Rice fortification: Govt of India 'covering up' its one-size-fits-all approach to anaemia

By Dr Vandana Prasad, Kavitha Kuruganti 
An RTI response by the Ministry of Women and Child Development reveals knee-jerk and self-protecting measures in the form of a few circulars issued by the Ministry of Food and Public Distribution as well as the Ministry of Women and Child Development with regard to fortified rice being distributed in the country under government schemes.
These circulars, which are a desperate attempt by the Government of India, to cover up on an unscientific one-size-fits-all approach to anaemia in the country, are apparently in response to grave irregularities in the government’s fortification programme highlighted by Alliance for Sustainable and Holistic Agriculture (ASHA) and the Right to Food Campaign (RTFC).
The Government of India has started scaling up its rice fortification intervention even before the so-called pilots were completed, or evaluation lessons culled out, ignoring numerous scientific, holistic and community-controlled approaches to tackling malnutrition. Reports of fact-finding visits to various districts in Jharkhand and Chhattisgarh have been put out by these collective platforms in the months of April and May 2022, that highlight grave issues.
The two citizens’ alliances have been raising concerns over public health and other impacts from the Government of India’s baseless, massively-scaled up programme of fortified rice distribution in schemes such as PDS, ICDS, PMGKAY and MDMS/POSHAN, making fortified rice inescapable for the poor who rely on these programmes for their food.
A major health concern raised was on risks to citizens for whom iron is strictly contra-indicated, such as those with thalassemia and sickle cell disease (SCD). The FSSAI (Fortification of Foods) Regulations 2018 recognize this risk and seek to warn patients about the dangers of consuming such iron-fortified rice.
The risk is not just to these patients, as scientific evidence shows. Iron-fortified foods are contra-indicated for other conditions too, including acute infections, acute malnourishment, certain stages of malaria and tuberculosis, or even diabetes.
Ignoring the existing body of evidence, and widely-practised medical approach of avoiding iron for such medical conditions, the Government of India embarked on an ill-conceived and ambitious plan to feed iron-fortified rice to citizens, to tackle anaemia.
Such a one-size-fits-all reductionist solution to anaemia ignores numerous conditions specific to our country, and in fact showcases the disconnect between policy-making and actual situation of the poor.
What is shocking is that the Government of India, under pressure from the evidence showcased by ASHA and RTFC, is now escaping its responsibility by simply issuing circulars to state governments, asking them to “comply”.
On 27th May 2022, the Department of Food and Public Distribution, GoI issued a letter to Departments of Food and Civil Supplies and FCI to request compliance to FSSAI’s statutory regulations, drawing the recipients’ attention to Regulation 7 (which mandates a warning label for SCA and Thalassemia patients).
An email is issued by the same Department on July 13th 2022 asking for dissemination of notification dated 27/8/2021 on Food Safety and Standards (Fortification of Foods) First Amendment Regulations 2021 issued by FSSAI.
It says, “All States/UTs and FCI were requested therein to bring it to the notice of all concerned and ensure strict compliance” of the FSSAI notification “while distributing fortified rice under TPDS, ICDS, PM-POSHAN schemes and in other welfare schemes. This may be displayed at the Fair Price Shops appropriately along with the posters/banners about fortified rice”.
The Ministry of Women and Child Development followed this up with their own letter to all state governments, on 1st August 2022.
RTFC and ASHA said in a statement:
“It is irresponsible of the Union Government to thrust the reckless scheme of rice fortification onto state governments, but force them to bear the consequences of the same including statutory compliances. 

"State governments have been expressing helplessness in the face of GoI’s aggressive push of fortified rice in conversations with civil society groups, that too not from the Health Ministry but unreasonably by the Ministry of Food and Public Distribution.”
While this is so, the problem only gets compounded further now. Poor, unaware citizens in different parts of India will now be subjected to two different messages being put out at the fair price shops (while it is unclear what babies and children in schools are supposed to do with the new compliance-related circulars) – one that is promotional, and one that displays a statutory regulation.

Government is behaving irresponsibly towards citizens who are at risk from its fortified rice programmes

In a situation where no choices are being given to the beneficiaries and worse, in a situation when many citizens with contra-indicated medical conditions do not even know (unscreened/undiagnosed/unaware) that they are not supposed to consume iron-fortified rice, how are such circulars going to help?

RTFC and ASHA in the statement added:
“This is irresponsible behaviour from the Government of India, where they think their responsibility ends by such Circulars. What about choices for beneficiaries? What about the fact that many patients have not been screened and diagnosed? What about the fact that such labelling compliance will not help in a situation where fortified rice is being given in loose form, or cooked form?
“What about the fact that for many poor for whom such rice is contra-indicated, the government food schemes are their lifeline? What will happen to the entitlements of these people under National Food Security Act?”
When ASHA and RTFC conducted fact finding visits to Jharkhand and Chhattisgarh -- both states with high disease burden of SCD and Thalassemia -- to observe whether any steps had been taken to screen and protect such patients, they found that no steps had been taken apart from some lackadaisical compliance at times to the FSSAI labeling regulation, on gunny bags that reach dealer shops.
Since the rice is given in lose form in PDS and cooked form in school/ICDS meals programmes, and since many of the patients are illiterate, there was no way for patients to read labels. Moreover, most were undiagnosed since no screening was being done.
Such unsuspecting patients were given no warning and were being forced to consume iron-fortified rice as they were poor and couldn’t buy non-fortified rice from the market, said ASHA and RTFC.
India has one of the highest disease burdens of thalassemia globally with almost 3.9 crore carriers, as well as the largest number of children with β-thalassemia in the world. India also has highest prevalence of Sickle Cell Disease in South Asia, with some 2 crore estimated carriers.
India has been ranked the country with the second highest numbers of predicted SCD births. All such patients are at risk along with several others who are contra-indicated – such as those with Malaria and Tuberculosis, said ASHA and RTFC.