Science, Society & Health Policy

The National Iodine Deficiency Disorders Control Program

(NIDDCP)

Dr. Chandrakant S PandavDr. Denish Moorthy Prof. M G Karmarkar

Clinical Epidemiology UnitAll India Institute of Medical

Sciences

November 20th 2001AIIMS, 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 PolicyRelationship 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 PolicyE.g. Deep vein thrombosis

On an inpatient Vs. outpatient basis

Public PolicyEvaluation of the use of research findings & determinants of that

use

2) Information

1) Health Problem/Issue

3) Institutional

structure for

decision making

4) POLICIES

The World In Which Policies Were Being Made

2) Information

1) Health Problem/Issue

3) Values

4) Institutional

structure for

decision making

5) POLICIES

World In Which Policies Should Be Made

2) Information

EvidenceData

Research

Researchers &

Universities

AdvocacyMedia

KNOWLEDGE

World In Which Policies Should Be Made

3) Values

CORE VALUESIdeologies

INTERESTS

BELIEFSCasual Assumptions

World In Which Policies Should Be Made

4) INSTITUTIONAL STRUCTURE FOR DECISION MAKING

FORMAL STRUCTURELegislatureExecutive

BureaucracyJudiciary

INFORMAL STRUCTURENetworksCoalition

StakeholdersCitizens

World In Which Policies Should Be Made

2) Information

1) Health Problem/Issue

3) Values

4) Institutional

structure for

decision making

5) POLICIES

World In Which Policies Should Be Made

The National Iodine Deficiency Disorders

Control Program (NIDDCP)

From Information to Knowledge

Information

Evidence - Large no. of studiesData - Disaggregated and aggregated dataResearch - Evidence based

Community & Lab studies

Researchers & Universities –Epidemiologists, Public Health Specialists, Scientists & Nutritionists

Advocates - ScientistsMedia - Print & Electronic

KNOWLEDGE

World In Which Policies Were Being Made

Prof. V. Ramalingaswami[8 August 1921 – 28 May

2001

Legacy of The LegendScience & Society

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)

Study design : Community based prospective controlled trial

Study area : Kangra Valley , Himachal Pradesh Divided into 3 zones –A , B , C

Study period : 1956 - 1972

Study Duration : 16 years

Study population : 1,00,000

Kangra

Kangra Valley Study Area

From Pathankot To Kulu

Dharamsala

Zone – AKI SALT

Zone – BPLAIN SALT

Zone – CKIO3 SALT

Genesis of National Programme - 2The Kangra Valley Project (1956-1972)

Study Population : School Age Children (SAC)

Intervention : 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 g of Iodine

*Salt Produced at Sambhar Lake with UNICEF Assistance

Genesis of National Programme - 3

The Kangra Valley Project (1956-1972)

Intervention : ADMINISTRATIVE

Price parity

Legislation

Govt. shops

Outcome variable: Goitre prevalence among school age children

Genesis of National Programme – 4

Prevalence of Goitre in School Children in Zone A - KI

38

19

8

05

10

15202530

3540

1956 1962 1968

Year

Prev

alen

ce o

f Goi

tre%

Prevalence %

INTERVENTION

Genesis of National Programme – 5

Prevalence of Goitre in School Children in Zone BControl Zone till 1962; then KI

40 42

15

0

10

20

30

40

50

1956 1962 1968Year

Prev

alen

ce o

f Goi

tre

% Prevalence%

INTERVENTION

Genesis of National Programme – 6

Prevalence of Goitre in School Children in Zone C- KIO3

38

15

5

0

10

20

30

40

1956 1962 1968

Year

Prev

alenc

e of

goi

tre %

Prevalence %

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

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 : 12 (UNICEF assistance)

Location: Rajasthan : 5Gujarat : 3West Bengal : 4

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

2) Information

1) Health Problem/Issue

3) Institutional

structure for

decision making

4) POLICIES

The World In Which Policies Were Being Made

New scientific evidence : 1962 – 1983

Neonatal Hypothyroidism program – A pilot study

Use of the primary health care setup to determine the incidence of neonatal hypothyroidism & Initiate treatment

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

Institutional Structure For Decision MakingEfforts Since 1980s

FORMAL STRUCTUREExecutive - Law making decisionsLegislature - Political supportBureaucracy - Policy decisions

INFORMAL STRUCTURENetworks - NGOs, Health care providers, public health expertsCoalition - Partnership of educationists & communication expertsStakeholders - Salt industry, salt regulatorsCitizens - Consumers

World In Which Policies Should Be Made

Questions asked by Mrs. Indira Gandhi:

1) What is Iodine Deficiency?

2) Why should I be Interested in National Goitre Control Programme (NGCP)?

3) How is it going to contribute towards Prime Minister’s 20 Point Programme?

The Turning Point of The Programme:1983

Meeting With The Prime Minister of India: Mrs. Indira Gandhi

Effect on people : HUMANS Health & Socioeconomic impact

Effect on animals : LIVESTOCK Clinical & Reproductive disorders,

decreased productivity

Low Availabilityof iodine : PLANTS Iodine poor feeds &

fodders, goitrogens

SOIL EROSION WATER, SOIL Environmental iodine deficiency

Iodine Deficiency – A Disease of The Soil

1) Unborn Child (Foetus)

2) Newborn Child (Neonate)

3) Child & Adolescent

4) Adult

Iodine Deficiency Disorders & Human Life Cycle

Brain Cell Growth

Iodine Deficiency Iodine Sufficiency

Iodine Deficiency is the single most

common cause of preventable mental retardation

School age children living in

iodine deficient environment

on an average, have

13 I.Q. points

less than those living in

iodine sufficient environments

Iodine Deficiency & Learning Abilities

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

Iodine Deficiency = Goitre = Visible Swelling

No Pain = Not a cause of Mortality = Cosmetic problem

Cretinism rare

IDD – The Hourglass

Historic View

Current View

Mental & Physical growth

Loss of Energy-hypothyroidism

Learning Disability, Poor Motivation

Child Development and Child Survival

Human Resource Development