|Year : 2013 | Volume
| Issue : 2 | Page : 45-46
Thyroid: Disorders of a lesser gland
Sanjay Kalra1, Ambika G Unnikrishnan2, Manash P Baruah3
1 Department of Endocrinology, Bharti Hospital and BRIDE, Karnal, Haryana, India
2 Department of Endocrinology, Amrita Institute of Medical Sciences, Cochin, India
3 Department of Endocrinology, Excel Center (Unit of Excel care Hospitals), Barthakur Mill Road, Ulubari, Guwahati, India
|Date of Web Publication||16-Apr-2013|
Manash P Baruah
Excel Center (Unit of Excel care Hospitals), Barthakur Mill Road, Ulubari, Guwahati-781007
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kalra S, Unnikrishnan AG, Baruah MP. Thyroid: Disorders of a lesser gland. Thyroid Res Pract 2013;10:45-6
A group of conditions, which include 'cardiovascular diseases, cancer, mental health problems, diabetes mellitus, chronic respiratory disease and musculoskeletal conditions': This is how the World Health Organization (WHO) defines non communicable diseases (NCD).  Largely preventable, linked by common risk factors, underlying determinants and opportunities for intervention; these are the attributes that link these seemingly disparate diseases.
The WHO report that NCDs are the leading cause of mortality in the world.  This shift towards NCD, and away from acute, infectious diseases, is being experienced in developing countries including India. The government has launched a National Programme for Prevention and Control of Cancers, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS), to combat the menace of these insidious illnesses. 
The NCD Alliance, as well as other global stakeholders, list four main diseases which contribute to 80% of the mortality burden of NCD: Cardiovascular disease (CVD), stroke, cancer and diabetes.  The United Nations General Assembly, too, in its deliberations on NCD, focuses on these four groups of conditions. No where in the list of NCD, is thyroid disease mentioned.
Thyroid disorders are by and large, non-communicable and non-infectious. They are a leading cause of morbidity worldwide, as shown by epidemiological data. They may be an under reported cause of premature mortality, too, though the etiology of death reported is usually a complication of thyroid disease. Thyroid disorders are as preventable as diabetes and cancer. The success story of prevention of iodine deficient disorders (IDDs) is perhaps the best example of prevention of an NCD worldwide.  A similar success story can be scripted if we are able to minimize the adverse effects of various environmental thyroid disorders (ETDs) today.
The incidence of hypothyroidism is rising rapidly, as is the prevalence. This increase is seen amongst people of almost all continents, across all age groups, and in both genders. Thyroid disorders share a bidirectional association with virtually all the NCDs. Cardiovascular disease is more common in hypothyroidism. Cancer of the thyroid is well known. Hypothyroidism and hyperthyroidism are associated with a variety of mental health problems. Hypothyroidism is more common in type 1 diabetes, just as diabetes is more frequently seen amongst hyperthyroid patients. Hypothyroidism is linked with respiratory dysfunction, as well as musculoskeletal complaints.
Do thyroid diseases not qualify, then, based on the WHO description, as an NCD of global public health importance?
The public health impact of thyroid disease has been appreciated in recent years.  A decompensated thyroid state during pregnancy is linked with cognitive dysfunction in the offspring. Thus, thyroid diseases not only impact current societal health, but also future health of the nation, in a manner no other NCD does. 
Why then, is thyroid not on the global public health agenda? Why is it not counted in the list of NCDs of importance? Are patients with disorders of the thyroid, children of a lesser God? Are doctors treating them, caretakers of a lesser gland?
It is not hard to find at least some reasons for this apparent discrimination. Arguably, CVD, stroke, cancer and diabetes have high mortality, which attracts public attention. The clinical profile of these diseases is such that people affected by them are easily 'visible'. A person with hemiplegia, another showing the effects of chemotherapy, yet another with an amputated diabetic foot; these images stir emotions and stimulate actions by the lay population, non-governmental organizations, policy makers, medical stakeholders. Diseases of the thyroid, in contrast, are blessed with low mortality, even in cases of thyroid malignancy. Most people with thyroid diseases look normal; the pictures of huge goiters, stunted growth and florid hypothyroidism are, mercifully, a snap shot of the past.
