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This post provides an update on our progress and explains our decision to explore opportunities to add value to iron and folic acid fortification in India. Having extensively reviewed the academic literature and NGO reports, and having spoken to experts in the field who strongly encouraged us to develop this project even as non-experts, we set out to understand where in the world a new fortification initiative might have the most impact. The approach to our evaluation was driven by data and expert guidance.
For an overview of why we began working on iron and folic acid fortification and for background information about iron deficiency anemia and neural tube defects, please see our previous post. We began our evaluation with country-level analysis of available data, including disease burden, potential intervention scale, status quo fortification gap of centralized mills, and potential risks (contraindications). These were complemented by estimated parameters for more subjective factors, including conflict, crowdedness, language barriers, and miscellaneous positive factors. These scores were standardized and weighted to compute a composite score for each country. Data are available in this spreadsheet. Disclaimer These scores and the suggested weights are certainly not a literal indication of the importance of further fortification efforts in the countries evaluated. While this framework was useful in guiding our location selection, we do not claim that its guidance is absolute nor do we claim that fortification (or access to plentiful nutritious food and good health, for that matter) is any less important in locations with lesser scores. Consider this spreadsheet as a visualization of various factors relevant to determining with limited information where our new initiative might be expected to have the highest potential impact. Selection criteria Disease burden was modeled as the combined DALY rate of iron deficiency anemia and neural tube defects. Potential intervention scale was modeled as the log of the country’s population. As such, larger countries with greater potential scale were nonlinearly compared (e.g. India’s population of approximately 1.3 billion was scored approximately twice as high as Sudan’s population of approximately 40 million). This transformation was deemed reasonably aligned with assumptions of potential scale (e.g. the feasibility of working within one state in India compared to at a national level in a smaller country). The status quo fortification gap of centralized mills was calculated given data aggregated by the Food Fortification Initiative on staple food consumption, centralization of milling of rice, wheat, and corn, and the amount of that staple that is currently fortified. As such, an estimate of the the centrally produced fortifiable food not currently fortified was used in comparison. The primary potential risk factor (contraindication) considered was the burden of malaria, expressed by national DALY rate. Existing data and meta analysis suggest that iron supplementation programs are associated with increased risk of malaria contraction in high burden regions lacking malaria services. Iron supplementation differs from iron fortification: supplementation involves consumption of high-dose iron tablets at varied frequency (daily to biannually, depending on program) whereas fortification involves consumption of low-dose trace amounts of iron consumed regularly through fortified staple foods. To our knowledge and informed by expert consultation, data on the impact of fortification on malaria risk is not currently available. Even so, several programs are currently underway under the assumption that the low dose of fortification would not carry the same risk. We believe this is an area of worthwhile exploration and would be happy to work with a health economist or statistician to analyze existing data to produce informative evidence. Given the present uncertainty, we included malaria risk as a contraindicating factor in our location selection. Political feasibility, the presence of ongoing war or political instability, was subjectively rated to reflect both the feasibility of working with government approval or collaboration, the endurance of implemented programs, and safety establishing projects. Language barriers were considered to reflect our confidence that we could build partnerships with local organizations and governments. Countries where English is spoken (our native language) scored higher than countries where Spanish, German, or French is spoken (our non-native languages), which scored higher than countries where none of the four languages is spoken. Crowdedness, the presence of existing actors already doing (or planning to do) work similar to our aims, was assessed by reviewing the governmental and NGO efforts currently underway in countries scoring highest on the aforementioned factors. A subjective score was assigned to each evaluated country. Miscellaneous positive factors included existing relationships with potential partners or influential people. Selecting India Considering these factors, India emerged the most promising location to explore specific opportunities for our work. By comparison to other top candidates, India scored slightly to moderately lower on disease burden, higher on potential intervention scale, higher on status quo fortification gap, substantially lower on malaria risk, slightly lower on political feasibility (the average scores of top locations was heavily skewed by Bhutan), higher on crowdedness, lower on language barriers, and higher on miscellaneous factors. Put another way, reasons to work in India compared with other top candidates included potential intervention scale, status quo fortification gap, low malaria risk, lower language barriers, and positive miscellaneous factors, even though other top candidates had somewhat higher disease burdens and appeared less crowded. Across India, 38.3 percent of the population suffers from iron deficiency anemia (compared to 2.3 percent in the US). Anemia affects 55.3 percent of women and 69.5 percent of children in India considering all causes (including anemia resulting from iron deficiency, intestinal worms, etc.). Expert views Having connected with several experts working in the field, we have overwhelmingly received encouraging responses to our initiative (and have been grateful for pushback, as well). Despite several actors’ efforts on micronutrient fortification in India, it became clear from conversations with organizations working on fortification in India that there is plenty of room for further focus. Anemia is a substantial problem in India and existing interventions are sparsely implemented.
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