Is there a pharma boom going on in India?

Stock market fluctuations are too unreliable of an approach to assess an entire industrial sector. Wild speculations apart, something tangible needs to underpin any boom. While Indian Pharma doesn't have upcoming blockbusters, several trends augur its healthy growth.

Indian Pharma: Essentially High Volume-Low Value Global Supplier Of Generics

The world's 3rd largest pharmaceutical industry by volume (10% of global production) but only 14th by value (1.5% of global value) suggests Indian Pharma is a high-volume, low-value proposition (1).

A highly fragmented industry with ~10000 manufacturers, though only ~250 are large-scale, generics dominate Indian Pharma (2), contributing no less than 40% of the US generic drug import for example.

US FDA drug approvals reveal Indian Pharma doesn't have a strong presence in the US new drug market. Of the 96 new drugs it approved in 2013, only 2 were from Indian companies, Lupin's Suprax (active ingredient Cefuroxime) and Alembic's extended release form of anti-depressant desvenlafaxine (3). Thus, a boom can't be justified on hopes of extremely big paydays down the road from expensive new blockbusters selling on drug markets like the USA or the EU. That's simply not Indian Pharma's track record nor is such a US-like process even likely in India, where the government deliberately intervenes with powerful instruments like price controls and compulsory licenses. Through the latter mechanism, if the Indian government deems an originating firm’s listing price unaffordable, it can force them to license their technology to a generic competitor, an extremely strong countervailing force that, though seldom used, hangs like a Damocles sword over the pricing decisions originator firms make when trying to sell their products in India (2, 4), a situation utterly unlike the rampant drug price gouging that's today the norm in the US. This is why drugs in India are among the cheapest in the world (2). Also why Indian Pharma depends on drug volume not price for its profits.

Indian Pharma: Nearing An Inevitable Fork In The Road, Will It Be Super Generics or Biosimilars Next

On the plus side, Indian pharma has built up an enviable infrastructure, with the largest number of US FDA compliant API (Active Pharmaceutical Ingredient) manufacturing plants outside the US (>262), ~1400 WHO GMP-approved plants and 252 European Directorate of Quality Medicines (EDQM) approved plants (1). This capacity has made Indian Pharma a global leader in generics, supplying anti-HIV drugs widely across Africa, Asia, Latin America for example.

Long specializing in generics, Indian pharma faces a major fork in the road in terms of how to expand and diversify in an extremely rapidly changing global pharma landscape. In the ongoing Patent cliff, i.e., patent expiration of blockbuster drugs coming off of patent since 2011 continuing through to 2019, bulk of the patent loss on traditional pharmaceutical drugs has already occurred. Far fewer are expected after 2017. Thus the generics market can only remain a high volume-low value proposition for Indian Pharma.

To gain value, Indian Pharma has to climb the value chain. Developing new drugs all by itself is an extremely costly proposition with very high regulatory burden. New drug development never having been its expertise, options that best leverage Indian Pharma's existing expertise and capability are super generics and biosimilars.

Super Generics represent an incremental innovation to Indian pharma's already well-established generics capability. Though they entail greater regulatory burden, Indian Pharma's making steady inroads into this space (see below from 3, 5).

As generics are to patented drugs so Biosimilar are to biologics (6). Indian Pharma is a relative newcomer in the biologics and biosimilars arena. Making biosimilars, while much more arduous and expensive compared to generics (see below from 7), may yield greater long-term payoff in terms of expanding technological capability which could serve as a launching pad for in-house new drug development down the road.

The ongoing Patent cliff on biologicals (3, see below from 7) is thus a net opportunity for Indian Pharma to enter the biosimilars sector.

Biocon was one of the early entrants, getting approval for its biosimilar CANMab, a remake of Roche's Trastuzumab (Herceptin), a breast cancer drug (8).

Indian Pharma: Steadily Increasing Global Reach Through Mergers, Acquisitions & Joint Ventures

Joint ventures offer a ready-made platform for global pharma to leverage R&D capabilities of well-established Indian entities as Contract research organization (CRO), which helps to considerably reduce cost of new drug development.

In the long-term, expansion of Indian CROs can also help Indian Pharma gain the technological, managerial and regulatory know-how necessary for new drug development, something they currently lack.

Indian Pharma's also been steadily increasing its presence in other countries through acquisitions. A 2016 study reported that 67 Indian companies valued at >US $6 billion made 191 acquisitions across 33 countries from 2000 to 2012 (see tables below from 9, 10).

Indian Pharma: Serious Teething Problems With Clinical Trials

Vast genetic diversity, large 'treatment-naive' population, ~30% urban dwellers with >67 million living in India's 6 largest cities alone plus cost of conducting a clinical trial in India is < 50% of that in the US, all these factors make India an attractive destination for conducting clinical trials. However recent speed-bumps in the form of serious lack of oversight in clinical trial recruitment and informed consent processes (11, 12, 13) have chilled Indian clinical trial activity. A lessons learned mind-set on the part of global pharma and its local regulators and clinical trial partners would help resume trial activity.

Indian Pharma: Dwindling Opportunities For Contract Research For API (Active Pharmaceutical Ingredient) Manufacturing For Europe & USA

Along with China, India leads in API manufacture (see below from 14).

In their efforts to reduce manufacturing costs in Europe and USA, in recent years their Big Pharma increasingly off-loaded API manufacturing to cheaper sites located in places like India. This meant increased scrutiny from foreign regulatory authorities like the US FDA. Indian Pharma leads the pack in number of US FDA warning letters (15). While these setbacks can be and indeed are being interpreted several ways, a pragmatic interpretation would be to see them as a steep but necessary learning curve for Indian Pharma to effectively compete in supplying essential drugs to the US and the EU. Indian Pharma got here by becoming an expert mass manufacturer of API. However, shoring up manufacturing to meet their more stringent regulatory standards is beneficial in the long-term as it improves Indian Pharma's QA/QC, data integrity and compliance standards. High profile warning letters are also beneficial in highlighting a glaring shortcoming in the Indian Pharma regulatory landscape, namely long-standing, tremendous shortage of well-trained and qualified drug inspectors (16, 17), something the Drug Controller General of India, G.N. Singh himself conceded in Jan 2014 is a situation that desperately needs improving (18).

'You cannot equate the Indian regulator with the US one. We are still evolving and it will take us at least 10 years to reach that level. We do not have resources and infrastructure equivalent to those of US FDA. We have a total staff of 650, compared with US FDA's 13,000. Look at the size of our manufacturing industry. The Indian industry is currently supplying generics to over 214 countries.

Also, as a national regulator, the steps that we are taking are voluntary. Manufacturing compliance and quality assurance is a state subject.'

To add to Indian Pharma's woes,

• On 16th July, 2015, the European Commission directed all its member states to suspend national marketing authorization of 700 generic drugs tested and approved by GVK Biosciences (19).
• An early 2016 decision by the US government's made it mandatory for APIs to be manufactured locally for government procurement. According to Live Mint (20), currently ~88% (9 out of 10) of prescriptions dispensed in the US are for generics. India and China are the largest API suppliers to the US. Of the US $2 to 3 billion worth of API that India exports to the US, ~40% is for government purchase so this decision will definitely hit Indian Pharma exports and companies with holdings or subsidiaries in the US.

