Health activists question exclusion of anaemia from National Family Health Survey

Public health activists in Karnataka have released a document questioning the basis for union government’s decision to exclude anaemia from the upcoming National Family Health Survey (NFHS-6). They say the research paper based on which the government made its decision was unsound.

Anaemia is the cause of 20 to 30% of maternal deaths, and lack of measurement and interventions would have disastrous consequences, the document says. Anaemia prevalence in India was 40 to 65% as per NFHS-5.

The document prepared by public health doctor Sylvia Karpagam, Siddharth Joshi of the civil rights group Ahara Namma Hakku, and Dr Veena Shatrugna, retired deputy director at the National Institute of Nutrition, has been endorsed by around 100 people so far, mainly doctors. It would be shared with the health ministry, ICMR, UNICEF, etc., Dr Karpagam said.

The document says that government’s decision to not measure anaemia was based on a research paper published in Lancet Global in 2021. The paper said that WHO’s haemoglobin cut-off that NFHS followed was incorrect for the Indian population, as it had been developed based on studies among white adults. It went on to develop a cut-off for India that’s 1-2 g/dl lower than the global standard, which would indicate a much lower anaemia burden for the country.

The document argues that the methodology of the Lancet paper was flawed mainly because of the population it studied. Hb cut-offs for the country should be arrived at based on the Hb levels of healthy populations that have no social, economic or nutritional constraints in accessing nutrients. But the paper was based on a sub-sample from India’s Comprehensive National Nutrition Survey (CNNS) of 2019, which was not a healthy or representative population, the document says.

Of the 8,087 people from the CNNS sub-sample, the majority were from rural and backward communities. As per CNNS, only 3-9% of children they surveyed had a minimum acceptable diet or iron-rich foods, yet the Lancet paper used this survey’s sub-sample to define “healthy population,” the document says.

The Lancet paper didn’t look at the clinical consequences of anaemia such as maternal deaths as well.

The document also points to an Indonesian study which had strict criteria to relook at cut-offs, and found their cut-offs to be comparable to WHO’s.