Kamal Ghorui
Being a city boy whose imagination was mostly fed by adventure stories, I was fascinated by the idea of climbing a tree to pick fruit. So, when I discovered that the house we were visiting had a line of guava trees in the garden laden with fruit, I really had no choice.
Guava trees tend to branch out quite early, so it was barely a climb to get to one of the boughs that were, so it seemed, bending down with the weight of the fruits they were carrying.
Then it was just a matter of sliding on my butt a few feet down the bough, and I was there, or so I thought, when I noticed some movements along my bare legs: there was a parade of robust-looking red ants heading straight inside my shorts. I won’t spell out the rest, except that my mother was astounded by how fast I ran across the lawn towards the nearest toilet.
And I learnt that guava trees house red ants who, when disappointed in their quest — I can’t say what they were hoping to find — bite. Hard.
I still love guavas. Especially those we call dansha in Bangla, at the cusp of ripeness (which does sound vaguely obscene). Sweet and sour with a hint of acrid, a burst of freshness, a light bulb that lights up inside your mouth, great in chaats and salads. Full of vitamins, combining lots of fibre and a low glycemic index, and more surprisingly perhaps, a good source of iron (especially the pink ones).
Apparently, the fact that they are high in vitamin C elevates our body’s ability to absorb the iron: a 2024 randomised controlled trial, by a long list of authors led by Varsha Rani from Chaudhary Charan Singh Haryana Agriculture University, finds that 6-10 year olds who were fed moong dal with guava for their school lunch over a seven-month period were 50% less likely to suffer from anemia than those who got just moong dal.
This is important, even very important, because there are two billion people with anaemia in the world, and India has the highest: nearly 60% of women and children and more than 30% of males are anemic by the now accepted global norms.
We have a higher fraction of anaemic people than in Bangladesh or Pakistan, more in the range of countries much poorer than us. Despite guavas being crisp, delicious and easy to pick (as long as you mind the ants).
The wide prevalence of anaemia might make it seem innocuous, but that would be a mistake. First, because according to the most recent round of the National Family Health Survey (NFHS), more than 50 million children are reported as severely anaemic, a debilitating and sometimes life-threatening condition that interferes with both physical growth and intellectual development.
Moreover, among those under three, 9% are severely anaemic, which puts them at risk of impaired brain development.
Second, anaemia in pregnant women is dangerous for both the child and the mother. According to a recent article in Lancet Global, severely anaemic women are seven times more likely to bleed to death on the birthing table than moderately anaemic ones, and while severe anaemia is relatively common, my calculation is that about three lakh such women give birth every year, and a significant number of them die.
But even mildly anaemic people suffer. Anaemia reduces blood haemoglobin levels, and haemoglobin transports the oxygen that reinvigorates muscles.
As a result, anaemic people get tired sooner. In the early 2000s, a team including Duncan Thomas, who is a friend and a professor of economics at Duke University, carried out a large-scale (17,000 participants) study in central Java of what happens when working-age people, mostly farmers and labourers, take iron supplements.
The study population was not particularly anaemic — less than 8% of men were even moderately anaemic, significantly below current Indian rates. Yet even in this population of marginally anaemic people, iron supplementation increased productivity.
The men slept less and worked more days. Earnings went up by 15%. That could be a lot of money for India as a whole, given the prevalence.
Unfortunately, at least in India, the problem is not solving itself.
According to the NFHS, for most groups in India, anemia rates went up between 2015-16 and 2019-21. It is true that there was the pandemic, but the magnitudes are large enough to be concerning. For adolescent girls, the national average went from 54% to 59%, but in Assam, for example, the reported increase is more than 24 percentage points.
Of course, many factors drive these numbers — intestinal worms, for one, reduce iron absorption. Malaria does the same thing. And, of course, not having enough to eat — poorer people are more anaemic.
But the differences are surprisingly small: the richest group in the data (not the super-wealthy since they don’t deign to fill out surveys) is only 20% less anaemic than the poorest. And some of the richer states, like Punjab, Haryana and Gujarat, have the highest levels of anaemia.
All of this, to my mind, points to an obvious culprit — diet. Richer Indians are more likely to be vegetarian, which can explain why the income gradient is not steeper. Relatedly, as people become less poor, they start eating like the elites — more paneer and less meat or foraged greens — which could be partly why anaemia has risen.
Bangladeshis and Pakistanis eat more red meat than us, and red meat is, alas, the source of the kind of iron that the body absorbs readily (liver, in particular, is a great source of iron, though I always resisted my mother’s attempt to sneak it into my diet), which might explain why they do slightly better.
