This article addresses Fluorosis and linked disorders, a public health problem prevalent in India over 8 decades [1]. Activation of activities by the state health departments for its mitigation are of importance.  Although investments made in  basic and applied researches and the wealth of information that India has, no other nation can claim to possess.  The enormity of the health problem and patient material availability for research attracted 

the scientific community from diverse disciplines to investigate the issues [2-7].  A multidisciplinary approach essentially required to understand the activities of fluoride causing Fluorosis and linked disorders. Water supply engineers played a prominent role for decades.  Besides water, fluoride entry is through food adulterated with calcium fluoride (CaF₂) with 157 ppm fluoride [8], as a spice to enhance aroma and taste of food.  It is added to pickles and snacks.  Rock salt lead to addiction and the issue seldom discussed.  Rock salt is added to fresh lime water and served as a beverage.  In urban settings, refrigerated water sold near bus stops, petrol stations and offices display lime, sugar and rock salt on the cart and a glass of fluoridated water is sold for Rs.2 – 3 / glass. The common public is unaware rock salt has high F‾ and it is a poison. Fluoride is also consumed through chewing tobacco, aracnut, as these are rich in fluoride content [9,10]. ‘Churans’ with high rock salt sold is labelled, indicating rock salt added.  The supermarkets are loaded with masala powder for pav bhaji, chana, rajma and a variety of other dishes.  The ingredients added are indicated on the packet which include black and white salts.  The white salt is the iodized salt recommended for use.

The public and the patients of Fluorosis should be alerted to avoid  consuming snacks with rock salt and not used in cooking [11]. During the present times, the disease has become more complex to understand. The conventional Dental, Skeletal and Non-skeletal forms of Fluorosis were easily identifiable [12].  The fact remains fluoride being a highly reactive, electronegative element has other bio-chemical characteristics;  it is an enzyme inhibitor, hormone disruptor and neurotoxin [13-16], and when the level of fluoride in circulation get higher, diseases surface in various organs and systems, which the health professionals never anticipated.  The fluoride linked disorders, which need to be detected through  tests focussing on fluoride levels in serum, urine and drinking water.  It is also mandatory to get an X-ray radiograph, preferably of the fore-arm when the calcification of interosseus membrane is visible at the earliest onset [12]. The complexity of the disease(s) is addressed through a novel approach.  The aim of this communication is to ensure the activities for mitigation through a novel approach is activated.

The study was conducted in a highly endemic state of Rajasthan.  The human resource in a sample of 5 Teaching Hospitals and 6 district Hospitals in the state were chosen for knowledge upgradation.  Fig.1 shows the locations of the 2 different kind of institutions chosen.

A doctor in a health delivery outlet, whether a Teaching Hospital or a  District Hospital is unaware how to suspect the disease through health complaints unless it is at the very advanced stage when the patient has scoliosis, kyphosis and disability in walking .  Unaware of the metabolic disorders linked to Fluorosis.  Unaware of the diagnostic protocol.  Unaware of the simplest procedure to control and prevent the disease(s). These are honest hard facts.  Attention was not paid to mitigate Fluorosis except for supporting water supply agencies for provision of safe water.  Those who consume safe water may also become victims of Fluorosis as a result of consuming fluoride from other sources.  This article is based on the facts listed above and through a novel approach of interacting and probing the reasons.

Rajasthan state was chosen as it is one of the most severely endemic states for Fluorosis in India.  All the 33 districts affected [17-20].  The Public Health Engineering Departments are well informed of the hardware  aspects as well as water treatment. But the aim of the project was  to activate the programme in the state for the mitigation of Fluorosis and linked disorders where the doctors have a vital role to play [11].

The project is structured differently from the earlier formats. The doctors, were addressed through medical education programmes in 5 Teaching Hospitals located in 5 districts, ie., Ajmer, Bikaner, Jodhpur, Jaipur and Udaipur.  Besides, the doctors posted in 6 District Hospitals in Ajmer, Jodhpur, Jaipur I, Jaipur II, Udaipur and Tonk were also addressed.  Each district has 6 taluks (blocks). Doctors are deployed in district Hospitals in Comminuty Health Centres (CHCs), Primary Health Centres (PHCs) and Urban dispensaries.  The Sub-centres have no doctors; but grass-root level functionaries ie. Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives (ANMs) posted.  The project is brought under one umbrella, the manpower ie., doctors and paramedicals, updated.  This approach was adopted for the first time in India.  The Teaching Hospital doctors are under the jurisdiction of the Principal and District Hospital doctors under the Chief Medical and Health Officer (CMnHO). All the 5 Principals and 6 CMnHOs attended the programme, besides their doctors.

