Last night, I began to watch Best of Enemies, an American film about school integration in Durham, a town in the deep South, at a time when the Ku Klux Klan functioned with impunity, and recruited young men to “save our way of life”, by intimidation, arson, lynching, and economic boycott.
ON OUT-MIGRATION. In the book US OF ASIA and its sequel EARLY MENON, South Indian states demand a say in how the taxes earned from their states are used and implemented in two north Indian states that famously have more seats and Parliament despite poor progress. When there is pushback, they institute a visa system for out-migrators from those states- they don't get jobs in South-Indian states unless they ensure control of budgets and implementation.
I'm curious about the source for the "anemia is a colonial concept" as my limited understand is that there might be more than meets the eye there. I did a deep-dive into anemia data in India last year, inspired by conversations with my father who has been working on implementing anemia screening camps for children in our hometown of Belgaum. One of the main research pieces I grappled with was the recent work done by Harshpal Sachdev and colleagues with data from the Comprehensive National Nutrition Survey. They asked a simple-yet-complex question - what happens if we use hemoglobin thresholds defined by the Indian population rather than those based on White populations, the latter of which define the WHO thresholds? Some of their results are published in this Lancet paper - https://www.sciencedirect.com/science/article/pii/S2214109X21000772 - the bottom line being that using nationally-derived hemoglobin thresholds dramatically lowers the percentage of people considered anemic. I believe the WHO is considering revising their one-size-fits-all thresholds for ones more tailored to the varying biologies of ethnicities - https://nyaspubs.onlinelibrary.wiley.com/doi/full/10.1111/nyas.14090.
I can't recall where I read this comment on anemia, but will try and dig it up.
But we've been down this road before, on stunting, saying that its OK if Indians are short, because Indians ARE short. Till they aren't - the average Karnataka resident is much taller than she was 2 decades ago. I think there's a reflexive defensive attitude here, when we know that nutrition, public hygiene and disease are problematic and we need better benchmarks on all fronts.
It's a great point and one that Brendan, the co-founder of Fortify Health brought up in his response, with a comparison to the United States and race -
"For example, in the United States, the standard measure of estimated kidney function (eGFR) was for years adjusted by race under the faulty logic that black people have more muscle mass on average, so higher levels of creatinine (an expected product of muscle breakdown) should fall within the normal range. There are significant consequences of this given that eGFR is used to determine eligibility for transplantation and directs medical therapy. Only recently have US doctors acknowledged that such a system was not accurately capturing poor kidney function and the risks and treatment indications associated with it, systematically introducing a lower standard of care for black patients. Examples like these should make us wary of insisting biological difference between populations, rather than other social structures, defines a “normal parameter.” "
He also brings up stunting in India -
"Stunting provides another example. Let’s suppose that in India, the average adult male height is 165cm whereas in Finland it is 180.7cm (wikipedia). We might want to conclude there is only a genetic difference responsible. But there is also a significant effect of stunting due to nutritional differences. As it turns out, childhood stunting in India has improved dramatically (62.7%->34.7%) over the last 20 years (World Bank) not because genes changed but because society changed. Even a “healthy” subgroup defined to establish a normal height for an Indian may show a distribution that is shifted towards lower values because of stunting, yet the distribution would be shifted towards higher values with nutritional improvement that leads to increased height and decreased risks of illness that may not lead to exclusion from a “healthy” sample."
I agree that we need to be very careful in ascribing biological causes to ones that could be primarily societal-driven, as in the case of stunting. But we also need to be careful not to underestimate biological causes of differences, because they do exist. Interventions seeking to address stunting in the Japanese would be a tad misguided for instance!
The tricky business with anemia is that we know large ethnic differences do exist for certain sub-types (the prevalence of sicke-cell anemia amongst people with Sub-Sahara African roots) and both iron and hemoglobin appear to have a very complex role in various biological processes...
I hundred percent agree that this is one of those questions that really should not be politicised but appears to already be so...
Much of the debate you addressed was about the cost-effectiveness of iron to ameliorate anemia, and one of the points made is that anemia is often due to infectious diseases (ID), hence iron is not enough. If one is concerned about anemia per se, and not about a specific line of treatment, then one needs to take a much wider view.
Lowering the standards is, I am sure, a hotly debated matter, and one I will look at...
As an Indian-American, my Anecdotal experience is that the second generation kids are taller and Heather than their parents. I would put this down to nutrition and clean air. Also as someone who grew up in Bihar ( now Jharkhand) , I see the stunting effects of malnutrition every time I visit. We are a continent, not a country.
May I add my prayer that we have safe, reliable, comfortable, accessible, affordable and sustainable public transport available in all corners of India (with type and frequency dictated by population density of course), so that we can stop driving our cars most of the time, and the rich and not so rich can travel side by side.
Intriguing. Also listened to your musings of the road trip to Bihar Sir, with Amit. Amazing insights and those naked truths of stunted growth of kids, sand mafia, No hope of future and no urge to even try fixing some plumbing problems at least .. stared right into our face. Leave aside the facade of being the world leader.
ON OUT-MIGRATION. In the book US OF ASIA and its sequel EARLY MENON, South Indian states demand a say in how the taxes earned from their states are used and implemented in two north Indian states that famously have more seats and Parliament despite poor progress. When there is pushback, they institute a visa system for out-migrators from those states- they don't get jobs in South-Indian states unless they ensure control of budgets and implementation.
A whole raft of speculative fiction can be written around the issue of the North-South divide on most socio-economic factors.
