1. Action on Fluorosis in Saurashtra, Gujarat
INREM Foundation
Fluoride Knowledge and Action Network
Presentation in NDDB,
January 2
2014

2. Parts of presentation
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

3. I) Fluorosis situation in
ground: previous action and
learning

4. Millions suffering in India
Juvenile
crippling is
increasing

5. The real Fluoride picture is much more widespread than this
10 states are
highly affected
and 24 states
report cases
Estimated 65 million
are exposed to high
fluoride in drinking
water
Source: CGWB, 1999

6. Factors causing Fluorosis
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

7. 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

8. 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

9. Steps in Detection
Testing of drinking water
Testing of food – nutrition & fluoride
Dental & skeletal fluorosis surveys
Blood and urinary fluoride testing
X-rays of fore-arm & affected limbs

10. 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

11. Community water filtration
Domestic water filtration
Rain water harvesting
Protecting safe water sources

12. We can use the following Nutrition programme for
Fluorosis:
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
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

13. Nutrition enhancement
Calcium, Magnesium supplements
Dried Amla
Amla tablets
Green leaves
Til Chikki

14. 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

15. Impact of Safe water and Nutrition Intervention in Jhabua, MP
May-2010
Dec-2012

16. Local institution for convergence – Fluorosis
Mitigation Centre
Health Service
Diagnosis
Counselling
Periodic checkup
Training
Doctors / ASHA
NGOs / PRIs
Potters
Fluorosis
Mitigation
Centre (FMC)
Research
Impact of mitigation
Upscaling/Absorbment
Communication
Mass level
Doctors
Periodicals
Teachers
Technologies
Locally made filters
Nutrition enhancement

17. 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

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

19. 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

20. 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.
Apart from
these
institutions,
several others
have shown
Arghyam: It is a public charitable trust located in Bengaluru. It strives to interest and
support sustainable efforts that enhance equity in access to water for all.
participated in
The initial support for the Secretariat for this network has been provided by the Initiation
Arghyam.
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

21. What are the initial network activities?
Enabling knowledge exchange
Portal
Social media
Workshops
Newsletter
Advocacy
Regional Initiatives
Initiating state level
groups
Synthesizing state level
white papers
Experiences from national fluorosis programme
Community water treatment experiences
State of Sector report for Fluoride and Fluorosis in India
Working with Fluorosis Task force of ICMR
Apart from
these, the
network
responds to
specific
opportunities
from members
and helps
facilitate new
initiatives

22. 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

23. III) Collaboration of NDDB
with Fluoride Network

24. 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

25. Suggested objectives of this collaboration
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

26. 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

27. 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

28. 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,

29. 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

30. 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

31. 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

32. 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