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BRIEF RESEARCH ARTICLE
Year : 2021  |  Volume : 65  |  Issue : 1  |  Page : 57-59  

Expounding on the concerns of indian politicians regarding fluorosis: A qualitative analysis of parliamentary questions on fluorosis over two decades


1 Senior Lecturer, Department of Public Health Dentistry, Madha Dental College and Hospital, Chennai, Tamil Nadu, India
2 Reader, Department of Public Health Dentistry, Madha Dental College and Hospital, Chennai, Tamil Nadu, India
3 Professor and Head, Department of Public Health Dentistry, Madha Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Submission09-Aug-2020
Date of Decision01-Nov-2020
Date of Acceptance31-Dec-2020
Date of Web Publication20-Mar-2021

Correspondence Address:
Nesa Aurlene
F 1 Hyder Manzil, Kamakodi Nagar Main Road, Pallikaranai, Chennai - 600 100, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijph.IJPH_1013_20

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   Abstract 


Fluorosis is a major public health problem in India affecting nearly 20 states. Despite more than three decades of fluorosis prevention efforts, fluorosis continues to be a widely prevalent disease in India. The debilitating effects of skeletal fluorosis are well documented and pose a serious health risk to people who consume excess fluoride. In order to understand whether fluorosis was being given importance as a public health problem by elected politicians, we analyzed parliamentary questions posed in both the houses of the Indian parliament during the question hour. Thematic analysis revealed three major themes, namely health hazards, fluorosis control, and magnitude of fluorosis. The analysis revealed that politicians have posed questions regarding all the aspects that are necessary for fluorosis control in India. However, we have identified the certain key issues which have to be improved and certain obligations that the Government of India has to fulfill for successful fluorosis mitigation in India.

Keywords: Fluorosis, politics, public health, skeletal fluorosis


How to cite this article:
Aurlene N, Aravinth V, Balan I N, Kote S. Expounding on the concerns of indian politicians regarding fluorosis: A qualitative analysis of parliamentary questions on fluorosis over two decades. Indian J Public Health 2021;65:57-9

How to cite this URL:
Aurlene N, Aravinth V, Balan I N, Kote S. Expounding on the concerns of indian politicians regarding fluorosis: A qualitative analysis of parliamentary questions on fluorosis over two decades. Indian J Public Health [serial online] 2021 [cited 2021 Apr 13];65:57-9. Available from: https://www.ijph.in/text.asp?2021/65/1/57/311509




   Introduction Top


Fluorosis is considered a major public health problem in India with 20 states out of 29 being endemic for fluorosis.[1] In the certain endemic areas of India, the prevalence of skeletal fluorosis among inhabitants has been found to be as high as 25%, leading to bone deformities that ultimately lead to disability.[2] The earliest efforts at fluorosis control in India can be traced back to a sub-mission on control of fluorosis under the National Drinking Water Mission introduced in 1986. This mission mainly created awareness on fluorosis as it was a newly identified health problem in the country at the time. Later, the Government of India (GOI) introduced the National Program for the Prevention and Control of Fluorosis (NPPCF) in its 11th 5 years plan during the years of 2008–2009. The strategies of this program are surveillance of fluorosis, capacity building, equipping hospitals with diagnostic facilities for fluorosis, management of fluorosis cases through diet modification, surgeries or rehabilitation, and health education.[3] However, despite control measures being implemented data released by the Integrated Management Information System (IMIS) of the Ministry of Drinking Water and Sanitation in 2014 estimated that 14,133 habitations in India are affected with excess fluoride and 11.7 million people are still at risk for developing fluorosis.[4]

The Indian Parliament is the highest legislative body of the country and is composed of the Lok Sabha or the lower house and the Rajya Sabha or the upper house. A question hour in both houses of the Parliament of India is an hour dedicated to put forward questions to various ministries and is essentially a method of making the government accountable for its actions. These questions are freely accessible through the Rajya Sabha and Lok Sabha's website and provide for a way to track, critique, and review the Government's policies and actions. This novel study uses an inductive thematic analysis approach to qualitatively analyze the context of parliamentary questions posed on fluorosis over two decades in the Indian parliament.

