Seeing red: New critique note questions the argument that WHO haemoglobin cut-offs that define anaemia don’t apply to India

A recently published critique note outlines the problems with a 2021 paper published in Lancet Global that called for a revision of the WHO standards for anaemia in the Indian context. The paper was quoted in a recent article in the Economic Times that expressed disbelief that an economically rising India would still have between 40–65 percent of its population as anaemic.

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A new critique note has lambasted recent suggestions by some public policy and health experts that India must move away from the World Health Organisation (WHO)'s haemoglobin cut-offs that define anaemia.

As per WHO guidelines, 40-65 percent of children, women and men in India are anaemic. A recent report in the Economic Times (ET) expresses disbelief that despite India's growing economic prosperity, the percentage of anaemic people in the country would remain so high.

The ET report goes on to critique the WHO standards themselves, questioning its relevance in the Indian context. In doing so, the report relies on a single paper titled Haemoglobin threshold to define anaemia in a national sample of healthy children and adolescents aged 1-19 years in India: A population-based study, published in Lancet Global in 2021.

It is this paper that the critique note, authored by Dr Sylvia Karpagam (public health doctor and researcher), Dr Veena Shatrugna (Retired Deputy Director of the National Institute of Nutrition, Hyderabad) and Siddharth K. Joshi (Public health researcher), has chosen to examine and review.

According to Karpagam and others, the authors of the paper are in a tearing hurry to reduce haemoglobin cut-offs for anaemia to reduce its prevalence from being a severe or moderate public health problem to a low or no public health problem because it shows India in poor light.

Arguments for revising the WHO definition of anaemia

The paper, written by Professor Harshpal Singh Sachdeva and others, criticise the WHO definition of anaemia, which the authors claim to be drawn from five studies done more than 50 years ago on predominantly White adult populations.

As per the WHO, anaemia in children under the age of five years and among pregnant women is defined as a haemoglobin concentration of less than 110 grams/Litre (g/L) at sea level. In non-pregnant women, it is less than 120 g/L.

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The paper suggests that this definition should be re-examined based on the haemoglobin values of a 'representative healthy population' of children and adults.

The authors have argued in the paper that such data is scarce in low and middle-income countries. Thus, the data from 2019's Comprehensive National Nutrition Survey (CNNS) has been analysed to assess the age and sex-specific percentiles of haemoglobin levels. CNNS has also been referred to assess cut-offs to define anaemia for the Indian population.

The paper uses a methodology to apply exclusion criteria to CNNS data and filter it to a 'healthy population'. The paper claims that the reference percentile derived from this population is suitable for national use in India.

Using this methodology, the authors of the paper have identified a primary analytical sample of 8,087 individuals from a sample of 49,486 individuals. Carrying out an analysis of this data set of 'normal population', the paper shows that haemoglobin cut-off levels for India can be reduced by 1.5 gram, which would be reflected in lowering anaemia prevalence to less than 20 percent.

Revising the data does not solve the anaemia problem in India 

According to the critique note titled Nutritional revolution by reducing haemoglobin cut-offs? Anaemia is not a numbers game, the data used in the paper, derived from CNNS data, cannot be said to be based on a healthy or representative population.

According to one expert, "The paper uses a tailor-made dataset to arrive at its conclusions."

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The paper has excluded participants with serum iron, folate, vitamin B12 and retinol deficiencies. It has also excluded the population with a history of smoking. Participants having other vital deficiencies have also been excluded. The paper completely relies on biochemical indicators rather than the nutritional and socio-economic constraints to haemoglobin synthesis.

The expert told The Leaflet that this is a dangerous strategy that can have a negative impact on policy decisions and adversely impact the health of vulnerable population groups.

As the critique note itself says, anaemia has serious clinical consequences, especially in pregnancy— 20-30 percent of all causes of maternal mortality can be traced to anaemia. Decisions about cut-off can only be made with an assessment of clinical impact, the note avers.

The authors of the note have expressed shock over the fact that the data used in the paper specifically excludes pregnant adolescents, considering that teenage pregnancies and anaemia are a huge concern for this age group.

Case of lack of accountability

A group of WHO scientists identified as early as 1968 that anaemia is a late manifestation of nutritional deficiency. This means that people can have nutritional anaemia even before it is identified by screening tests.

The authors of the critique note state that it is clinically alright to over-diagnose anaemia than to miss out on someone who actually does have it.

The Lancet Global paper, in an attempt to provide optimistic figures of the decline in anaemia has run the real risk of missing out on women who have mild or moderate anaemia, thereby delaying or denying them preventive and primary care. In the context of India, if women present with mild or moderate anaemia (9-11 g/L), the paper would label them as normal.

It also manages to promote the same discourse that it ostensibly seeks to challenge. By admitting that only a small representative 'healthy population' of India can compete with global (or even White) standards set by the WHO, it gives the lie to the notion of a prosperous, developing India. While India is growing economically, perhaps the concentration of this wealth in a few hands is what still keeps vast sections of the society below acceptable standards of health like the one represented by the WHO cut-offs for anaemia.

Reality vs data manipulation

This is not the first time that attempts have been made to statistically undermine a given public concern. During the COVID-19 pandemic, attempts were made to manipulate the data on death rates. When demands were made to make the COVID data public, the request remained unanswered.

During the pandemic in 2021, a group of 300 Indian scientists had written a public letter to Prime Minister Narendra Modi, stating the lack of access to the data held by the Indian Council of Medical Research (ICMR). The ICMR data remains inaccessible to anyone outside of the government as well for many within the government.

Over the last few years, a pattern of either delaying access of crucial public data or not disclosing the same information has been witnessed, unless the same is requested through a Right to Information (RTI) application.

For instance, the last population census took place in 2011 and it was supposed to be carried out in 2021. The census, which has been carried out every decade since 1881, has been delayed indefinitely for the first time without any legitimate excuse.

The same is the case with the National Crime Record Bureau (NCRB) data, which has been consistently delayed. The NCRB's annual data is the only source of crime records in India. The 2017 report was delayed by two years and was released in October 2019. The last NCRB report was released in 2020.

Also read: Data on COVID deaths in India: Lessons for building a robust healthcare system in India

Many experts say that the lag in the availability of crucial information in the public domain indicates some sort of political interference. Statistical data is the true indicator of whether the policies of the government are proving to be in the best interest of citizens or not.

The availability of such data in the public domain allows researchers and scholars to devise a plausible solution to the concerned problems. The lack of data in the public domain just does the opposite.

Such attempts of dealing with public issues by interfering with the data remain a concern, especially when there is a lack independent oversight.