Thus, Indian Pharma outlook looks bright if it leverages its proven generics expertise into expanding into super generics and biosimilars. Becoming a preferred destination as a clinical trials site and an essential cog in the drug supply chain to the US and the EU, however, need more work in improving its compliance and manufacturing to match their more rigorous standards.

Bibliography

1. Pharma Industry Promotion | Department of Pharmaceuticals

2. http://www.pacificbridgemedical....

3. Suri, F. K., and A. Banerji. "Super Generics—First Step of Indian Pharmaceutical Industry in the Innovative Space in US Market." Journal of Health Management (2016): 0972063415625566.

4. Duggan, Mark, Craig Garthwaite, and Aparajita Goyal. "The market impacts of pharmaceutical product patents in developing countries: Evidence from India." The American Economic Review 106.1 (2016): 99-135. https://openknowledge.worldbank....

5. Stegemann, Sven, et al. "Improved therapeutic entities derived from known generics as an unexplored source of innovative drug products." European Journal of Pharmaceutical Sciences 44.4 (2011): 447-454. https://www.researchgate.net/pro...

6. http://www2.deloitte.com/content...

7. Daubenfeld, Thorsten, et al. "Practitioner’s Section." Journal of Business Chemistry 13.1 (2016): 33. http://www.businesschemistry.org...

8. The Hindu, Jan 18, 2014. Biocon launches cheaper breast cancer drug

9. Trehan, A., Gaikwad, A. Indian Pharma Industry: Trends, Predictions and Challenges. Asia-Pacific Biotech News, 2014: 18: 27-44. Asia Pacific Biotech News - PR NEWSWIRE

10. Jayanthi, Bhargavi, S. N. V. Sivakumar, and Arunima Haldar. "Cross-border Acquisitions and Host Country Determinants: Evidence from Indian Pharmaceutical Companies." Global Business Review 17.3 (2016): 684-69.

11. Tirumalai Kamala's answer to Should we have an international forum to resolve clinical trial mishaps?

12. Tirumalai Kamala's answer to Is it true that Bill Gates faced trial in India for illegally testing tribal children with vaccines?

13. Tirumalai Kamala's answer to Do western drug companies test more dangerous drugs on the poor in India, and should they be held accountable?

14. CHEManager Europe, April 2012. Will API Manufacturing Move out of India and China? http://thomsonreuters.com/conten...

15. Business Standard, Aneesh Phadnis, May 5, 2016. Indian drug units violate most US pharma regulators' rules

16. Kadam, Abhay B., et al. "Correcting India’s chronic shortage of drug inspectors to ensure the production and distribution of safe, high-quality medicines." (2016). http://www.allysonpollock.com/wp...

17. A report on fixing India's broken drug regulatory framework. Dinesh S. Thakur, Prashant Reddy T. June 4, 2016. http://spicyip.com/wp-content/up...

18. Business Standard, Sushmi Dey, Jan 30, 2014. If I follow US standards, I will have to shut almost all drug facilities: G N Singh

19. European Medicines Agency - Human medicines - GVK Biosciences

20. Live Mint, Reghu Balakrishnan, Shine Jacob, Feb 6, 2016. No major impact on API import ban in US

https://www.quora.com/Is-there-a-pharma-boom-going-on-in-India/answer/Tirumalai-Kamala

What kind of impact will allowing women to own land under their own names have on India?

Undoubtedly, along with education, economic self-sufficiency is the cornerstone for a woman's emancipation and autonomy, be it in India or anywhere else. However, in India at least two powerful obstacles stand in their way. One, all too often prevailing local cultural practices trump laws. Two, rural landholding sizes are shrinking fast in India. Since most Indians are still rural, this adversely impacts women's emancipation through land ownership.

In India, All Too Often Local Cultural Practices Trump Laws

Dowry laws prove this all too unambiguously. Bridegroom and/or his family demanding dowry from the bride's family remains a mainstay in many parts of India (Dowry system in India). Obviously commoditizing women, the dowry system constitutes systemic, structural abuse. When dowry's deemed insufficient, women are physically and psychologically abused, threatened, terrorized (1), even killed (2). Given the pernicious effects stemming from its systemic prevalence, the Indian Parliament passed the Dowry Prevention Act in 1961 (3). Neither demands for dowry nor dowry deaths abated so much so that the law was amended in 1983 (4) with a view to strengthening it. Did dowry demands and deaths stop? A decided no. The National Crime Records Bureau is the government agency that maintains records of all reported cognizable crimes in India. Their data show that ~1 woman is killed over dowry every hour (see Table 5(A) in 5). To top it, we have no way of knowing how accurate these data sets even are, and given dowry represents subjugation, under-reporting is more than likely.

Indian Rural Landholding's Shrinking Fast

Most Indians are still rural. For e.g., in 2011, ~833 million Indians (~69%) lived rurally compared to ~377 million in cities (6). Yet, individual rural landholding plot sizes almost halved in India since 1992 (See figures below from 6, 7, 8).

Rather than helping empower women through landholding, this trend disfavors them by increasing competition for land in an enormous, decidedly male-dominated culture.

Available data bear out both these concerns. ~400 million Indian women are rural. Almost 80% of them work in agriculture or related work, and are responsible for ~70% and 90% of food and dairy production,respectively. Yet <13% own the land (9) even as agriculture contributes 14 to 15% of India's GDP (10, 11). Glance at random at an Indian news piece about agriculture. Without fail, men are described as farmers. Women? As agricultural workers. Extent of gender-based disenfranchisement is so deep it casually pervades even the frame the highly educated use to examine salient issues.

Irony is India's Constitutional Fundamental Rights guarantees equality of opportunity and rights to all citizens (12). As well, the Hindu Succession Amendment Act 2005 was a landmark progressive and pro-women piece of legislation in a ~1.3 billion population where~80% are Hindu. However, cultural practices all too easily subvert and/or thwart laws allowing Indian women to own land under their own names. Prevailing culture ingrains subservience in women from an early age so lack of awareness and information is a major impediment.Women are thus easily pressured/coerced into writing off their property in favor of their brothers or other male relatives. Dowry's still prevalent so a woman's not considered eligible for more share post-marriage even when she patently is under the law.

Data suggest such socio-cultural practices severely limit Indian women's access to land ownership (9). For e.g., in West Bengal state, the government land title document, patta, had space for only one name. Even when meant to give joint ownership to husband and wife, practice was to write the husband's name as the family head. Only recently has the patta been re-designed to provide joint land titles to both husband and wife. Even when the patta is in their names with their photographs, as in the states of Andhra Pradesh and Karnataka, women typically never see it and believe their husbands have the title. Research in Odisha state uncovered that >30 year old single men, but not women, were considered a household. Such women weren't counted and thus denied access to government welfare schemes including land allocation. Only after this was uncovered did the state government start a program to count such single women in a few districts, and start allocating them homestead plots (9).

Despite such steep barriers, women landholders are a barely perceptible but growing segment in different parts of rural India.

How Landholding Could Help Indian Women's Empowerment

A 2005 Indian study showed women who owned land were 60% less likely to be subjected to domestic violence (13).

A 2007 Nepalese study showed landholding women have greater decision making power at home and their children are less likely to be severely malnourished (14).

A 2008 Ethiopian study showed landholding men and women invest twice as much time on its soil and water conservation (15). Implication? Ownership makes people better stewards of their land and environment.

Case studies of Indian landholding women reveal (see photos below from 16, 17).

• Their living standards and confidence improve.
• They command their community's respect.
• They garner greater decision making in their families.

