We know how to treat anemia. So why is it still so common?

The staff at nonprofit CARE Guatemala were accustomed to seeing cases of anemia, which affects over half of infants in some rural and indigenous parts of the country. Still, program manager Ruben Jordan was shocked when he encountered eight-year-old Marjorie. Severe chronic anemia had impacted both her cognitive and physical development, leaving her unable to attend school. “Her hemoglobin levels were critically low, requiring hospitalization,” he said. Marjorie’s case was severe, but not uncommon. Globally, 1 in 4 people worldwide are estimated to suffer from anemia, a condition in which a lack of healthy red blood cells inhibits oxygen transportation around the body. Yet despite the prevalence of the disease and the availability of cost-effective solutions, little progress has been made in reducing the global burden. The 2012 World Health Assembly set a target of halving anemia in women of reproductive age — a group particularly at risk — by 2025. This was later extended to 2030, but not a single country is on track to meet this goal. Experts argue that tackling anemia requires a more nuanced approach that goes beyond iron intake to address social determinants, health care gaps, and better data collection. Part of the problem is that the initial symptoms, which include fatigue and poor concentration, are “insidious,” said Samuel Scott, a research fellow at the International Food Policy Research Institute, or IFPRI. “The impacts may not be visible compared to something like malaria,” he said. However, research has linked the condition to developmental delays in children, reduced concentration and cognitive function, and a staggering seven-fold increased risk of dying from life-threatening bleeding known as postpartum hemorrhage after childbirth. Policymakers and funders are increasingly recognizing anemia as a threat to progress on gender equality goals — women and girls are disproportionately affected — and to economic development. Lost productivity from physical and cognitive impairment is equivalent to almost 1% of global gross domestic product annually. Existing solutions Iron deficiency is the leading cause of anemia worldwide, and oral iron supplementation is, on paper, a straightforward and cost-effective solution — particularly for pregnant women, who are both more likely to suffer from anemia and at greater risk of adverse outcomes. In India, a vast government scheme provides iron and folic acid tablets free of cost to pregnant women from the second trimester onwards. However, iron pills often cause gastric discomfort, and adherence is low. Indian government data from 2019-2021 shows only 44% of women consumed at least 100 iron and folic acid tablets during pregnancy, despite the recommendation that they be taken daily. There is a “need for a greater focus on last mile delivery,” said Scott, with the current emphasis on procurement rather than less tangible goals such as strengthening delivery systems and educating women about compliance. Iron fortification of food can overcome some of these hurdles, by incorporating low, better-tolerated doses of iron into daily routines. Lucky Iron Life is a Canadian social enterprise that sells electrolytic iron ingots designed to be added to cooking pans. When boiled, the cooking tool releases 6 to 8 milligrams of bioavailable iron into each meal, “equivalent to eating a steak,” said partnerships manager Caitlin McKay. It can be reused an estimated 1825 times, or daily for five years, making it a reliable source of low-dose iron in the home and eliminating the burden of procurement — a process which largely falls on women, said McKay. A range of randomized controlled trials from independent research studies have found that adherence is high, and significantly reduced mild to moderate anemia. In Guatemala, Marjorie’s mother joined a CARE project which introduced her to the product, along with training on dietary diversity and improved hygiene practices. Within six months, Marjorie had “regained energy, improved concentration, and reintegrated into school activities,” said project manager Jordan. Partnering with local nonprofits such as CARE Guatemala, which understands the local drivers of anemia and can integrate the product into its existing programs, has been essential for social impact, said McKay. CARE Guatemala staff members provide visual guides on using the product, and “conduct hands-on demonstrations using local recipes,” said Jordan, which “ensures families learn how to use the product effectively and sustain its use over time.” The product itself is tailored to suit different cultural contexts. The original ingot was shaped like a fish, which is considered lucky in Cambodia. But when the company expanded into India, “we realized we need another shape to respond to vegetarians,” said McKay. The ingot is now sold to Indian consumers and nonprofits in the shape of a leaf. “It's really important that anything that you put in your food needs to be culturally appropriate,” said McKay. Another solution is to fortify the food itself. Micronutrient fortification of foods such as breakfast cereal, flour, salt, and milk, has helped to significantly reduce the burden of diseases such as goiter, caused most commonly by iodine deficiency. “That's the whole idea — making sure that you select a staple food or condiment that is widely consumed,” explained Venkatesh Mannar, who helped to popularize iodized salt in the ‘90s as a consultant for the World Health Organization. But fortifying foods with iron proved technologically trickier and can change the flavor and appearance of food. Fortified rice provided through India’s public distribution system, a government welfare program, was rejected by some recipients after