The case for action on anemia — leave no one behind

By Devex Editor 14 June 2016

A community health worker screens a mother and her baby at the Sambhavna Trust Clinic in Bhopal, India. Improving nutrition and avoiding anemia is one of the best investments we can make to achieve lasting progress in global health and development. Photo by: Bhopal Medical Appeal / CC BY-NC

Iron deficiency anemia is the most widespread nutritional disorder in the world, affecting over 1.6 billion people, with the highest rates being South Asia and Central and West Africa.

It disproportionately affects children and women of reproductive age with far-reaching health consequences such as cognitive dysfunction and an inability to reach  their full potential. It may be because nutritious food or iron supplements are not available, but it can also be that malaria during pregnancy has not been detected and acted upon. Untreated anemia due to malaria may lead to the inability to fulfill a healthy pregnancy and deliver a healthy baby. For this reason the 1,000 days between a woman’s pregnancy and her child’s second birthday offers a unique window of opportunity to shape a healthier and better future.

The right nutrition during this 1,000-day window can have a profound impact on a child’s ability to grow, learn and rise out of poverty. Acting on anemia and reducing its prevalence  can help drive progress against the other global nutrition targets; and to shape a society’s long-term health, stability and prosperity.

What are the actions?

Improving nutrition and avoiding anemia during this window is one of the best investments we can make to achieve lasting progress in global health and development. In order to know who is at most risk, screening for anemia is key.

In recognizing this, in 2012 the World Health Assembly endorsed six global targets for improving maternal, infant and child nutrition with the goal of achieving them by 2025.

As African Development Bank President Akinwumi Adesina pointed out in an April interview with Devex, malnutrition still often doesn’t get the kind of attention that it should.

“You see a child — the child is playing on the playground. But that child is too short for their age. They are stunted. Their brain is gone. You only feel the impact in the future,” he said. “So we want to take it to what I call ‘grey matter infrastructure.’ In the same way in which we invest in infrastructure for growth, I want us to invest in grey matter infrastructure for Africans. We’re going to raise the game on this.”

“It’s not acceptable to me that Africa is losing 11 percent of its [gross domestic product] because of malnutrition, and also that we have 58 million kids who are stunted,” Adesina said. “That is the future of Africa being wasted right there. So it’s very important for us in Africa to take decisive action to end it.”

One of the WHA targets is a 50 percent reduction in anemia among women of reproductive age.

Maternal anemia is associated with higher risk for mortality and morbidity in expectant mothers and low birth weight, prematurity and risk for impaired physical and cognitive development for the baby. Given that it is also associated with other global nutrition targets — including stunting and wasting — WHA member states agreed that combating anemia is vital for not only people’s health but their nations’ productivity and development.

Nutrition and the SDGs — and anemia?

The 17 Sustainable Development Goals and their associated 169 targets were recently officially adopted; the indicators will provide governments with a very clear picture of what they need to do, and what would serve as further value-added actions.

While some of the indicators will not be applicable to all countries, the full implementation of the indicators are vital in order to “leave no one behind,” as pledged in the 2030 agenda.

According to target 2.2 in Global Goal 2 on Zero Hunger, the stated aim is to eradicate “all forms of malnutrition” and it mentions specific population subgroups including children under 5, adolescent girls, pregnant and lactating women, as well as older people.

“Many organizations — including Save the Children and UNICEF — have called for a comprehensive way to measure progress in this target that measures all forms of malnutrition, and measures malnutrition in all the groups mentioned in the target as agreed by member states,” said José Manuel Roche, head of research at Save the Children UK, who has represented the organization at multiple IAEG-SDG meetings.

Despite an initial proposal to measure six indicators for target 2.2 including stunting, wasting, overweight, breast-feeding, anemia and mid-upper arm circumference, the measurement has been limited to the three lagging indicators, leaving out the leading indicators, anemia, breast-feeding and MUAC.

Ana Lucía Márquez Escobedo from the Hunger Project Mexico, who has been reviewing the indicators and advocating for changes with the Mexican government and IAEG, said it was disappointing anemia was not included as part of the SDG indicators.  

“We need the right indicators. We need to know not only if people are increasing their calorie intake, but whether their nutrition is improving,” she said. “That is why a measurement such as anemia is so key.”

Overcome the challenges

Meera Shekar, lead health and nutrition specialist at the World Bank, told Devex one of the biggest challenges to anemia reduction was its perceived complex nature.

