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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.

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science society health policy the national iodine deficiency disorders control program niddcp

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

outline of presentation
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…
slide3

ITERATIVE LOOP

Research, Policy, Programme

POLICY

RESEARCH

PROGRAMME

slide4

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

slide5

The World In Which Policies

Were Being Made

1) Health Problem/Issue

2) Information

3) Institutional

structure for

decision making

4) POLICIES

slide6

World In Which Policies Should Be Made

1) Health Problem/Issue

2) Information

3) Values

4) Institutional

structure for

decision making

5) POLICIES

slide7

World In Which Policies Should Be Made

2) Information

Evidence

Data

Research

KNOWLEDGE

Researchers &

Universities

Advocacy

Media

slide8

World In Which Policies Should Be Made

3) Values

CORE VALUES

Ideologies

BELIEFS

Casual Assumptions

INTERESTS

slide9

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

slide10

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

slide12

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

slide13

Legacy of The Legend

Science & Society

Prof. V. Ramalingaswami

[8 August 1921 – 28 May 2001

slide14

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
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
slide17

Kangra Valley Study Area

Dharamsala

From Pathankot

Zone – B

PLAIN SALT

To Kulu

Zone – C

KIO3 SALT

Zone – A

KI SALT

genesis of national programme 2
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

genesis of national programme 3
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
slide23
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
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

slide25

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
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

slide27

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
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
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

slide30

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

slide31

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?
slide32

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

slide33

Iodine Deficiency Disorders

& Human Life Cycle

  • Unborn Child (Foetus)
  • Newborn Child (Neonate)
  • Child & Adolescent
  • Adult
slide34

Brain Cell Growth

Iodine Sufficiency

Iodine Deficiency

Iodine Deficiency is the single most

common cause of preventable mental retardation

slide35

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

slide36

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
slide37

IDD – The Hourglass

Historic View

Iodine Deficiency = Goitre =

Visible Swelling

No Pain = Not a cause of

Mortality = Cosmetic problem

Cretinism rare

Mental & Physical growth

Loss of Energy-hypothyroidism

Learning Disability, Poor Motivation

Child Development and Child Survival

Human Resource Development

Current View