New Delhi: On August 15, 2021, Prime Minister Narendra Modi mounted the Red Fort, a place that tempts leaders to make grand speeches to the crowd below. He announced that more than half of Indians would be fed rice fortified with micronutrients by 2024 to eradicate anaemia. But in haste, he served a public health policy that was raw and potentially dangerous to health.

Documents accessed by The Reporters’ Collective reveal that while going ahead with the decision Modi ignored the fact that the majority of pilot projects launched by his government to test the rice’s nutritional impact had not taken off at all. The government overruled the finance ministry’s red flag calling the move “premature” before understanding its impact on human health. Sacks of fortified rice were trucked out despite the head of the country’s leading medical research body calling for wider consultations following “serious concerns” on the “adverse effects” of fortified rice on children.

But Modi, unhindered by internal and external warnings, announced the government’s plan to mandatorily supply fortified rice to over  80 crore Indians, most of them poor, under all food security schemes. So far the government, to mitigate rising incidence of anaemia and micronutrient deficiency, has allocated over 137.74 lakh tonnes of fortified rice to states for beneficiaries under different welfare schemes.

Official data shows that over 1.7 million children in India are classified as “severely acute malnourished”. Of particular concern to public health activists is the rise in anaemia– caused by deficiency in dietary iron. Overall, it’s estimated that 67.1% of children under five and 57% women between 15-49 years of age in India are anaemic. In 2019-2021, anaemic cases among children rose 9% compared to 2015-16. The government claims rice fortified with iron, folic acid, Vitamin B-12, will mitigate India’s problem of rising micronutrient deficiency, also called hidden hunger.

Globally, food fortification has been one of the weapons in the war against micronutrient deficiency. In India, the most famous was the campaign to fortify salt with iodine to eliminate goitre. Even as the government’s plans to supply fortified rice under all welfare schemes by 2024 powers on, it has simultaneously begun supplying fortified wheat, oil and milk under select welfare schemes in some states. 

Experts say the artificial injection of micronutrients by fortification is not a long-term solution. They say a diversified diet and adequate food delivered at affordable prices are the solutions. But, in the past, to cut costs, the Union government has actively worked to either (sidenote)diminish[Read the report by The Reporters' Collective here](/sidenote) or restrict access to fresh nutritious food under its various food security schemes. And now it has fallen back on supplying artificially fortified food to improve the population’s health.

But science hasn't yet given a thumbs up to fortified rice.

Fortified rice is made by beating rice grains into a dough, adding micronutrients to it and then machine-carving the dough back into grains that resemble rice. One such artificial kernel is mixed with 100 normal rice grains.

To test if such fortified rice really cures anaemia and other micronutrient deficiencies like stunting and wasting, the government launched test projects under a pilot scheme in February 2019. They were to go on till March 2022. But instead of waiting for the results of all the pilots, Modi announced a full blown scheme in 2021, affecting over half of the country’s population.

By then, nine of the planned fifteen pilot projects across fifteen states that consented to the pilot scheme had not even taken off. But government officials took Modi’s Independence-Day announcement as a call to action and even cited the Prime Minister’s speech when seeking administrative approvals for the scheme. 

The states didn’t show much appetite for the pilot scheme, and rice was supplied in just six districts – one district per state – at project halftime. And four states started distributing rice just after Modi’s Independence Day speech. Result: The pilot scheme flopped.

“So many people questioned us about why our pilots were not successful,” said Sudhanshu Panday, the then Secretary in the Food and Public Distribution Department, at a seminar held in Delhi on 25 October 2021. “We had started pilots in 15 states -- one district in each of (the 15) states. But there were fundamental problems in the pilot,” he said, adding that “the problems were purely logistics and supply-side related”. He did not go into how these pilots with fundamental flaws could have generated valid scientific results. 

India’s state-run think tank NITI Aayog’s senior adviser Anurag Goyal too, in an internal meeting of the government on universalising the scheme admitted that the pilots were “not very successful”.

But, when asked about the success of pilots in Parliament on August 5, 2022, the Women and Child Development Ministry lied: “The pilot was successful in ensuring the ecosystem for fortified rice throughout the country.” It said that the pilots allowed key players in the scheme to prepare for a universal scale-up. However, it remained mum on the impact of fortified rice in nutrient deficiency despite it being one of the key objectives of the pilot.

Department of Expenditure, in an Office Memorandum, warned in 2019 that universalising fortified rice supply without first studying the outcomes of the pilot project is premature.

The Collective sent detailed queries to the NITI Aayog, the Food and Public Distribution Department and the Women and Child Development Ministry. None of them responded despite reminders.