Medical Education programme for Doctors in Teaching Hospitals:

The target audiences were ●Principal, ●Head of Department, ●Senior Grade Professors of Pre, Para and Clinical Departments of  5 medical colleges. Each medical education (ME) session lasted for a 3 hour duration and dealt with all aspects of fluoride poisoning and Fluorosis,  The effects of F‾ on cacellous and cortical bones are   distinctly different and revealed.  The  pathogenesis in soft  tissues viz. the musculature, red blood cells, spermatozoa were dealt with.  It was also of interest to the participants, how the gastro-intestinal system was severely damaged due to the environmental    toxin fluoride. The affliction was traced to the sub-cellular levels and also corroborated with biochemical abnormalities.  The diagnostic procedure  for Fluorosis,  differential diagnosis required when overlapping clinical manifestations were observed with other health problems.  It was a rewarding experience for the doctors to know the recovery from the disease in a shorter time span through practice of interventions when the disease detected early.

Medical Education (ME) on Fluorosis and linked disorders for other Faculty members and Junior Doctors in teaching hospitals were also held in separate sessions during a second round of deliberations. This was the first time such an indepth sharing of information on Fluorosis took place citing case studies. Doctors recorded that it was the first time during several years in their service they learnt and understood the complex nature of the disease and severity of the problem which was addressed, through scientific means and recovery assured to the victims. The attendance sheets with the details and their speciality, research interest, if any, contact details obtained from the doctors, a record for their participation in the MEs. Doctors were informed to write their views on the ME any suggestion they wish to offer in terms of the gain from the ME, suggestions to improve the presentation if any and finally they grade the ME; and return the sheets to the organizers of the ME. These were evaluated for assessing the impact of the ME

Medical Education programme for Doctors in District Hospitals.

Doctors from each district comprising of 6 blocks from 6 districts, were updated.  Each block is looked after by a  Block-Chief Medical Officer (BCMO). Those sessions unlike in teaching hospitals, were held as a part of a monthly review meetings held by Chief Medical and Health Officers (CMnHOs). Conducting ME with the monthly review meetinghad its merits and demerits.  Besides doctors, accountants, administrators and others who look after district hospital activities were attending the meetings. The information shared had wider circulation among the non-medical section of the employees of the district hospital.  But the number of doctors were limited.  The CMnHOs co-ordinated and  the discussions were focused on the budget; directed to expedite payment of bills and submit accounts.  Views on medical aspects were on maternal and infant death and vaccination schedule, any epidemic disease in the district. But fluoride and Fluorosis was seldom discussed.  The expert team was able to gather information and understood why Fluorosis disease do not get attended to and why mitigation of the disease is not taking place. Fluorosis disease  was alien to the health professionals in the districts where the programmes were executed. 

 Sensitization for Para-medicals (ANMs &ASHAs)

Auxiliary nurse midwives (ANMs) and their Supervisors, Accredited Social Health Activists (ASHAs) and their Supervisors were included in the sensitization workshops as they are a part of the health system. Besides they were conveyed what they would communicate to the village community during home visits was dealt with as the most important issue.  Those procedures were necessary to reach out to the individuals due to varying ailments they were likely to attend Outpatient Departments in the teaching hospitals or in CHCs, PHCs and/or Dispensaries.  They ought to know  how F‾ poisoning through water and food  seriously affect their well-being. The Paramedical functionaries were informed to write down their details in the attendance sheet. They were evaluated for their understanding of fluoride and Fluorosis disease, through the answers provided in the  precoded pre and post training questionnaires. The questions in pre and post training questionnaires were different. But would provide a reasonably good idea of the disease and information need to be conveyed to the village community.

The medical education sessions, discussions followed, led to the understanding of 3 major issues, that in the state ●Fluorosis Diagnostic Facility in teaching hospitals was non-existing, ●Libraries were devoid of literature on Fluorosis, ●The ME and associated activities had a significant impact as it was a novel approach.

