Why Fortified Rice Isn’t A Silver Bullet For Poor Indians
Text by Kavitha Iyer
During fortification, the nutrients that are stripped from rice when it is processed, are reintroduced at a later stage.
It has been 18 months since the pandemic-induced loss of livelihood set “everything, absolutely everything” out of whack for Ahmadi Shaikh, and a daily cup of dal is still beyond reach for her family at dinnertime. Ahmadi, in her forties and mother of seven children, lives in Dharavi, once known as Asia’s largest slum. The ‘bissi’ or canteen she used to run, where migrant workers could eat lunch for Rs 40 ($0.55), remains closed since it went out of business during the nationwide lockdown announced in March 2020. Her husband does not have work, or wages, on many days.
Among the still-unspooling challenges associated with Covid-19 for India’s poor, Ahmadi lists nutrition as the most vital. So, like many in Dharavi, she is happy to hear that the rice supplied to poor households through India’s giant Public Distribution System (PDS), the world’s largest food subsidy programme, will soon be fortified, packed with more nutrients than ever.
“But will it make us less hungry?” she asks.
On August 15, in his Independence Day address to the nation this year, Indian prime minister Narendra Modi announced that by 2024, rice given to the poor in India through the PDS, the school mid-day meal scheme and other government programmes will be mandatorily fortified.
Food fortification is the practice of adding vitamins and minerals to commonly consumed foods at the processing stage, to increase their nutritional value. Across the developing world, large-scale food fortification is seen as a scientifically proven, affordable and scalable policy measure to address the problem of malnutrition.
Official data indicates that anaemia is a grave public health problem in India on account of being widespread—according to the National Family Health Survey (NFHS-4) in 2016, 53.2% of non-pregnant women and 50.4% of pregnant women were found to be anaemic
In 2020, NFHS-5 data showed that in 13 of 22 states and union territories where survey data was available, the number of children who suffered stunting had risen since the previous survey. In 12 states, the incidence of wasting had risen.
The prime minister’s message was on point. It’s time to tackle the malnutrition scourge; more nutritious rice will make healthier Indians.
But fortification of food items to tackle nutritional deficiencies is not a novelty in India, where fortified vegetable oil and iodised salt made their first appearance on grocery shelves in the 1950s. Around 2000, rice and wheat began to be fortified too. Fortified foods, along with a clutch of other supplementary nutrition schemes in an anti-anaemia mission, appear to have fallen short. But that is not the reason for growing concerns among nutrition experts and scientists regarding the proposed fortification of all rice to be procured by the government.
In January this year, the Food Safety & Standards Authority of India (FSSAI), a body under the ministry of health and family welfare, issued draft regulations for mandatory fortification of edible oil and packaged milk with Vitamins A and D. Before the prime minister’s announcement, in a pilot project, fortified rice was already being supplied through the PDS in 15 districts.
So, on one hand, there is the knotted matter of choice — what kind of rice poor Indians want to eat. But also, medical science and plain old common sense both pose the wider questions of why a more holistic approach to nutrition is not preferred, and whether Indian foods and diets have somehow been evolutionary failures in meeting nutritional requirements.
For Indians looking at the alarming incidence of anaemia and malnutrition, the dilemma is also how, if food comes from agriculture (some food, in any case), and nutrition comes from food, state plans for better nutrition are inexplicably disconnected from the farm. In the state’s view, the latter appears to have the limited role of producing calories, to then be rendered nutritious by industry.
It’s really Ahmadi’s question about hunger, turned on its head: Can the nutritional outcomes of farming not fulfil my family’s needs, and why not?
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One fifth of all the world’s rice production is in India, which also consumes more rice than any other country. The PM’s announcement means that more than 30 million tonnes of rice under various schemes will be fortified. That is a lot of rice to fortify, based on the premise that every second Indian woman may be anaemic.
That India houses an unbearable load of anaemia is itself a suspect claim, says Professor Anura Kurpad of St John’s Medical College in Bengaluru, also associate editor of the American Journal of Clinical Nutrition.
In a series of scientific papers (here and here), Dr Kurpad has made three significant arguments on the matter: First, there is under-estimation of haemoglobin levels and therefore overestimation of anaemia in the country, he says. Second, haemoglobin ‘cutoff’ levels to assess anaemia are themselves inappropriate for India and require revision.
And third, the prescribed levels of iron intake for Indians were earlier so high as to be neither required, nor even safe.
Dr Kurpad, chairman of the Indian Council of Medical Research’s (ICMR) expert committee on nutrient requirements of Indians and of the FSSAI’s nutrition and fortification scientific panel, believes it is ridiculous to believe today that almost an entire country, or 70%, is suffering from anaemia, or any disease. “That makes no sense. It’s nuts,” he says. “It is like a perfect storm. A variety of new data has come together to tell you that we’ve been doing the wrong thing.”