One Questionable Pilot

The only study the government had in its hands before it moved to universalise fortified rice was a Tata Trusts research from a pilot project in Maharashtra’s Gadchiroli district.

The pilot project, which began in November 2018, focused on Bhamragad and Khurkheda, villages, with a total population of 1,22,398. 

In reply to another question, the government told Parliament that the study had shown fortified (sidenote)rice[The Government of Maharashtra had conducted an evaluation study regarding the effectiveness of rice fortification and found it useful,” Sadhvi Niranjan Jyoti, Minister of State for the Consumer Affairs Ministry, told Parliament on 27 July 2021.](/sidenote) was “useful”.  It did not mention the actual results of the study. 

The Reporters’ Collective accessed the study. It also asked Tata Trusts to respond to queries on it. “The pilot found a positive change in the target categories of the 2 program blocks in Ghadchiroli, and that such a programme was feasible,” a Tata Trusts spokesperson informed The Collective over mail.

The study shows improvement in the haemoglobin levels of those served fortified rice for 11 months. But the study also shows that mothers in the age group of 19-49 who were served fortified rice had shown reduced smoking habits by 30% while those who were not, cut down smoking by 8%. The study results also show that consumption of alcohol increased among mothers in the age group of 19-49 by 350% when they were not served fortified rice and by only 21% when they were served the fortified staple. The scientists behind the study or Tata Trusts does not explain in the study how or why they correlated fortified rice consumption to smoking and drinking habits of these mothers. 

In their response, quite incredibly, Tata Trusts also states, “The full immunisation status was also found to have improved in both intervention blocks. The treatment/care at the Health Centre for medical problems of children had also improved.” Again, it did not elaborate how this could be linked to consumption of fortified rice.

Experts The Collective spoke to say the study is “very poorly designed” and pointed out that neither have the results of the pilot project been published in any journal and nor are they peer-reviewed. The focus of pilots, public health researchers have previously pointed out, seems to be more on logistical feasibility rather than impact on nutrition.

Eighteen days after the government’s reply to Parliament claiming the Tata Trusts study had been useful, Prime Minister Modi announced the plan to supply fortified rice across the country even as the government’s pilot scheme had collapsed.

While government officials insisted in Parliament that pilots had been successful, bureaucrats internally admitted to the lacklustre response and need for more evidence to study the efficacy of fortified rice | Pic from minutes of Expenditure Finance Committee Meeting held on September 2021

Served in Haste

With their pilot projects failing, the government instead relied on select scientific studies to justify supplying fortified rice to over 80 crore citizens.

In June 2021, the Department of Food and Public Distribution compiled a list of thirteen research papers for an internal presentation to Consumer Affairs Minister Piyush Goyal, whose ministry is responsible for the procurement and distribution of fortified rice.

A closer look at this evidence the Food Department compiled raises more questions about the decision to supply fortified rice. 

While eleven of the thirteen on the list showed efficacy of fortified rice, two explicitly say that fortified rice has little effect on iron, Vitamin A and haemoglobin levels. 

Another paper on the list used to justify fortified rice is co-authored by a researcher who has been publicly warning of the risks of supplying fortified rice.

Curiously the food department omitted a (sidenote)review[Read the Cochrane review here](/sidenote) by Cochrane, a UK-based scientific nonprofit whose evaluations, experts The Collective spoke to say, are considered a gold standard on efficacy of fortified rice in scientific literature.

The Cochrane review aggregates evidence from many studies on efficacy of fortified rice and analyses their results. In the case of fortified rice, its analysis of 17 research papers found no mention in the presentation. Six of thirteen papers in the Food Department’s list of evidence to prove fortified rice’s efficacy are among the 17 studies reviewed by Cochrane.

This review showed “Fortification of rice with iron alone or in combination with other micronutrients may make little or no difference in the risk of having anaemia or presenting iron deficiency.” The researchers further noted, “we are uncertain about an increase in mean haemoglobin concentrations in the general population older than 2 years of age.”

“One thing is very clear, the Cochrane Review is the most respected source of evidence globally,” said Dr HPS Sachdev, who serves as senior consultant for the Union government’s Food Safety and Standards Authority of India’s (FSSAI) panel on Nutrition and Fortification. FSSAI would later go on to classify the fortified rice kernel under ‘high risk category’, which means if it is not manufactured properly it can lead to devastating health effects. 

“I would go by that (Cochrane review). I have gone through the review. Excellent review with standard methodology. Even if there is evidence that has come subsequently (after the review was published) which shows positive results it must be added to that. We need to look at overall conclusions,” he added.

