In a government school in rural Telangana or an urban slum in Hyderabad, morning assembly is often interrupted by a familiar thud. A girl, usually around 14 or 15, suddenly faints. She likely has had a full plate of rice for dinner and a packet of biscuits for breakfast. Yet, she faints, because of a sudden fall in the oxygen level in her blood. This is not a one-off case, but a common phenomenon in many south Indian states.
States like Telangana, Tamil Nadu, Karnataka, Kerala, and Andhra Pradesh boast of the highest GDPs, literacy rates, and healthcare indices in India. Yet, when it comes to the nutritional status of adolescent girls, they are statistically indistinguishable from, and sometimes worse than, poorer northern states.
These states have a long history of running the mid-day meal scheme successfully and pioneering in providing adequate food for the children. How do states that feed their children so well still fail to nourish them?
The answer lies not just in biology, but in the sociology of the food plate: caste-based dietary exclusion, the urban slum trap, sanitation challenges, and environmental factors that hinder nutrient absorption.
Hidden hunger and its medical roots
To understand the crisis, we must first define the enemy. According to the World Health Organization (WHO), anaemia is a condition where the number of RBC (Red Blood Corpuscles) cells or the haemoglobin concentration within them is lower than normal, leading to reduced oxygen absorption and transport in a human body. This manifests as fatigue, light-headedness, shortness of breath, sudden black-outs, and an overall cognitive decline – symptoms that impair a girl's ability to focus in class or engage in physical activities.
In south India, anaemia takes the form of "hidden hunger," where girls consume enough calories, mostly from carbohydrates like rice, but lack critical micronutrients such as iron, folate, and vitamin B12. Adolescence exacerbates this, as menstruation and growth spurts increase iron requirements dramatically.
This biological vulnerability is particularly acute in rural south India, where adolescent girls face additional challenges like heavy agricultural labour during growth spurts, increasing energy demands and iron loss. A 2025 study in rural Dharwad, Karnataka, found 47.4% anaemia prevalence among adolescent girls, linked to poor dietary diversity and seasonal food shortages.
Without matching diets, girls slip into anaemia shortly after puberty. Environmental enteropathy, a gut condition caused by chronic exposure to faecal pathogens, further damages nutrient absorption, turning food into a futile intake.
A wealthy region with poor blood profiles
The statistics are jarring. Despite south India’s economic might, the blood profiles of its teenage girls tell a story of chronic neglect. According to the National Family Health Survey-5 (NFHS-5, 2019-21), 59.1% of adolescent girls (aged 15-19 years) in India are anaemic. In the south, the figures challenge notions of "progressive" development:
Telangana: 64.7%, higher than the national average.
Andhra Pradesh: 60.1%, also above average.
Karnataka: 49.4%, below average but still affecting nearly half.
Tamil Nadu: 52.9%, close to the national figure.
Kerala: 32.5%, the lowest but not immune, with 35-40% in some subgroups.
Furthermore, 15-25% of girls under 18 in these states face stunted growth or malnutrition, with the prevalence of anaemia often higher in rural areas. For instance, in Telangana it is 72.8% in rural and. 64.7 in urban per NFHS-5.
Caste gradients exacerbate this: Scheduled Caste (SC) and Scheduled Tribe (ST) girls in Karnataka and Telangana show anaemia rates 12-15% higher than general category girls.
This is a socio-economic catastrophe in the making: an anaemic adolescent grows into an anaemic mother, perpetuating cycles of low birth-weight babies and maternal mortality.
Beyond poverty: A mix of biology and sociology
If financial stability isn't the missing link, what is? The causes are multifaceted, blending biology with sociology, affecting both rural and urban girls, but often more severely in rural areas due to limited access to nutritional requirements.
The caste factor: Caste influences access to iron-rich foods. In government schools and hostels, menus are often standardised to avoid offending dominant castes, excluding affordable, iron-rich meats, which are staples for Dalit and Adivasi communities.
NFHS-5 sub-studies reveal a stark caste gradient: SC/ST girls suffer from higher anaemia due to "dietary exclusion", not just poverty. Upper-caste girls face absorption issues from phytates in vegetarian diets, while SC/ST girls lack access to nutrient-dense traditional foods stigmatised in institutional settings.
The gender paradox: Anaemia strikes adolescent girls disproportionately, creating a stark gender divide: NFHS-5 reports 59.1% in girls versus 31.1% in boys aged 15-19 years. Biologically, menstruation causes monthly iron loss, compounded by growth spurts. Sociologically, intra-household bias favours boys with better portions of nutrient-rich foods like meat or eggs, as seen in rural Tamil Nadu and urban Telangana households. This paradox is worse in rural areas, where girls' anaemia reaches 60%, perpetuating cycles of inequality and higher maternal risks later in life.
The rural access trap: While urban slums dominate discussions, rural areas in south India, which is home to over 70% of the population, face unique barriers. Limited healthcare infrastructure means fewer anaemia screenings and delayed deworming. Seasonal malnutrition from monsoon-dependent agriculture reduces access to fresh greens and proteins, while distance to anganwadis hinders supplement distribution. In rural Kerala and Andhra Pradesh, studies from 2025 highlight how poor road connectivity exacerbates this, leaving girls more vulnerable to chronic infections and nutrient gaps.