All too easily overlooked barring an occasional news report, the impossibly slender shoulders of extraordinarily strong women like Chandra Subramanian carry an inordinate burden (photos below from 18). Following local tradition, she was married to her aunt's son at16. Husband and wife worked in a hosiery factory in Tiruppur, the knitwear capital of India. At 24, her father was killed in a road accident. Her husband committed suicide 40 days later. Such twin blows would prostrate the ordinary, not Chandra. This plucky mother's story reveals a person of remarkable strength, wit, and resilience (18). Chandra's mother inherited a 12 acre property on her husband's death and split it equally between her three children. Now 28, on her 4 acre share, Chandra grows vegetables, paddy, sugarcane, corn. Working almost 16 hours a day, she's up at 4 AM performing household chores and fixing her children's lunch. After harvesting vegetables, she walks her kids to school, then heads back to the fields until lunch. On market days, she packs her vegetable sacks on her moped and rides the 15 kms to the nearest town, Sivaganga, to sell her fresh produce. The photos documenting Chandra's life are a tonic. They declare in no uncertain terms that the truly intrepid can just buck up and keep going, no matter what.

That her mother inherited her father's land is the 1st critical emancipating event in this saga. Next, that Chandra inherited an equal land share from her mother is the 2nd critical emancipating event. So much else that's essential for a woman's emancipation is invisible and needs must be gleaned from reading between the lines. That a single woman alone on a farm is likely safe in this part of India. Implies a fully functioning local law and order machinery. That the local culture accepts financially independent single women. The astounding can-do spirit of Chandra and her ilk represent the best humanity offers but it can only blossom when laws aren't mere lip-service but actually implemented in deed. This is where there's many a slip between cup and lip in India.

Bibliography

1. Bloch, Francis, and Vijayendra Rao. "Terror as a bargaining instrument: A case study of dowry violence in rural India." The American Economic Review 92.4 (2002): 1029-1043)
2. Dowry Murder: The Imperial Origins of a Cultural Crime. Veena Talwar Oldenburg. Oxford University Press, 2002. http://www.amazon.com/Dowry-Murd...
3. http://ncw.nic.in/acts/THEDOWRYP...
4. http://www.498a.org/contents/ame...
5. https://www.google.co.in/url sa=t&rct=j&q=&esrc=s&source=web&cd=2&cad=rja&uact=8&ved=0ahUKEwiUuKLu7evLAhXCVyYKHQIkCawQFggeMAE&url=http%3A%2F%2Fncrb.nic.in%2FStatPublications%2FCII%2FCII2014%2Fchapters%2FChapter%25205.pdf&usg=AFQjCNHw2-Wo1JnDhbYTPbZqqLKBNuv2MQ
6. Chandramouli, C. (15 July 2011), Rural Urban Distribution Of Population (PDF), Ministry of Home Affairs (India). http://censusindia.gov.in/2011-p...
7. Agricultural Land Holdings Pattern in India. NABARD Rural Pulse, Issue - 1, Jan-Feb, 2014. https://www.nabard.org/Publicati...
8. The Hindu, Rukmini S., Dec 17, 2015. http://www.thehindu.com/data/rur...
9. Anisa Draboo, Yojana, November 2013. http://iasscore.in/pdf/yojna/Wom...
10. Agriculture Census in India. U.C. Sud, Indian Agricultural Statistics Research Institute, New Delhi, India. http://www.iasri.res.in/ebook/TE...
11. How Land Rights Can Strenghten And Help Accomplish The Post 2015 Development Agenda: The Case Of India. Anisa Draboo. 2015 World Bank Conference On Land And Property. Washington D.C., March 23 to 27, 2015. https://www.google.com/url?sa=t&...
12. Rao, Nitya. "Women’s access to land: An Asian perspective." Expert paper prepared for the UN Group Meeting ‘Enabling Rural Women’s Economic Empowerment: Institutions, Opportunities and Participation’. Accra, Ghana. 2011. http://www.un.org/womenwatch/daw...
13. Panda, Pradeep, and Bina Agarwal. "Marital violence, human development and women’s property status in India." World Development 33.5 (2005): 823-850. https://www.amherst.edu/media/vi...
14. Allendorf, Keera. "Do women’s land rights promote empowerment and child health in Nepal?." World development 35.11 (2007): 1975-1988. http://www.ncbi.nlm.nih.gov/pmc/...
15. Deininger, Klaus, Daniel Ayalew Ali, and Tekie Alemu. "Impacts of land certification on tenure security, investment, and land market participation: evidence from Ethiopia." Land Economics 87.2 (2011): 312-334. http://www.umb.no/statisk/ncde-2...
16. In pictures: How the right to own land transformed the lives of these five women. The Scroll, Anisa Draboo, March 8, 2016. http://scroll.in/article/804799/...
17. Landesa, Rural Development Institute. http://www.landesa.org/resources...
18. Small farmer, big heart, miracle bike. The Hindu, Aparna Karthikeyan, March 8, 2016. http://www.thehindu.com/news/nat...

https://www.quora.com/What-kind-of-impact-will-allowing-women-to-own-land-under-their-own-names-have-on-India/answer/Tirumalai-Kamala

What is your personal experience of the difference in the way basic science research is conducted in the USA and India?

As a biomedical researcher, I consider the research I did during my Ph.D. in India to be the most rigorous by far. It was the only project where statistics were appropriately and correctly applied right from the first step, the experiment design, continuing with blinding of the samples through to data analysis.

Goal of my Ph.D. project was to figure out if prior exposure to environmental mycobacteria (NTM, Nontuberculous mycobacteria) could explain why the largest TB vaccine trial had failed to protect against adult pulmonary TB. Conducted from 1967 to 1980 on ~360000 people across 209 villages and 1 town in South India, prior exposure to environmental mycobacteria emerged as a plausible reason. Only there was no data on NTM in this environment, if yes, what species and where, in the soil/water/dust. I was just one person. How could I cover such a vast population over such a vast area? That's where statistics entered the picture, exactly where it should, in the experimental design itself. A professional statistician crunched the numbers to determine how many villages I should cover, how many houses per village, which villages, i.e., make sure I comprehensively sampled the entire trial area in as unbiased a manner as possible. Starting with this design, he carefully shepherded every step of my Ph.D. project and even blinded the samples I brought back from the field, only decoding them after I'd generated all the data. Since I don't have any other experience on basic research in India, I don't know if my experience if generalizable so I'll leave it at that. 

Moving on from differences between India and US, I'll highlight two dubious practices that are rampant in basic biomedical research the world over, at least if we go by the published literature. Overarching problem consists of two features

1. Statistics are misused, usually applied only at the back end to analyze the data after it's been generated, instead of the optimal approach which is to apply them from the beginning in the experiment design itself.

2.Definition of scientific misconduct is too narrow, completely ignoring the most prevalent practice, which isn't outright fraud but rather data selection.

Compared to basic research, rigorous statistical science applied to human clinical trials is the norm. Only very slowly is this mindset permeating into basic research to replace this ridiculous state of affairs. Last year, we saw the publication of the first randomized clinical trial in mice (1). 