Fluorosis Diagnostic Facility

Fluorosis Diagnostic facility was non-existent in the state, either in the government or private hospitals. As a result, patients having joint pain were considered  and treated for  Arthritis.  Fluorosis, was seldom considered as a possibility;  joint pain is the common health complaint of the two diseases though  have distinctly different etiology and pathogenesis. Arthritis affected small and large joints and formed inflammatory reactions. Whereas Fluorosis affects only the major joints and no overtly visible inflammatory reaction. The disease without confirming were treated by pain killers. It is considered unethical to treat patients with pain killers without correct diagnosis. Such treatment led to kidney failure [21-23], aggravating the agony of the patient(s) and their families. The Doctors were unaware of the linkage of Fluorosis with other metabolic disorders was amply evident.

Medical Books on Fluorosis

A list of important books on Fluorosis was provided to the Principals to procure for  the medical colleges for the central and departmental libraries. This is the basic minimum requirement to introduce Fluorosis to the medical and dental fraternity. Unawareness of the disease looms large among the faculty of the medical colleges in the state and the community therefore were paying a heavy price for it. 

Teaching of Fluorosis

In a medical college, besides Community Medicine all other disciplines viz. Medicine, Paediatrics, OBGY, Surgery, Anaesthesiology and some of the Super Specialities Viz. Cardiology, Gastroenterology, Endocrinology and  Neurology are required to teach the undergraduates,  interns and residents as the diseases emerge due to F‾ toxin. The disease ought to get into the main stream medical education and patient care services. As F¯ is a ●neurotoxin, ●hormone disrupter and an ●enzyme inhibitor,[6-16] upon ingestion of fluoride,  health issues surface which may fall under any of the disciplines mentioned above and doctors seldom suspect fluoride poisoning as the cause of the ailment.  This is also to record all anaesthetic agents are with fluorine gas and special care to be taken in operation theatres (OTs) to prevent gas emission and inhalation; special masks to be worn by all personnel in OTs including the technicians and nurses.  A study reported in Anaesthesiology as early as 1968[24], revealed that in the US, over a period of 20 years, the cause of death of Anaesthesiologists ascertained was due to renal failure.^.  Fluoride ingestion for a prolonged period either through ingestion or inhalation has disastrous consequences [25,26].

Impact of Medical Education

Following the conduct of ME for the doctors, there was extensive discussions.  There was considerable excitement among the doctors for the knowledge gained. Participants were not knowing rock salt (CaF₂ ) having high fluoride  was detrimental to  health.  Many ideas about research  were discussed;  to the  extent possible. Many of the doctors had health issues among 

their family members who were non-responding to prescribed drug. This was explained as gastrointestinal mucosa lost microvilli due to fluoride poisoning led to non-absorption of drugs orally administered. If the drug was administered through intramuscular / intravenous route, desired results would be achieved. The agonizing experiences of Fluorosis afflicted victims were discussed. The doctors were disappointed that the hospital authorities have not developed infrastructure for Fluorosis diagnosis.

Details of medical education 

The total number of 222 doctors  updated on Fluorosis and Linked disorders in the 5 medical college hospitals, the decisions arrived at and requirements specified, reported in Table 1. 

Table 1: Shows the details of the Medical Education (ME) programmes conducted in the 5 Teaching Hospitals, with the total number of participants attended.

Doctors trained 281 in the 6 district hospitals of Rajasthan block-wise reported in Table 2. 

Table: 2: Human Resource Developed through conducting Medical Education (ME) programms for Doctors of 6 District Hospitals functioning under Chief Medical and Health Officers (CMnHOs).

The blocks from where doctors did not attend the ME sessions were also indicated. It was a new experience for the CMnHOs, to attend a ME with practical information in such great detail imparted for patient care services. 

Total number of 503 doctors attended the MEs on Fluorosis and Linked disorders from the 5 teaching hospitals and 6 district hospitals in the state. The views expressed in writing by  doctors randomly chosen from 5%, reproduced in Table 3.

Table 3: The views expressed and recorded by the Doctors;  a sample of 25 from the 12 MEs conducted in the 5 Medical Colleges and 6 District Hospitals reproduced below. 

The views recorded are from 5% doctors randomly chosen from the sheets with their views, were returned to the Organizers. The doctors, a high %  graded the CME “Excellent

The language and expressions of the doctors retained, so that the excitement and inspiration of the doctors who were  a part of the activities and how they propose to apply the knowledge gained specified.

Paramedical Functionaries and the sensitization workshop

The Paramedical functionaries 568 attended the workshops. The contents of the training programme indicated in Table 4a. 

