There is a rush to cash in on micronutrient deficiency in India through fortification of food. However, Health experts say fortification should be done though evidence-based strategies (Courtesy: Nandi Foundation).
Andhra Pradesh Foods, a state government enterprise, is ramping up its fortified food production capacity. It provides ready-to-eat and ready-to-cook foods like upma mix, sweet porridge and khichdi mix, fortified with iron, zinc and other vitamins, to infants and pregnant and lactating women under the Centre’s Integrated Child Development Scheme (ICDS).
The effort to double its production and increase the number of beneficiaries from three million to five million has come following its partnership with the Global Alliance for Improved Nutrition (GAIN). The Swiss NGO has offered it a grant of US $1.8 million. “It is also providing us technical support, for instance, to increase the shelf-life of fortified food products,” says P Satyanarayan Reddy, managing director of AP Foods.
Andhra Pradesh is not the only state where fortified food is the flavour of the times. Global NGOs, pharma companies and international donor agencies are all scrambling to provide aid, technology and partnerships to fight malnutrition, or hidden hunger, in India. According to UNICEF, one in every three children in the country is malnourished.
For instance, PATH, an international NGO, along with US pharma giant ABOTT, is pumping $1.5 million to introduce iron-fortified rice in the Indian market under brand name Ultra Rice. In 2009-10, PATH launched pilot projects in Rajasthan and Andhra Pradesh where it fed Ultra Rice to around 245,000 schoolchildren under the mid-day meal (MDM) scheme. When asked if the NGO studied the impact of the fortified rice on the children, Dipika Matthias, director of PATH’s Ultra Rice project, said, “As the introduction scheme was not a clinical trial, no biological data was collected from the children.” The project, also funded by the US Department of Agriculture, Bill & Melinda Gates Foundation and GAIN, plans to reach out to five million people over the next three years through government food distribution schemes like the Public Distribution System (PDS), MDM scheme and ICDS.
| Let’s get it clear
Fortification: It is a process in which external nutrients (vitamins and minerals) are usually added in chemical forms to commonly consumed foods to increase the nutrition level.
Biofortification: It is a technology where a nutrient is either increased or added to a crop through conventional plant breeding or by tweaking the genes through GM technology.
How fortified
If you think eating fortified or bio-fortified food is enough to meet your micronutrient deficiencies, think again. Micronutrient availability to human body depends on three factors: quality and quantity of micronutrients and ability of the body to absorb a particular nutrient.
B S Ramakrishna, professor of gastroenterology, CMC Vellore, says micronutrients have a longer shelf-life in drugs than in fortified food. Minerals like iron and zinc do not get completely absorbed by the body. In a healthy person, 10 per cent of iron ingested gets absorbed. He cautions against excessive intake of vitamins. Fat soluble vitamins like A, D and E should be taken under guidance as body has no mechanism to get rid of the excess. They can get deposited in liver and lead to complications.
Even biofortified crops have limitations. “The nutrient content of added beta-carotene decreases with time in bio-fortified crops,” says K N Rai of ICRISAT. NIN experts say light sensitive and labile nutrients like Vitamin A, B-complex and iodine also degrade over time.
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Although intentions behind fortification of food could be genuine, nobody knows what is going on. There is no monitoring on the safety issues associated with fortified food products. In several states pilot projects are going on through government schemes without any knowledge of the government.
In October 2011, while reviewing the implementation of MDM scheme, the world’s largest school feeding programme, a mission to Madhya Pradesh found that NGO Naandi Foundation was supplying fortified meal under MDM scheme but government officials remained oblivious of it. The mission received information that the Foundation was fortifying wheat flour with iron, folic acid and zinc on alternate days. “During our visit, we found there was no permanent nutrition expert posted in the centralised kitchen. We were told that the nutrition expert visits when required from the Foundation’s Hyderabad headquarters,” says Sachin Jain, a mission member and advisor to Supreme Court Commissioners for Madhya Pradesh. His team noticed several other irregularities, such as there was no transparency in purchase and procurement; machine-made chapattis would became so hard that children find them difficult to eat. The situation is likely to prevail in other states too, Jain adds.
