A global health project: Creating sustainable solutions to address anemia at Munsel-ling school in rural northern India

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Anemia is a major public health concern in India, especially with­in the rural population. Six years ago, a group of medical students from the University of British Columbia began a collaboration with a boarding school in the Spiti Valley area of Northern India. The team found a high prevalence of anemia within the school population and devised a set of sustainable proj­ects to improve student health, includ­ing health education, greenhouses, water and sanitation, and iron supplementation. Health screens were also integrated ev­ery year to track changes in the popula­tion’s health over time. To date, these in­terventions have significantly decreased the students’ levels of anemia over the five-year period. However, the most effec­tive intervention appears to be direct iron supplementation, yet the sustainability of this practice remains challenging.

Introduction
Spiti Valley is a col­lection of remote villages located in the Himachal Pradesh province of India, situated at an altitude of 3,800 meters (Figure 1). For approximately seven months of the year the valley is inacces­sible due to snow on the high mountain passes, which limits access to health care and basic services. In 2006, a group of University of British Columbia (UBC) medical students working with Dr. Videsh Kapoor developed UBC’s first Global Health Initiative (GHI) program, the Spiti Project. This project estab­lished a partnership with the Munsel-ling Boarding School in the village of Rangrik and its affiliated local Non-Government Organization (NGO), Rinchen Zangpo Society for Spiti Development. The school is privately run and is currently respon­sible for the education of approximately 700 children from surrounding commu­nities, housing three quarters of the stu­dents for the entire school year. Since its inauguration, the Spiti Project has also collaborated with the Vancouver-based Trans-Himalayan Aid Society (TRAS) and several other NGOs for funding.

In 2006, the first UBC Spiti Valley team met the local population to assess com­munity health concerns. One pressing discovery was the high levels of anemia in the school children. Since then, teams of UBC students, mainly from the faculty of Medicine but also Dentistry, Engineering, Land and Food Systems, Journalism, and Integrated Science, along with a number of family practice residents, have designed and implemented various proj­ects to positively impact the health and anemia of the students.

Anemia refers to a disease state in which there is a decrease in the number of, or an abnormality in, an individual’s red blood cells (RBCs). It is therefore difficult for the remaining RBCs to carry enough oxygen to the tissues of the body. Severe enough anemias can be deadly; further, often the effects of anemia include cog­nitive and physical development abnor­malities in children, fatigue, dyspnea, and a reduction in physical performance in adults(1). The World Health Organization (WHO) classifies anemia based on vary­ing hemoglobin (Hb) thresholds that take into account age, gender, physiological status (ie. pregnancy), and altitude (2). The most common cause of anemia world­wide is iron deficiency; therefore, anemia levels can be an indicator of both poor nutrition and poor health (3).

According to data calculated by the WHO, India has a severely high preva­lence of anemia in its population (>45%) (2). This is considered a public health con­cern – especially in young children, preg­nant women, and non-pregnant women of reproductive age (3).

Interventions
In order to assess lev­els of anemia at Munsel-ling, Hb levels of each student were measured in 2006. There were approximately 400 students, both males and females, ranging in age from 4 to 16. There are several major causes of anemia worldwide including iron deficiency (most common), folate deficiency, chronic disease, and blood loss. It was therefore important for the team to identify the specific etiology of Munsel-ling’s anemia in order to create an intervention strategy. In 2007, the UBC team took a second set of Hb levels as well as 200 blood smears from the most severe cases. These smears were analyzed by hematologists in both New Delhi and Vancouver. The etiology of the anemia was determined to be of a mixed nutritional deficiency cause, including iron. Further diet analysis done by UBC Land and Food Systems students re­vealed that the mainly vegetarian diet of the students was lacking in several other nutrients including folate and vitamin B12. Discussion of these results with the local community resulted in the creation of a multi-pronged approach to target anemia and overall health in the school children. This approach included en­hanced nutrition through greenhouses, water sanitation, health education, and direct iron supplementation. Also imper­ative to the program were annual health screens to measure the effectiveness of interventions.


