Fortifying Lives

FOR A COUNTRY THAT HAS BEEN MARRED by malnutrition in children, India finally took a key step to reduce the problem recently when the Union Cabinet gave its approval to fortifying rice and supplying it under various nutrition programmes.

Under the plan, fortified rice—a staple in a large part of the country—will be provided for various programmes in a phased manner over the next two years. The cost: ₹ 2,700 crore, a relatively insignificant amount when compared to the gigantic outlays for various welfare schemes that are currently run by the government. In the first phase—already under implementation—fortified rice will be delivered under the Integrated Child Development Services (ICDS) and PM-POSHAN, earlier known as the mid-day meal scheme. By next March, this will be extended to the Targeted PDS (TPDS) and other schemes, covering districts with a high burden of stunting in children, and aspirational districts. Finally, by March 2024, it will be extended to the remaining parts of the country. So far, the Food Corporation of India (FCI) has purchased 88.65 lakh metric tonnes of fortified rice for this purpose.

The India-wide rollout of the plan comes after three years of running pilot projects in 11 states. In each of these states—Uttar Pradesh, Madhya Pradesh, Uttarakhand, Jharkhand, Chhattisgarh, Odisha, Andhra Pradesh, Telangana, Tamil Nadu, Maharashtra and Gujarat—one district was picked for implementing the scheme. In his Independence Day speech last year, Prime Minister Narendra Modi nnounced the fortification of rice to address the problem of malnutrition.

There is hardly any state in the country where the lack of nutrients, such as vitamins A, B12, and D, zinc, iron, folic acid and others, does not lead to growth challenges. The percentage of children who are stunted remains unacceptably high. This is not a function of the economic conditions of a particular state. Various iterations of the Comprehensive National Nutrition Survey (CNNS) have found stunting and even severe stunting among children. Stunting is defined as low height for a child’s age and wasting—low weight for height. Both conditions are due to malnutrition, among other causes. In both, a child is unable to reach his/her physical and cognitive potential.

The fortification programme needs intervention of the Centre as private suppliers may not have the wherewithal to supply the amounts needed

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In India, both are widespread and found in states with very different developmental orientations. In Punjab, a ‘rich state’, the CNNS for 2017-18 found that 24.3 per cent of children under the age of five were stunted and another 8 per cent were severely stunted. The state also reported wasting among children of this age. Similarly in Kerala, a state known for its ‘developmental orientation’, the percentage of children below five years of age who were stunted was 20.5 per cent. Micronutrient deficiency is again largely agnostic to the territory. The highest levels of vitamin D deficiency in children and adolescents have been reported in Punjab. Jharkhand has the highest percentage of children and adolescents with a deficiency of vitamin A.

Himachal Pradesh reports the same problem for zinc. Every state has its own catalogue of these deficiencies that have not received attention. Until now.

Indian foods are ‘calorie-rich’ but are imbalanced in terms of various nutrients. The best way to fix the problem is to diversify food intake to ensure that the Recommended Dietary Allowance (RDA) for micronutrients is met. But for various reasons—cultural, economic and behavioural—this does not happen. Over time, different strategies to address the issue have been tried. But this has often led to charged situations and nutrition experts have now veered away from strategies that advocate diversity in food intake. To overcome this problem, without forcing any behavioural changes, the best option is to fortify the most common items of consumption in the food basket. There is enough experience globally for the option to be replicated successfully in India.

There are different options available to handle the micronutrient crisis. Apart from fortifying rice with iron, double fortification of salt, with iodine and iron, is possible. Iodine fortification has been done for a long time in India. Wheat flour can be fortified with vitamin A, as can edible oil and milk. It made sense to go for fortifying rice, to begin with, as it is a staple in large parts of India. Other options can be tried in the time ahead after evaluating the results with fortified rice. At the moment, different states of India have different fortification regimes. In Karnataka, for example, fortified edible oil is available in all districts, double fortified salt in six, and fortified rice is in the pipeline in four districts. Goa has fortified oil and double fortified salt for all its districts. The pattern is repeated across different states and Union territories. The challenge now is to ensure a uniform system where all foods selected are fortified and made available across the country. This will take time.