The urban slum trap: While the rural girl battles distance and scarcity, her urban counterpart faces a different, denser enemy. Urbanisation myths assume city girls fare better, but latest data debunks this. In Chennai and Hyderabad slums, poor drainage and shared toilets lead to recurrent worm infestations, with parasites feeding on blood and causing internal bleeding. A 2019 study in Kancheepuram found 36% of urban schoolgirls had intestinal parasites, directly linked to anaemia.
The rice trap: South Indian diets are cereal-heavy, offering little iron, with intra-household distribution favouring males, leading to a 'male-female paradox' where girls, despite similar environments, suffer 59.1% anaemia rates compared to 31.1% in boys (NFHS-5).
The junk trap: Working mothers, often domestic helpers in urban areas or agricultural laborers in rural ones, leave at dawn, resulting in "tea and biscuit" diets for daughters – calorie-filled but iron-deficient. In Bengaluru slums and rural Karnataka villages, obesity-linked anaemia emerges from high-calorie junk food or seasonal food scarcity.
The sanitation trap: Malnutrition in the south is driven also by environmental enteropathy, where gut linings are damaged by faecal pathogens from open drains, preventing iron absorption. A hygienic rural home might absorb 15% of dietary iron; a Bengaluru slum absorbs only 5%.
Robust policies, leaky implementation
Both the Union and state governments have recognised this crisis with robust frameworks.
At the national level, Anemia Mukt Bharat (AMB) employs a 6x6x6 strategy: six interventions (including IFA supplementation and deworming) for six beneficiary groups via six mechanisms. Weekly Iron and Folic Acid Supplementation (WIFS) partners with schools and Anganwadis for "blue tablets." Mission Poshan 2.0 focuses on dietary diversity.
State-specific initiatives also are implemented in plenty. Telangana’s Indiramma Amrutham (2025) distributes peanut chikkis for nutrient density. Andhra Pradesh’s Rashtriya Kishore Swasthya Karyakram (RKSK) funds hemoglobin testing and sanitary napkins. Tamil Nadu’s Puratchi Thalaivar MGR Nutritious Meal Programme has been fighting malnutrition since 1982. Kerala’s Mission Poshan 2.0 emphasises holistic wellness. Karnataka pushes fortified foods in mid-day meals.
Good schemes, bad sociology
Despite these strong policies and schemes, why do more than 50% of girls in the majority of south Indian states remain anaemic, with rural girls often facing higher rates (e.g., 60% rural vs. 55% urban in NFHS-5)?
Tablet fatigue and compliance gap: Teachers distribute "blue iron tablets," but girls discard them due to nausea and constipation, exacerbated in slums with shared toilets. Field reports show massive gaps between distribution and consumption, with little counselling.
Last-mile failures: In tribal and rural pockets like Wayanad (Kerala) or Raichur (Karnataka), supply chains break down. Anganwadis lack supplements or produce. Policies reach weaker sections inadequately, exacerbating the male-female paradox as girls in these areas may receive even less priority in household nutrition distribution.
Meat-free meals: Despite iron coming from animal sources being better absorbed, political resistance blocks eggs or meat in Karnataka schools.
Cure over prevention: Schemes focus on post-anaemia iron rather than preventive dietary diversification, like cooking with drumstick leaves or millets.
De-medicalising nutrition: From pills to plates
To resolve the paradox, south India must shift from pills to systemic changes.
Deworming as vital as feeding: Integrate "WASH-Nutrition" for slum sanitation to curb worms and enteropathy. More effective than food quantity alone.
Diverse, inclusive diets: Move beyond cereal-heavy meals, mandate bio-fortified crops like iron-rich pearl millet and double-fortified salt in mid-day meals. If meat is contentious, prioritise culturally sensitive options.
Promoting home greens: In rural contexts, this could include promoting home gardening for iron-rich millets and greens to counter seasonal shortages, as piloted in 2025 rural Karnataka initiatives.
Support for working moms: Urban anaemia ties to time poverty. Community kitchens, like Amma Canteens, are nutrient-focused and ensure breakfasts, breaking the ‘biscuit cycle’.
Tech-enabled tracking: Scale Andhra Pradesh’s digital hemoglobinometers for instant results; mandatory "health report cards." Fortification, like Telangana’s chikkis, makes nutrition automatic.
The girls of south India are the region's future doctors, engineers, and leaders. But they cannot build that future if they are too tired to stand through the school assembly. The wealth of these states must be measured not in GDP, but in their daughters' haemoglobin levels.
By addressing caste, slums, and sanitation sociologically, not just medically, south India can break the anaemia paradox, fostering healthier generations. This requires equal attention to rural realities, where access barriers and gender biases amplify the male-female paradox, ensuring policies bridge urban-rural divides.
John Roberts is south India regional director of Child Rights and You (CRY).