1. Dr. Chandrakant S Pandav Dr. Denish Moorthy Prof. M G Karmarkar
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 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. Research, Policy, Programme
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 1) Health Problem/Issue
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
Link between clinical epidemiology and health policy
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. 4) INSTITUTIONAL STRUCTURE FOR DECISION MAKING
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. Department of Laboratory Medicine, to take us through the study
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

15. Genesis of National Programme - 1
The Kangra Valley Project ( )
Study design : Community based prospective controlled trial
Study area : Kangra Valley ,
Himachal Pradesh
Divided into 3 zones –A , B , C
Study period :
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 ( )
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 ( )
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. Ramalingaswami’s work since 1978
to take us through the events thereafter

26. NGCP Activities ( )
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 1) Health Problem/Issue
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. Questions asked by Mrs. Indira Gandhi: What is Iodine Deficiency?
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?

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
Unborn Child (Foetus)
Newborn Child (Neonate)
Child & Adolescent
Adult

34. Iodine Deficiency is the single most
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. Iodine Deficiency = Goitre = Mortality = Cosmetic problem
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