no iodine or very little. This, despite the fact that refined iodised salt is more easily available here than in the hills.
Parameswar Mahaseth, general manager of the Salt Trading Corporation, the sole authorised dealer of salt in Nepal, puts it bluntly: "After the Indian government's decision became effective, we have noticed that substandard salt that is unsuitable for human consumption is being sold in tarai markets." A UNICEF conference of South Asian countries held last November in Kathmandu also acknowledged that the flow of non-iodised salt into Nepal has increased after India lifted the ban.
Salt produced in the Indian state of Rajasthan is made from underground water which is particularly low in sodium chloride-salt containing less than 96 percent sodium chloride is considered inedible. Salt with less than the minimum sodium chloride content is meant to be disposed of by burying. Not surprisingly, it often finds its way into unwary consumers' houses masquerading as some popular brand or another. To avoid the additional charges involved in burying substandard salt, producers and distributors prefer to simply sell it-at sixty percent the cost. After the STC discovered six months ago that salt consignments failing the standards test of the Office of Salt Commissioner of India is sold freely to poor villagers in both sides of the border, it decided to carry out more raids.
Monitoring iodine in salt in Nepal has always been challenge, because what we use is made in India and so cannot be controlled at the production level. The picture is complicated by a poor transportation infrastructure within Nepal, which makes access to consumers difficult, and by Nepal's landlocked location. This means Nepal needs to keep in store its salt requirement for six months to one year. Salt over time loses iodine content, and to maintain a healthy level of the mineral by the time salt reaches our tables, the original product needs to have 50ppm of iodine. India, in contrast, only requires 30ppm.
There are problems on the domestic front. Consumers here unfortunately prefer large crystal salt, whose iodine content tends to evaporate fast, particularly during transportation and storage. Moreover, many consumers wash the crystal before they use it, which further lowers the level of iodine. The preference persists because crushed, refined salt is perceived to be less clean (as it cannot be washed) than crystal salt.
Salt Trading Corporation data shows that Nepalis consumed 133,000 metric tons of salt last year, of which 63 percent was the crystal form commonly called dhikke noon. In the coming fiscal year (2002/2003), the STC aims to ensure that half the country will use refined, iodised and packaged salt. But these figures can be misleading because salt imported from Tibet, the small amount of salt produced in Nepal annually (six metric tons), and Indian salt that comes in clandestinely are not accounted for. The real figure is probably around 160,000 metric tons. The NMSS estimates that about 65 percent of the population has access to adequately iodised salt, 18 percent gets inadequately iodised salt, and a huge 17 percent of Nepalis consume non-iodised salt.
A collaborative effort of Nutrition Section of the Ministry of Health, the STC, the Indian government and UNICEF was launched in 1973 to increase the availability and demand of iodised salt in the country. The project ended in 1998. To ensure proper levels of iodisation, refined and crushed salt in sealed 1 kg bags was introduced. But even after almost three decades of campaigning, the most successful iodisation programme in Asia has not ensured lasting faith in its product. That, says STC's Mahaseth, is because of a poor marketing strategy. "We concentrated on reducing goitre prevalence rather than making refined salt popular," he explains.
The proportion of low UIE (urinary iodine excretion) values has declined from 52 percent in 1985 to 39 percent in 1998. Not surprisingly, the lowest UIE values are found in rural areas and in the tarai.
Government thinks one way to deal with possibly plateauing levels of awareness and iodised salt consumption is ending the monopoly of the STC and allowing the private sector to participate in the salt trade. The Iodised Salt Distribution Act was drafted two years ago and a proposed regulation allows the formation of a committee to decide who will be allowed to import salt and distribute it.
The failure of Nepal's last experience with privatising salt when the official programme ended in 1998, which led to the four-year moratorium on private salt trading, should be ample warning of the pitfalls of such an approach. Four years ago, Nepal's Dugar Group was allowed to deal in iodised salt but the business house failed to supply the promised amount on time, and when NGOs tested the iodine level in Gyan Noon, the Dugar Group's brand, the iodine level was found to be as little as seven 7ppm. "Monitoring mechanisms are poor in Nepal, it is easier to monitor one dealer of salt than multiple dealers," said Macha Raja Maharjan, National Programme Officer with The Micronutrient Initiative.
Substandard salt flooding the tarai aside, India's own experience should give us pause. The competition in the Indian market after the entry of the private sector has not benefited consumers there-they pay NRs 11.20 for a kg of iodised salt, 20 percent more than they used to until last year, and 40 percent more than what Nepali consumers pay.