Figure 1 | Map of Spiti Valley Himachal Pradesh. Courtesy of Wikipedia. http://en.wikipedia.org/wiki/Spiti_Valley

Greenhouses
The diet of the school children is mostly vegetarian, consist­ing of grain products and vegetables. Nutritional analysis based on three-day average intake of the school children revealed deficiencies in vitamin B12, iron, zinc, and vitamin A4. It is both dif­ficult to transport and to grow fruits and vegetables in Spiti Valley. Road access to the area is blocked for the majority of the year due to snow and mudslides. Furthermore, due to the high altitude and landscape of Spiti Valley, it is diffi­cult to grow crops in fields most of the year. However, there is an abundance of sunshine in Spiti Valley and greenhouses in neighbouring communities have used this natural resource to both enhance dietary intake of iron and folate and pro­vide a valuable source of income (5).

In 2008, Munsel-ling school built its first greenhouse, following the design of a French NGO, Groupe Energies Renouvelables, Environnement et Solidar-ités (GERES), which has constructed sim­ilar greenhouses in surrounding areas. Future UBC teams funded an additional two greenhouses with the focus of grow­ing iron-rich vegetables that are suited to the local Spiti diet. UBC teams also helped the school write a successful pro­posal to the Rinchen Zangpo Society to fund a fourth greenhouse.

In the summer of 2011, our team conduct­ed a thorough analysis on the function­ing of the greenhouses. The greenhouse staff was successfully growing spinach and mustard; however, we determined that with better agricultural practices in regards to sowing seeds, watering, fertil­izing, and crop diversification, the green­houses could become more cost effec­tive and better enhance the diet of the students. Therefore, our future goal is to work with the greenhouse staff to teach agricultural skills regarding these areas.

Water and sanitation
Clean water is im­perative to prevent Gastro-Intestinal (GI) infections which can lead to anemia. At Munsel-ling the water is supplied from a government source in the mountains. Survey analysis and water testing done by UBC teams revealed that the drinking water was contaminated with both hel­minths (including roundworms) and the bacterium Escherichia (E.) coli. Surveys revealed that many of the students ex­perienced diarrhea and saw worms in their stools. The 2008 UBC team wrote a water tank proposal which was success­fully funded by both UBC and TRAS. In 2010, the water tank was built and a chlo­rine injection system for purification was implemented.

However, E. coli testing in 2011 was posi­tive at all water sources except for a single well-based hand pump. Investigating this issue, we discovered that the chlo­rination instructions left by the team in 2010 were too complicated to follow in English and the effort was eventually abandoned. Thus, our 2011 team gave a thorough demonstration of the sanitation technique to the health nurse, who was in charge of the water chlorination. We also printed and laminated the chlorination instructions in English, Hindi, and Bohti (local dialect). After the completion of wa­ter chlorination, all drinking water sources tested negative for E. coli.

Nonetheless, there are still problems with the water purification system that require future adjustments. Chlorination does not kill worms; ideally, a filtration system needs to be implanted upstream of the water source. Furthermore, water freezing in the winter damages the tanks and pipes if they are not prop­erly emptied in time. We have advised school staff that all tanks and pipes should be emptied prior to the freeze up and water should be sourced from the hand-pump or boiled before con­sumption. We also need to engage the staff and students to illustrate the con­nection between dirty water and health problems, including worms, diarrhea, and ultimately, the exacerbation of ane­mia. GI infections, including worms, are known to contribute to anemia(5).

In addition to improving the water puri­fication system, sanitation at the school needs to be enhanced. UBC-funded toilet blocks were built to prevent children from toileting outside, especially near the wa­ter source. However, a survey conducted by our 2010 team revealed that many stu­dents do not use the toilets because they are dirty and dark and younger children are afraid of falling into the hole. Now that we know these concerns, we can begin to address them. Some ideas for the fu­ture include lighting the toilet blocks and working with the students and staff to create a cleaning schedule.