Naandi Foundation, which has been providing mid-day meal to over a million children in five states since 2003, says it supplies fortified wheat and lentils. “We had experimented with fortified rice using PATH’s Ultra Rice. But we suspended it as it formed lumps on cooking. Children did not find it palatable,” says Leena Joseph of the Foundation. The non-profit claims a study by the All India Institute of Medical Sciences in 2010 showed haemoglobin levels in children rose by 10 per cent after consuming its fortified food for three months.
Studies by the National Institute of Nutrition (NIN), a body of the Indian Council of Medical Research (ICMR), however, showed an otherwise result. “Consumption of iron-fortified rice through MDM for eight months significantly raised the level of stored iron in body. But it has not made any significant additional impact on haemoglobin status, says K Madhavan Nair, micronutrient research scientist with NIN. It takes at least four to five years to observe the actual impact, he adds. Researchers with the institute say fortification should be done through evidence-based strategies.
ICMR has set guidelines in this regard. For example, a kg of wheat flour should be fortified with 60 mg of iron and 1,500 microgram of Vitamin A. But whether NGOs conform to the guidelines can only be monitored by the Food Safety and Standards Authority of India. FSSAI did not respond despite repeated communications asking whether it has rules and regulations in place for fortifying foods supplied under government schemes and whether it monitors the products.
The next big revolution is biofortification.
Unlike fortification, biofortification is a process where nutrients are increased in a food by tweaking the crop.
ICMR has already formed an Interagency Group on micronutrients to look into techniques to improve nutrition of food through biofortification.
K N Rai, principal scientist with the Internation Crops Research Institute for the Semi-Arid Tropics (ICRISAT), says biofortification is a better way than fortification. “This is a more natural way to improve nutrition. It solves the problem in a better way through the grains that people are already eating.” He added that at present ICRISAT is working on increasing iron and zinc in sorghum and pearl millet and beta-carotene in pigeonpea and groundnut in India (see ‘India set to grow biofortified crop’, Down To Earth, March 1-15, 2011). Nigeria, Mozambique and Zambia are already growing biofortified cassava, sweet potato and maize, he adds. B Sesikeran, director of NIN, says biofortification is still in the initial stage of scientific development. With time, it may become an ideal technology. But unlike fortication, it would not be suited for fortifying a food grain with multiple micronutrients, he adds. Loveleen Kaur Khera, a dietician in Chhattisgarh, says before deciding what is better, we must understand the Indian psychology. Vitamin pills are a good source of nutrients, but they are counted as medicine. Similarly, fortified food are not considered natural. Besides, stability of micronutrients in fortified food is a concern.
Biofortified food faces a bigger challenge. The commonly used technique to grow such crops is genetic engineering, which is under cloud on safety issues. Since colour and taste are important aspects of the Indian food, people would not accept any new product unless it is palatable, she adds.
For instance, people in West Bengal are complaining against the fortified wheat flour provided under PDS. It is red in colour and does not taste good. Its shelf-life is short. Khera says natural food is the best source of nutrition.
One tries every day to develop new mechanisms in the thoughts and into execution to get wonderfully effective and highly efficient operations in a hospital. The trial and error methods end mostly into errors, wonder why?
While theories would tell a lot about best management tactics to be successful in managing hospital operations, it would be easier for some to understand a few commonest ways which are conveniently disastrous for smooth operations in a hospital. Hospital managers (those who have failed and those who may fail) need to understand and stay away from these practical failure mechanisms:
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Operating without strategy and strategy without vision
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Visibly centralised power
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Leading from the front , yet from the back office
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Drivers with no ownership
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Fire fighting
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Distance from the consumer
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Pound wise and penny wise too!
