Preventing Goitre in India
An estimated 40 million people in India alone suffer from goitre. A large percentage of these are cretins, who are mentally or physically retarded. Far from being a "cosmetic" problem, goitre is a disease that retards health and productivity.
The endemic goitre belt in India stretches across the entire sub-Himalayan region from Jammu and Kashmir through Himachal Pradesh, Uttar Pradesh, Sikkim, all the way to Arunachal Pradesh. Recent surveys also show endemic pockets in Kerala, Andhra Pradesh, Madhya Pradesh, Maharashtra, Bihar and Gujarat.
The cause of goitre was identified long ago as iodine deficiency. Prevention and control of goitre through the distribution of iodised salt has been well-known, and goitre was eradicated in the developed countries several decades ago through the application of this technology. India's own National Goitre Control Programme languished after a promising start. It failed to make a significant impact in many areas due to administrative incompetence, lack of coordination between the various agencies involved, and commercial and vested interests.
The Goitre Control Programme, with its coverage limited to a few hyper-endemic sub-Himalayan states, is in dire need of improvement. It is naive to believe that by merely extending the salt iodation programme to cover the entire country, the problem will be solved. It is still necessary to ensure that the salt produced by numerous manufacturers is in fact iodated.
In recent years, intensive efforts have been made to promote iodised oil injection as a strategy for control of endemic goitre in Asian countries. Those promoting this method recommend injections only as an interim measure till the national salt iodation programmes pick up, and then too only in areas that are hyper-endemic and "inaccessible." Even though this claim at first appears reasonable, careful examination reveals its weaknesses.
Iodised oil for injection is currently manufactured in France (China manufactures some for its limited use). Practically all the iodised oil being used in injection programmes in Asia is now being procured by international agencies from a commercial firm in France. The cost of this approach has been estimated to be about 35 times higher per head per year than the cost of the salt-iodation strategy. It must be remembered that the support of international agencies will eventually be withdrawn. Other conditions of the injection programme are that injections have to be repeated at least once every five years, disposable syringes are needed, as is considerable health manpower.
It would be impossible for poor Asian countries to sustain a national goitre control programme based on injections of iodised oil with their own resources. If the objective is to achieve self-reliance, it would be prudent for Asian countries not to allow themselves to be side-tracked, but to use their resources to strengthen the salt-iodation programme.
The argument that iodised oil injection programmes are being promoted only as a temporary measure could prove deceptive in the long run. Experience in some Asian countries that have opted for the injection approach shows that the salt-iodation programmes have considerably slackened, while the injection programmes have continued in their original strength.
Wherever a salt-iodation programme has been effectively implemented, its impact has been evident however hyper-endemic the area. The argument that iodised oil injections are appropriate to "inaccessible areas (meaning sensitive frontier hill areas as far as India is concerned) does not stand scrutiny.
Moreover,there are really no areas that are "inaccessible to common salt. A salt famine has never been reported even in the remotest communities. People in these areas know how to procure their salt and they do procure it; the problem is to ensure that the salt is iodated. In any case, it would be absurd to suggest that areas which are "inaccessible to common salt would be more easily accessible to periodic massive injection programmes.
Dr. C. Gopalan is Director of the Nutrition Foundation of India.