Thyroid disorders are treated by a lesser number of specialists. The membership of the Indian Thyroid Society, for example, is much less than that of similar professional bodies related to cardiology, neurology, diabetes, or oncology. Their collective voice is not as loud as that of other specialties, a major disadvantage in a society moving from democracy to ochlocracy.
Is it possible (tongue in cheek) that we thyroidologists have argued our case at a slower pace and with less zeal, allowing colleagues from other fast paced specialties to catch the early bird prize?
There exist other equally understandable but unpalatable reasons! All the 'important' NCDs have difficult investigation and treatment paradigms, each competing with the other in terms of expenses and complexity. Advances in medical sciences seems to broaden the ambit of these treatment regimes, but serve to make them more and more out of reach of ordinary patient and physicians. This is especially true in a 'pay from pocket' medical market like India, where health insurance covers only a miniscule proportion of the population. Thyroid disease, in contrast, seems to be relieved well by economical therapeutic interventions. Optimal therapy for hypothyroidism cost just Rs 1 per day (less than 2 US cents) in India, while medical drug therapy for Graves' disease is slightly more expensive. This may explain the public perception of thyroid diseases as "lesser" illnesses.
Other reasons for the absence of thyroidology from the NCD label are difficult to explain. Patient advocacy is one of the duties of every physician. Being concerned with our patients' holistic health, we cannot limit our intervention to drug therapy alone. We continuously use the concept of ecosensitivity to "work" our patients' social and physical environment, in order to ensure optimal health. Yet, thyroidologists seem to have been silent on the issue of including thyroid disease as one of the major NCDs. This is not due to lack of epidemiological data, or biochemical evidence. Thanks to researchers across the globe, we know the impact of thyroid disease on human health. It is also not due to lack of experience: endocrinologists are well versed with the trials and tribulation of taking diabetes to the center stage of international health politics. Is this then a new form of clinical inertia? Perhaps, we can practice noun piling to create a new term; 'advocacy inertia' or even better, 'selective advocacy inertia in thyroidology'.
Let us make a beginning to break this log jam: The Indian Thyroid society, Endocrine Society of India, and Association of Physicians of India should jointly spearhead a campaign to include thyroid disease in the National NCD programme. The direct and indirect impact of thyroid disorder on quality of life should be adequately highlighted. A case should be made for detecting and managing hypothyroidism in pregnancy, so that we can achieve a more intelligent India tomorrow.  Access to all for thyroid investigations and treatment, especially antenatal women and children, should top the agenda. A concerted effort to reduce exposure to environmental thyroid disruptions must be encouraged. 
Patient advocacy groups should be formed and supported to help achieve this. Mass media, including e-media can be utilized to enhance thyroid awareness. The existing 'Think Thyroid' month (January) campaign of the Indian Thyroid Society is a perfect vehicle to spread public awareness. Other campaigns can centre around October, the 'Iodine Deficiency Disorder' (IID) month, especially 21 October, which is the global IID day.
The International Thyroid Awareness week (mid year), World Thyroid Day (25 May), and the Thyroid Cancer Awareness Month (September) are other occasions which lend themselves to spreading thyroid knowledge. Instead of advocacy inertia, let thyroidology be known for proactive advocacy. Instead of being considered a lesser gland, let thyroid occupy the centre stage (which it justifiably deserves) in the global NCD movement.
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|2.||NPCDCS: Managing Non-Communicable Diseases. Available from: http://pib.nic.in/newsite/efeatures.aspx?relid=76249. [Last accessed on 2012 Sep 11]. |
|3.||The global epidemic. Available from: http://ncdalliance.org/globalepidemic. [Last accessed on 2012 Sep 11]. |
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