The US ORI (United States Office of Research Integrity) defines Scientific misconduct as consisting of data fabrication, data falsification or plagiarism. But far more than any of these, the most prevalent practice is something that's not even on the radar, data selection, i.e., cherry-picking data. Practice is rampant. Rarely do animal model studies show data combined from different experiments. Take a look at any recent paper, even ones published in Nature or Science. Invariably a figure legend would say something along the lines of, 'Data from one representative experiment out of 3, 4 or 5 different experiments is shown'. Why not show combined data from all experiments performed? How could such a shoddy practice be the norm? Simply means intra-group variation between experiments was greater than inter-group variation within one single experiment. Either experimenters are shoddy or techniques too unrefined. Either way, cannot trust such data. And this is still the norm in basic biomedical research.  

Bibliography:

1.  Llovera, Gemma, et al. "Results of a preclinical randomized controlled multicenter trial (pRCT): Anti-CD49d treatment for acute brain ischemia." Science Translational Medicine 7.299 (2015): 299ra121-299ra121. http://stm.sciencemag.org/conten...

https://www.quora.com/What-is-Tirumalai-Kamalas-personal-experience-of-the-difference-in-the-way-basic-science-research-is-conducted-in-the-USA-and-India/answer/Tirumalai-Kamala

What are the differences and similarities between India and America when it comes to racism?

Assuming America means the US, in my experience, India and the US are depressingly similar when it comes to racism. Both have a long shameful history of deliberately disenfranchising specific groups of people, who are then socially shunned, economically decimated, and culturally sidelined, of course after the dominant groups appropriate whatever they like or want. As well, this history is much longer in India, the group in question the Dalit, formerly called Untouchables. In the US, it's blacks and Native Americans. Process is also depressingly similar, the marginalized are deliberately segregated geographically, economically, educationally. In both countries, widespread protest movements galvanized change with governments enacting laws attempting to empower and enfranchise, through a variety of Affirmative action programs. However, ensuing changes are often cosmetic and cultures stubbornly hold on to the disenfranchising status quo. After all, easier for the privileged to view their accomplishments as merit-based rather than feasting off the banquet of generational entitlement, easier to dismiss the deliberately, systematically downtrodden groups as deserving of their lowlier fates. Difference is India retains a more visible and persistent feudal structure that exacerbates caste and class divides.

My earliest memory of bigotry is from my own family. With India still stubbornly feudal, everyone worth their salt has servants, now euphemistically called domestic workers. Change in name, not dignity. We had a couple, wife for house work, husband the gardener. I was around 3 or 4 years old. Living with us, my widowed paternal grandmother, conservative, rigid and very casteist. She'd wash her own clothes and hang them out to dry in the back yard. That day, as she used her long bamboo stick to hang it out on the back yard clothes line, Katayan, the gardener, accidentally brushed against her washed saree while weeding a garden patch. I'll never forget the Tamil cry that burst out from her lips, 'Dushta, dushta', i.e. wicked, wicked. Striking him once on the shoulder with her stick, she then agitatedly set to pulling her saree off the clothesline and ran off with it to wash it again, his body's accidental brushing apparently enough to 'pollute' it.

Of course, this was decades back and India has come a long way from such decrepit and utterly repulsive ideas or so the elite would have us believe but nothing could be further from the truth. By many measurable metrics, access to education, literacy rates, per capita income, Dalits remain marginalized and disenfranchised, entirely by design and not by accident. Sure, the Indian media often touts tremendous individual Dalit success stories but the reality is similar to the US. After all, one Obama in the White House doesn't mean blacks are suddenly equal to whites in terms of access to opportunities, wealth and power, and protection under the law, does it? And, lacking even the fig leaf of an Obama, Native Americans are left out of the conversation altogether.

Years later, a conference room at the US NIH fills up as people stream in for a meeting or presentation. Walk in on the tail end of some desultory conversation about a topical news issue, obviously about blacks. Shockingly, a senior white researcher, a famous name in fact, says of course, it's well known that among blacks it's the stupid ones that got caught in the first place. I'd never heard of such a flagrantly odious and self-serving theory to explain black enslavement. To hear it at all was shocking, to hear it stated by someone so highly educated even more so. That it was said at all in that room only emphasizes how spaces deemed to represent power in US society continue to systematically exclude blacks. Of course, that room was filling up with white Americans and immigrants deemed deserving, no blacks.

My own experience of racism in the US was less overt, often expressed as persistent suspicion. For e.g., being asked for my ID when presenting a credit card at the check-out when those ahead of and behind me, all whites, weren't. Once is a quirk. Often? That's a pattern. Then there was that ominous entanglement with a white cop my very first year in the US. Having written about it elsewhere (1), the recent, steady drip-drip of news stories of blacks killed in police encounters underlines in no uncertain terms how lucky I was to not end up with the same ignominious fate, shot and killed during a police encounter.

Recently, India was roiled with the high-profile Suicide of Rohith Vemula, a Dalit scholar at the University of Hyderabad. Didn't make as much of a buzz on Quora. Inevitably, what I read  included commenters unabashedly engaging in character assassination of a young man who's no longer around to defend himself. After all, at a time when internet penetration is <30% in India, no surprise haves would dominate in their access to it. Meantime, protestors in India are rightfully calling it institutional murder. After all, Dalits who demand to be seen as peers are actually perceived as dangerous interlopers and treated as such, creating conditions not so different from those that provoked the recent protests at 2015 University of Missouri protests. Why did Rohith's suicide touch such a nerve? The poignance and eloquence of his suicide note (2). Even birth in penury to a laborer and a seamstress couldn't prevent his rare and marvelous writing talent from blossoming. As James Baldwin famously seared the American public's conscience in his 1963 interview (3) with Dr. Kenneth Clark on the Negro and the American Promise, so Rohith's forlorn words reverberate in India today, in a culture that pays lip-service and doesn't sincerely engage in righting egregious historical wrongs, whose entrenched elite lack the generosity and humanism necessary to restore dignity to the ranks of the generationally oppressed by reaching out, mentoring and nurturing their talent. 

Racism is much more stark and overt for the thousands of African students now streaming into India for higher studies. As a black American PhD Student at the Delhi School of Economics wrote in 2009 (4),

'Discrimination in Delhi surpasses the denial of courtesy. I have been denied visas, apartments, entrance to discos, attentiveness, kindness and the benefit of doubt. Further, the lack of neighbourliness exceeds what locals describe as normal for a capital already known for its coldness.

My partner is white and I am black, facts of which the Indian public reminds us daily. Bank associates have denied me chai, while falling over to please my white friend. Mall shop attendants have denied me attentiveness, while mobbing my partner. Who knows what else is more quietly denied?

"An African has come," a guard announced over the intercom as I showed up. Whites are afforded the luxury of their own names, but this careful attention to my presence was not new. ATM guards stand and salute my white friend, while one guard actually asked me why I had come to the bank machine as if I might have said that I was taking over his shift'.

Be it Caste Hindus in India or whites in the US, bigotry goes underground following laws ostensibly banning it. Enacting laws isn't the same as implementing them. Entrenched power doesn't give its hegemony away. It has to be wrested out of cold dead, usually male, hands. Meantime, institutionalized bigotry cleverly engages in tokenism to gain the cover of plausible deniability, something B. R. Ambedkar, Dalit architect of India's constitution foresaw (5). Obvious symbols of tokenism, when blacks and mixed race sporadically rotated through my NIH lab, systematic lack of structural support and thoughtful mentoring ensured their inevitable failure. Self-fulfilling prophecy in place, such tokenism also gestates the far more dangerous seed of resentment within the easily self-satisfied and less self-aware among the privileged, yes, the same ones quick to myopically complain about oppressive levels of political correctness in society.

