science, society & health policy the national iodine deficiency disorders control program...
TRANSCRIPT
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