Ideally, different states with their own particular problems should be able to formulate plans and take steps to sort this problem as health is a state subject. With the widespread prevalence of nutrient deficiency and the fact that key welfare schemes, such as the National Food Security Act (NFSA), ICDS and PM-POSHAN, are designed and funded by the Centre, it makes sense for the Centre to take the necessary steps.

Necessity is one thing, but doing what is needed is often a bureaucratic gauntlet in India. The problem has been visible for decades now but the essential steps were initiated only in recent years. The first step was to decide what to do. If the answer was clear—fortification—the practical steps needed took time. The first steps towards food fortification as a solution were taken three years after the NFSA was passed when discussion on fortification standards began. The same year, the Food Fortification Resource Centre was created under FSSAI. Three more years passed before these standards were notified. Anyone who follows how food regulations are evolved in India knows the multiple vetoes built into the system. Civil society, activists, nutritional bodies and standards organisations all have a say in what is finally notified. By the time the country was ready for the step, the pandemic arrived. As a result, government priorities changed and the focus was to get enough food for workers and persons stranded across the country.

THE COST OF FORTIFYING RICE IS WORTH NOTING and at ₹ 2,700 crore, it is a fraction of the annual food subsidy bill. This bill has gone up significantly since the NFSA was passed in 2013, on the eve of the 2014 General Election. In many ways, the fortification story tells of the policy failures over the decades in India. When the law was passed, there was a vigorous and often acrimonious debate on the cost of providing food security to each citizen. Different estimates were presented and many were ‘tailored’ to show that the cost was not exorbitant. At that time, no one paid attention to the issue of nutrition. With a bit more expenditure, the entire programme could have given a new direction to the issue of nutrition and health, especially for children. The step had to wait for nearly a decade but has finally been taken.

In the first phase, fortified rice will be delivered under the Integrated Child Development Services (ICDS) and PM-POSHAN, earlier known as the mid-day meal scheme

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India has a long history of fortifying food items. But that has happened over time and in bits and pieces. The programme to fortify oils with vitamins dates to the early 1950s. Similarly, the programme to iodise salt was launched in 1986 and rolled out in the entire country by 1992. As with all such programmes, there is no dearth of debate and controversy. That happened when the salt iodisation programme was launched, and one can expect the naysayers to enter the present rice fortification programme as well.

It goes without saying that there will be a number of challenges in the period ahead. For one, the fortification of staples like rice is new in India. Ensuring an adequate pick-up of the fortified grains requires communication strategies to reduce barriers to acceptability. India is a diverse country where habits and attitudes to adopting new things vary tremendously. Perhaps this is one reason, apart from logistics, that the programme is being rolled out over three phases, spanning three years.

The other issue is availability. While FCI and other agencies have bought 88.65 lakh metric tonnes of fortified rice, this amount will need to be augmented in the years ahead. At the moment, the emphasis is on providing enough fortified rice for existing programmes. Hence the initial rollout in key welfare schemes alone. The fortification programme needs intervention of the Centre as private suppliers may not have the wherewithal to supply the amounts needed. Over and above everything, the issue of maintaining quality standards and oversight, especially in the case of food items, poses challenges of their own. These are challenging issues that require time to resolve. Acceptability, availability and adaptation to local conditions will determine how the programme fares.

India is probably among the last major countries to adopt the fortification of food as a strategy to overcome nutritional challenges. The strategy is now used even in countries with far fewer resources than India. The effects are obvious: the number of children with stunting and who are wasted is embarrassingly high in India. The economic cost of stunting and wasting is high, even as it is hard to quantify. But its psychological and social damage is clearly visible to anyone who has cared to see children afflicted with what is a preventable condition. That it took India nearly 75 years after Independence to address it speaks of failure at multiple levels over so many decades.

About The Author

Siddharth Singh

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