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.
India’s food politics, and the barriers to consuming iron-rich foods
The bioavailability of iron in iron-rich foods ranges from 70-86% in organ meats and red meats to 19-25% in vegetables such as spinach, lettuce, etc. A daily dietary intake of 40 mg of ascorbic acid or Vitamin C through foods such as amla, lemons, oranges, guava, etc. considerably enhances the absorption of dietary iron. In fact, the presence of even small quantities of meat and Vitamin C in a meal enhances the absorption of iron from both plant (non-haem) and animal (haem) food sources.
However, as with most plant-based foods, cereals and millets contain anti-nutritional factors such as phytates, tannins and oxalates which reduce the bioavailability of iron, so fortifying these food groups especially with iron is a wasteful intervention. A meta-analysis published in 2019 showed that fortification of rice with iron makes no difference to the risk of developing anaemia or iron deficiency.
Several reports and studies provide irrefutable evidence that diversity of food is where India is most lacking. There is a need to shift beyond cereals and millets (which offer energy but not enough nutrients) to include, in adequate quantities, milk/dairy, eggs, meat (poultry, fish, red meats), vegetables, pulses, legumes, fats/oils, etc. Without all of these components in the diet, no amount of fortification is going to make the Indian population healthy.
The United Nations Food and Agriculture Organisation (FAO) reports that India sees the lowest meat consumption per person among all Organisation for Economic Co-operation and Development (OECD) member countries, at 3.9 kg per capita in 2023 (this includes poultry, sheep, pork, beef and veal meat). The main barriers identified in consuming these foods are related to availability, affordability, accessibility, knowledge and cultural preferences. Interestingly, Kapoor and Debroy themselves acknowledge in their article that whole grains contribute mainly to calorie intake, and that nutrient-dense foods such as fruits, vegetables, legumes, meat, fish and eggs are consumed in lower quantities in India.
In spite of this, India being a caste-ridden society innately rejects all animal source foods other than milk and dairy as ‘tamasic’, ‘polluted’ and ‘untouchable’, thus erasing most iron-rich foods from the menu. This poster by the Food and Nutrition Board of the Ministry of Women and Child Development, which makes no mention of organ meat or red meats among foods to be consumed for the prevention of anaemia, is a case in point.
This implicit caste-based prejudice against iron-rich foods, leading to their erasure from health and nutrition discourse, is reflected across the board even by doctors, researchers, bureaucrats, nutritionists, civil society and elected representatives.
Even as the government is pushing unscientific interventions such as rice fortification on people, it is also actively taking away nutrient-dense foods from our plates. A concerted effort is underway to criminalise and erase all those nutrient-dense animal source foods which challenge the myth of Indian vegetarianism — through cattle slaughter bans, restrictions on meat trade, and awarding of mid-day meal contracts to ‘sattvic’ organisations such as Akshaya Patra which overtly and covertly oppose including eggs in the mid-day meal scheme.
Kapoor and Debroy acknowledge that “inadequate protein intake is a concern”, and that a balanced and diverse diet theoretically can provide all the necessary micronutrients for a healthy life. But why is a balanced and diverse diet now pushed into the realm of the theoretical? Is it only theoretical because the ‘practical’ is sabotaged by irrational casteism and communalism? If indeed the country was governed based on evidence, then policymakers would have taken necessary cognisance of this article by Dasgupta et al (2023) which quantifies how beef bans in India have reduced haemoglobin levels of women in beef-eating communities by 1.2 g/L (grams per litre) and increased severe anaemia by 27% of the mean level in those communities.
Fortification is not a solution to hunger and malnutrition
While doing nothing to address anaemia, fortification will only increase food costs and dependence on corporations, while reducing the shelf life of foods and taking away food sovereignty from communities. Taboos and prejudices around food, especially among those wielding power, should be addressed seriously. Interventions to improve the country's nutritional status have to be based on sound scientific principles rather than a caste-corporate nexus. Traditionally consumed animal meats, poultry, eggs, fish, roots, greens, vegetables, pulses, etc. have supported local economies, protected families from poverty and contributed vital nutrients to their meals, but attempts are underway to derail these existing foods and economic systems.
Supporting traditional, sustainable options for production and consumption of nutrient-dense foods while subsidising meat, dairy, eggs, vegetables, pulses, legumes, oil, etc. is the only way forward to raise the quality and quantity of Indian diets. Jumping on the fortification bandwagon without due diligence will be hugely detrimental to the country’s already precarious health and nutritional status.
Dr Sylvia Karpagam is a public health doctor and researcher working on Right to Health and Nutrition, especially of marginalised and vulnerable communities. Views expressed here are the author’s own.