Science Society Health Policy The National Iodine Deficiency

Science, Society & Health Policy The National Iodine Deficiency Disorders Control Program (NIDDCP) Dr. Chandrakant S Pandav Dr. Denish Moorthy Prof. M G Karmarkar Clinical Epidemiology Unit All India Institute of Medical Sciences November 20 th 2001 AIIMS, New Delhi

Outline of Presentation 1) Iterative Loop: Research – Policy Programme 2) World In Which Policies Were Being Made 3) World In Which Policies Should Be Made – A Case Study of NIDDCP 1) Lessons Learnt From the NIDDCP 2) In Summary…

ITERATIVE LOOP Research, Policy, Programme POLICY RESEARCH PROGRAMME

Clinical Policy and Public Policy Relationship between Clinical Epidemiology & Public Policy Basic (Bench) Research – Uncovers Promising Intervention Clinical Epidemiology – Assesses Efficacy & Effectiveness Economic Evaluation – Assesses Efficiency Health Policy – Assesses Implementation Clinical Policy E. g. Deep vein thrombosis On an inpatient Vs. outpatient basis Public Policy Evaluation of the use of research findings & determinants of that use

The World In Which Policies Were Being Made 1) Health Problem/Issue 2) Information 3) Institutional structure for decision making 4) POLICIES

World In Which Policies Should Be Made 1) Health Problem/Issue 2) Information 3) Values 4) Institutional structure for decision making 5) POLICIES

World In Which Policies Should Be Made 2) Information Evidence Data Researchers & Universities Advocacy Media KNOWLEDGE

World In Which Policies Should Be Made 3) Values CORE VALUES Ideologies BELIEFS Casual Assumptions INTERESTS

World In Which Policies Should Be Made 4) INSTITUTIONAL STRUCTURE FOR DECISION MAKING FORMAL STRUCTURE Legislature Executive Bureaucracy Judiciary INFORMAL STRUCTURE Networks Coalition Stakeholders Citizens

World In Which Policies Should Be Made The National Iodine Deficiency Disorders Control Program (NIDDCP) 1) Health Problem/Issue 2) Information 3) 4) Institutional structure for decision making 5) POLICIES Values

From Information to Knowledge

World In Which Policies Were Being Made Information Evidence - Large no. of studies Data - Disaggregated and aggregated data Research - Evidence based Community & Lab studies Researchers & Universities – Epidemiologists, Public Health Specialists, Scientists & Nutritionists Advocates - Scientists Media - Print & Electronic KNOWLEDGE

Legacy of The Legend Science & Society [ Prof. V. Ramalingaswami 8 August 1921 – 28 May 2001

Prof. Madhu G Karmarkar, Former Prof. & Head, Department of Laboratory Medicine, AIIMS, who has been intimately associated with Prof. Ramalingaswami’s Kangra Valley Study and events thereafter to take us through the study

Genesis of National Programme - 1 The Kangra Valley Project (1956 -1972) Ø Study design : Community based prospective controlled trial Ø Study area : Kangra Valley , Himachal Pradesh Divided into 3 zones –A , B , C Ø Study period : 1956 - 1972 Ø Study Duration : 16 years ØStudy population : 1, 000

Kangra

Kangra Valley Study Area Dharamsala From Pathankot Zone – B PLAIN SALT Zone – A KI SALT To Kulu Zone – C KIO 3 SALT

Genesis of National Programme - 2 The Kangra Valley Project (1956 -1972) Ø Study Population : School Age Children (SAC) ØIntervention : TECHNICAL 1. Baseline survey in 1956. 2. Salt* distributed to the 3 zones Zone A – Potassium iodide Zone B – Unfortified salt Zone C – Potassium iodate 3. 15 gms of salt/person/day 4. So as to ensure 200 mg of Iodine *Salt Produced at Sambhar Lake with UNICEF Assistance

Genesis of National Programme - 3 The Kangra Valley Project (1956 -1972) ØIntervention : ADMINISTRATIVE Ø Price parity Ø Legislation Ø Govt. shops Ø Outcome variable: Goitre prevalence among school age children