rumors spread that it was made from plastic. Mannar argued that government support is needed to kickstart markets and gain public trust. Double-fortified salt, containing both iodine and iron, would be cost-effective if rolled out at scale, he said, costing just 15 INR ($0.17) per person annually in India. And like Lucky Iron Life’s ingots, the low doses mean it is also better tolerated than oral supplements, aiding adherence over the long term. “The basic technology has been established, and the efficacy has been established,” said Mannar. “Now it’s up to countries to take it to scale.” New research Low-dose food fortification can overcome issues of adherence, increasing iron stores in the body over the long term. But in severe cases, or when iron needs to be boosted rapidly such as during pregnancy, iron is often injected intravenously. Until recently, that has been difficult to do in low-resource settings without sufficient medical supervision, as infusions took multiple hours and held a risk of allergic reactions. But new drugs in use in countries such as the United States and Australia have made intravenous injections much quicker and safer, facilitating high-dose total iron replacement in a 15-minute infusion. “When I saw those drugs being used, I thought, well, that could be perfect for low-income countries,” said Sant-Rayn Pasricha, a clinical hematologist and researcher at the University of Melbourne. “We could rapidly restore a woman's iron stores even in just a few minutes, in an infusion with minimal risk.” His research team is currently conducting a series of trials in Malawi and Bangladesh funded by the Gates Foundation, to test the efficacy of intravenous iron compared to standard-of-care oral iron in pregnant women with anemia. Their research, published last month in the journal Nature, showed that intravenous iron given to Malawian women in the third trimester of pregnancy was clearly superior to standard-of-care oral iron in reducing anemia at the time of delivery. The benefits were seen until at least one month postpartum. Notably, however, a previous study where intravenous iron was given earlier on in pregnancy, in the second trimester, found no significant effect at the time of delivery. The team hypothesized that this may have been due to the presence of undetected malaria, which can also cause anemia, diluting results. Two ongoing trials in Bangladesh, which has a much lower incidence of malaria, will help to clarify — but Pasricha said that this highlights the need for more context-specific data on the prevalence and drivers of anemia. Evidence gaps Currently, however, there are huge gaps in the data, making it hard to target interventions effectively. Pasricha is working alongside a team of experts on a new Lancet commission on anemia, which is aiming to synthesize the reasons why global goals have so far not been met, he said. The team is documenting evidence gaps in our understanding of the biological and social processes that lead to anemia, as well as barriers to implementation and funding. A major data gap is on the prevalence of anemia itself, said Pasricha. Most of the global data we have on anemia is derived from capillary blood estimates — finger-prick tests that measure hemoglobin levels. These tests are easier to conduct in low-resource settings, but can lead to an overestimate of anemia prevalence compared to venous blood tests. This complicates efforts to pinpoint local causes and track progress — but it also creates dangerous space for ambiguity and political manipulation. When national survey data in India showed a rise in anemia cases, discrediting the achievements of an extensive government program, officials dismissed the results as faulty and switched data collection to an alternate methodology. Without full transparency and in the absence of comparable datasets, however, Scott is worried that this could create the misleading narrative that “the problem is disappearing. When, in fact, it would be due to a methodological difference,” he said. Better data is also needed on the underlying social determinants of anemia, said Scott. “When you look at what is possibly explaining the changes in anemia over time, we consistently see things like women's education, household socioeconomic status, family planning as the top factors,” he said. Evidence from the Philippines shows that increasing access to antenatal care and family planning services helped to reduce the incidence of anemia. But funders and policymakers neglect broader solutions in favor of iron supplementation and fortification programs, said Scott, which have more tangible metrics for success. “A large number of pills distributed does not necessarily mean a job well done,” he said. Research shows that in some regions, less than half of anemia cases could be addressed through iron supplementation, however. Other biological processes that can lead to anemia, such as acute or chronic infections, pregnancy, air pollution, or genetic disorders, are less well understood, said Pasricha. Without better research on how these issues intersect, “it's very hard to solve the problem in a specific manner.” In 2023, WHO launched the first comprehensive framework on reducing anemia, acknowledging that efforts so far had failed to address the complexity of the disease’s underlying causes. But, drawing on his research experience in Malawi and Bangladesh, Pasricha said it is time to move away from a single set of guidelines. “It's really evident that things are different between population sites,” he said. “Treating the whole low-income context as a single entity is not precise enough.” Update, Feb. 27, 2025: This article has been updated to clarify that Lucky Iron Life sells electrolytic iron ingots designed to be added to cooking pans.