Table: 4a: Attendance in the sensitization workshops conducted for *Paramedical workers – ANMs, ASHAs and their Supervisors. 

The number of different categories of the field functionaries attended the workshop  shown in Table 4b. 

Table: 4b: Paramedical functionaries attended the workshop in the 6 districts, the information compiled from the attendance sheets.  Though designation was specified to be indicated, overlooked by some.

ANM - Auxiliary Nurse Midwife;     ASHA - Accredited Social Health Activist

The paramedical personnel were equally excited to learn such a lot in a day which has relevance to their daily life and activities in the “Rasoi” would lead to good health of the members of the family.  Fluorosis mitigation activities in a state to achieve success, all the paramedical functionaries  should attend the workshop; block-wise information required who attended the awareness generation workshops held by the  experts.

Inadequacies in the organization of the MEs

It came to light that hundreds of doctors and paramedical functionaries  were not informed to attend  the MEs or the workshops. Therefore yet another activity was undertaken, to assess the actual number of personnel which include doctors and other staff working in the different blocks of a district.  Assessment was made in one district Ajmer and results are reported in Table 5. 

Table 5 shows the number of health delivery outlets in Ajmer district in all the 8 blocks and manpower existing.

The 8 Blocks in Ajmer district are : ● Shrinagar, ● Bhinai,  ● Arain, ● Kishangarh, ● Jawana, ● Masuda, ● Kekri, ● Pisanganj

*MOs – Medical Officers , NS – Nursing Staff

ANM - Auxiliary Nurse Midwife;     ASHA - Accredited Social Health Activist

No ASHAs in CHCs, PHCs. They are only in Sub-centres and Urban dispensaries.

Considering the total number of manpower existing and those underwent training, it was evident that only a small percentage attended the workshops Table 6. 

Table 6 : Total number of Doctors and others underwent training in Ajmer District against the existing Human Resource 

The remaining doctors in the District  would essentially require ME on Fluorosis by the Experts

To organize, finalize the date(s) and inform the Experts would  be the responsibility of the CMnHOs / BCMOs of the districts.

There are large number of personnel  with “No knowledge of  Fluorosis” require update to achieve the best output for Fluorosis mitigation.  During initial discussions with CMnHO for organizing MEs and sensitization workshops, the information on the total human resource existing in the district(s) need update was not made available; possibly due to underestimation of the importance of addressing the disease. The CMnHOs were also totally unaware of the usefulness of the MEs & sensitization workshops. To ensure all ANMs and ASHAs attend to the experts on the subject, would also  require  additional sessions.  It is only then, the desired goals would be 

achieved. The information provided would be helpful to plan and execute the activities in a district effectively. Such efforts would lay down a firm foundation to address the disease, block by block, district by district in a state. Those activities are  absolutely   necessary. The  alternate  suggestion offered  by  the CMnHOs was that the trained Doctors would train the remaining doctors and paramedical functionaries.  The concept was based on “Training of the Trainers”. The doctors updated became trainers. Considering the complexity of Fluorosis, the neglect faced for decades, the experts were of the view that training by trained trainers may be considered at a later date. It was too early to hand over such a responsibility to the existing trained human resource, who had exposure for a few hours only. When they acquire adequate exposure to the disease, develop infrastructure for training,  then only such  a system would yield beneficial results.

Reaching out to village community

This is to record that paramedical functionaries were sensitized and informed their responsibilities for disseminating the essential information among the village communities.  The most important information to convey is that  ● every family should know the fluoride content in the drinking and cooking water by getting a sample from the source (half a cup of water in a plastic bottle) tested from PHED Lab in the district using Ion meter.  In safe water, ●F‾ would be <1.0 mg / L, ● fluoride is a poison and should not be consumed if  it was > 1.0 mg/L, ● high fluoride 157 ppm is present in rock salt (kala namak) sold on wayside on carts in Rajasthan; community should not procure, for themselves or for  their cattle, ●Pregnant women should not consume food items containing rock salt as it will cause anaemia and damage to the foetus leading to maternal and infant mortality, ● fluoride is present in many food items; which include achar, masala, habit forming substances like chewing tobacco, supari, churans, use of fluoridated mouth rinse, toothpaste etc. ● change in dietary regime  lead to recovery from Fluorosis and linked disorders in a short span of time.  Drugs are not required for treating Fluorosis.  It is the observation, antioxidants from fruits and vegetables are more effective [27] compared to commercially available antioxidant tablets. Those ought to be avoided from prescribing to the patients. 

