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Commentary: from iodine deficiency to anomalous fetal development.

It was fortuitous that I was the District Medical Officer (DMO) for the Western highlands district of Papua New Guinea (PNG) in 1966. At that time, McCullagh had already carried out pioneering work using intramuscular iodinated oil as a depot preparation for treating the goitre of iodine deficiency and had given a clinical description of the associated endemic cretinism found in that area. It was Basil Hetzel’s perspicacity that recognized the importance of the problem, not only for goitre but also for endemic cretinism. It was a serendipitous observation that goitre and cretinism had been reported from the Jimi Valley of the Western highlands district of PNG. The Jimi Valley was a remote area, access to which was made by the first administrative patrol in July 1953 followed by the establishment of an administration patrol post in 1958. As late as 1966, there was no vehicular access to the valley but four small airstrips enabled access and catered for provision of supplies and dealing with emergencies. This background of remoteness with difficulty of access provided an ideal milieu for a controlled trial. The role of dietary iodine deficiency in the genesis of endemic goitre had been recognized for over a century. The geographical co-existence of goitre with endemic cretinism had also been noted over many years. Paracelsus in 1587 reported, ‘but to speak of these creatures that they perchance also have defects of the body, that is they carry growths with them such as goitres and the like: this perhaps is not a characteristic of fools, but also of others, however it fits most of them’. However, although in some areas the introduction of salt iodization had been accompanied by a decline in the prevalence of endemic cretinism; in other areas, a decline in the prevalence had been noted before even the recognition that iodine had a pivotal role in the development of endemic goitre. Endemic cretinism declined in prevalence in parallel with economic and social development. It was this situation that led to the decision for a controlled trial being the only route to providing a definitive answer to the problem. It was agreed that Ian Buttfield would perform the initial patrol giving the intramuscular iodine and placebo injections. Meeting at my house in Mount Hagen early in 1966, Basil Hetzel, Ian Buttfield and I discussed the mechanics of carrying out the trial. In view of the remoteness of the area and the scattered population involved, this phase was no sinecure. Nevertheless, Ian and his newly wed wife deserve unreserved congratulations for their achievement for enrolling a trial population of 16 500. It was the intention that Ian would follow up the trial, however, subsequent events conspired against this. Three years later, in 1969, there had been no follow-up by which time I had completed my stint of DMO for the Western highlands and had been made DMO for the Sepik district stationed in Wewak. Concern at the failure to follow up led to my seeking and being granted permission by the Director of Public Health Department, Roy Scragg, to carry out a follow-up patrol. The initial follow-up patrol was successful in examining 60% of the children born to the trial population. My self-congratulation in achieving this level of success was short-lived. On telephoning Roy Scragg, he gave orders for me to return to the Jimi Valley and examine the missing 40%. After a short rest, a second follow-up patrol was carried out that increased the success rate to 90%. Again, a call to Roy Scragg merely elicited the response to return to catch the remaining 10%. My chagrin at yet another period of absence from home and family was considerable. Nevertheless, after the third patrol, 98% of the infants born into the trial had been examined. This was my introduction to epidemiological research. Roy Scragg had impressed on me the importance of reducing the non-response rate in epidemiological studies. This proved a life-changing event. It led from having the administrative responsibilities of a DMO to a position in the Institute of Medical Research in Goroka with the remit of the continued follow-up of the trial and an assessment of the problems of iodine deficiency in other areas of PNG. The main objective of the trial was achieved by demonstrating that the relief of iodine deficiency in Published by Oxford University Press on behalf of the International Epidemiological Association