Anemia Awareness

Anemia Awareness

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Upleta Medical Camp_4

Whenever we met in a group and discuss the difference in medical care and systems between USA and our home country India. What was remarkable differences that most of the patients visit in India is for some problem like illness and treatment while here majority doctors spend lots of time of their practice keeping people healthy like routine physical examination, blood count, chemistry panel, mammography to prevent breast cancer and Pap smear to prevent cervical and endometrial cancer in women, colonoscopy examination to detect any pre- cancerous condition in man and women both and so on. Checking body mass index, blood sugar, cholesterol, and triglyceride or giving vaccination to prevent numerous disease and conditions and so on.

If you compare as such we see fewer people gets sick and many of the disease are milder like pneumonia or prevented by giving flu vaccine altogether. As an oncologist I see many cancers picked up in early staged and cured. More than 60% of patient with cancer survive more than 5 years while numbers India is extremely poor. Few of us decided to learn about our health care system pattern in India and try to understand and how we can get involved there.

In 2000 my friend Uka Solanki, Govind Lalani and I met and decided that we start a medical camp, learn and try to understand and find niche or an opportunity where an opportunities exist to make a difference. As I saw very advanced staged cancer and very high incidences of tobacco related cancer we started mission to educate and create awareness in various villages and started tobacco prevention various ways like explaining to current users and went to school how we can prevent to start by various ways including writing assays and sponsoring debate. This issue is one of the most important challenges for Indian people. There are many programs for tobacco prevention however it is done in bit and pieces. We need to start comprehensive program where we can rehabilitate ongoing users and most important prevent our kids starting this evil.

Second thing we learnt that each and everybody and especially women were anemic. In spite of this highly prevalent issue very few people had comprehensive knowledge about the cause, treatment, side effects and duration of the treatment. Our patient living in village has no access to clean water, sanitation was poor and there was difficult to prevent oral fecal contamination. At the same token there was quite a lack of understanding among illiterate in spite of government had very good program about starting sanitation programs and grants and giving prophylactic anti worm medications and iron treatment to prevent and high protein and nutritional diet in schools. I felt this was one of the biggest challenges. As being board certified hematologist I had very good understanding about this subject however I felt very helpless. I started studying public health issues in India, started spending more time learning about all iron related problems and publication in Indian and various western Medical Journal as well as spending sizable time for this subject.

This time I met Jayesh K. Patel who was an assistant collector at Jamnagar and secretory of Umiya Parivar. He has very powerful executor and has special skill in communication. First he tried to understand the subject, conceptualize medical issue very well and started supporting this by various means. Specially presenting this in various committees and meetings and he had an excellent convincing power. Sometime we came across people who will say my hemoglobin is 9 and I have no problem. Other day I went to Akila News Paper office and owner of the new paper said my hemoglobin is 10 and I feel great and I have no problem. We try to explain them when a person drive Maruti 800 Fronti, that car works but that person cannot understand the difference until he drives Skoda or BMW what the power difference is. We are talking about especially when person with hemoglobin below 10 compare to hemoglobin above 13. Most important it is not only low hemoglobin but why it is low. Either person is bleeding or might have inflammation in intestine which is not absorbing iron, that means person is suffering from anemia and abdominal disease which is making him sick, tired and measurable in daily life. Unfortunately this happens more often in poor people who also has to work long hours and cannot afford to be treated.

As we all are aware that more than 45% diseases in our community are related to waterborne diseases. Beside stomach upset, nausea, vomiting, diarrhea, dysentery, constipation, kidney stone, arthritis, malnutrition it is also one of the most important causes for anemia. Water has many virus, bacteria, protozoa and worms and any of those can cause various forms of gastro intestinal conditions. Parasite worm infestation in gastro-intestinal tract causes inflammation and also causes blood loss from bleeding as well as sucking blood; it also prevent absorption of iron as well as utilize iron which we take in our diet. It also does not allow absorbing other important nutrients which are very essential in the growth of developing mind and body.

According to recent report by UNICEF, Indian Health ministry 92% young female has iron deficiency and more than 80% have iron deficiency anemia. This is one of the most important causes of weakness, loss of energy, poor school grades as well as inability to compete in sports and this can also affect every aspects of life in so many ways.

