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Written by: Dr Sylvia Karpagam The Union government’s mass rice fortification programme, which it aims to implement nationwide by 2024, has been met with serious objections from several civil society groups and doctors ever since it was announced by Prime Minister Narendra Modi in 2021. The programme involves adding rice kernels fortified with micronutrients (iron, folic acid, Vitamin B12) to regular rice in a 1:100 ratio, and distributing it universally under the Public Distribution System (PDS), mainly to low-income families. The government claims that this is a cost-effective way to increase vitamin and mineral content in diets, to fight malnutrition and anaemia. This claim has been met with serious criticism from members of the scientific community who have repeatedly cautioned that rice fortification is likely to cause more damage than any measurable benefit, that it is not cost-effective, and that there isn’t adequate evidence to back its implementation on such a large, and mostly irreversible scale. The fact that all of these legitimate concerns are being summarily ignored shows how little evidence matters to those who sit in the higher echelons of decision-making. Yeasayers, in the meantime, regularly parrot the government’s claims of how good the rice fortification programme is for the country, ignoring all evidence and concerns to the contrary. A relentless spate of unthinking articles about the 'magical benefits’ of large-scale fortification of rice with iron are being published in India. The most recent one was published in The Mint on September 20, authored by Bibek Debroy (chairman of the Economic Advisory Council (EAC) to the Prime Minister) and Amit Kapoor (visiting scholar at Stanford University). “Rice fortification can help tackle our problem of hidden hunger,” the headline claimed. First of all, there is nothing ‘hidden’ about India’s hunger. It is in fact obscenely visible, except when shrouded behind green plastic sheets to be hidden from foreign visitors during events such as the recent G20 summit. The Global Hunger Index (2022) which uses multiple indicators, importantly child stunting (low height for a certain age) and child mortality, places India in the ‘serious’ category, at rank 107 out of 121 countries. But ‘hidden hunger’ has a different meaning here. And the micronutrient-related definition of ‘hidden hunger’ is the presence of multiple micronutrient deficiencies, as a result of consuming an energy-dense but nutrient-poor diet. It is estimated to affect more than two billion people globally, “particularly in low- and middle-income countries where there is a reliance on low-cost food staples and where the diversity of the diet is limited". An oversimplified solution to a complex problem That India does indeed have multiple nutritional deficiencies and that our children receive inadequate nutrition is well established. Data from National Family Health Survey 5 (NFHS-5) for 2019-20 shows that only 11.3% of children aged 6-23 months receive an adequate diet. The Comprehensive National Nutrition Survey (CNNS, 2016-18) found that 35% of children under five are stunted and 33% are underweight. Moreover, 18% of the children under five were deficient in Vitamin A, 19% in zinc, 14% in B12, 14% in Vitamin D, and 23% in folate. While one could manifest clinically with deficiency of one or the other of these nutrients, it doesn’t mean that the other deficiencies are absent. Picking a visible deficiency of only one nutrient such as iron, and attempting to replace it artificially through fortification, is like catheterising a sick patient while denying her oxygen, antibiotics, transfusions and all other essential support that she may need to get better. Although iron can often be the most common deficiency in cases of anaemia (wherein the haemoglobin levels are low), consuming this mineral doesn’t mean it will magically transform by itself into haemoglobin in the body. The proper management of nutritional anaemia requires several other nutrients such as protein, Vitamin C, B complex, Vitamin A, zinc, selenium, magnesium, copper, etc. If haemoglobin levels of a population have to be improved, foods that provide all of these nutrients are essential. Iron is not always a benign mineral In the standard therapy for severe malnutrition and newly diagnosed tuberculosis, iron treatment is initially withheld because infectious agents seek out this mineral to multiply and thrive in the body. TB treatment is initiated before anaemia is addressed. If the anaemia is due to the TB infection, it resolves with the TB treatment. Iron therapy is given only if the anaemia persists in spite of TB treatment. Similarly, early iron therapy in a person with severe malnutrition and impaired immunity can cause a flare-up of underlying infection. Considering that malnutrition and tuberculosis can often remain undiagnosed and therefore untreated in India, it’s hard to believe that policymakers would surge ahead with iron fortification of rice on such a large and irreversible scale. Is it because there is an underlying, unspoken understanding that these conditions affect the poor more than the elite? Results of iron and folic acid supplementation in Tanzania and Nepal in children aged 1-35 months show that routine supplementation in a population with high rates of malaria can result in an increased risk of severe illness and death, with the risks far outweighing any immediate benefits. This led to a premature termination of the trial. The authors advocated for revision of current guidelines for universal supplementation with iron and folic acid. Anaemia is an illness that has to be managed on a case-by-case basis. Large-scale, artificial introduction of iron can potentially have many detrimental effects. On the other hand, prevention of anaemia through an improved diet has the incomparable advantage of also preventing many other nutritional deficiencies that Indians are documented to have. Read more here...