In one study based in the northern Indian state of Uttar Pradesh and published in 2019, Dr Kurpad and his colleagues showed that NFHS data underestimates blood haemoglobin levels, because finger-prick samples of capillary blood that government surveyors collect show lower haemoglobin levels than blood samples drawn from veins. Comparing venous and capillary blood samples collected from 1,000 women in UP, they found capillary samples pegging anaemia at 59.2%; but using venous samples, anaemia prevalence was 35.2%; almost half.
On the World Health Organisation’s haemoglobin cutoffs to define anaemia, Dr Kurpad explains that these were based on studies of predominantly white adult populations, done over 50 years ago. “A single cutoff for the whole world is itself being re-examined by the WHO. These are being consulted upon right now,” says Dr Kurpad. “But that process could take years. [There has been] no recommendation yet. But our stand on unnecessary fortification is being noticed by academics in other Asian countries.”
Finally, there is the previous inflated daily nutrient requirement for iron for women and children. Indian nutrient requirements used to be called RDA, or recommended daily allowance, published by the ICMR’s National Institute of Nutrition (NIN), and these were as high as 30 mg per day or iron for adolescent girls. This is a nearly impossible level of iron intake to fulfill through food without a large daily intake of meat.
Dr Kurpad co-chaired a committee to re-evaluate iron requirements that the NIN then corrected, the downward revision bringing it to 14 mg per day for women of reproductive age and 18 mg for adolescent girls, levels that Indian diets can well provide through diverse food groups in appropriate quantities. “We have overstated the diagnosis of anaemia in the country, and also the poverty of the Indian diet,” he says. What most poor Indians need, according to him, is the wherewithal to afford such a meal.
Traditional and heirloom Indian varieties of rice are packed with medicinal and nutritional properties. However, only a small fraction of these varieties are still cultivated.
Those simple meals could include traditional Indian rice varieties that contain up to 20 times more nutrients than fortified rice, according to Dr Debal Deb. “The problem is that people don’t know about these, and institutions are not interested in promoting or selling these varieties,” he says.
Nicknamed ‘India’s Rice Warrior’, Dr Deb is a scientist-turned-farmer who grows 1,460 traditional varieties of rice on his research farm in Odisha, perhaps one of the last vestiges of India’s rice diversity that once boasted of nearly 100,000 different varieties. “And I have the advantage of studying these 1,460 varieties. My laboratory is the only one in the world where we study medicinal properties of different varieties of rice.”
In multiple scientific papers, Dr Deb has written about the therapeutic and medicinal properties of rice varieties. Garib-Sal, for example, a variety known to folk medicine practitioners of West Bengal, was once recommended as a diet for patients with gastrointestinal diseases. Grown in very small quantities in the Purulia and Birbhum districts of Bengal, Garib-Sal looks wheatish in colour with its husk. Dr Deb’s studies showed that this variety of rice had traces of silver in its aleurone layer, or the outermost layer of the endosperm.
The biochemical and nutritive properties of Garib-Sal showed it had significantly lower levels of sugars, higher dietary proteins and more B vitamins than white rice varieties. Dr Deb says its micronutrients could prevent various immunodeficiencies. Other varieties he studied showed higher Vitamin A levels, more iron, more dietary fiber, etc.
Hundreds of rice varieties may have medicinal or nutritional properties that haven’t been studied. Hundreds more varieties are simply not grown any longer, and the few farmers producing some heirloom varieties find there is no market for them. Only public procurement or price support can bring profits to farmers growing these traditional varieties of rice, says Dr Deb.
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The whole thing is reminiscent of an old public service clip on state-run telly that showed a man cutting down a tree and then, missing its bounties, attempted to replace it with a plank of wood, festooned with green bits of plastic for leaves, says Dwiji Guru, an independent technology developer who has been working to popularise millets among growers, processors and consumers.
Not just heirloom or traditional varieties of nutrient-rich rice, but all rice loses nutritional value in the processing stage. Originally, milling of rice involved stripping rice grains of their husk. Since the last four or five decades, as a premium came to be placed on the whiteness of rice, millers put the grains through an abrasive polishing process that strips the bran layer, the dietary fibre rich in minerals. The bran then makes its way to another processing unit, to extract rice bran oil, a byproduct and an additional revenue stream, the cherry on top of white rice millers’ profits. The fortification of rice follows a similar trajectory as that of the television ad, stripped of nutrients during its processing and then re-processed downstream to reintroduce those nutrients.
The idea of fortifying rice as a panacea for malnutrition is also misplaced in its singular focus on rice, which is not a pan-India household staple. Or wasn’t so until recently.
Curiously, study groups on nutritional requirements for Indians, the Ministry of Health and Family Welfare, the Ministry of Women and Child Development and others agree that poor Indians’ diets need diversification. The poor need either nutritious items from various food groups provided to them as subsidies, or the ability to afford that diversity. Equating food with rice, and nutritious food with fortified rice, are both just as baffling.
Even though millets have become au courant among a small subsection of urban consumers, these hardy nutri-cereals have largely been replaced by wheat and rice.
