GULU, Uganda—For 52-year-old Katereke, cassava has been both a staple food and a source of suffering. Despite being a staple food for millions, cassava contains compounds that can inhibit iodine uptake, leading to goitre. Katereke is one of the many victims who flock to Lacor Hospital in Gulu, northern Uganda, every January for free thyroid surgery.
“I’ve been battling this sickness for 25 years,” he says, referring to his goitre, a condition characterized by an enlarged thyroid gland. Despite years of medication, his condition persisted, leading him to seek surgical intervention.
Katereke’s journey with goitre began in his youth. “I realized I had it when I was in senior one,” he recalls. “During my secondary school years, I started noticing the swelling.” For years, he relied on local herbs and traditional remedies, hoping they would alleviate his condition. “For 25 years, I’ve been using local herbs,” he says. “The local people advised me to go for local herbs, thinking they could help.”
As a carpenter by trade, Katereke’s work involves physical labour, which became increasingly difficult as his condition worsened. His daily routine includes working as a carpenter and driving, which he hardly manages with the discomfort caused by the goitre.
Katereke’s diet primarily consists of cassava, a staple food in his region. “At home, I normally eat cassava, kaunga, sweet potatoes, beans, and sometimes meat,” he explains. “I eat cassava every day.” This reliance on cassava, while providing sustenance, also contributed to his health issues.
Dr. Roberto Santoro, a surgeon from Florence University, has been working in Uganda since 2012. He sheds light on the prevalence of goitre in the region. “The reasons are many,” he says. “One of these is the iodine deficiency in the water and food. Cassava, which is widely consumed here, contains goitrogen substances that can contribute to the condition.”
The turning point for Katereke came when he decided to seek medical help at Lacor where Dr. Santoro and his team were conducting a free thyroid surgical camp. “I came here on Monday,” he says. “When I met the doctor, he told me they were ready to operate if I could afford the necessary drugs.”
Dr. Santoro told Katereke that the procedure required to relieve his suffering was called a total thyroidectomy. A total thyroidectomy is a surgical procedure that removes the entire thyroid gland. The thyroid is a butterfly-shaped gland in the neck that produces hormones that regulate metabolism and other bodily functions.
After the removal of the thyroid gland, its function would be replaced by a drug known as thyroxine, a synthetic version of the hormone produced by the thyroid gland. It works by replacing the thyroid hormones that the thyroid gland cannot produce and relieves the symptoms of hypothyroidism such as tiredness, weight gain, and depression.
The cost of the medication was a significant concern for Katereke, who would have to spend an average of 30,000shs a month on the medication for a lifetime, so he decided to retreat, but “my brother said, ‘No, you go and get the surgery. We shall manage it,'” he recalls.
Dr. Santoro’s team has treated over 500 patients in the ten years that they’ve been coming to Lacor. He emphasised the importance of screening and proper medical intervention. “We screen every year 80-100 patients by ultrasound and examination,” he notes.
“Total thyroidectomy is a viable option, but it requires lifelong medication, which is a significant burden for many and this is a very important point,” he stresses. “Patients need to know they have to spend part of their money on these tablets for the rest of their lives.”
Dr. Solomon, a senior lecturer in food science and nutrition, provides a comprehensive overview of cassava’s role in northern Uganda. “Cassava is consumed by 7 out of 10 families here,” he says. “It’s processed into various products, including flour, chips, and even alcohol.” There are different ways cassava is prepared and consumed, from dried cassava chips to high-value cassava flour used in baking.
Because of the high reliance on cassava in this region, the risk for goitre is also high. Research has established a clear link between cassava consumption and the prevalence of goitre. A study conducted in Kilifi County, Kenya, found that raw cassava consumption posed a high risk for goitre, with 62% of goitre patients consuming raw cassava compared to lower percentages for cooked, milled, roasted, and fried forms.
The study highlighted that adult women, pregnant women, and children were more susceptible to goitre than adult males. The presence of goitrogenic compounds in cassava, which interfere with iodine absorption, was identified as a significant factor.
Experimental studies in Bayelsa State, Nigeria, have demonstrated a link between endemic goitre and chronic ingestion of cassava, both fresh and cooked. These studies suggest that the compounds in cassava can contribute to thyroid disorders.
Research has consistently shown that cassava contains goitrogenic compounds, such as cyanogenic glucosides, which release cyanide when improperly processed. This cyanide can interfere with iodine uptake by the thyroid gland, leading to goitre. The risk is particularly high in regions where cassava is a dietary staple and iodine intake is low such as northern Uganda.