Every living organism or human beings have to perform numerous metabolic processes to survive. They need numerous elements and specially oxygen. Iron is very important for various oxidative processes in the body, This is very essential for the nervous system, heart, blood, muscle and other organs. Iron also works as cofactor for zinc, magnesium and other trace elements which are essential for development, growth and cognitive function. Lack of any elements can interfere with survival, normal body function, learning and physical functions.

With cooperation from our community leaders, educators and various health care workers in particular Dr. Rabadia we were able to create the awareness of this important issue. Mr. Ukabhai Solanki and I had sponsored a project and were able to check around 38,000 women and children in Upleta Taluka of Rajkot District. Those showed that none of our women had hemoglobin above 12. In Gujarat we have better education, industry and awareness still our results are not different from national statistics.

What can be done?

We might have to take multidisciplinary approach. The cause of most of the anemia is iron; however folic acid and Vitamin B12, B6, and other vitamin and mineral deficiency are also common. Most of these are secondary to inability to absorb various vitamins and nutrients in intestine rather in lack of presence in diet, though many of that we also lack in our diet. I have tried to learn from literature and was not able to get enough information the most important cause of infection and inflammation of intestine where usual absorption of iron and other nutrients takes place. Various worm infestation and bacterial infections like H. Pylori and various other infection of the gut remains might be very important cause of iron deficiency anemia.

Worm infestation comes from various ways. Hookworm can enter through skin it can enter the body and water also remains one of the most important cause from many worms. Since our toilet system is not hygienic, every time after defecation person has to wash hands with soap and water (this also prevents hepatitis and numerous other communicable disease). Lack of understanding such simple things can cause oral fecal contamination after defecation. We all know this can easily be done if you have toilet in home and use soap to wash hands after toilet. Besides those who are already infected should be treated initially with worm killing medicine like Albendazole in the beginning and repeated once every three months.

Other important way is to drink germ free water. Either drinking water after boiling or filtered water will be free of germs and parasite (worms). This will prevent recurrence of worm infestation if one is treated initially with medication and subsequently start using clean water. We know these will not cure somebody who is already has iron and other nutrients deficiency. The best way is to start iron treatment that has hemoglobin less than 13 for female and 13.5 for male.

This numbers seems little high for Indian physicians and pathologist because somehow they are used to see lower number, in my personal experience as a hematologist treating very large population of iron deficiency over the years and from the literature review I have come across large number of patients who have low iron saturation and low serum ferritin means person has iron deficiency in women who have hemoglobin 12.5 or higher sometimes. This is very important point because person might have close to normal hemoglobin still might be suffering from iron deficiency. Our goal is to replenish iron store which will help them improving hemoglobin and many other ways because iron is very important for each and every metabolic process of body as mentioned earlier. This needs to understand as very important step and some time it can take one to two years of iron treatment to normalize iron storage of body.

I recently received a mail from one of my patient in India who has hemoglobin 12.3. Hemoglobin was close normal and her doctor was in puzzle whether to give her any treatment. I suggested getting her iron level and that was has iron saturation only 13%. This was consistence with iron deficiency anemia. The most sensitive test for iron deficiency is serum ferritin especially when it is low. Normal or high serum ferritin can be also with iron deficiency when there is inflammation in the body. In his situation one can get iron saturation which can be done by getting total iron and total iron binding capacity (TIBC). If iron saturation is below 20% that suggest iron deficiency and I will treat with iron even if serum ferritin is very high.

It is very important to have full correction of iron deficiency. Student’s growth, intelligent, physical strength, energy and competitiveness whether in sport or education will require best hemoglobin and adequate iron storage. Most iron deficiency anemia will improve when treated, however if this fail than one should check iron level and sometime may need treatment with folic acid, vitamin B12 injection and other medicine. However this will be decided by your doctors. I am very confident that 50 to 60% anemia will be cured with iron, therapy, after deworming of guts, practicing good sanitation with hygiene practice and clean water with good nutrients.

