Why anemia needs its own SDG indicator

Anemia is an important condition to address, yet isn’t always getting the global or national attention it deserves despite being linked to and impacting the health and well-being of so many affected across the globe, said Lena Wahlhed, director of alliance development at HemoCue, a health care company developing medical diagnostic products for point-of-care testing.

It should have its own indicator within Sustainable Development Goal 2 on ending hunger and achieving improved nutrition, as well as in SDG 3 on health and well-being for all, she said.

Anemia, according to the World Health Organization, occurs when an individual is deficient in certain nutrients, sometimes as a consequence of malaria, or associated with infectious diseases such as tuberculosis, or HIV. It is most prevalent in low- and middle-income countries, especially among young children, adolescent girls, and pregnant women. But anemia is also related to noncommunicable diseases such as diabetes, mental illness, and cancer, and can lead to life-long impaired health, said Wahlhed.

Wahlhed believes if more hemoglobin testing took place, it would help to identify anemia and address its causes. “When the SDGs were established, the measures that were agreed to for malnutrition in SDG 2 were stunting, wasting, and being overweight,” she said. “They are lagging indicators — the leading one may actually be anemia,” she said.

Wahlhed said that implementing anemia screening programs for the affected populations may improve health and reduce maternal mortality, as well as reduce the future number of stunted and wasted children. A low hemoglobin level indicates the presence of anemia, and such tests should have its place also in resource-constrained settings.

Sitting down with Devex on the sidelines of the 78th session of the United Nations General Assembly, Wahlhed explained the intersection of anemia with other illnesses, how diagnostic tests can be made more accessible, and why world leaders need to give anemia its own “headline.”

This conversation has been edited for length and clarity.

Anemia doesn’t quite get the global attention of other diseases but can have serious repercussions on health. Can you explain its impacts and how it intersects with other illnesses?

If I have anemia due to malaria and cannot correct this, or don’t know that I need to correct it, then the next time I get malaria and my hemoglobin level drops further, it could be fatal.

A young girl who cannot correct a low hemoglobin level may enter pregnancy being anemic and risk passing that on to the baby. While it may be more prevalent in LMICs, it’s important to address globally. As years go by, noncommunicable diseases such as diabetes may be present. Anemia is one of the most common blood-related disorders in diabetes and may be present also as an early indicator of chronic kidney disease. While anemia per se is not a diagnostic criteria on its own, in the later CKD stages, it’s a factor to look out for.

Anemia cuts across the continuum of life and should therefore also be part of the continuum of care. It's an increasingly important parameter to look at. You need to not just see anemia but the reason for it. Because that reason needs to be corrected in different ways. There is an awareness, yet the awareness needs to be translated into action.

Anemia also has the effect that you get tired, you get weak, and you don't have the energy to do the things you enjoy, or study, or work — tasks that can affect your mental health as well. Depression and anxiety have also been linked to anemia.

What is HemoCue’s role as a health care company in tackling anemia and these other associated diseases?

HemoCue was founded 40 years ago by two laboratory engineers who were frustrated because, at that point in time, there was no robust, easy-to-use system for hemoglobin which was, and still is, such an important parameter. As the saying goes, they said “There has to be another way to do this differently.” So they developed the microcuvette and an analyzer. That microcuvette contains the reagent that’s needed to perform hemoglobin measurement. Then you have the analyzer that's factory calibrated, and that facilitates ease of use. If I go to my primary care center in Sweden or the United States, they have the HemoCue hemoglobin device. And if I go to a rural entity in Africa, Latin America, or in Asia, they can use the HemoCue Hb system and do so without sacrificing quality. You should not have to sacrifice quality and accessibility just because of where you live. Everyone is entitled to the diagnostics that are needed. Everyone is entitled to essential health and essential diagnostics.

What are the barriers that prevent such diagnostic tests from being available in every health care center around the world?

I think funding. Awareness. Connecting awareness to local needs to local implementation, and to translate this to adequate treatment options based on its likely cause. Resolving conflicting agendas and translating knowledge into action. If we look at mother and child health, adolescent health, pregnant women, malaria and HIV, diabetes care, cancer screening and mental health, all those situations ought to include hemoglobin testing. It can be done as part of primary care, at the community level by midwives or community health workers.

How critical are such diagnostic tools when thinking about trying to achieve universal health coverage?

They go hand in hand. Essential diagnostics and essential medicines are a very good place to start to achieve UHC at the primary care level — or first line of care level. Without diagnostics on hand, it becomes difficult to treat the right patient the right way. I think these should be incorporated into the dialogue along with looking at what health issues are prevalent and be guided by the Appendix to the WHO Essential Diagnostics List on how to be equipped — and as was highlighted here at UNGA, the importance of midwives, community health workers, and nurses who are doing a tremendous job in serving their communities. The many different causes of key health issues are important to address. Anemia hasn't had its own headline, so to say, but it has been underneath all of them.

If there is one thing I hope to achieve, it is to be the voice for this important matter — to allow the doctors and nurses the diagnostic tools they need. As part of the global community and a representative of HemoCue — a company that has the solutions to make a difference — I see myself as a key advocate for “walking the talk” and universal health coverage. The importance of diagnostics was also shared at the side discussion during the World Health Assembly in Geneva earlier this year.

Five years from now, what progress would you have liked to have seen made?

Improved health in women and pregnant women across LMICs. For a pregnant woman, her pregnancy and her childbirth actually depend on her health as an adolescent, because if she enters her pregnancy being anemic, that affects both herself and her baby. It is an intergenerational cycle, which I think is important to address. I hope that more women have healthy pregnancies and deliveries and that more babies are born healthy and are allowed to thrive.

I hope that we can also support the most vulnerable women and all those being affected by HIV and tuberculosis. We tend to think about NCDs as something that is most prevalent in high-income countries, but that is not the case. There is a high incidence of diabetes and cancer also in LMICs. I hope that we can look at health for everyone and do so with a holistic view. What’s important is to see the person in their own specific context and use the essential diagnostics to do as much as possible at the first line of care.

What was also discussed during UNGA was CKD, NCDs, and the prevalence of anemia in these different groups: what are the similarities, and who do we actually need to look into? It might be that they have a low-income and vulnerable life, and maybe don't go to the health care centers. There needs to be a different way of finding these women.

When I was at WHA in Geneva earlier this year, I met professor Dr Woo Lin Ying who had started the Rose Foundation in Malaysia. She shared the importance of anemia but also their novel ways in screening for cervical cancer. Cervical cancer has a higher prevalence among women living with HIV. These women often do not go to the primary health care center, but they need to be found. So the foundation went looking for these women in different places and had a different kind of dialogue. It is all about health for all and leaving no one behind. It’s about determination and preference of leading indicators so that we can act to prevent and not determine the lagging consequences in hindsight. It’s about adherence to WHO essential medicine and the WHO Essential Diagnostics List, supporting WHO Anemia Action Alliance and WHO Diabetes Compact to build sustainable primary or first line of care. And we should use UNICEF’s Let’s Test program.

HemoCue would be delighted to be the partner along the way — in the planning, implementation, and for sustainable usage of diagnostics for UHC, including anemia and diabetes programs— making sure we leave no one behind.

For more information about HemoCue’s point-of-care essential diagnostics, visit hemocue.com or send an email to AnemiaAction@hemocue.se or EssentialDiagnostics@hemocue.se.