Impact of sensitizing paramedicals

The training imparted to the paramedical functionaries particularly the ASHAs and ANMs an important entity is rather difficult to evaluate for its impact or usefulness served. The Rajasthan experience led the sensitization workshop evaluation based on the answers obtained from pre and post training questionnaires. The questionnaires were structured in such a manner, aimed to get the best out of the field functionaries. The results obtained, i.e. the number of functionaries participated, and their correct responses  projected in Figure 2. 

*In Jaipur I, although 92 attended only 80 submitted the filled questionnaires

†In Jaipur II, although 96 attended only 94 submitted the filled questionnaires.

‡In Jodhpur and Tonk, the attendance was 109 and 92 respectively, the filled answer sheets recovered are 90 in    both districts.

The results obtained have been analysed statistically by STATA 14.0 software. The results indicate that the knowledge gained is highly relevant for the functionaries to communicate and convey important messages to the  village community. They can convey correct massages on all aspects of fluoride and Fluorosis disease, for its prevention and control in the state. ASHAs and ANMs have the important role to play and should be encouraged. In Fluorosis mitigation activities, their active participation would only yield beneficial results. The impact of the sensitization workshops  for the paramedical functionaries assessed through their knowledge before and after attending the workshop through pre and post training questionnaires and the results obtained  highly significant at p value < 0.0001, Table 7. 

Table 7: Paired Samples t-tests comparing pre & post training evaluation scores of the candidates and it is out of 10.

The data was analyzed by STATA 14.0 software. Scores are reported in terms of Mean ± Standard Deviation (SD) and paired ‘t’ test was used to compare the change in scores before and after the training program. The p value <0.0001 is considered highly significant.

The activities for mitigation of  Fluorosis and linked disorders carried in Rajasthan state the achievements in obtaining the hidden facts  have been substantial and the existing limitations in the system reported. The information imparted to doctors and paramedical functionaries were with a view that it should have lasting effect and Fluorosis mitigation programmes in the state;  should set an example for other endemic states to follow in the nation. 

Reasons for failure in Fluorosis mitigation in the past :

It is now evident that the innumerable MEs held in various endemic states across the length and breadth of the nation  over decades sponsored by UNICEF, WHO and other national agencies, did yield the beneficial results, but 100% doctors were not trained.  Introducing the system ie., Training by trained doctors, did not yield the benefits. ASHAs and ANMs were not sensitized.  These are revelations surfaced from the state project implementation. Lessons learned  are activities required to be activated.  The views of the doctors on the MEs reported in Table 3, is the testimony.  Fluorosis mitigation activities can be speeded up to reach out to the community for availing benefits to lead a healthier and better life, provided there is integration of activities.

Inter-departmental collaboration :

It is considered necessary that inter-departmental collaboration would lead to better results.  The Ministries dealing with education, health and water supply focus on provision of safe drinking water and sanitation should participate in the programme. School teachers from education department of the state should be inducted so that the health of the students and teachers improve.  Rock salt adultered masalas for cooking mid-day meal should be banned.  The only salt for use is the white iodized salt, which are  required to improve the health of the children and correct iodine deficiency disorders [5].

School children :

To involve schools so that every school should have safe water (F‾ <1.0 mg / L ) for drinking and mid-day meal  preparation.  The above is to benefit the children, raise hemoglobin and correct anaemia.[6]  The parents when attended the Parent-Teachers meetings were informed to improve diet through diet editing and improved nutrients. This was adequate to correct anaemia and raise Hb upto 14.50 g / dL[28].  Weekly Iron & Folic acid supplementation (WIFS) introduced since 2012 to rectify anaemia did not yield beneficial results as children were consuming high fluoride containing food and water. 

Doctors 

The state health department should involve doctors as there was a need, for updating the medical fraternity on the harmful effects of fluoride consumption through a variety of sources. Fluorosis Linked Disorders, viz., •anaemia, • maternal & infant and new born mortality, • pre-term delivery; hypertension • extreme weakness • gastro-intestinal problems, • kidney failure, • neurological disorders are now surfacing due to fluoride poisoning.  The doctors are unaware of these aspects of fluoride poisoning.

