Anaemia Is an Indisputable Issue for India, Dropping It From NFHS-6 Is a Blunder

India cannot cannot afford to look away from anaemia. We must look closer. Here's why.

NFHS-5 revealed that over 67 percent of children and over 57 percent women suffer from anaemia.

(Illustration: Aroop Mishra/The Quint)

Anaemia has continued to be a thorn for India through the years if the National Family Health Surveys (NFHS) are to be believed. The NFHS-5, the latest of the surveys, revealed that over 67 percent children and over 57 percent women suffer from anaemia.

We are now being told that the NFHS is, in fact, not to be believed in this regard. The upcoming NFHS-6 will thus not record anaemia.

The survey employed a digital haemoglobinometer which uses capillary blood to measure haemoglobin. Several studies have reported that capillary blood isn’t reliable and may report higher or lower haemoglobin levels.

The gold standard for measuring haemoglobin is venous blood, that is, blood drawn from veins. The NFHS acknowledges this and carries a footnote, “As NFHS uses the capillary blood for estimation of anaemia, the results of NFHS-5 need not be compared with other surveys using venous blood.”

In other words we have always known not to use capillary blood tests as a diagnostic measure for anaemia. We have always known that the NFHS isn’t comparable with other surveys that use venous blood for measuring haemoglobin.

The NFHS, with all these caveats, is a nationally representative survey that also provides data at the state and district level for anaemia. This will no longer be the case.

Why NFHS Data Is Crucial For States?

The survey which samples around 7 lakh individuals will not document anaemia. Instead, this estimation shifts to Diet and Biomarkers Survey of India (DABS-I) which will sample a much smaller number for the same.

The DABS-I will use venous blood and will hence need more trained personnel for carrying out the testing. (Capillary blood requires only a finger prick.)

Perhaps, it is important to have such a national and state representative survey that will indicate more accurate levels of anaemia.

However, the lack of district level data raises alarms. If we look at the latest NFHS data, we can see that there is a lot of variation in the levels of anaemia within a state.

For instance, an International Food Policy Research Institute (IFPRi) compilation based on NFHS-5 shows us the districts in each state which are performing poorly.

For instance, see these figures from Karnataka and Rajasthan that show the highest burden districts for anaemia in children. 

This information allows for corrective measures to be introduced in the required districts appropriately. If the NFHS does not carry out anaemia estimation district wise, the state will need to address it.

Lack Of Data More Worrying In the Backdrop Of Mass Interventions

This is especially worrying in the backdrop of the mass interventions for anaemia. Some of them have been around for a long time (like the IFA tablet supplementation) and some are additionally being rolled out like the fortification of rice with iron.

A recent report has suggested that fortification of rice with iron has been rolled out despite the government not satisfying its own checks for the same. Both these blanket solutions disregard the many causes of anaemia.

Anaemia can have genetic, dietary, as well as other acquired causes. Iron supplementation may play a role in curing iron deficiency anaemia but even in these cases iron is not sufficient to cure the problem.

In fact, iron supplementation can be harmful in several cases (thalassemia, sickle cell disease, etc). Then, depending on universal iron fortification and provision of the same through ration shops poses a threat to the health of the people of the country.

Zooming Out On Anaemia

That anaemia is an issue for India is indisputable. Any doctor who has worked in a government hospital labour ward will tell you the number of times they have treated pregnant women with haemoglobin of 4 grams per decilitre (venous). These are just the ones that reach the hospital.

Anaemia is thus not a problem in isolation. It impacts infant and maternal mortality. It causes cardiac illness and fatigue. It causes deterioration of overall ability to fight infections. And it can hinder the growth and development of children.

From proximate causes like infection, inflammation, chronic illness, cancer, dietary deficiency, and even loss of blood to larger causes like food security, employment, caste disparity, gender discrimination – all the causes of anaemia must be addressed if we are to improve the health of the nation.

On the contrary, we are zooming out and getting a blurrier picture of the situation.

As the data regarding districts will be unavailable it will become tougher for the state governments to focus on areas where anaemia levels are higher.

How can you compare coverage of iron supplementation with the change in anaemia levels if you don’t have information regarding the same?

In the absence of this information, the pumping of iron into the diet of Indians would be a shot in the dark.

Even if we are to accept that the method of measuring haemoglobin through capillary blood is imperfect, we need to know the trends regarding the same.

Universal solutions for problems that vary locally can be harmful and imply a callousness to the health of people.

From researchers and activists to local governments to civil society organisations, the nationally representative data disaggregated down to the district level has been an important tool for advocacy and to address anaemia and strengthen our response to it.

Failing to tackle anaemia while investing in insufficiently tested measures while reducing sample sizes for upcoming surveys does not appear like a promising plan to address the looming specter of anaemia.

In the backdrop of changing patterns of diseases and overburdened health systems, we cannot afford to look away. We must look closer.

(Dr Shivangi Shankar is a Medical Doctor currently studying Public Health. She writes about mental health, doctor-patient relationships, caregiver health, awareness regarding diseases, issues concerning healthcare workers, and public health in India. This is an opinion piece and the views expressed above are the author’s own. The Quint neither endorses nor is responsible for the same.)