The Rajya Sabha and Lok Sabha's advanced search engine was used to search for questions on fluorosis using the key word “fluoride” between the years of 1999 and 2019. After screening the questions for its relevance to fluorosis, a total of 107 questions were included in the study. The questions were coded into nodes on NVivo 12 software (QSR International Pty Ltd., Version 12, 2018), and a total of 202 nodes were obtained. These nodes were then exported to MS Excel, and the rest of the coding was done manually using Braun and Clarke's phases for thematic analysis.

From the thematic analysis of the parliamentary questions, three main themes with some extent of overlap were identified, namely health hazards, fluorosis control, and magnitude of fluorosis. Sub-themes were defined under these main themes according to the subject of the inquiry, which are represented in [Figure 1]. [Table 1] gives an account of the specific questions that were asked under each theme and sub-theme.
Figure 1: Themes and sub-themes defined from the thematic analysis of parliamentary questions on fluorosis

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Table 1: Examples of questions posed by politicians under each theme and sub-theme

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Any large-scale public health problem requires political will and policies to enact change and bring about a resolution of the problem. Fluorosis is similar in this regard, and hence, this study was done to give insight into the key issues that politicians discussed with regard to fluorosis.

Although some questions under the theme of health hazards revealed a lack of knowledge on the negative effects of excess fluoride, other questions revealed an in-depth understanding of fluorosis. For example, politicians queried about the role of fluoride in sources other than water and their role in contributing to fluorosis. Studies have found that many Indian staple foods have a high content of fluoride and may contribute to fluorosis.[5]

Under fluorosis control, queries on the details of the funds released and utilized for fluorosis control in each state simultaneously addresses the varying needs of funds in each state while also holding each state accountable for utilizing funds appropriately. Queries on establishing Fluorosis Mitigation Centers in India shows awareness and commitment to establishing these centrally funded centers in the country. Queries on surveys undertaken to determine the extent of fluorosis in the country reveals the need to accurately determine the extent of fluorosis problem in the country, as well as to assess the success of fluorosis mitigation efforts. Politicians inquiring about whether the government has customized the diet of people living in fluoride endemic areas reveals the knowledge on diet modification being able to effectively reverse the effects of fluorosis.[6]

The results of the thematic analysis revealed that politicians in India see fluorosis as a public health problem of major importance and that questions are posed on the multiple facets of the problem that presents unique challenges in managing this crippling disease. However, it is seen that despite three decades of control efforts, fluorosis is still a widely prevalent disease in India.

We wish to summarize some of the shortcomings of the NPPCF and to highlight some of the obligations that the GOI has not yet fulfilled in this study. First, there is no reliable and accurate data on how many districts in India are affected with fluorosis. The most recent estimates from the Ministry of Water Resources (2017) states that around 335 districts out of a total of 739 districts are affected with fluorosis and nearly 100 million people in India are at risk for developing fluorosis.[7] This figure is in drastic contrast to the IMIS report (2014) that states 11.7 million people in India are at risk for developing fluorosis.[4] Second, the optimal water fluoride concentration is fixed at a higher level than is needed for India. In 2016, experts from the International Society for Fluoride Research recommended that the optimal water fluoride concentration must be fixed at 0.5 ppm rather than the existing 1 ppm in India.[8] Third, Regional Fluorosis Mitigation and Research Centers which were conceived to serve as a center for research on fluoride and as a hundred bedded care center to treat fluorosis patients exclusively must be established in India. The proposal to set up these centers was put forward in 2012 after members of the Rajya Sabha posed questions on the project.[9] These centers were to be established in two states, namely Nalgonda district in Telangana state and Gandhinagar in Gujarat state. However, no fluorosis mitigation centers have been established to date in India.[10]

The NPPCF requires revamping as a committed national program dedicated to the prevention of fluorosis in the country. Right now fluorosis control and research efforts in India are being led by individual district or State level organizations such as the Fluorosis Mitigation Research and Resource Center in Hubli, Karnataka and District Fluoride Monitoring Center, Nalgonda. The NPPCF must also take an active role in surveying the prevalence of fluorosis in the country and maintain a registry of the number of people and habitations affected with fluoride in each state of the country. Currently, the Ministry of Water Resources or the Ministry of Drinking Water and Sanitation provides the data for fluoride contamination in the country, and there are wide discrepancies between each report that has been published.