I hope - and largely believe - the nation will hold without internal barriers.
Thanks for writing this Mohit.
I'm curious about the source for the "anemia is a colonial concept" as my limited understand is that there might be more than meets the eye there. I did a deep-dive into anemia data in India last year, inspired by conversations with my father who has been working on implementing anemia screening camps for children in our hometown of Belgaum. One of the main research pieces I grappled with was the recent work done by Harshpal Sachdev and colleagues with data from the Comprehensive National Nutrition Survey. They asked a simple-yet-complex question - what happens if we use hemoglobin thresholds defined by the Indian population rather than those based on White populations, the latter of which define the WHO thresholds? Some of their results are published in this Lancet paper - https://www.sciencedirect.com/science/article/pii/S2214109X21000772 - the bottom line being that using nationally-derived hemoglobin thresholds dramatically lowers the percentage of people considered anemic. I believe the WHO is considering revising their one-size-fits-all thresholds for ones more tailored to the varying biologies of ethnicities - https://nyaspubs.onlinelibrary.wiley.com/doi/full/10.1111/nyas.14090.
It's still a complex subject however and there's good reason to be critical of this line of research/reasoning. If you happen to be interested in getting into the weeds, I'd recommend the back-and-forth between me and the founder of a non-profit Fortify Health on the EA Forum - https://forum.effectivealtruism.org/posts/2gG7eeDD5uqud4Rfm/cost-effectiveness-of-iron-fortification-in-india-is-lower [founder's response linked in the comments]
Akash,
I can't recall where I read this comment on anemia, but will try and dig it up.
But we've been down this road before, on stunting, saying that its OK if Indians are short, because Indians ARE short. Till they aren't - the average Karnataka resident is much taller than she was 2 decades ago. I think there's a reflexive defensive attitude here, when we know that nutrition, public hygiene and disease are problematic and we need better benchmarks on all fronts.
It's a great point and one that Brendan, the co-founder of Fortify Health brought up in his response, with a comparison to the United States and race -
"For example, in the United States, the standard measure of estimated kidney function (eGFR) was for years adjusted by race under the faulty logic that black people have more muscle mass on average, so higher levels of creatinine (an expected product of muscle breakdown) should fall within the normal range. There are significant consequences of this given that eGFR is used to determine eligibility for transplantation and directs medical therapy. Only recently have US doctors acknowledged that such a system was not accurately capturing poor kidney function and the risks and treatment indications associated with it, systematically introducing a lower standard of care for black patients. Examples like these should make us wary of insisting biological difference between populations, rather than other social structures, defines a “normal parameter.” "
He also brings up stunting in India -
"Stunting provides another example. Let’s suppose that in India, the average adult male height is 165cm whereas in Finland it is 180.7cm (wikipedia). We might want to conclude there is only a genetic difference responsible. But there is also a significant effect of stunting due to nutritional differences. As it turns out, childhood stunting in India has improved dramatically (62.7%->34.7%) over the last 20 years (World Bank) not because genes changed but because society changed. Even a “healthy” subgroup defined to establish a normal height for an Indian may show a distribution that is shifted towards lower values because of stunting, yet the distribution would be shifted towards higher values with nutritional improvement that leads to increased height and decreased risks of illness that may not lead to exclusion from a “healthy” sample."
https://forum.effectivealtruism.org/posts/SnSAJpPZjLj2JWC56/responding-to-recent-critiques-of-iron-fortification-in
I agree that we need to be very careful in ascribing biological causes to ones that could be primarily societal-driven, as in the case of stunting. But we also need to be careful not to underestimate biological causes of differences, because they do exist. Interventions seeking to address stunting in the Japanese would be a tad misguided for instance!
The tricky business with anemia is that we know large ethnic differences do exist for certain sub-types (the prevalence of sicke-cell anemia amongst people with Sub-Sahara African roots) and both iron and hemoglobin appear to have a very complex role in various biological processes...
I hundred percent agree that this is one of those questions that really should not be politicised but appears to already be so...
I read your note after I wrote my first response.
Much of the debate you addressed was about the cost-effectiveness of iron to ameliorate anemia, and one of the points made is that anemia is often due to infectious diseases (ID), hence iron is not enough. If one is concerned about anemia per se, and not about a specific line of treatment, then one needs to take a much wider view.
Lowering the standards is, I am sure, a hotly debated matter, and one I will look at...
Fanatical Vegetarianism is killing our young--add an egg to midday school meals.
More global integration and federalism is important as well
So true, Vladan.
I will make notes for my next version of this piece...which I will relook at a year from now.
Hmm...or anything with that protein content
As an Indian-American, my Anecdotal experience is that the second generation kids are taller and Heather than their parents. I would put this down to nutrition and clean air. Also as someone who grew up in Bihar ( now Jharkhand) , I see the stunting effects of malnutrition every time I visit. We are a continent, not a country.
Thanks for writing this Mohit.
May I add my prayer that we have safe, reliable, comfortable, accessible, affordable and sustainable public transport available in all corners of India (with type and frequency dictated by population density of course), so that we can stop driving our cars most of the time, and the rich and not so rich can travel side by side.
Thanks, Saikat.
That's a great addition
Intriguing. Also listened to your musings of the road trip to Bihar Sir, with Amit. Amazing insights and those naked truths of stunted growth of kids, sand mafia, No hope of future and no urge to even try fixing some plumbing problems at least .. stared right into our face. Leave aside the facade of being the world leader.
Thanks again for such lucid read.
Thanks, Sukhjinder.