The Food Department’s list of evidence also includes a 2004-05 study in Bengaluru schoolchildren that found a decline in iron deficiency among those who were fed fortified rice. But it also noted an increase in levels of a protein called serum ferritin – linked to a rise in the risk of diabetes. 

One of the seven authors of this research was Dr Anura Kurpad, who is a member of NITI Aayog’s National Technical board on nutrition. He has been publicly warning of the risks associated with high ferritin levels.

Dr Kurpad’s trial that established a potentially dangerous increase in ferritin now finds itself in a list of studies that the government uses, ironically, as evidence of rice fortification’s efficacy because it showed a dip in iron deficiency in school children. 

But why should people worry about fortified rice when salt, similarly fortified with iodine, has been consumed by millions across the country for more than half a century?

“One of the reasons salt fortification is probably successful is because it’s very hard to overeat salt,” Dr Kurpad explained to The Collective.

“At some point you’re going to say that the food is too salty and don’t eat it. Rice, on the other hand, is very easy to overeat.” 

Experts also pointed out that unlike iron, excess amounts of iodine goes out of the body through urine. There is no natural way for the body to rid itself of excess iron.

“Our study was focused on very poor people,” Dr Kurpad told The Collective over phone. “Secondly, we were also focussing on iron-deficient people. These studies were not a general, universal thing.”

“If you look at studies around the world that focussed on the general population, they were all put together in the Cochrane review. It showed there’s no benefit of rice fortification on anaemia,” he added.

When The Collective asked Dr Kurpad if there had been any discussion on rice fortification’s efficacy at NITI’s National Technical Board on Nutrition, he replied, “No. Not as far as I know.”

The government’s own top medical research body Indian Council of Medical Research has previously (sidenote)shown[Read more here](/sidenote) that fortified rice had no substantive effect on mitigating  anaemia levels among school-going children.

Public health experts have been warning of the risks of mandatory rice fortification. 

This also made its way to NITI Aayog’s file notings. Professor Ramesh Chand, NITI Aayog’s member on agriculture, said in November 2021, “Some medical experts have expressed serious concern about the adverse effect of iron-fortified rice on the health of children. This was also mentioned by DG (Indian Council for Medical Research)...”

“Therefore, there is a need for consultation with a wide range of experts on the effect of fortification of rice on human health before pushing it further,” he added. Multiple Right to Information requests with the ICMR, India’s top medical research body, reveal there have been no consultations on the issue.

Professor Chand in his note added, “In any case, such intervention should be for the short term only.” The government has overruled this suggestion too. 

Ramesh Chand, NITI Aayog member, points out in a file noting that experts have raised ‘serious concern’ over supplying fortified rice to children.

Most experts are wary of adding what are, in essence, drugs to food. The medical experts Professor Chand referred to in his file note have been vocal in their criticism. One of them is Dr Kurpad. “They’re already running an iron supplementation program under Anaemia Mukt Bharat. That’s more than enough because it gives a lot of iron. Why on earth would we then want to go for fortification, which is a much weaker method than supplementation?,” Kurpad asked.

Fortified rice is also harmful to people suffering from diseases that worsen with iron intake.

“So, we do know that for example, you don't want to give iron to people with thalassemia and sickle cell anaemia. We also don't want to give it to those in the acute phase of tuberculosis,” Dr Vandana Prasad, the founding secretary of Public Health Resource Society, told The Collective.

The Food Department’s operational guidelines on fortification try to address this concern with a ‘Not recommended for people with Thalassemia and people on low iron diet,’ label on bags carrying food items fortified with iron.

The Collective travelled to Jharkhand to review how the fortified rice distribution was working in villages with predominantly tribal communities which have higher incidence of sickle cell anaemia. Jharkhand has the highest number of thalassemia and sickle cell anaemia patients in the country. The number of people suffering from sickle cell anaemia in Jharkhand is estimated to be twice the national average.

In multiple instances in Kuchiyasholi, a village in Jharkhand’s East Singhbhum district, for several months gunny bags with fortified rice did not carry the labels that warned of the harmful effects of fortified rice on people suffering from thalassemia. 

Responses to the recent Right to Information queries by activist Kavitha Kuruganti, reviewed by The Collective, showed that the Centre does not have any means to profile those suffering from thalassemia or sickle cell anaemia from among the beneficiaries of the fortified rice. Yet the government steamrolled this rice into millions of homes across the country.

(After Prime Minister Modi had launched the countrywide scheme, a top government body carried out a review of fortified rice pilot studies. The report was never made public. We reveal it in part 2.)