Now I am not about to suggest that vegetarians switch to eating red meat: for one, Cheyenne, whose drawings define these columns, would walk out on me (she is vegetarian). But it is true that vegetarians find it harder to get enough iron: even when plants have lots of iron, that iron is not easily absorbed.
To get enough iron without eating red meat probably means moving quite far from the alu-paneer-dahi-dal-chawal-roti diet that seems to be taking over North India’s vegetarians.
It troubles me that in the vegetarian’s paradise that is India, most restaurants offer just a couple of vegetable dishes, perhaps an eggplant bharta and a navratan korma? And though I will eat eggplant in any form, it contains nasunin, which makes it harder for the body to absorb iron.
Unfortunately, changing diets is hard, as all of us who tried at some point to reshape our bodies have experienced: millet kheer is nice, and definitely healthier, but my mouth wants kheer with Bengal’s wonderful gobindobhog rice. Sugar-free ice cream is a nice idea, but I am happy to leave it in the freezer.
Anaemia Mukt Bharat, the government’s recently launched anti-anaemia program, has therefore taken the alternative route of iron supplementation through pills and syrups. This could work for younger kids who get them with school meals, or even the toddlers who attend the anganwadis (but not everyone does), but for adolescents and adults, it relies on taking the pill on schedule, not once or for a month but potentially for their whole life.
This is not easy and in addition, iron can be constipating, so people often resist supplements even if they really need them.
This is why the WHO and many experts push for the fortification of staples like rice, wheat or salt with iron (and nutrients that support the absorption of iron).
The government of India has also broadly accepted this idea for some years now. However, we still lack evidence that these fortified staples can be delivered at scale without losing much of their benefits. Especially in the hot and humid climate of much of India. And even if delivery is possible, will consumers want them?
In the early 2010s, the government started mandating that government school lunches be cooked with Double Fortified Salt (DFS), salt with both iron and iodine added. To understand how much it helps with anaemia, we implemented a study in Bihar. Households in randomly chosen villages were encouraged to buy DFS by subsidising the price and improving access.
The study found some impact on anaemia among adolescents, but the households really did not like the salt and stopped using it before it could have much of an impact.
They claimed that it tasted bad (we couldn’t taste the difference) and that it made the food turn dark (which it did). However, we sensed that they were also not convinced of its benefits — the only villages where people continue to buy the salt, some years after the initial intervention, were those (chosen at random) where we showed a sitcom that my childhood friend Pradip Saha made based on our script, aimed at persuading them.
In it, a young man is worrying whether the son his pregnant wife will deliver will grow up to be strong (unlike himself, who is a bit of a joke in the village).
He wants to do something about her anaemia, but finds it implausible that strength can come from salt. It is only when his old teacher tells him that guavas can also help that he starts contemplating the possibility that the body works in ways that he does not understand.
The government is now pursuing the path of fortified cereals by trying to make it mandatory in school meals and the public distribution system. However, establishing a reliable supply chain and a quality testing infrastructure for fortified rice has proved difficult, and recently the government has suspended its use in the public system.
This might be the right time to revisit persuasion. There are supposedly traditional varieties of rice that can deliver much more iron to the body than the now most common breeds.
If this is true, it will need rigorous testing — creating markets for those varieties could be an important element of the strategy, especially since it reaches the more affluent groups who do not use the public schools or the PDS, but are almost as afflicted by anaemia as the rest. And somewhere in the process, we should tell people about guavas.
GUAVA RECIPES
Here are two simple and tasty ways to get more guavas into your diet:
Peruchi Koshimbir (Spiced guava salad):
Soak 1/4 cup moong dal in water for 4 hours. Drain and mix with 1/2 cups finely diced cucumber and carrots, 1 cup finely diced firm, almost ripe, guava, 1 green chili, very finely sliced and 2 tablespoons finely chopped cilantro. Dress with 1 tablespoon lemon juice and ½ tsp salt. Finish with a chhaunk of ½ tsp mustard seeds, 1 sprig of curry leaves and a pinch of hing in 1 tbs oil.
Guava raita:
Grate 3 ripe (but not too soft), seeded guavas (1 cup). Mix with 1 cup not too sour-yogurt, 1 tsp roasted and ground cumin seeds, ½ tsp deghi mirch, ½ tsp salt, ¼ tsp sugar, and ¼ cup roasted and broken walnut kernels.
This is part of a monthly column by Nobel-winning economist Abhijit Banerjee, illustrated by Cheyenne Olivier
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