She explained that barriers to anemia reduction were predominantly rooted in poverty — from timely access to health care, lack of women’s empowerment and poor sanitation. Shekar noted that while diet is a critical prevention strategy for anemia, there was a desperate need to strengthen nutrition knowledge and awareness of iron needs, complemented by ensuring poor people have access to affordable, iron-rich foods.

“While supplements are an effective means to prevent and control some forms of anemia, they will not be sufficient to eliminate the problem, nor do they present a sole, sustainable solution,” she said. “Unfortunately, most countries only finance anemia prevention and control efforts for pregnant women, and these are not often delivered at scale or with sufficient quality.”

“Much work remains to identify effective models and scaling up the delivery of interventions for the prevention and control of anemia for children, non-pregnant women, and entire populations,” Shekar added.

How to diagnose anemia

Though anemia is not directly included as a target indicator in the Global Goals agenda its importance makes organizations around the world highlight the need to tackle the issue.

Business Sweden consultant Christian Hellqvist Herder, who works on United Nations and EU affairs, said that it “makes sense” to measure anemia in order to tackle nutrition and the SDGs, adding that “if we’re actually going to do this worldwide then we need to see what’s happening now with anemia.

“What we’d like is that the World Health Organization, UNICEF, Save the Children and other nongovernmental organizations give recommendations to every member country to measure anemia because it will gain the people, support the communities and help their country,” he said. “While it’s up to every individual country to decide, I’d really like to see that recommendations be given because anemia is so important when it comes to nutrition.”

Hellqvist Herder added that developing a comprehensive global anemia screening program would be invaluable and advocated the measurement of hemoglobin — to detect anemia — using a solution where the results are delivered immediately and accurately.

Swedish company HemoCue develops and manufactures such devices, which are already being used in more than 130 countries,  also in demanding climates. The HemoCue Hb solution appears to be reaching those who need it most — for example, reaching female garment workers in the southern state of Karnataka, India, where the state labor department has an intensive anemia screening and treatment program for workers; it is also being used in large public health programs around the world, while at the same time being used in high-end facilities.

Improve outcomes for the future

The early detection of anemia could have the potential to mitigate the long-term consequences of the disorder, said Dr. Jeffrey Griffiths, professor of public health and community medicine at Tufts University School of Medicine in Boston. Griffiths is also involved with the Feed the Future Innovation Lab for Nutrition, the U.S. government’s global hunger and food security initiative which looks at the linkages between agricultural interventions and practices and nutrition and health across Asia and Africa.

“It used to be thought that so long as anemia was treated then any earlier period of anemia could be wiped away,” he said. “However, studies from Central America show that children who had anemia treated were at substantial disadvantage compared to children who had not had anemia. Early detection might mitigate these long-term consequences.”

HemoCue’s hemoglobin measurement device. Photo by: HemoCue

According to Griffiths, that’s why the early detection of anemia using HemoCue’s hemoglobin measurement device — which he describes as “a global gold standard” and “accurate and easy to use” — is so vital.  

The World Bank’s Shekar noted that cost-effective technology that could strengthen the diagnostic capacity of resource-constrained health systems and improve nutrition surveillance was a “positive solution in our books.”

The benefits of HemoCue solutions for anemia are also recognized by Save the Children, which believes it is the most effective instrument to assess anemia in the field. The organization is about to start using it next month in Mali for a World Bank-funded project.

Save the Children UK’s Manuel Roche said that while the Zero Hunger goal was aspirational, the way it was going to be measured should also “reflect the ambition expressed in the Agenda 2030 declaration.”

The SDGs — leave no one behind

And looking ahead, given that every second pregnant woman and about 40 percent of preschool children in developing countries are estimated to have anemia, the Hunger Project Mexico’s Márquez Escobedo said now was the time to move from the discourse of the SDGs towards concrete, practical action and implementation.

 “The SDGs are about not leaving anyone behind. We need to make sure the agenda is owned by rural poor communities … and we need to know that not only their calorie intake is increasing but their nutrition is improving. That is why a measurement such as anemia is so key.”

Where resources are limited, addressing anemia does not need to be a separate program: it is of profound importance and can be included in malaria, malnutrition and HIV/AIDS programs — but also as a general health indicator and capacity-building initiatives. Although women and children are most vulnerable, it is too important to leave anyone behind.

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