Somebody will ask why not treat everybody with iron and why we should check hemoglobin or any other test? As we understand iron has many important functions in our body but at same token iron also is heavy metal and once in the body it does not get excreted like many other elements or medicine we take, High iron cause harm if it is taken for long time without monitoring iron level. Usually body knows how much iron is needed and it absorb what needs. There are several genetic conditions where the absorption pump is defective and that person can cause iron overload so without reason nobody should be given iron specifically for long time. Those who takes iron without their doctors permit, please check with them periodically and explain what you are doing. Iron requirement increases during puberty, during menstruating life for women, pregnancy, lactation, for infants and child during growth phase.

Iron also retained and stored in body, in some inflammatory disease like chronic infections, rheumatoid arthritis, lupus and liver disease. If person has this condition and anemia that should be checked with total iron, total iron binding capacity, iron saturation and serum ferritin. If person has high iron and still has anemia than one should consult a good physician, find the cause and treat accordingly.

As mentioned there are several genetic disorder where the absorption pump is defective because of mutation in the gene and in that person some time serum ferritin level goes high. Every physician is always worry that person might take too much iron and that can damage vital organs. Usually iron deficiency patient has low ferritin and it may require at least one to two years before iron overload occurs in patient who has iron deficiency. Be concerned but do not treat iron deficiency halfhearted, if necessary get serum ferritin level or iron saturation every 6 months.

I have seen patient with ferritin above 5,000 and this is very dangerous. Somehow this is from defects in gene and that is called hemochromatosis. This gene defect is more common in white people, however this tells us that nobody should take unnecessary iron, if your hemoglobin is normal one should not take iron more than 3 months. There are lots of restrictions using iron without reason except during pregnancy. That is why if we give iron for 3 months those needs to be tested and once hemoglobin is above 15 they should stop unless their blood test shows low iron saturation. Somebody would suggest why not we check iron level before we start therapy to everybody. Unfortunately this test is still expensive for poor patient than iron treatment. However somebody who really wants to know they should do and decide about iron treatment. Nobody should worry getting three month iron therapy without checking iron level when their hemoglobin is below 13.

Can iron deficiency be treated with good nutrition such as green leafy vegetable, spinach, jiggery and other known iron rich foods?

If person has mild iron deficiency and does not have healthy eating habit that may need to correct with balanced diet but still needs iron supplement or treatment. First one needs to correct existing iron deficiency with iron therapy. Good nutrition can prevent iron deficiency but once person has iron deficiency than there is no choice but first get iron therapy and then prevent future iron deficiency with good and balanced diet. Let me emphasized that good nutrition and balanced diet is very important for everybody and it is not only anemia but number of medical illness can be prevented, however all the disease cannot be cured by good diet alone.

We also should understand that when there is iron deficiency and try to find the cause. We should ask what underlying cause for iron deficiency is. As mentioned above worm infestation is the most important cause besides menstruation blood loss in women, extra demand during growth for babies and adolescence, during pregnancy and lactation. Again in this situation improving iron rich food is essential but it may not be adequate. Remember clean water, improve hygiene with hand washing, treat worm with medication, good nutrition and iron treatment can improve this condition, make person healthy, pink and strong.

Can iron deficiency affect your school performance or sports competitiveness?

This is very important question because anemia means low hemoglobin. By now we understand hemoglobin which is content of red blood cell and is very important for carrying oxygen to your lungs, heart, brain, kidney and other vital organs in the body. If person has low hemoglobin that cannot exchange oxygen efficiency than person have to increase the heart rate and breathing rate and that is responsible for shortness of breath and that is why one cannot compete effectively in sport. Again do not forget iron is the most important substances for carrying out our most essential metabolic processes.

Some athletes take erythropoietin hormone injections before real competition. Most of the athletes already have very good hemoglobin 15 or above. With erythropoietin hormone hemoglobin goes even higher; person has less shortness of beat and can bit opponents easily. That is cold Epo Doping and during Olympic and other important international game every athletes are checked whether they have injected this drug or not? If somebody wins because of this injection it is illegal and their medals are stripped off and athletes are disqualified, fines and sometimes forbidden from future events. What I am trying to show the importance of good hemoglobin. Again I am trying to stress that if you have high hemoglobin you have more energy and you can be more competitive in sport, study and all other aspects of life.

