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India needs to look beyond iron deficiency to reduce its anemia burden

By guest contributors Parth Sharma and Vasundhara Rangaswamy

Globally, India has one of the highest burdens of anemia. Realizing this, India’s central government reemphasized the need to address it through the Anemia Mukt Bharat (Anemia Free India) program in 2018. The Anemia Mukt Bharat (AMB) program follows a 6x6x6 strategy. There are six interventions via six institutional mechanisms in six beneficiary groups. Despite improved coverage of iron and folic acid (IFA) supplementation, a key intervention of the program, a rise in anemia was noticed in all groups as per the National Family Health Survey (NFHS) 2019-21. A critical examination of AMB operational guidelines suggests that the current approach to reducing anemia in India needs to be revisited.

In the AMB program, five out of six interventions focus mainly on preventing or treating iron deficiency anemia (IDA). These five interventions include prophylactic IFA (Iron Folic Acid) supplementation, periodic deworming, behavior change communication, fortification of government-provided food with IFA and vitamins, and use of digital hemoglobinometers and point-of-care tests to diagnose anemia followed by iron therapy. The sixth intervention addresses non-nutritional causes of anemia, with a special focus on malaria, hemoglobinopathies, and fluorosis though only in endemic areas. Furthermore, hemoglobinopathies screening is limited to premarital and preconception stages in endemic areas. No guidance has been given for the diagnosis and treatment of other nutritional and non-nutritional causes of anemia. Consequently, irrespective of the underlying etiology, every anemic person receives oral iron, and pregnant women with severe anemia or those not compliant with the oral form, get the injectable form.

Iron deficiency makes up only 1040% of all anemias in India while other micronutrient deficiencies, hemoglobinopathies, anemia of chronic illnesses, and anemia of unknown etiology comprise the rest. This means, as per the current guidelines, 60-90% of anemic people may be receiving unnecessary iron therapy. Not only is their cause of anemia left unaddressed but they are also made to endure the side effects of oral iron therapy which can range from distressing gastrointestinal symptoms to alteration of gut microbiomes that can lead to poor gut immunity and recurrent diarrhea. Also, the guidelines recommend taking iron tablets after meals. This is ill-advised. It is well known that iron is better absorbed empty stomach as interaction with other minerals and food inhibits its absorption by 50-60%. Emerging evidence also highlights that smaller doses are associated with better absorption and better compliance due to fewer side effects.

Lastly, monitoring and assessment of the program are lamentable. They are not in line with its primary objective to reduce anemia prevalence among all beneficiary age groups. Six of the updated seven key performance indicators are related to coverage of IFA doses in beneficiary groups and one on the percentage of stock available for the red IFA tablet. Noticeably, these are process indicators rather than outcome indicators. In quarterly progress reports, reduction in the prevalence of anemia has been taken into consideration only for two out of the six intended beneficiaries. For adolescents, a reduction in severe anemia, and for pregnant women a reduction in mild and severe anemia is being recorded. Data on the reduction in the prevalence of anemia in children (6-59 months old and 5 to 9 years old), lactating mothers, and other women of reproductive age groups is not even being collected. Is this arbitrary approach justified when dealing with one of the most serious health problems in the country?

It is time the Indian policymakers took another look at the existing approach to addressing anemia. Between 2016 and 2020, close to 470 million USD were sanctioned for the anemia control program. Despite huge investments,  the burden of anemia is not trending down. It is not only a waste of precious resources and lack of communication of the right information about anemia and its panacea but is also a disservice to people suffering from the consequences of a complacent public health system. In times when ‘precision public health’ should be promoted, the ‘blanket approach’ to anemia diagnosis, treatment, and prevention is missing the mark. 

About the authors:

Parth Sharma is a community physician, public health researcher, and the founding editor of Nivarana, a public health information and advocacy organization. He completed his MBBS from Christian Medical College and Hospital, Vellore, and is currently doing an MD in Community Medicine from Maulana Azad Medical College, Delhi, India. He leads the Oncology and Palliative Care research group at the Association for Socially Applicable Research (ASAR) and his research interests include health equity, palliative care, and preventive oncology. His ultimate dream is to contribute to creating a world free from suffering.

Vasundhara Rangaswamy is a primary health care physician, a lab medicine specialist and student mentor practicing mainly in rural central India. She is a fellow with a US based not for profit organization Association for India’s Development (AID), that supports grassroots development activities in India. She coordinates a multistate rural and urban marginalized community health program of AID. She likes to pen poems on health inequity in particular.

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.

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