“Putting brakes on anaemia: how to safeguard the health and rights of women and girls through fortification”

The theme of this year’s World Population Day has been aptly named 'Putting the brakes on COVID-19: how to safeguard the health and rights of women and girls now.' The COVID-19 pandemic continues to wreak international havoc, affecting millions across the world. According to the Director General of the World Health Organisation, Dr. Tedros Adhanom Ghebreyesus, the worst from the pandemic is yet to come, which all the more highlights the importance of being vigilant and resilient to counter the virus. However, as with most large-scale crises, it is having a disproportionate impact on the people who are poor and marginalised, especially women and children.

The impact of COVID 19 on economy, health system, food supply and nutrition

The disease and the accompanying restriction on movement is taking a toll on the economy and impeding the functioning of the general health service system and food supply;

1. 1. Impact on the economy: 
   1. The World Bank predicts a 5.2% contraction of global GDP due to decrease in investments, erosion of human capital through lost work and schooling and fragmentation of global trade and supply linkages. The pandemic will plunge most countries into recession, with per capita income contracting in the largest fraction since the late 19th century. According to the International Monetary Fund (IMF), the global economy is expected to contract by 6.5% in 2021 when compared to what it was in January 2020. IMF predicts that the Indian economy will contract by 4.5% in 2021, and according to the eminent economist and the former chief statistician, Dr. Pronab Sen, India’s unemployment rate will increase to 8.5% if the stimulus package in India is not widened.
   2. Women are mostly engaged with the informal economy, and many may fall into poverty, due to the disruptions posed by the lockdown. 
2. 2. Impact on routine health services:
   1. Routine health services have been impacted across the country with most of the critical health services from immunizations to mental health affected. There has been a disruption in the distribution of iron and folic acid (IFA) tablets, which is critical in preventing anaemia. These will have deleterious effects on the outcomes of major infectious and non communicable diseases, as well as malnutrition. According to a study published in the European Respiratory Journal, India could see an additional 95,000 deaths due to tuberculosis. It is expected that within 6 months, 300,000 children in India may lose their lives, largely due to disruption in immunisation services and lack of nutritious diet.
3. 3. Impact on food supply and nutrition: 
   • Analysing the data from Centre for Monitoring Indian Economy (CMIE), the University of Chicago estimates that more than 80% of Indian households will see a dip in their incomes due to the restrictions and the subsequent loss of livelihoods. This translates to less purchasing power and increased inability to access a diverse variety of food items including fruits, vegetables, dairy and meat products. The dietary diversity in India was poor even before the pandemic. According to the Comprehensive National Nutrition Survey, only 21% of children aged 6 to 23 months were fed an adequately diverse diet (CNNS, 2018). The crisis that has unfolded would only make things worse.
   • The lockdown has also disrupted the food supply system at all levels. Farm work has been impacted by the lack of labour and disruption in the transportation system.  Food processing has been impacted due to the closure of factories.
   • The effects of the lockdown and subsequent disruptions will cause people to rely more on monotonous nutrient poor diets and shift away from fruits, vegetables and animal source foods, which are the main sources of essential micronutrients in diets. In the face of drastic declines in income, vulnerable households will quickly give up nutrient-rich foods in order to preserve their caloric intake.

What is anaemia?

Anaemia is a condition, which particularly affects women and young children, whereby the number of blood cells or the haemoglobin concentration is lower than normal. We need haemoglobin to carry oxygen around the body, and if a person has too few or abnormal red blood cells, or not enough haemoglobin, there will be a decreased capacity of the blood to carry oxygen to the body’s tissues. This results in symptoms such as fatigue, weakness, dizziness and shortness of breath, among others. In children, this can hamper their cognitive abilities affecting the learning outcomes. Anaemia also impacts worker productivity and psychosocial well being.

​The most common causes of anaemia include nutritional deficiencies, particularly iron deficiency, though deficiencies in folate, vitamins B12 and A are also important causes; haemoglobinopathies; and infectious diseases, such as malaria, tuberculosis, HIV and parasitic infections. Iron deficiency is one of the most common forms of anaemia caused due to the lack of iron in the diet. Studies suggest that iron deficiency is the cause for somewhere between 25 and 40% of all anaemia in preschool children and women of reproductive age.

The burden of anaemia on women and children 

Globally half a billion women of the reproductive age (15 to 49 years) are anaemic, including almost 40% of pregnant women of the same age group. It continues to be one among the major causes of maternal mortality worldwide, making this a major global health problem. In India, almost half of all women of reproductive age are anaemic (NFHS 4, 2016). 

​Figure 1: Prevalence of anaemia among children (%) below 6 years of age in India, Source: NIN, 2016

Figure 2: Prevalence of anaemia among women  of reproductive age (%)  in India,  Source: NIN, 2016

From  Figures 1 and 2, it is clear that there is a high burden of anaemia in India across regions, with states in the north and east being the worst affected. The condition also seems to have an intergenerational impact, with effects carrying over through families. Anaemia is a major contributor to maternal deaths in the country. Anaemia among pregnant and lactating women is set to rise because of the disruption in health services and widespread diet shifts, thereby leading to increased maternal mortality in the future. In India, the central and state governments have promisingly accelerated activities and interventions through the “POSHAN Abhiyan” and “Anaemia Mukt Bharat”, yet there is now a prevailing concern that the achievements made in addressing anaemia and other micronutrient deficiencies may be hampered or reversed, due to the COVID-19-caused disruption in the routine health and nutrition services across India. 