 ASHAs and ANMs are required to spread the message, the importance of consumption of safe water (F‾ <1.0 mg / L) and safe food to prevent Fluorosis and linked disorders  in every household.  Upon fixing a tap and providing safe water in  households, the water supply engineers would no longer attend to community requirement.  It is the ASHAs and ANMs, who ensure every household consume safe water for drinking & cooking as there is a need to improve the health of the members of the family.

The above when  get implemented, the nation would achieve health improvement in the social sector, through integrating activities through the available manpower in different sectors. Presently information  not reaching out to the community specifically in the lower socio-economic strata of the society.  There is a need for school teachers and ANMs and ASHAs to get involved in the national programme of great significance.

Reduction / elimination of Fluoride intake

The Slogan on “Radio, TV, Print Media”, ●Hypertension mukth Bharat, ●Anaemia mukth Bharat,  shall be achieved only when F‾ intake  is reduced to normal range in blood and urine of every individual. Infrastructure to test blood serum and urine for  fluoride to be developed in all  teaching and district hospitals across the country. 

Strengths and weaknesses 

This communication highlighting the strengths and weaknesses  in addressing Fluorosis mitigation in India. The strength is highlighting the extensive researches carried out on the disease and voluminous literature  on all aspects  of the disease available in India for projects on Fluorosis for implementation.  In spite of this major strength, why the concerned state government officials are inactive in endemic states?  The major weaknesses may be responsible for it.

The weaknesses in state departments as evident from Rajasthan state are listed:  ● The Directors of medical education and health services have not incorporated teaching of Fluorosis and patient care services in state medical colleges. ●The medical students, interns and residents are not taught  the disease in detail like other diseases in their formative years of medical education.  ●Therefore, the doctors in service in different avenues are unaware how to address the disease.  It is the doctors, who advise bureaucrats and policy decisions are made. When the bureaucrats are ill-informed of the ground realities, implications of the disease,  no decisions are taken. This is what is happening in present times.  ●There is no infrastructure in hospitals to diagnose Fluorosis disease.  ●Patients visiting OPDs whether teaching hospitals or district hospitals get a raw deal, treated with drugs uncalled for, aggravating the disease.  ● Patients of Fluorosis do not recover, the condition get worsened, get crippled and paralyzed.  ●When funds are made available for medical education on Fluorosis, it becomes the area of low priority and not conducted well. 

The unawareness of health administrators in the state is appalling.  The lethargy and unconcerned attitude towards the disease is glaring. The medical officers with a basic medical degree are important functionaries in the health system and with “0” knowledge  what can be expected from such personnel.  In a district 100%  doctors ought to attend the MEs, great relief would then gained by the patients. There should be follow-up with  proper guidelines.  The disease therefore remained as a chronic health problem, can be easily rectified.The Paramedical workers are  a very useful work force are yet to be inducted into the programme  as late as 2020.   If the state health department take the lead, it would begin to move in the right direction.   

In conclusion, the project activities carried out,  provided insight into conditions prevailing and what can be done to rectify the issues. Fluorosis mitigation activities in a state shall yield successful outcome, when the following are taken into consideration.  ●The district manpower available from all blocks, should get updated. ●Support facilities to be established viz. diagnostic facility, books to be made available in libraries.  ●The “Training of Trainers” programme to be held in abeyance.  ●The information for paramedicals to convey to village community should be on their finger tips.  Every doctor in a health delivery outlet should be answerable for mitigation of the disease.   It is the firm belief that the vast array of important issues neglected for a long time and absolute unfamiliarity of Fluorosis mitigation procedures among the existing manpower have contributed to the problem.  When positive steps taken at the right time would yield beneficial and long lasting effects in the country.  A recent article addressing anaemia in pregnancy and school children through a field tested novel strategy by the author to alert senior medical consultants, who function as advisors to the government was contributed [29].  The British medical journal, The Lancet, recently reported on “Fluorosis, an on-going challenge for India”, which highlights on water fluoride, food fluoride through rock salt.  It is stated corrections are required for settling issues right [30].