Health education
Of all our interventions, we have always been the most cautious with health education. The reason for this is twofold: first, we did not want to in­fringe on local teachers’ roles; secondly, to run these health education seminars, we needed to remove students from valu­able classroom time. Despite our trepi­dation, the teachers and principal have been very accommodating each year as we teach topics such as oral hygiene, hand washing, and sexual education.

To ensure sustainability of health educa­tion at Munsel-ling, the 2010 and 2011 Spiti teams consulted the teachers to cre­ate a Health Council composed of grade 9 and 10 students. Over the past two years, UBC students have mentored the Munsel-ling Health Council, which now teaches a health education curriculum to younger students. Each year, a new Health Council is made and the previous council teaches the new one. This en­sures project sustainability and gives the students responsibility over their own health.

Iron supplementation
While our other interventions are meant to contribute to anemia prevention indirectly, iron sup­plementation is an efficacious method of treating anemia directly (3). Each year, a three-month supply of ferrous sulfate tab­lets is paid for by the UBC team, bought in New Delhi, and then transported by the team to Spiti Valley. With the aid of the school nurse and housemothers, or dormitory supervisors, 30 mg tablets are given to children under age 13 and 50 mg tablets to those over 13 each day over three months as per WHO recom­mendations (4). Supplements are given to all children despite their classification as anemic or not.

Health screens In order to assess the ef­fects of our interventions on anemia, we conducted health screens. The screening is also important for the well being of the children, as it helps to identify those that are in immediate need of further medical attention.

The health screens consist of five sta­tions set up in the school’s health clinic. The first station involves recording the height and weight of the children, which is completed by the school nurse. For the second station, a HemoCue moni­tor is used to sample Hb levels in the children’s blood. Values used to define anemia were taken from the WHO mini­mal Hb levels and calibrated for altitude (4). The third health screen station includes a basic cardiovascular and respiratory exam. The fourth station is a head and neck exam, primarily to look for dental carries, visual anomalies, and hearing difficulty. The final station involves a der­matological screen where lice, worms, and scabies are diagnosed.

Results
As displayed in Table 1, anemia prevalence was found to be 88.4% in 2007. In 2008, it decreased to 78.3% and in 2009 to 71.3%. In 2010, the preva­lence again increased to 89.5%. In 2011, the prevalence decreased to 84.1%. Other prevalent medical issues include head lice (76% in 2011), dental carries (73% in 2011), and worms (12% in 2011). Further details regarding these results can be found in the paper published by El-Zammar et al. (4).

Table 1 | Number of children and percentage anemic at Munsel-ling school

2011 2010 2009 2008 2007
No. of children 696 434 416 384 379
Mean age 8.97 10.34 10.2 10.2 9.8
Sex male, n
(%)
334
(48.5%)
225
(51.2%)
213
(51.2%)
199
(52%)
202
(53,4%)
Mean Hb,
g/L
133.5 128.9 141.1 134.6 130.3
Anemic, n
(%)
376
(84.1%)
385
(89.5%)
295
(71.3%)
299
(78.3%)
321
(88.4%)

Central opinion and discussion
Due to the multifactorial nature of the anemia at Munsel-ling, all of our inter­ventions combat anemia from different perspectives. Greenhouses provide iron-and folate-rich nutrition, water sanitation decreases the incidence of diarrhea and worms which can contribute to anemia, and health education provides knowledge regarding hand washing which decreases the incidence of infec­tion. Iron supplementation directly com­bats anemia.

Each year, we have seen a successive decline in prevalence of anemia. However, in 2009, iron was not distrib­uted to the children due to a unique holi­day event where children did not attend school. The following year, anemia prev­alence returned to its original level. In 2010, iron tablets were again distributed to the children, and our 2011 team as­sessed that the anemia levels decreased once again, suggesting that supplemen­tation significantly decreases anemia.