The limitations of this study are that the subjective interests of the politicians in asking questions regarding fluorosis cannot be elucidated with this study design. Performing an in-depth interview with the politicians asking the questions was beyond the scope of this study. Asking a question was taken as a proxy for interest in fluorosis in this study when in reality the topic may not be of much interest to the politicians asking questions. However, this is the first study of its kind to the authors' knowledge and provides some insight into the specific issues that decision makers talk about with regard to fluorosis in the Indian parliament. We also hope to provide some visibility to the fluorosis problem that has been plaguing the country for decades and still continues to threaten people's quality of life in India today. Future research in this area may be conducted using in-depth interviews of fluoride activists, politicians, and the people affected with fluorosis to gain even deeper insight into a multifaceted public health problem in India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Fluorosis | National Health Portal of India. Nhp.gov.in. 2016. Available from: https://www.nhp.gov.in/disease/non-communicable-disease/fluorosis. [Last accessed on 2020 Jul 22].  Back to cited text no. 1
    
2.
Nirgude AS, Saiprasad GS, Naik PR, Mohanty S. An epidemiological study on fluorosis in an urban slum area of Nalgonda, Andhra Pradesh, India. Indian J Public Health 2010;54:194-6.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Susheela AK, Toteja GS. Prevention & control of fluorosis & linked disorders: Developments in the 21st Century – Reaching out to patients in the community & hospital settings for recovery. Indian J Med Res 2018;148:539-47.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Eparlib.nic.in. 2014. Available from: https://eparlib.nic.in/bitstream/123456789/655398/1/10293.pdf. [Last accessed on 2020 Jul 22].  Back to cited text no. 4
    
5.
Rao K, Mahajan C. Fluoride content of some common South Indian foods and theircontribution to fluorosis. J Sci Food Agric1990;51:275-9.  Back to cited text no. 5
    
6.
Gupta S, Gupta R, Seth A, Gupta A. Reversal of fluorosis in children. Pediatr Int 1996;38:513-9.  Back to cited text no. 6
    
7.
Crore People Drinking Contaminated Water in India. The Economic Times; 2017. Available from: https://economictimes.indiatimes.com/news/politics-and-nation/10-crore-people-drinking-contaminated-water-in-india/articleshow/62191841.cms. [Last accessed on 2020 Jul 22].  Back to cited text no. 7
    
8.
Fluoride in Water: 'Safe Level of Flouride in Water is 0.5 ppm' | Hyderabad News-Times of India. The Times of India; 2016. Available from: https://timesofindia.indiatimes.com/city/hyderabad/Safe-level-of-flouride-in-water-is-0-5-ppm/articleshow/55381397.cms. [Last accessed on 2020 Jul 22].  Back to cited text no. 8
    
9.
Fluoride Mitigation Centre to be Set up in Gandhinagar | Ahmedabad News-Times of India. The Times of India; 2012. Available from: https://timesofindia.indiatimes.com/city/ahmedabad/Fluoride-Mitigation-Centre-to-be-set-up-in-Gandhinagar/articleshow/13539890.cms. [Last accessed on 2020 Jul 22].  Back to cited text no. 9
    
10.
Reddy K. Fluoride Mitigation Centre in Cold Storage. The Hindu; 2014. Available from: https://www.thehindu.com/news/national/telangana/fluoride-mitigation-centre-in-cold-storage/article6234590.ece. [Last accessed on 2020 Jul 22].  Back to cited text no. 10
    


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