A quote often attributed to Gandhi advises, 'First they ignore you, then they laugh at you, then they fight you and then you win'. Yet the process isn't so conveniently linear, tying itself in the pretty bow tie of victory at the end. All too often, initial victories are pyrrhic and the persistently disenfranchised need to cycle back through the process. So, be it India or the US, we're cycling back to the 3rd stage. In both cultures, pressures from such an abhorrent and unsustainable form of institutionalized apartheid are now again coming to the boiling point. Maybe a course correction, maybe some more laws, some more tokenism, ending with marginally more power to the Dalits and blacks. Dare we ever hope for better than this?

Foot-notes

1. Power without accountability creates a desert where disdain blooms at the expense of humanism and dignity by Tirumalai Kamala on TK Talk  

2. Rohith Vemula's suicide letter published by the Times of India, Jan 19, 2016. Full text: Dalit scholar Rohith Vemula's suicide note - Times of India 

3. James Baldwin interviewed by Dr Kenneth Clark, 1963. WGBH American Experience
 . Bonus Video  

4. Outlook India, Diepiriye Kuku, June 29, 2009. 'India Is Racist, And Happy About It' 

5. Dr. B.R. Ambedkar Interview by BBC Radio, 1955. Round Table India - Dr Ambedkar Remembers the Poona Pact in an Interview on the BBC 

https://www.quora.com/What-are-the-differences-and-similarities-between-India-and-America-when-it-comes-to-racism/answer/Tirumalai-Kamala

How economically advanced are the slums in India? What kinds of products do they produce?

'How economically advanced are the slums in India?'
Advanced is a loaded word in general and especially so in the context of slums. Generally, we're taught to denigrate slums and look down on people who live there. The truth is, in the face of both governmental inertia and societal apathy, slums develop out of necessity and are a veritable bee-hive of economic activity and resourcefulness, the likes of which are unprecedented in all other social strata and endeavors. Not only that, over time, the economic activity of slums becomes the very life blood of not only cities in which they exist but through the inexorable process of globalization, its tentacles feed every part of global economic activity. Nowhere is this truism clearer than in Dharavi, the sprawling slum at the heart of Mumbai, India's most populous city, and its financial and entertainment capital.

Dharavi's location: very economically advanced

• To its north, the Mahim-Sion link road
• To its south-west, the central railway line
• To its south, the western railway line
• Close proximity to Mumbai's newest, swankiest business district, the Bandra Kurla Complex.
• Thus, Dharavi is surrounded by 4 railway stations, several bus-lines, and is close to both international and domestic airports of Mumbai (1).
• Location-wise it doesn't get better than this (see figures below from 2, 3, 4), especially for swamp land that a little more than a century back was deemed worthless, and thus ignored and neglected by governments.
• Total area? ~550 acres (~175 hectares), i.e., smaller than New York's Central Park, but with an estimated, astounding density of ~18000 people per acre in some areas, i.e., 6 to 8X more dense than Manhattan.
• Even densities of up to 336, 643 have been measured in some areas of Dharavi (5).

A very brief history of Dharavi explains why its location is now so economically advanced

• Predating the current city of Mumbai, in the late 17th century, local Koli fishermen lived in the swamp lands near the Mithi River.
• Recognizing the great potential of a natural harbor, in 1534 the Portuguese captured seven separate islands, the as-yet-non-existent Mumbai, which became a wedding gift to England's Charles II in 1662.
• Promising 'free settlement, freedom of religion and unregulated trade', the British East India Company encouraged internal migration to stock the growing city with the labor necessary to feed its global trade from this vital port city (1).
• Starting in the 1800s, the city of Mumbai began reclaiming land to accommodate its increasing population. Over time, the reclaimed land in the swampy areas near Mahim river became Dharavi (3).
• The government back then considered Dharavi unfit for inhabitation.
• Swamp land near-impossible to build on, inconveniently far from the then city center, deemed of no interest.
• For a century, impoverished migrants from all over India seeking economic opportunity in the booming port city had little choice but to settle in places like Dharavi.
• It was 'unregulated, available and free of cost' (1).
• As the city of Mumbai grew further north from its southern base, communities labeled undesirable were forcibly evicted to the then city edges, i.e., nearer to Dharavi.
• The impoverished migrants provided a ready supply of cheap labor and conveniently in return, the city, government, employers needed to provide little in terms of services.
• Not housing, not stable employment, nor health care, let alone investment in terms of insurance and pensions.
• New migrants and the original inhabitants, the Kolis, developed the land themselves, without any government support.
• Over time, families and relatives of pioneer migrants came to settle and Dharavi's population grew in distinct patterns of caste, religion and occupation.
• As the then city proper South Mumbai boomed, those unable to afford housing there also gravitated towards Dharavi.
• Historically, the colonial overlords lived in the wealthier South Mumbai and that old class divide still brands the city even as it consumes its neighboring environs in its insatiable appetite for growth (see figure below from 6).
• In the process and over time, Mumbai's growth around and beyond the previously shunned and derided Dharavi has today made it one of the most monetarily valuable and coveted real estates in the world.

• Eventually, with the city council being forced to recognize Dharavi as part of Mumbai's central municipality (7), a few public toilets and water taps were installed.
• With this denominational change, Dharavi residents earned at least a modicum of respect.
• Estimated anywhere from half a million to a million in number, they'd become important vote banks for local politicians.
• Ever since, they exist in a constant tussle between their original no man's land identity limned in sheer pluck and ingenuity, and the western-oriented dreams of politicians, city planners and Mumbai's middle class who aspire to live in a 'world-class' city, whatever that means.
• Already there's a pattern to note. Cities attract two types of migrants, those considered desirable and the rest, undesirable.
• The former tend to be the affluent or middle class while the latter are typically the rural impoverished who leave ancestral homes for better economic opportunities in cities, often in desperation.
• Historically, cities and their governments didn't care about the latter migrants so didn't prepare for them, welcome them or even accommodate them in a civilized and methodical manner.
• Dharavi serves as a convenient poster-child for this process. Today comprising ~80 neighborhoods, ~1 million inhabitants and ~100,000 microenterprises, migrants living there include potters from Gujarat, leather tanners from Tamil Nadu, embroidery specialists from Uttar Pradesh, and many others.
• By and large, they are either Muslims or Hindu lower castes including the so-called untouchables.
• They may have left their ancestral land behind but they brought with them the specialized knowledge pertaining to family trades, culture and practices. These formed the bedrock of Dharavi's economic activity.
• Sign of chameleon-like adaptability, today recycling is one of Dharavi's major economic activities.
• Unencumbered with environmental, factory or labor regulations makes Dharavi's labor and production costs low, at the expense of health, safety and longevity.
• Current cottage industries in Dharavi include large-scale recycling, leather tanneries, metal work, wood work, machinery manufacturing, printing, garment finishing, and shoe, luggage and jewelry manufacture (8).

'What kinds of products do they produce?'

Dharavi's recycling business

Dharavi is estimated to recycle ~80% of Mumbai's plastic, numbers estimated to be far higher than those in the UK (9; see figures below from 4, 10, 11). As the world's ninth most populous city, this is no mean feat.

Dharavi's potteries (figures from 11, 12, 13, 14).

From hand embroidery to leather goods to goat intestines that will eventually end up as surgical thread (see figures below from 4, 11, 15), Dharavi's economy is complex, mulifaceted, just like the migrants who've made it their home.