It should be noted that at the time of Hb measurement, the children are likely at their lowest levels of Hb as the green­house growing season has just begun, and it is the longest period since their iron supplementation ended (approximately 8-9 months). Iron supplementation is done over the summer months because this is when UBC teams go to Spiti during their holiday. Furthermore, transport to the area can only occur when the passes open, usually in May. Nonetheless, our results indicate that iron supplementation plays a significant factor in decreasing anemia prevalence in this population.

Despite the success of direct iron supple­mentation, it is not sustainable in its cur­rent form. UBC pays for the medication and transports the supplements to the school. However, this responsibility could be transferred to the school. A re­cent study illustrates that twice-weekly supplementation is more effective than daily supplementation over a course of three months (7). This would decrease the cost of the supplements. Furthermore, the school greenhouses can be used as a source of income to buy iron supplements by selling excess crops to villagers (5).
Regardless of the success of iron sup­plementation; greenhouses, water and sanitation, and education programs should continue at the school. Green-houses provide students with iron- and folate- rich food during the months they do not receive iron supplements. Sanitation should continue to be promoted to prevent further helminth infections and thus GI losses. This education can be expanded to the larger community of Rangrik so as to combat anemia in the general population. Health Council stu­dents can not only teach their younger peers, but also their families.

Conclusion Greenhouses, water and sanitation, health education, and iron supplementation are all programs to decrease the high prevalence of anemia at Munsel-ling school. Our results have indicated that iron supplementation is effective; however, it is not sustainable in its current form. We hope to explore the possibility of twice-weekly supplementa­tion so that supplementation can become sustainable. Furthermore, we need to continue engaging school officials, local NGOs, and the local government to maximize the positive effects of green­houses and water and sanitation projects. We hope that through this collaboration we can continue to amend sustainable solutions to combat anemia at Munsel-ling school so that the children can suc­ceed in school and therefore have a chance at a better future.

About the authors
The authors are all third year medical students at UBC. They traveled to Munsel-ling school in Spiti Valley, in rural northern India, during the summer of 2011. They are part of a larger team con­sisting of students from various disciplines who have traveled to Munsel-ling since 2006 to create sustainable solutions to anemia. The project was started in 2006 by Dr. Videsh Kapoor in the department of Family Medicine at UBC.

References

  1. Lozoff B. Iron deficiency and infant development. J Pediatrics. 1994; 125: 577-578. http://dx.doi.org/10.1016/S0022-3476(94)70010-9
  2. WHO, UNICEF, UNU. Iron deficiency anemia: assessment, prevention, and control. A guide for programme managers. Geneva, World Health Organization. 2001. WHO/NHD/01.3.
  3. McLean E, Cogswell M, Egli I, Wojdyla D, de Benoist B. Worldwide prevalence of anemia, WHO Vitamin and Mineral Nutrition Information System, 1993 – 2005. Public Health Nutr. 2009; 12(4):444-54. Epub 2008 May 23. http://dx.doi.org/10.1017/S1368980008002401 PMid:18498676
  4. El-Zammar D, Yan M, Huang C, Fang D, Petigara F, Bornn L, et al. Assessment and management of ane­mia in a population of children living in the Indian Himalayas: A student-led initiative. UBC Medical Journal. 2011; 2: 12-18
  5. Groupe Energies Renouvelables, Environnement et Solidarités. http://www.geres.eu/en
  6. Ezeamama E, Friedman J, Olveda R, Acosta L, Kurtis J, Mor V, McGarvey S. Functional significance of low-intensity polyparasite helminth infections in anemia. J of Infectious Diseases. 2005; 192: 2160- 2170 http://dx.doi.org/10.1086/498219 PMid:16288383
  7. Hawamdeh HM, Rawashdeh M, Aughsteen AA. Comparison between once weekly, twice weekly, and daily oral iron therapy in Jordanian children suffering from iron deficiency anemia. Matern Child Health J. 2012. Mar 4 Epub ahead of print.

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