Genesis of National Programme – 4 INTERVENTION

Genesis of National Programme – 5 INTERVENTION

Genesis of National Programme – 6 INTERVENTION

The Kangra Valley Project (1956 -1972) Conclusions Iodine supplementation in the form of adequately iodised salt on a regular and continuous basis reduces goitre prevalence Recommendations Ø Establish a National Goitre Control Programme

Scenario after Kangra Valley Project Second Five Year Plan (1962) National Goitre Control Programme (NGCP) launched Aims : 1) Initial survey to identify endemic areas 2) Production & Supply of iodised salt to endemic areas 3) Impact assessment surveys after five years Approach : Endemic district specific salt iodisation

Dr. Chandrakant S Pandav, Member, Clinical Epidemiology Unit, & Addl. Prof. , Centre for Community Medicine AIIMS, who has been intimately associated with Prof. Ramalingaswami’s work since 1978 to take us through the events thereafter

NGCP Activities (1962 -1983) Total No. of Salt iodisation plants (UNICEF assistance) : 12 Location: : 5 : 3 : 4 Rajasthan Gujarat West Bengal Estimated need/year : 1. 00 million tons (100%) Production Capacity / year : 0. 38 million tons ( 38%) Actual production / year : 0. 15 million tons ( 15%) Goitre = No pain = Not a cause of mortality = = Cosmetic Problem = Low priority program

The World In Which Policies Were Being Made 1) Health Problem/Issue 2) Information 3) Institutional structure for decision making 4) POLICIES

New scientific evidence : 1962 – 1983 1. Neonatal Hypothyroidism program – A pilot study Use of the primary health care setup to determine the incidence of neonatal hypothyroidism & Initiate treatment 1. Gradual shift of focus from endemic goitre to iodine & brain development Studies on iodine deficiency & IQ (13. 5 points) & learning skills in school children from iodine deficient & sufficient areas

New epidemiological evidence: 1962 -1983 • Delhi study : Endemic Goitre in Delhi, 1980 • Extra Himalayan foci of IDD reported • 1984 – 86 : ICMR multicentric study 14 districts in 9 states Goitre Prevalence : 21. 1% Endemic cretinism: 0. 7% No state or union territory is free from Iodine Deficiency Disorders as a public health problem

World In Which Policies Should Be Made Institutional Structure For Decision Making Efforts Since 1980 s FORMAL STRUCTURE Executive - Law making decisions Legislature - Political support Bureaucracy - Policy decisions INFORMAL STRUCTURE Networks - NGOs, Health care providers, public health experts Coalition - Partnership of educationists & communication experts Stakeholders - Salt industry, salt regulators Citizens - Consumers

The Turning Point of The Programme: 1983 Meeting With The Prime Minister of India: Mrs. Indira Gandhi Questions asked by Mrs. Indira Gandhi: • What is Iodine Deficiency? • Why should I be Interested in National Goitre Control Programme (NGCP)? • How is it going to contribute towards Prime Minister’s 20 Point Programme?

Iodine Deficiency – A Disease of The Soil Effect on people : HUMANS Health & Socioeconomic impact Effect on animals : LIVESTOCK Clinical & Reproductive disorders, decreased productivity Low Availability of iodine : PLANTS Iodine poor feeds & fodders, goitrogens WATER, SOIL Environmental iodine deficiency SOIL EROSION

Iodine Deficiency Disorders & Human Life Cycle 1) Unborn Child (Foetus) 2) Newborn Child (Neonate) 3) Child & Adolescent 4) Adult

Brain Cell Growth Iodine Deficiency Iodine Sufficiency Iodine Deficiency is the single most common cause of preventable mental retardation

Iodine Deficiency & Learning Abilities School age children living in iodine deficient environment on an average, have 13 I. Q. points less than those living in iodine sufficient environments

Implications of Loss of I. Q. 1. Poor Scholastic performance 2. Frequent failures / grade repetitions 3. Absenteeism / Drop outs 4. Major implications: Education for All 5. Consequent economic & social effects 6. Drain on Human Resource Development

IDD – The Hourglass Historic View Iodine Deficiency = Goitre = Visible Swelling No Pain = Not a cause of Mortality = Cosmetic problem Cretinism rare Mental & Physical growth Current View Loss of Energy-hypothyroidism Learning Disability, Poor Motivation Child Development and Child Survival Human Resource Development