Acknowledgements: It is gratefully acknowledged the grants-in-aid provided by the Government of India, Ministry of Health and Family Welfare, Department of Health Research through the Indian Council of Medical Research. The assistance of Dr. G.S. Toteja, Senior Deputy Director-General and Incharge, ICMR Task Force on Fluorosis, is acknowledged.  The criticism and comments of the Chairman, Fluorosis Task Force, was indeed useful for the investigators dwell deep into the issues in the field.  The team acknowledge  the guidance and assistance provided by Prof. R.M. Pandey, Head, Department of Biostatistics, All India Institute of  Medical Sciences, New Delhi, for evaluating the data by statistical tools. Dr.Jitender Harchandani, Consultant of National Programme on Prevention and Control of Fluorosis (NPPCF) posted in Ajmer acknowledged for assisting in taking stock of  the existing Human Resource  available in all the blocks in Ajmer district. Ms. Shanta Nair of the Foundation is acknowledged for her inputs in the preparation of the manuscript.

The authors declare that they have no conflict of interest

No funding sources

The study was approved by the Saudi Electronic University

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28. Susheela et al. "Anemia in Adolescent Girls: An Intervention of Diet Editing and Diet Counseling." Natl. Med. J. India 29.4 (2016): 200-204.

29. Susheela and Kumari. "Addressing Anemia in Pregnancy and School Children Through a Field Tested Novel Strategy." Ann. Natl. Acad. Med. Sci. (India) (2020). https://doi.org/10.1055/s-0040-1710161.

30. Del Bello. "Fluorosis, an Ongoing Challenge for India." The Lancet Planetary Health 4.3 (2020): e94-e95. Published by Elsevier Ltd. Open Access article under the CC BY 4.0 license.

The unawareness of health administrators in the state is appalling.  The lethargy and unconcerned attitude towards the disease is glaring. The medical officers with a basic medical degree are important functionaries in the health system and with “0” knowledge  what can be expected from such personnel.  In a district 100%  doctors ought to attend the MEs, great relief would then gained by the patients. There should be follow-up with  proper guidelines.  The disease therefore remained as a chronic health problem, can be easily rectified.The Paramedical workers are  a very useful work force are yet to be inducted into the programme  as late as 2020.   If the state health department take the lead, it would begin to move in the right direction.   

In conclusion, the project activities carried out,  provided insight into conditions prevailing and what can be done to rectify the issues. Fluorosis mitigation activities in a state shall yield successful outcome, when the following are taken into consideration.  ●The district manpower available from all blocks, should get updated. ●Support facilities to be established viz. diagnostic facility, books to be made available in libraries.  ●The “Training of Trainers” programme to be held in abeyance.  ●The information for paramedicals to convey to village community should be on their finger tips.  Every doctor in a health delivery outlet should be answerable for mitigation of the disease.   It is the firm belief that the vast array of important issues neglected for a long time and absolute unfamiliarity of Fluorosis mitigation procedures among the existing manpower have contributed to the problem.  When positive steps taken at the right time would yield beneficial and long lasting effects in the country.  A recent article addressing anaemia in pregnancy and school children through a field tested novel strategy by the author to alert senior medical consultants, who function as advisors to the government was contributed [29].  The British medical journal, The Lancet, recently reported on “Fluorosis, an on-going challenge for India”, which highlights on water fluoride, food fluoride through rock salt.  It is stated corrections are required for settling issues right [30].

Acknowledgements: It is gratefully acknowledged the grants-in-aid provided by the Government of India, Ministry of Health and Family Welfare, Department of Health Research through the Indian Council of Medical Research. The assistance of Dr. G.S. Toteja, Senior Deputy Director-General and Incharge, ICMR Task Force on Fluorosis, is acknowledged.  The criticism and comments of the Chairman, Fluorosis Task Force, was indeed useful for the investigators dwell deep into the issues in the field.  The team acknowledge  the guidance and assistance provided by Prof. R.M. Pandey, Head, Department of Biostatistics, All India Institute of  Medical Sciences, New Delhi, for evaluating the data by statistical tools. Dr.Jitender Harchandani, Consultant of National Programme on Prevention and Control of Fluorosis (NPPCF) posted in Ajmer acknowledged for assisting in taking stock of  the existing Human Resource  available in all the blocks in Ajmer district. Ms. Shanta Nair of the Foundation is acknowledged for her inputs in the preparation of the manuscript.

The authors declare that they have no conflict of interest

No funding sources

The study was approved by the Saudi Electronic University

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30. Del Bello. "Fluorosis, an Ongoing Challenge for India." The Lancet Planetary Health 4.3 (2020): e94-e95. Published by Elsevier Ltd. Open Access article under the CC BY 4.0 license.