Science, Society

1
Science, Society Health PolicyThe 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 20th 2001 AIIMS, New
Delhi
2
Outline of Presentation

• Iterative Loop Research Policy - Programme
• World In Which Policies Were Being Made
• World In Which Policies Should Be Made
• A Case Study of NIDDCP
• Lessons Learnt From the NIDDCP
• In Summary

3
ITERATIVE LOOP
Research, Policy, Programme
POLICY
RESEARCH
PROGRAMME
4
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
5
The World In Which Policies Were Being Made
1) Health Problem/Issue
2) Information
3) Institutional structure for
decision making
4) POLICIES
6
World In Which Policies Should Be Made
1) Health Problem/Issue
2) Information
3) Values
4) Institutional structure for
decision making
5) POLICIES
7
World In Which Policies Should Be Made
2) Information
Evidence Data Research
KNOWLEDGE
Researchers Universities
Advocacy Media
8
World In Which Policies Should Be Made
3) Values
CORE VALUES Ideologies
BELIEFS Casual Assumptions
INTERESTS
9
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
10
World In Which Policies Should Be Made The
National Iodine Deficiency Disorders Control
Program (NIDDCP)
1) Health Problem/Issue
2) Information
3) Values
4) Institutional structure for
decision making
5) POLICIES
11
From Information to Knowledge
12
World In Which Policies Were Being Made
Information
Evidence - Large no. of studies Data -
Disaggregated and
aggregated data Research - Evidence based
Community Lab studies
KNOWLEDGE
Researchers Universities Epidemiologists,
Public Health Specialists, Scientists
Nutritionists
Advocates - Scientists Media - Print
Electronic
13
Legacy of The Legend Science Society
Prof. V. Ramalingaswami 8 August 1921 28 May
2001
14
Prof. Madhu G Karmarkar, Former Prof. Head,
Department of Laboratory Medicine, AIIMS, who
has been intimately associated with Prof.
Ramalingaswamis Kangra Valley Study and events
thereafter to take us through the study
15
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

16
Kangra
17
Kangra Valley Study Area
Dharamsala
From Pathankot
Zone B PLAIN SALT
To Kulu
Zone C KIO3 SALT
Zone A KI SALT
18
Genesis of National Programme - 2

• The Kangra Valley Project (1956-1972)
• Study Population School Age Children (SAC)
• Intervention TECHNICAL
• Baseline survey in 1956.
• 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

19
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

20
Genesis of National Programme 4
INTERVENTION
21
Genesis of National Programme 5
INTERVENTION
22
Genesis of National Programme 6
INTERVENTION
23

• 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

24
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

25
Dr. Chandrakant S Pandav, Member, Clinical
Epidemiology Unit, Addl. Prof., Centre for
Community Medicine AIIMS, who has been
intimately associated with Prof. Ramalingaswamis
work since 1978 to take us through the events
thereafter
26
NGCP Activities (1962-1983)

• Total No. of Salt iodisation plants 12
• (UNICEF assistance)
• Location Rajasthan 5
• Gujarat 3
• West 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
27
The World In Which Policies Were Being Made
1) Health Problem/Issue
2) Information
3) Institutional structure for
decision making
4) POLICIES
28
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

29
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
30
World In Which Policies Should Be Made
Institutional Structure For Decision
Making Efforts Since 1980s
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
31
The Turning Point of The Programme1983 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
  Ministers 20 Point Programme?

32
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
• SOIL EROSION WATER, SOIL Environmental
  iodine deficiency

33
Iodine Deficiency Disorders Human Life Cycle

1. Unborn Child (Foetus)
2. Newborn Child (Neonate)
3. Child Adolescent
4. Adult

34
Brain Cell Growth
Iodine Sufficiency
Iodine Deficiency
Iodine Deficiency is the single most common
cause of preventable mental retardation
35
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
36
Implications of Loss of I.Q.

• Poor Scholastic performance
• Frequent failures / grade repetitions
• Absenteeism / Drop outs
• Major implications Education for All
• Consequent economic social effects
• Drain on Human Resource Development

37
IDD The Hourglass

• Iodine Deficiency Goitre
• Visible Swelling
• No Pain Not a cause of
• Mortality Cosmetic problem
• Cretinism rare

Historic View
Mental Physical growth Loss of
Energy-hypothyroidism Learning Disability,
Poor Motivation Child Development and Child
Survival Human Resource Development
Current View