Dharavi is already organically exporting its microenterprise, mixed-use space economic model to other slums

Dharavi's staggering complexity, ingenuity and industriousness begs the question, what's a slum?

 

What is a slum?

Apparently, the word slum was first used to describe dense, impoverished and unsanitary housing of 1820s London (16). The UN's attempt to define slum, 'Slums are neglected parts of cities where housing and living conditions are appallingly poor. Slums range from high-density, squalid central city tenements to spontaneous squatter settlements without legal recognition or rights, sprawling at the edge of cities' leaves much to be desired and unsatisfactory when applied to Dharavi. A more detailed attempt captures key slum attributes, with the worst ones having all of them (16):

• 'Lack of basic services: Inadequate access to safe water sources and sanitation facilities is the most significant feature. It is sometimes supplemented by absence of electricity, waste collection systems, surfaced roads, rainwater drainage and street lighting.
• Substandard housing or illegal and inadequate building structures: Houses are often constructed with non-permanent materials. Given local conditions concerning climate and location, these materials may be unsuitable for housing.
• Overcrowding and high density: A majority of the slum dwelling units suffer from high occupancy and the living space per inhabitant is scarce.
• Unhealthy living conditions and hazardous locations: Due to lack of basic services, such as sewage, waste and pollution management, unhealthy living conditions occur. Buildings may also be constructed on hazardous or unsuitable land.
• Insecure tenure: Lack of formal documents entitling settlers to occupy land bring about an insecurity in residential status.
• Poverty and social exclusion: As a cause and consequence of slum conditions; income and capability poverty restrain human and economical development.
• Minimum settlement size: A single household cannot be referred to as a slum since the term constitutes a precinct.'

Is Dharavi a slum?

• Strictly using the UN's more detailed yardstick, no doubt Dharavi is a slum (see figure from 17 on the left). But the reality is far more nuanced and murky.
• Even a straightforward survey of Dharavi's inhabitants puts paid to the notion of ranks of the desperately impoverished belonging to the lowest rungs of society.
• As Mumbai grew upward, around and beyond Dharavi, reaching out to and encompassing its  erstwhile suburbs, its perennial, desperate housing shortage drove new waves of Dharavi migrants, from blue collar workers like carpenters and electricians to white collar workers such as engineers, graphic designers and even those in the civil service such as clerks and police, all pulled to Dharavi by a common thread, affordable housing (see figure below from 18 on the right).
• For example, a study showed that 'in Mumbai in May 2006 we had 4,426 Police Constables (13 more than there were a year earlier) and 81 Police Inspectors living in slums: officers of the law who are illegal residents of the city' (14).
• According to Krishna Pujari, who organizes a controversial slum tour through Dharavi, 'All sorts of people live in Dharavi. MNC [multinational corporation] workers, BPO [business process outsourcing] workers, 60 percent of our police force' (10).

In Dharavi, lack of modern amenities equals lack of basic dignity

• Lack of proper water supply, sewage systems, toilet facilities makes cholera, malaria, typhoid, dengue common in Dharavi.
• Unregulated, toxic industries (tanneries, paints, plastic recycling) further contribute to chronic diseases.
• In Dharavi's leather accessories manufacture, 15 to 17 hour days are common, including 2 to 3 hour breaks for lunch and dinner. Only ~1% of these enterprises and workers have access to on-premise toilet facilities (8).
• Such callousness reveals an unpleasant though essential truth. Querying the use of the word slum is far from an exercise in semantics. It holds a mirror to our values. Inconsiderate, superficial, unthinking, uncaring? Sure, slum’s fine. Introspect and probe? Slum’s revealed as yet another way to shun and otherize.
• By now, copious news coverage and sociological research confirms that, lack of public or private investment notwithstanding, Dharavi generates valuable economic output for Mumbai and beyond.

In terms of its economic output, quite unlike modern, organized labor with entrenched long commutes and other environmentally unsustainable practices such as high-rise sleeper/bedroom communities, strip malls, colossal car showrooms, etc, it's not just a question of what but also how.

• Much of Dharavi is mixed-use space, i.e., living and working quarters cheek by jowl.
• Small-scale microenterprises, with most businesses employing 20 or less.
• The recycling aspect of Dharavi's economy makes it even more avant-garde.
• Whatever is intended by the use of the phrase 'economically advanced', Dharavi far outpaces conventional notions of sustainable economic development.
• Enlightened politicians and city planners, if such species do exist, could see in this aspect of Dharavi an economy of the future, the much-vaunted, eminently desirable Circular economy.
• Desirable because other than abandoning a wantonly destroyed Mother Earth to take to permanent space stations or colonizing Mars or some such science fiction fantasy a la WALL-E, sustainable economic development is the only way out for humans and for Mother Earth.
• From such a perspective, instead of looking to teach down to, Dharavi becomes a place to learn from.
• A natural experiment in urbanology, what Dharavi lacks is the modicum of dignity that non-slum dwellers take for granted, clean running water at home, hygienic sewage drainage, indoor toilets, basic health care, job safety and security, and regulated pay.
• As for what it takes to make a sustainable living-working space in the 21st century, Dharavi's natural experiment already points us the way ahead. If that isn't economically advanced, I don't know what is.

Bibliography

1. Page on bekon.lth.se
2. Eriksson, Charlotta. "Dharavi: Space, time, human condition towards a theory on unplanned settlements." (2013). http://www.diva-portal.org/smash...
3. Page on artdurnev.com
4. Page on yimg.com
5. Echanove, Matias, and Rahul Srivastava. "The High-Rise and the Slum: Speculative Urban Development in Mumbai." (2012): 789-813. Page on berkeley.edu
6. Mumbai case study
7. Engqvist, Jonatan Habib, and Maria Lantz. Dharavi: documenting informalities. Royal University College of Fine Arts, 2008.
8. Page on nceuis.nic.in
9. Waste not, want not in the &#163;700m slum
10. 404 page - Motherland Magazine
11. National Geographic Magazine - NGM.com
12. Page on comm-dev.org
13. Megha Gupta's Dharavimarket.com aims to sell products by Dharavi's craftspeople across the world - The Economic Times
14. Page on udri.org
15. http://kaustuv.net/projects/MIRG...
16. http://mirror.unhabitat.org/pmss...
17. Dyson, Peter. "Slum tourism: representing and interpreting ‘reality’ in Dharavi, Mumbai." Tourism Geographies 14.2 (2012): 254-274.
18. Larsson, Emma, and Maja Nilsson. "Towards sustainable sanitation in slum areas: A field study in Mumbai." (2013). http://www.diva-portal.org/smash...

https://www.quora.com/How-economically-advanced-are-the-slums-in-India-What-kinds-of-products-do-they-produce/answer/Tirumalai-Kamala

Why is anemia a common problem among Indian women?

Short answer, anemia in Indian girls is predicated by both biology and socio-economic factors, i.e., unique confluence of biology, culture (diet, marriage age), and great variations in relative affluence and education.

Early marriage ---> early initiation of sexual activity ---> repeated early child bearing ---> recurrent iron loss. This emerges as a major reason for anemia among Indian girls.

Thus, large part of anemia in Indian girls ensues from exacerbation of their inherently greater risk of iron loss attendant to their biology, i.e., pregnancy, child birth and breast feeding. Such exacerbation is cultural, i.e., tendency for early marriages and child births, as well as dietary, i.e., inadequate iron intake and inefficient absorption.