The importance of fortification

​A varied array of interventions exist that are designed to prevent and correct iron deficiency anemia. These include dietary improvement, fortification of foods with iron, iron supplementation, and other public health measures, such as control of intestinal parasites. Two of the biggest challenges, however, with iron supplementation programs are irregular supply of good quality tablets and compliance by recipients (Malhotra et al 2015; Mora 2002). Dietary diversification, which is considered a longer-term approach, may be the ideal way to improve a population’s diet, however, the amount of time it requires to make such a change and the inherent contextual factors that affect it (sociopolitical, economic, cultural, behavioral, to name a few) likely make dietary diversification an approach that needs to take place alongside other approaches that can more quickly ensure improved nutrient intake. Findings from CNNS survey conducted in 2016-18 indicate that 42% of children 6-23 months of age were fed the minimum number of times per day for their age, only 21% were fed an adequate dietary diversity, 6.4% received a minimum acceptable diet, and only 8.6% consumed iron rich foods.

One evidence-based and easily implementable means of addressing worsening food insecurity and malnutrition is food fortification. The emerging situation points to the heightened need to increase the focus on health and nutrition, and to  adopt strategies that are cost-effective and impactful. Governments should scale up preventative interventions in communities that are food insecure and have limited access to diversified diets. 

Food fortification, the addition of essential micronutrients to staple foods, has been declared as the most cost-effective, safest (Hurrell 2010), and most practical approach to increasing iron intake on a widespread and sustained basis (Gera 2012) that exists today. It does not require major behavioural changes on the part of the consumers, since the micronutrients are carried by staple foods that are commonly consumed by the people. It can also be implemented through the existing distribution networks and supply chains. The most recent systematic review (Imhoff-Kunsch et al., 2019) found that iron fortification can, on average, reduce anaemia by 34% if the anaemia is due to a lack of iron in the diet.

At Fortify Health, we work towards mainstreaming fortification of wheat flour (with iron, folic acid and vitamin B12) in the open market, as well as through the government safety net programmes (SNPs). Wheat is one of the commonly consumed staples in India. Indians consumed 98 million tonnes of wheat in 2019 (until September 2019), up from 95 million tonnes in 2018.  Wheat flour fortification is very cost effective.  At Fortify Health, we work with the millers in the states of Maharashtra and West Bengal, and facilitate fortification of their products by providing them with equipment and micronutrient premix, and by setting up monitoring and evaluation systems to ensure implementation quality as per established standards of Food Safety and Standards Authority of India (FSSAI). We are also in conversations with various government departments and agencies at the state and central levels to introduce fortified atta in government safety net programmes. 

Scaling up fortification to address anaemia

Looking at the gravity of the situation with regards to anaemia and its worsening effects of women and young children due to the pandemic, it is imperative that the governments and policy makers work towards making fortified foods universally available through all distribution channels. Food fortification along with other complementary strategies will go a long way in addressing anaemia and other micronutrient deficiencies. 

Scaling up fortification is more urgent and expeditious now than it was pre-COVID-19.  Given the disruptions in food supply chain and transportation, there could be an increase in consumer preference towards food products with stable shelf life such as maize, rice and wheat flour compared to those which are perishable like vegetables and fruits. Given this context, it is important that these staples are fortified with vitamins and minerals so that deficiencies of these micronutrients can be prevented. 

Addressing the entry barrier for fortification: One of the challenges that policy makers could face is ensuring a level-playing field for businesses for fortification. Most of the smaller mills which are Small and Medium Enterprises (SMEs) have been negatively impacted due to drop in the revenue and cash flows as a result of the lockdown and disruptions. This will prevent smaller mills from taking up fortification due to the costs involved in setting up fortification and the procurement of micronutrient premix. This is where Fortify Health’s initiative of supporting the millers in covering their entry and recurrent costs gain importance and this is a model that can be emulated at scale. 

Addressing the health services gap: It is also important to note that the disruption in the provision of IFA tablets from health centres will result in increasing the risks of anaemia among women and young children and given the way in which the cases of COVID 19 is increasing, we can safely assume that the health service system will stretched for many more months to come. Fortification of staples with iron and folic acid will fill this critical gap and therefore, it is important to increase focus on this strategy. 

Generating awareness around the consumption of fortified foods: The awareness regarding fortified is generally low in India. There is, therefore, a need to make people aware about the benefits of consuming fortified foods. The Food Fortification Resource Centre (FFRC), an autonomous body under the Food Standards and Safety Authority of India, is working towards creating more visibility for fortified foods through advertisements and media campaigns. Fortify Health aims to work with millers, FFRC, state-level Food and Drug Administration (FDA) and other like-minded organisations to increase awareness about the consumption of fortified foods.

In alignment with the efforts towards ‘Putting the brakes on COVID-19: how to safeguard the health and rights of women and girls now’, we must also include “Putting brakes on anaemia: how to safeguard the health and rights of women and girls through fortification.”

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​Written by Dr Muneer Mammi Kutty, Strategy Lead at Fortify Health