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Multi tasking teams and units
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I know the best, if not , still follow me
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It’s all yours, I need results
Excerpts from the article :
4. Drivers with no ownership
We have fantastic team, excellent managers, branded clinicians and alert executives all around and we are paying them all handsomely (often said that more than others would). Do we need anything else to be best in our services and functions?
We certainly wouldn’t need anything apart from this, if we have to lose them very soon. Nothing seems to work like handsome salaries, yet handsomeness loses its sheen in absence of belongingness and ownership. In absence of ownership, suddenly all would come to the top management and ask for salary hikes or would move on.
Can you answer a situation where all your ‘key’ resources come one by one and ask you, “I am not being paid enough here” or that “I am really satisfied here, yet I have made up my mind to leave because I have other reasons”!!
And even worse is when the teams start talking “What do we get for this extra effort, come on be relaxed”!
5. Fire fighting
“Hey there is a patient fighting on the reception, ask the manager to solve it”.
“The manager is busy solving a consultant’s problem of ‘AC making noise’, sir!”
“Ask the PRO to go there on the reception.”
“One PRO is escorting a VIP sir, to the station, the other one is busy doing logistics for JCI visit”.
“Then you go and give me a closure report for the problem”.
“I have to complete your file, Sir”.
“Ohk, do it, then coordinate with the managers and consultants to come to my cabin, we have an urgent meeting today, give me photocopies of these papers please and then you go to the reception.”
Heavens! The hospital is losing it; we can’t keep managing everything when it comes. These are micro level problems; unfortunately we are apt at doing all this at macro levels as well. Remember “if you get excellent results in fire fighting you are never going to prevent the fire from happening”, and a fire fighting team is more costly, inefficient and unreliable then a preventive mechanism.
The detailed article (All Ten Keys) is available below:
Keys to Failure in Managing Hospital Operations
Dr Rakesh Parashar
The massive fire at AMRI hospital, Dhakuria, Kolkata (Advanced Medicare & Research Institute Ltd.), on 09-12-2011 not only exposes the readiness of Indian Hospitals to prevent and handle disasters but also screams loud about the insensitivity of the hospitals towards the patient safety.
While insensitive and unaccountable patient care in Indian hospitals has been repeatedly talked about, the advent of high end super-speciality hospitals with so called ‘State of the Art’ facilities has been shown as an answer to the lack of patient centric approach of the hospitals. Widely emphasized often that the hospitals are ‘planned’ to handle all the disasters have proven to be an eye wash.
The hospital authorities have claimed that all fire fighting equipments were in place in this particular hospital, even after such a horrible fire. Why such equipments are there if those were of no use or are they all dummies to say that we meet the regulatory requirements or we meet the fire safety standards of NABH or some similar certification? Was there any training to the staff or any patient education to secure them in such a situation? If yes, how effective has it been? When would we value the ‘people with no choice’ or patients?
It’s not about a rare incidence but about doing some justice to their (hospitals’) own business. How ethical is it to allow even a scope for a place meant to save lives to turn into a death trap? It is not the story of one hospital but a mirror to the real situation of places where many people gather everyday with hopes to get well and go home to live longer lives! This makes it very clear that a mere certification (AMRI is NABH certified as well) does not ensure patient safety and quality unless it is seen as a responsibility toward the patients or ‘people with no choice’ who are often termed as ‘customers’ in the business jargon of the hospital ‘sector’.
While the patient has no choice but to hand over his life into the hands of such facilities, the governance has been lax enough to make basic preventive mechanisms a regulation. Lack of regulations, awareness and trainings of the staff, poorly planned facility and non accountable management of the hospital are the foremost reasons behind such tragedies.
HCIF condemns this tragedy and shares a deep pain with those who have suffered or are suffering. We wish to come up with disaster handling and emergency response awareness for hospitals, visitors and other health care organizations.
We appeal to our readers and conscious citizens that we ask for the basic safety information in the hospitals (as patients, attendants, activists..) which should extend to cover any hospital specific hazard ranging from hospital borne infections to disasters such as this one.
-By Dr Rakesh Parashar
(Health care management consultant)
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