There are also substantial, surprising and inexplicable regional differences.

While there are several types of anemia, I'll restrict my answer to nutritional anemia, specifically to Iron-Deficiency Anemia (IDA), the most common form of anemia in India (1, 2).

Anemia is assessed by measuring circulating blood hemoglobin levels. Typically, there are 3 levels, Mild (10 to 11.9g/dl), Moderate (7 to 9.9g/dl) and Severe (<7g/dl). Typically, in India, severe anemia prevalence tends to be <3%, moderate ranges from 5 to 20%, and mild from 25 to 44%. So the silver lining is that severe anemia levels are low.

Biological factors that contribute to anemia in Indian girls

• The most important biological reason for IDA is inadequate dietary intake of bioavailable iron (3; see figure below).
• There are unique factors associated with Indian diets that may predispose to IDA.

• Being heavily plant-based, it relies on the less bioavailable non-haem form of iron.
• Higher levels of Polyphenol and phytates (Phytic acid).
• Lower ascorbic acid (Vitamin C) to iron ratio which impedes iron absorption.
• Possible average gastric acidity levels that are sub-optimal for iron absorption.

Inadequate dietary iron intake

• Dietary iron is available in two forms, haem or non-haem.
• Haem form of dietary iron is commonly available in meat with the non-haem form in plant foods.
• Haem iron is much better absorbed so already we arrive at a partial answer to the question.
  
  • 90 to 95% of total daily dietary iron in Indian diets is non-haem iron (4).
  • Vegetarian diet iron bioavailability is 10% compared to 18% in omnivorous diets.
  • This means Indian diets are richer in the less efficiently absorbed non-haem iron.
• To compensate for this lower efficiency, nutritionists recommend increasing dietary iron intake by 80% (5).
• Adding another wrinkle, adequate dietary iron levels does not in and of itself explain India's anemia prevalence since Gujarat with ~23mg/day iron intake still has 55% anemia prevalence compared to Kerala's much lower 33% with just 11mg/day iron intake (4).
• Thus, inadequate iron intake explains Indian girls' anemia partly, not wholly.

Defective iron absorption

• More acidic the stomach, better the iron absorption.
  
  • With the caveat that the same studies didn't compare gastric acidity in India to other countries, an old study found that Indian gastric acidity averages ~3.4, much higher than the average of ~2.5 in other countries (6).
• Vitamin C (ascorbic acid) is a strong iron absorption enhancer of plant non-haem iron (7). Indian Vitamin C intake tends to be sub-par.
  
  • In a small (n = 54) 1985 study, vegetarian Indian children with IDA and low vitamin C intake given 100mg Vitamin C during lunch and dinner for 60 days had dramatic improvement, even full recovery from anemia (8).
  • Indian diets tend to have rather low levels of Vitamin C (4, 9).
  • A 2007 study of 214 men and 108 women found sub-optimal Vitamin C intake (recommended 0.4mg/dl) among both (7).
  • Young, married girls in urban Indian slums? Again,  sub-optimal Vitamin C intake (10).

• Indian diets have several dietary components that bind to bioavailable iron preventing its absorption. These include 

• Polyphenols. Tea, herb teas, cocoa, coffee, cinnamon, red wine are polyphenol-rich (11).
• Calcium (12), phosphorus, manganese, zinc.
  
  • Higher intake of Calcium and Phosphorus correlated with anemia in pregnant women (13).
  • Indians' tendency to drink tea/coffee with meals reduces bioavailability of dietary iron (5).

• These are all general reasons for IDA in India. Now let's examine the specific reasons for IDA in Indian girls.
• Here the most pertinent factors are blood loss during menstruation and pregnancies, and loss through breast feeding.
• Blood loss is perhaps the most important one since iron isn't excreted out through urine or feces but only through loss of cells, skin or blood cells for example. 
• Age of highest prevalence of IDA in Indian girls, i.e., 12 to 13 years old, coincides with menarche (first menstruation). Two inter-related problems reveal themselves here.
  
  • One, substantial numbers of Indian girls have menstrual abnormalities but don't seek medical help (14).
  • Two, menstrual blood loss increases daily total iron requirement, consumption of which is sub-optimal for many Indian girls anyway for reasons we've already covered, namely inadequate daily intake and inefficient absorption due to peculiarities associated with Indian diets. Thus, menstruation in Indian girls exacerbates their pre-existing tendency for anemia. 

Socio-economic factors that contribute to anemia in Indian girls

• The National Family Health Surveys (NFHS) are periodic Indian Government health surveys conducted since 1992-1993.
• It shows that currently ~27% of Indian girls aged 15 to 19 years are married. This tracks closely with UNICEF data (15). It's also currently one of the highest rates of early marriage in the world.
  
  • Studies show that married adolescent Indian girls tend to consume diets high in phytates, low in Vitamin C and iron, and unsurpisingly, have high prevalence of IDA (10, 16).
  • In a 2008 study on 118 young, pregnant, poorly educated, low-income Indian girls from North Indian villages, folic acid intakes also tended to be very low (9).
  • On average, Indian women have 297mg of iron loss (blood loss during delivery, iron transfer to newborn, iron content of umbilical cord) versus 150mg of iron conservation (no menstruation) during pregnancy (17). In other words, pregnancy leads to net iron loss. This can only be offset by higher iron intake and absorption.
  • Lactating women obviously have higher daily iron intake requirements, not just to meet infant iron requirement through breast milk but also to make up for loss during pregnancy and delivery.
  • Since daily iron intake requirements are already sub-par in India, deficiency is only exacerbated for pregnant and lactating women.

• Thus, early marriage ---> early initiation of sexual activity ---> repeated early child bearing ---> recurrent iron loss. This emerges as a major reason for anemia among Indian girls.
• In other words, large part of anemia in Indian girls ensues from exacerbation of their inherently greater risk of iron loss attendant to their biology, i.e., pregnancy, child birth and breast feeding. Such exacerbation is cultural, i.e., tendency for early marriages and child births, as well as dietary, i.e., inadequate iron intake and inefficient absorption.

• Several groups have analyzed the Indian Government's NFHS anemia data.
• Careful data mining of the NFHS and other epidemiological data shows that anemia tends to be higher among women who are illiterate, reside in rural areas, work in agriculture, are Hindu, Scheduled Caste (SC) or Scheduled Tribe (ST) (18, 19, 20).
• Poorest urban women are also more likely to be anemic compared to everyone else including their rural counterparts (21, 22). Why? Key factors include
  
  • Lower income, lower access to income and resources.
  • Higher rates of infection due to poor sanitation.
• Factors found to be protective against anemia
  
  • Belonging to middle/upper class.
  • Educated up to high school or higher.
  • Consuming alcohol or pulses.
  • Higher BMI (Body Mass Index).
  • Being Muslim.
• Alcohol consumption protects against anemia, especially among poorer rural women, particularly ST women (21).
  
  • Surprising? Yes and the underlying biology is still a mystery.
  • A robust literature links alcohol consumption to higher iron levels and absorption (23, 24, 25).
  • Alcohol may increase the fermentation process/gastric acid secretion or promote iron solubility/absorption/ferric ion reduction or could itself be an iron source.
• Pulses have high iron content and are also a surrogate for higher income.
• Muslim versus Hindu could be attributed to differences between iron-replete, i.e., non-vegetarian, versus iron-deficient, i.e., vegetarian, diets.
• On the whole, protective factors clearly suggest that higher income ---> better education ---> better diets ---> lower anemia.
  