Dr. Solomon cautions on the need for proper handling and processing to ensure safety and sustainability. “Farmers should use clean planting materials and practice crop rotation to avoid diseases,” he advises. “Cassava is a food security crop, but it must be managed properly to prevent health risks.”
The Ministry of Agriculture, Animal Industry and Fisheries has established a National Cassava Coordinating Committee (NCCC) to enhance coordination among stakeholders and develop a cassava strategy and policy. This strategy guides stakeholders in the cassava subsector and aims to improve food security and income for households participating in cassava production.
Despite the availability of a legal framework and the body of research, very few farmers and locals are aware of the risks posed by cassava consumption. Very little is being done to sensitise the masses according to Dr. Solomon.
Broadening Perspective: Zimbabwe’s Experience
Historically, iodine deficiency emerged as a public health issue in the mid-20th century in Zimbabwe, prompting the government to introduce strategies like iodine supplementation and mandatory salt iodization in 1986. These measures led to a notable decline in iodine deficiency disorders, including goitre.
However, the consumption of cassava has exacerbated the problem. In Zimbabwe, cassava consumption is most prevalent in the southern and eastern parts of the country, particularly in regions like Masvingo and Manicaland. These areas have adopted cassava as a staple food due to its resilience to drought and ability to grow in poor soils, making it a crucial crop for food security and economic stability.
The health impacts of iodine deficiency are far-reaching. Beyond goitre, it can lead to hypothyroidism, cognitive impairments in children, and complications during pregnancy. These issues are often compounded by poverty and limited healthcare access, making it difficult for affected communities to manage the condition effectively.
Professor Solwayo Ngwenya, a Zimbabwean academic, researcher, and medical health expert in Bulawayo, emphasized the ongoing burden of the condition. “Goitre is still a huge problem. We use iodized salts, which help reduce the incidence of goitre in the community,” he said.
Despite these efforts, untreated goitres can have severe consequences. “If allowed to grow to a big mass, a goitre can cause airway obstruction and possibly death. Long-term untreated goitre can result in cancerous changes, which will be fatal to the patient,” he warned.
To address this, Professor Ngwenya advised individuals to prioritize iodine-rich foods and use iodized salt. He stressed the importance of seeking medical attention early. “Patients should use iodized salts or known foodstuff rich in iodine. Early presentation to medical staff should one develop a goitre is advisable. Surgical treatment is recommended to prevent further complications,” he said.
The Economic and Social Benefits of Cassava
Despite the health risks, the many benefits of cassava make it difficult for the population in northern Uganda to minimize its consumption. Akumu Christine, a 47-year-old primary school teacher from Kanyagoga A Cell, supports her family by making a local brew from cassava over the weekends.
“I started making local brews from cassava when I was 15, mostly by helping my mother,” she recalls. “Sometimes, I’d do it alone on weekends. But I stopped until six years ago when I was older.”
Christine explains the brewing process: “The process involves drying raw cassava and fermenting it for a week. The ferment is then roasted on fire, mixed with fermented yeast and water, and left for three more days. After three days, the mixture is ready for brewing. After brewing, I usually invite one of my clients to taste the quality of the first lot before I continue to brew more.”
Cassava has been a lifeline for Christine and her family. “Cassava has helped me a lot because, as a primary teacher, sometimes our salary delays, and even if it comes in time, it’s insufficient to meet my needs,” she says. “So, I spend my weekends brewing alcohol. The money I get from it is what I use to pay school fees for my children, buy food, and meet other basic needs. This has brought a lot of positive change to my family.”
Christine’s story is a testament to the economic importance of cassava. “I usually invest between 50,000shs – 70,000shs in buying cassava and sorghum or maize corn to make yeast and I earn a profit of about 110,000shs,” she explains. “I sell a litre at 2,500shs to retailers and 3,000shs to those who drink from my joint. In good times, my supply is consumed within two days, but in bad days it can last up to a week or I even give on credit.”
Without cassava, local brewing would not be possible. “Our alcohol is free from harmful substances but I advise people to only drink after work, not in the morning,” Christine advises. “Personally, I have seen the numerous benefits of making and selling alcohol. It has schooled so many prominent people.”
While cassava remains a crucial part of the diet and economy in northern Uganda, addressing the health risks associated with its consumption is essential. By understanding the personal stories and expert insights from both Uganda and Zimbabwe, along with research findings, we can work towards safer and healthier practices for the future.
Community education, stronger monitoring of iodized salt production, and improved dietary diversity are crucial to addressing the remaining gaps and ensuring long-term health improvements for vulnerable populations.
