Published Nov 04, 2026 | 7:00 AM ⚊ Updated Nov 04, 2026 | 11:25 AM
Anaemia cannot be addressed without a functioning healthcare system that can identify its causes. (iStock)
Synopsis: In a strongly worded open letter, public health experts have challenged a proposal to expand the use of double-fortified salt to combat anaemia, warning that adding iron to iodised salt without adequately addressing the condition’s multiple underlying causes risks perpetuating India’s anaemia crisis.
India has been fighting anaemia for years, distributing iron tablets and fortified food among the vulnerable population. Still, millions of women and children remain anaemic.
The government temporarily discontinued its fortified-rice programme in February 2026. Now, a proposal by researchers to expand the use of double-fortified salt (DFS), which combines iodine and iron, has sparked another debate.
Though the government has not yet announced the replacement, public health experts are not impressed. They questioned whether expanding iron fortification without adequately identifying the underlying causes of anaemia would address India’s nutritional crisis.
Health for All, a collective of doctors, researchers, and public health professionals, sought the scientific rationale for successive iron-fortification interventions and the guiding health priorities.
In an open letter titled “Hopping from One Disastrous Intervention to Another for the Management of Anaemia in India,” the collective accused policymakers of favouring commercialised solutions over a comprehensive public health response.
“It must be made clear at the outset that any intervention must do no harm,” the letter warned.
The criticism followed the Centre’s February 2026 decision to temporarily discontinue rice fortification after an IIT Kharagpur study raised concerns about the stability of added nutrients under prolonged storage conditions.
The decision came after years of government investment in public welfare schemes to distribute iron-fortified rice, folic acid and Vitamin B12. Yet, the crisis remains unresolved.
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The methodology used to estimate India’s anaemia burden has come under scrutiny. Researchers have questioned whether capillary blood testing in national surveys may have overestimated anaemia prevalence compared with venous blood measurements.
Based on this argument, the government decided to map estimates through the Indian Council of Medical Research (ICMR) and the National Institute of Nutrition’s Diet and Biomarkers Survey in India (DABS-I).
Meanwhile, other researchers have countered, saying venous blood has been used for screening and is good for comparison, also easier to do in the field over large samples.
However, there is a catch. Data from the National Family Health Survey (NFHS) 5 showed 67.1 per cent of children under five and 57 per cent of women aged 15-49 were found anaemic during 2019-21. These figures were higher than those recorded in the previous survey. Interestingly, the government called the data-collection methodology skewed and said it showed a higher prevalence that was far removed from reality.
Doctors felt that these surveys couldn’t see the woods for the trees. “What is more troubling is the question India has failed to adequately answer: How much of its anaemia burden is actually caused by iron deficiency, and how much is being driven by other nutrition deficiencies, infections, chronic diseases, reproductive-health conditions and poverty?” they asked.
Speaking to South First, Dr Deepa Bhat, Professor and Head of Anatomy at JSS Medical College, JSSAHER, Mysuru, said iodised salt was a significant achievement in India’s public health landscape, but adding iron to it presented a complex challenge.
She argued that anaemia serves as an indicator rather than a definitive diagnosis. In tribal areas, a large share of anaemia cases is attributed to conditions like sickle cell disease, thalassaemia, B12 deficiency, and infections, none of which iron in salt addresses.
“Despite this, the current strategy is to introduce DFS initially in districts with high anaemia rates and significant tribal populations, precisely where haemoglobinopathies are prevalent. Since the removal of the warning label for sickle cell and thalassaemia patients from iron-fortified foods in 2024, families lack guidance on whether this salt is suitable for them,” Dr Bhat said.
Dr Sylvia Karpagam, a public health doctor, and Dr Veena Shatrugna, Deputy Director (Retd), National Institute of Nutrition and Steering Committee Member, Right to Food Campaign, argued that anaemia cannot be addressed without a functioning healthcare system that can identify its causes.
“Anaemia management therefore primarily has to be done by a functional and comprehensive public healthcare system where screening for inclusion and exclusion criteria is followed by appropriate interventions,” they noted in the letter.
Their intervention came at a time when scientific research has been challenging the assumption that iron deficiency accounted for most anaemia in India. A 2025 venous-blood-based study across eight Indian states, published in the European Journal of Clinical Nutrition, found that iron-deficiency-associated anaemia accounted for less than one-third of overall anaemia in the populations examined.
The findings, experts said, did not negate the benefits of iron supplementation for people who needed it. However, they questioned how effectively universal fortification could address a condition with multiple causes.
The letter pointed to reproductive health conditions, chronic diseases, infections and other clinical factors that can contribute to anaemia. Iron is essential for haemoglobin production and many biological functions. They argued, however, that excessive iron accumulation can be harmful, particularly in people with certain iron-overload disorders.
The risks depend on the amount and form of iron consumed, existing iron status and underlying medical conditions. The Health for All letter also questioned the strength of evidence supporting double-fortified salt as a population-wide solution.
A 2022 Cochrane review found that double-fortified salt probably reduced anaemia prevalence by around 21 per cent compared with iodised salt, although improvements in haemoglobin were modest and the certainty of evidence varied across outcomes. The reviewers called for stronger real-world studies to establish its effectiveness under routine conditions.
Dr Bhat’s primary concern was over the risk of false assurance. “If individuals assume the salt is ‘curing’ anaemia, they may cease seeking medical attention, leaving hereditary blood disorders undiagnosed. Fortification should not outpace diagnosis. Each DFS implementation in a tribal district should be accompanied by anaemia assessment and sickle cell screening via the existing NSCAEM platform.”
Also Read: Girls in families that prefer sons have higher anaemia rates
The doctors also challenged the tendency to promote fortified staples while leaving fundamental nutritional inadequacies unaddressed.
Drawing on national nutrition data, their letter pointed to widespread deficiencies in Vitamin A, zinc, B12, vitamin D and folate among children.
“The proper management of nutritional anaemia requires, apart from iron, several nutrients such as protein, vitamin C, B Complex, Vitamin A, Zinc, Selenium, magnesium, copper, etc.,” they wrote.
They argued that a cereal-dependent population cannot achieve nutritional adequacy merely by adding selected micronutrients to rice or salt.
The experts also raised a politically sensitive issue: The affordability and accessibility of nutrient-dense foods, including eggs, meat, pulses, milk, vegetables and fruit.
Iron from animal-source foods is generally more bioavailable than non-haem iron from plant foods. Vitamin C can improve non-haem iron absorption, while compounds such as phytates can inhibit it.
The authors questioned whether food fortification policies distracted attention from the economic and social barriers preventing families from eating diverse diets.
Their letter asked whether populations with inadequate access to nutrient-rich foods should instead continue to be offered supplements and more fortified samples as the principal response.
Also Read: India has no new anaemia figures
India’s anaemia control efforts included supplementation, deworming, testing, treatment and interventions targeting non-nutritional causes.
The current concern is whether the broader components have received the same attention, resources and accountability as the distribution of tablets and fortified food. How many women with persistent anaemia were screened to identify the underlying cause?
Experts said these questions become particularly important when large-scale interventions are changed before their long-term impact is fully established.
The temporary discontinuation of fortified rice and the subsequent debate over double-fortified salt offer an opportunity to reconsider India’s approach.
For a country confronting anaemia on such an enormous scale, the answer cannot be to move from one fortified staple to another without establishing who needs additional iron, who needs other treatment, and why so many Indians continue to have inadequate diets.
(Edited by Majnu Babu)