  • In fact, wealth tracks better with iron sufficiency than even education or caste (26).
  • Education comes second (27).
• One of the most interesting trends is a regional bias in anemia.
  
  • Anemia prevalence is highest among women in the Eastern states of India (4, 19, 22).
  • Assam, Bihar, Jharkhand, Odisha, West Bengal tend to have the highest women anemia prevalence rates (see figures below from 4 and 19). Why? No clear answer.
  • Anemia in general and IDA in particular is multi-factorial. 
  • Likely answer is some combination of biology and culture, i.e., dietary iron and micronutrient deficiencies, and cultural practices such as early marriages, tendency of less educated women, lower incomes.

• While there's substantial literature on high anemia prevalence in Indian women, there are fewer such studies in men.
  
  • In one study on 544 older rural Indian men aged 60 to 84, majority were anemic (28).
  • In fact, Indian men weren't even included in the 1st two NFHS, only being included in the 3rd one (2005-2006) (29).

Anemia rates in Indian women are the highest in the world (3). What could be done to reverse this trend?

• Centralized approaches would be to co-ordinate and encourage manufacture of fortified foods.
• This is something that the FAO (Food and Agriculture Organization) also recommends (30).
• The Micronutrient Initiative began in 2004.
  
  • Through it, the Tamil Nadu Salt Corporation (TNSC) manufactures double- and triple-fortified salts, Vita-Shakti, fortified with iron and folic acid, and Anuka, fortified with iron, Vitamins A and C (31, 32).
• As we explored earlier, certain peculiarities of Indian diets easily lead to IDA.
  
  • Cultural norms are extremely difficult to overcome.
  • Dietary habits are part of such norms.
  • However, there is a silver lining to this conundrum in that several foods that are already part of Indian diets, namely, egg, green vegetables, jaggery, whole wheat, onion stalks, pulses, are iron-rich.
  • Food-based approach is also safer than oral iron supplements which have side-effects such as gastro-intestinal upset (31).
• Better education of Indian girls will go a long way in alleviating their prevailing anemia levels. 
  
  • Would better ensure their conscious and conscientious consumption of iron-rich foods that are already part of Indian diets. So no need to re-invent the wheel in terms of dietary habits.
  • Would encourage their becoming better aware of their basic health parameters such as height, weight, blood type and hemoglobin levels.
  • Would help delay their marriage age.
  • Would help them make better, more empowered decisions regarding childbirth age, spacing between children, and increasing iron, Vitamins A, B12, C, folic acid and riboflavin intake during pregnancy.

Bibliography

1. Raman, L., A. B. Pawashe, and B. A. Ramalakshmi. "Iron nutritional status of preschool children." The Indian Journal of Pediatrics 59.2 (1992): 209-212.
2. Yip, Ray. "Iron deficiency: contemporary scientific issues and international programmatic approaches." The Journal of nutrition 124.8 Suppl (1994): 1479S-1490S. Page on nutrition.org
3. Balarajan, Yarlini, et al. "Anaemia in low-income and middle-income countries." The Lancet 378.9809 (2012): 2123-2135. Page on indiaenvironmentportal.org.in
4. Nair, K. Madhavan, and Vasuprada Iyengar. "Iron content, bioavailability & factors affecting iron status of Indians." Indian J Med Res 130.5 (2009): 634-45. Page on icmr.nic.in
5. Rammohan, Anu, Niyi Awofeso, and Marie-Claire Robitaille. "Addressing Female Iron-Deficiency Anaemia in India: Is Vegetarianism the Major Obstacle?." ISRN Public Health 2012 (2011). Page on hindawi.com
6. Goyal, R. K., P. S. Gupta, and K. H. Chuttani. "Gastric acid secretion in Indians with particular reference to the ratio of basal to maximal acid output." Gut 7.6 (1966): 619-623. Page on bmj.com
7. Chiplonkar, S. A., et al. "Are lifestyle factors good predictors of retinol and vitamin C deficiency in apparently healthy adults?." European journal of clinical nutrition 56.2 (2002): 96-104. Page on nature.com
8. Seshadri, S., A. Shah, and S. Bhade. "Haematologic response of anaemic preschool children to ascorbic acid supplementation." Human nutrition. Applied nutrition 39.2 (1985): 151-154.
9. Gautam, Virender P., et al. "Dietary aspects of pregnant women in rural areas of Northern India." Maternal & child nutrition 4.2 (2008): 86-94.
10. Tupe, Rama, > Shashi A. Chiplonkar, and Nandita Kapadia-Kundu. "Influence of dietary and socio-demographic factors on the iron status of married adolescent girls from Indian urban slums." International journal of food sciences and nutrition 60.1 (2009): 51-59.
11. Hurrell, Richard F., Manju Reddy, and James D. Cook. "Inhibition of non-haem iron absorption in man by polyphenolic-containing beverages." British Journal of Nutrition 81.04 (1999): 289-295. Page on iastate.edu
12. Hallberg, Leif. "Does calcium interfere with iron absorption?." American Journal of Clinical Nutrition 68.1 (1998): 3-4. Page on nutrition.org
13. Samuel, Tinu Mary, et al. "Correlates of anaemia in pregnant urban South Indian women: a possible role of dietary intake of nutrients that inhibit iron absorption." Public health nutrition 16.02 (2013): 316-324. Page on cambridge.org
14. Kulkarni, Meenal V., and P. M. Durge. "Reproductive health morbidities among adolescent girls: Breaking the silence." Ethno Med 5.3 (2011): 165-168. Page on krepublishers.com
15. Page on unicef.org
16. Sharma, Vridhee, et al. "NUTRITIONAL ANAEMIA AMONG CURRENTLY MARRIED FEMALES IN THE REPRODUCTIVE AGE GROUP IN RURAL JAMMU." Page on jemds.com
17. Apte, S. V., and P. S. Venkatachalam. "IRON LOSSES IN INDIAN WOMEN." The Indian journal of medical research 51 (1963): 958.
18. Bharati, Premananda, et al. "Prevalence of anemia and its determinants among nonpregnant and pregnant women in India." Asia-Pacific Journal of Public Health 20.4 (2008): 347-359. Page on isical.ac.in
19. Bharati, Susmita, et al. "Temporal trend of anemia among reproductive-aged Women in India." Asia-Pacific Journal of Public Health 27.2 (2015): NP1193-NP1207.
20. Agarwal, K. N., et al. "Prevalence of anaemia in pregnant & lactating women in India." Indian journal of medical research 124.2 (2006): 173. Page on icmr.nic.in
21. Bentley, M. E., and P. L. Griffiths. "The burden of anemia among women in India." European journal of clinical nutrition 57.1 (2003): 52-60. Page on nature.com
22. Ghosh, Saswata. "Exploring socioeconomic vulnerability of anaemia among women in eastern Indian States." Journal of biosocial science 41.06 (2009): 763-787.
23. Turnbull, A. Iron Absorption. pp369-403. In Jacobs, Allan, and Mark Worwood. Iron in biochemistry and medicine. Academic Press Inc.(London) Ltd., 1974.
24. Milman, N., and M. Kirchhoff. "Relationship between serum ferritin, alcohol intake, and social status in 2235 Danish men and women." Annals of hematology 72.3 (1996): 145-151.
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