Preface

John Stanbury's life completely encompasses the 20th century unraveling of the story of world wide iodine deficiency, its tragic consequences, and its preventability. This remarkable small book offers an educational and entertaining look into that life-work.

Goiter, a swelling in the neck caused by enlargement of the thyroid gland, has been recognized for centuries, and has a geographical association of goiter with mental deficiency. There were inklings of a relation of goiter to lack of iodine, but this was first proved by David Marine only in 1917. Nearly two decades later the story was advanced by demonstration of iodine in the structure of the active and essential secretion of the thyroid gland.

Up to this point goiter was considered primarily a cosmetic defect, or in some cultures a common and even desirable physical enhancement. Cretinism was considered an unusual problem that did not in itself merit special attention or association with goiter or lack of iodine. The beginning of the modern understanding that iodine deficiency is a much greater societal problem can be traced to the work of Rodrigo Fierro-Benitez and his colleagues in rural Andean Ecuador. They observed as early as 1960 that iodine deficiency was associated with cretinism, but Stanbury and his colleagues working with Fierro observed crucially that iodine deficiency was associated with a much more prevalent mental subnormality. First greeted with skepticism, this observation has since been abundantly confirmed, and led directly to the current worldwide campaign to eradicate iodine deficiency.

Dr. Stanbury has been a central player during the entire evolution of this medical story as quietly and unassumingly portrayed in this travelogue. In 1951 lie led an expedition to Mendoza, Argentina, a region at the time of severe endemic goiter. For the first time using a version of a Geiger counter and radioactive iodine, a physiological connection was made between iodine deficiency and goiter. The team found that to compensate for low levels of iodine in the diet, the thyroid enlarged so that it could accumulate more of the iodine circulating in the blood, and catch and reuse any iodine rather than allowing it to be excreted by the kidneys. This is an example of an attempt at compensation for a deficiency of supply of a hormone that is necessary for growth and development, but the compensation is often not complete and there are unfortunate consequences. Thyroid growth cannot protect against the ravages of extreme iodine deficiency. It has taken another fifty years to unravel all details of how the metabolism of hormone is altered in iodine deficiency to help protect the brain from hypothyroidism induced by lack of iodine. We now know that cretinism and iodine related mental deficiency are related to reduced iodine supply to both mother and fetus during pregnancy and during early postnatal life, but a full explanation of all the problems remains.

Following the Mendoza experience, Dr. Stanbury journeyed around the world researching iodine deficient populations, their special forms of cretinism, and relation to food intake such as cassava. He maintained a research laboratory at Massachusetts General Hospital which spawned a group of young physicians who became the leaders in thyroid research during the last half of the 20t'' century. Recognizing the need for governmental intervention if the problem was to be solved, Dr. Stanbury worked closely with the Pan American Health Organization in South America, pushed the formation of the International Council for Control of Iodine Deficiency Disorders, and for intervention through the World Health Organization and UNICEF. The fruit of this labor is the current WHO, UNICEF, ICCIDD sponsored campaign to eradicate iodine deficiency.

The book documents an amazing series of scientific journeys in a very personal and lively way with many interesting details that connect the research to events in the surrounding world of that period. It also portrays a striking cast of characters who participated in the events, all praiseworthy for their effort and determination, some with other motives. Person gains a bit of respectability by Posing with the researchers from Harvard. Fierro pursues his research in a humble, impoverished village in the Andes with a goitrous population, many of whom are mentally deficient. The author chronicles the price in human suffering related to lack of iodine. Professor Andries Querido of Leiden University, a consultant to the team, who spent part of his life in a Nazi concentration camp, has an episode of post traumatic stress during a field trip. Two types of cretins are differentiated in the Congo and Andes, and influences of dietary and mineral deficiency (selenium) on iodine deficiency are clearly identified by Ermans and Dumont of The Free University of Brussels. The party narrowly escapes capsizing in a tempest far from shore on Lake Kivu. Monkey stew is served for lunch. Fever, dengue, possible encephalitis, altitude sickness, bites and episodes of gastroenteritis assault the travelers. Pablo Picasso's ex wife joins the party briefly. Marauding Tamil rebels are narrowly avoided. Iodine deficiency, kuru and remnants of World War II are investigated in Papua-New Guinea.

Told in a series of reminiscences, we experience the observations of an astute and experienced traveler with a scientific goal. We learn much about the people and places, their customs, and some of the dangers of travel through the eyes of an understanding and sympathetic observer. And throughout we follow the search to understand the causes, many political in origin, of iodine lack, and its prevention. While this book is a personal remembrance of journeys to far corners of the globe, its final message is the extraordinary effort that has gone into bringing proper iodine nutrition to two billion people in the world who are at risk of iodine lack and its consequences.

Leslie J. DeGroot, MD Chicago, USA
26 March 2008

(See also the book's Overview, Table of Contents and Acknowledgements)