Even as the Centre tries to keep anaemia in check through flagship programmes, a government survey released late last year has shed light on the rising prevalence of the disease as key policies fail to reach those who need it the most. Anaemia prevalence has risen across major demographics since 2015-16, found the National Family Health Survey. Dig deeper, and experts point to a misdiagnosis of causes, poor awareness, and a possible misunderstanding of the disease itself.
In 2019, India was among the 35 countries with the greatest anaemia burden among children and pregnant women, shows World Health Organization data. Almost 67% of the children aged 6-59 months—the worst-hit group—were anaemic in 2019-21, up from 59% in 2015-16, according to the NFHS. The prevalence also rose among pregnant women, from 50% to 52%.
One reason why the Centre’s programmes may have met limited success is misdirected treatment, experts said. The policy centres around giving iron supplements to anaemic Indians. True, in the 1-4 age group, iron deficiency is the biggest cause of anaemia, but among older children, unknown causes make up the largest share, showed the 2016-18 Comprehensive National Nutrition Survey (CNNS). No such survey exists to trace causes among adults, said Dr. Purnima Menon, senior research fellow at the International Food Policy Research Institute.
“Iron deficiency is just one of the causes," she said. “Factors such as malaria, inflammation, genetic conditions and overall nutrition deficiencies can also lead to anaemia."
Since nearly half the cases are due to causes other than iron or folate deficiency, the policy should also focus on them, said Harshpal Singh Sachdev, a senior paediatrics consultant at Sitaram Bhartia Institute of Science and Research, New Delhi. Without adequate information on all causes, especially among adults, interventions based on iron supplements are unlikely to help reduce disease prevalence rapidly, he added.
Low compliance
However, even the iron supplements piece of the puzzle has implementation issues. The NFHS data points to a low uptake of supplements given under the Anaemia Mukt Bharat programme since 2018-19 across the country.
Children, adolescents, women of reproductive age and pregnant women irrespective of their anaemia status are to be provided with iron and folic acid (IFA) supplements under this scheme. Pregnant women are advised to take one IFA tablet daily for at least 180 days starting from the fourth month of pregnancy. But fewer than half of them in 19 major states took the supplements for that period despite most receiving the tablets.
“Women often are not aware about the significance of taking the supplements on health of the foetus and self and even forget to take them," said Sheila Vir, director of Public Health Nutrition and Development Centre.
Steps are needed to improve the implementation and raise awareness, she said.
Inadequate coverage
Yet another intervention that has fallen short of last-mile coverage under the Anaemia Mukt Bharat scheme is the deworming regimen, which is carried out to treat parasitic intestinal worms that can lead to anaemia. Under this measure, children, adolescents and women are to receive deworming medication twice every year. However, the deworming coverage of children aged six to 23 months was inadequate in all states and Union territories for which the latest NFHS data was available. Odisha (71.9%), Karnataka (56.5%) and Chhattisgarh (55.1%) had the best coverage, while Nagaland (15.2%), Manipur (16.4%) and Rajasthan (22.4%) fared the worst.
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If anaemia prevalence is to be contained, these schemes will need to reach the target groups better. Some of the other verticals of the programme—such as testing and treatment of the disease, communication campaigns to raise awareness, and intensification of screening and treatment of non-nutritional causes of the disease—could help as the programme gets older.
While the numbers indicate poor implementation, some experts also feel the current anaemia policy needs to be augmented and consider several other factors to understand the disease better. A study in The Lancet in June 2019 said the WHO’s haemoglobin (Hb) thresholds that India uses to assess anaemia could be overdiagnosing its prevalence. The WHO cutoffs came from studies in 1968 of predominantly white adult populations in Europe and North America. Using an analysis of the 2016-18 CNNS data, the study proposed that Hb thresholds in India were around 1-2g/dL lower than the WHO cutoffs. It also argued for using the venous blood method (extracting the blood from the arm) to assess anaemia, which is considered to be the gold-standard method and which the CNNS used, rather than using the capillary method (extracting the blood from a finger prick), which the NFHS uses. The capillary method underestimates haemoglobin in the blood, resulting in an overestimation in anaemia, the study observed.
“The lower prevalence of anaemia in the CNNS can be attributed to the correct method of venous collection of blood samples," said Sachdev, one of the authors of the study. “Haemoglobin estimation using the venous blood method gives a more accurate reading and the CNNS samples were also subjected to rigorous quality control."
Several socio-economic factors such as lack of women’s education, poverty, poor water supply and sanitation conditions predisposing to recurrent infections also aggravate anaemia prevalence. “The government policy should also take these into account to address anaemia and not just focus towards iron supplementation," said Sachdev.
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Topics plain-facts