Guru, who runs The Millet Foundation, believes the idea of putting more nutrients into rice because that’s what everyone is eating is “regressive”. He says, “Where are the nutrients lost in the food we eat? It is not lost in the rice, but in other things, which people are no longer eating.”
The dozens of millet varieties such as bajra (pearl millet) and ragi (finger millet) are good examples of foods no longer prominent at Indian dinner tables. They are rich in fibre, minerals, Vitamin B, calcium and antioxidants—common classification systems in India call them ‘nutri-cereals’. Over the decades, as India’s food subsidy programme and the Green Revolution focused on rice and wheat, millet cropping tended to yield lower remuneration. Farm area under millets declined, and a preference grew instead for farming sugarcane, cotton, maize and soybean.
Various state governments and the union government have tried to supply millets through the PDS, specifically as a measure to tackle hidden hunger and deficiency of micronutrients. Some states, including significant progress by Odisha, have begun to procure millets from farmers for distribution through the PDS. But for all their value as hardy, drought-resistant crops that pack a healthy punch, millets received neither the traction nor the force multiplying energies of commercial interest.
Millets cannot be seen as an alternative food staple. Instead, a holistic approach would be to tackle deficiencies through multiple sources of nutrition.
Farm area under millets fell by more than half in the decades since the Green Revolution. There is, indeed, a new resurgence of interest in millets among urban, conscious consumers, a sub-segment for whom diet diversity does not pose the problem of affordability. But experts also advise eating millets with care — in the absence of traditional wisdom about which seasons millets are best consumed in, and with what accompaniments or precautions, sudden and drastic changes in cereal choices pose health risks. Millets, or anything else really, cannot be seen as an alternative food staple in place of rice.
Guru points out that multiple surveys by civil society groups since the arrival of the pandemic have found poor Indians unable to afford dal, the primary source of protein in households that don’t consume or cannot afford meat. The idea that Indians’ nutrition needs can be resolved solely by fortifying rice is simply not rational.
Mumbai-based Dilnavaz Variava of the Anaemia-Free India Forum, was president of the Rotary Club of India’s rural development cell in 2013 when they partnered with a non-profit to set up kitchen gardens in Wardha in eastern Maharashtra.
The idea behind the initiative was to tackle iron and various other deficiencies through diet diversity. “Building up haemoglobin requires not only iron but also proteins, vitamins, folates, magnesium, zinc, selenium, etc,” says Variava, managing trustee of the Sahayak Trust.
An all-organic kitchen garden could make a measurable, scalable difference to haemoglobin levels, they found. These were gardens on which project participants grew and maintained more than a dozen varieties of vegetable plants. Three years later, the project wound down before it was taken up by Variava herself. Hearteningly, when her team surveyed the families that had been supported earlier, they found that 90% of the homes did not discontinue their kitchen gardens even when the programme’s support ended.
“They said they continued to maintain the kitchen gardens because they were getting fresh, toxin-free food at their doorstep, in abundance. They were saving money on vegetables, medical expenses were going down,” Variava recollects. The starter kits had been given to women, but families shared the labour, with older folk helping keep plants pest-free and children helping in the harvest.
Variava started her Organic Kitchen Garden For Nutrition programme in 2016, with 17 partners. They now have 240 partner NGOs, supporting 30,000 kitchen gardens during the last cropping season.
It is an approach the government can easily promote in rural India, government schools or other government institutions, emphasising that the vegetables are for self consumption, not for the market.
“Women, who normally eat last and have nothing nutritious to eat with their rice, will get vegetables, which will improve her health and that of her foetus, the health of developing infants and lactating women, and also tackle the issues of stunting and wasting seen in malnourished infants,” she says. Accessibility and affordability are assured too, for the food is available at their doorstep, and the cost of the garden is only Rs 100 in seeds, and the family’s hours of labour.
According to Variava, the government has been supportive of kitchen gardens, and can go a step further by providing seeds, and also cash support through the Mahatma Gandhi National Rural Employment Guarantee Act, India’s showcase anti-poverty scheme that guarantees employment, and wages, for 100 days a year.
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So, is food fortification bad?
Dr Kurpad’s paper published earlier this year, ‘When the cure might become the malady’, argues for caution in fortification. Just like medicines or antibiotics, he says, nutrients are beneficial in the right dose, but potentially harmful when consumed in excess.
Without a doubt, there are very poor Indians who need all the help they can get, including iron-rich and diverse diets as well as supplements. “But our policy response is to feed everyone in this country what we think is required by the poorest segment,” he says.
The lack of targeting is not innocuous, because more is often not better. Excess iron, for example, puts you at risk for diabetes or cancer, he says. “What we need is more precision nutrition, precision public health.”
This means re-assessing the impact of fortification programmes until now, and an honest assessment of the implications of mandatory fortification of hundreds of tonnes of rice. What poor Indians need is accurately targeted supply of fortified foods along with other measures, not an enormous market for rice fortification across the country.