What are the other issues from iron deficiency besides anemia?

Besides blood, iron is very important for muscle and nervous system. However the role in nervous development, growth and maintenance studied in intense research. Lack of iron in pregnancy can affect proper brain development, intelligence and many other developments. This can have dramatic effects in future generation. That is why women goes for prenatal care, takes special vitamins during pregnancy, anemia during pregnancy can have effects which indirectly can affect many generations to suffer. Still today our Indian women carry pregnancy at very low iron level and they might be more susceptible for all kind of complications because of low iron. Usually baby can drive all the available good blood from mother and so mother suffers various ways. Usually iron participates with zinc and copper and other trace elements and these are the most important process during intrauterine life of a baby. Lots of research being done in this arena and try to read through various search engines in web site of computer. Research for specific questions or email me at and I will be able to help to find some of the answers.

What we be general guidelines for iron therapy?

This is very interesting area, here in USA we measure serum ferritin and iron saturation level that iron level in blood. If it is low we stamp that as an iron deficiency and treat until that iron level is corrected. In general if person has hemoglobin above 14, that person should have very small chance of iron deficiency. Above 12, many people might have iron deficiency and those can be treated with one tablet of ferrous sulphate 325 mg at empty stomach with some acidic liquid like orange juice, lemon water if possible for few months and then repeat hemoglobin to see it improves or not?. We usually prescribe one tablet three times a day before meal. If person gets stomach upset they can try after food. Remember for most of the drug if taken at empty stomach that can absorb much better and you can retain drug in your system and gets best rewards for your disease and money spent no matter which medicine you use except that drugs is harsh for your stomach like aspirin, ibuprofen, prednisone and many other medicine.

There are some people who cannot take iron and has side effects than they can take twice a day, if not once a day and even that is also hard, try after meal. If person cannot take iron because of side effects like stomach upset, pain in abdomen, sever metallic taste or constipation as a last resort we can give in injection form but that should be decided by your doctor depending upon your health. There is intramuscular injection of iron dextran which can be given by Z tract injection in buttock area. However still this can be painful and can cause blackish discoloration at injection site. There are many intravenous preparations available and there is formula which can calculate how much an individual will need and whole dose can be given.

There are many things can interfere with iron absorption. Tea, coffee, milk, calcium, antacid, proton pump inhibitor and many other drugs interfere with iron and decrease absorption. On the contrary lemon juice, vitamin C and other acidic environment improve absorption that is why doctor recommend taking iron tablet with orange or lemon juice. Anti-acid therapy, milk, calcium can be taken after two hours of iron and that does not cause any problem.

Let me summarize again if person has hemoglobin below 12, for all practical purpose that person can be diagnosed having anemia. Here in USA, we usually do not treat anemia until we find out the cause for that anemia. If person has iron deficiency than we try to find out why person has iron deficiency except young children or menstruating women. In USA and other western countries most of the person has insurance or some form of governmental supplemental health card so it is easy to do. Beside USA is a conglomerate of many culture, people from Mediterranean area has anemia from thalassemia where hemoglobin has genetic defect and cannot produce normal hemoglobin in spite of enough iron and other important nutrients as mentioned above and they might have normal iron and many times iron therapy may be harmful to these patients, unless they have proven iron deficiency. Usually these can be diagnosed with help of reticulocyte count, hemoglobin electrophoresis, red cell width and specific genetic study. Some of this test is very expensive. People of African origin has sickle cell anemia where red blood cell changes its shape from oval to sickle like and that cell cannot survive 120 days which is the normal life span of hemoglobin. This patient gets numerous problems and one can learn more about this from web site. There may be more than 100 different causes of anemia and I will not go in detail because in our area iron and vitamin deficiency is the most common causes so anybody with anemia we treat with one tablet three times a day of ferrous sulphate 325 mg at empty stomach with some acidic liquid like orange juice, lemon water if possible and if possible suggest two to three months of supplement folic acid and Vitamin B12 therapy.

Usually after three months treatment we can recheck hemoglobin and monitor response and to decide future treatment. If person does not respond than we should like to find out the cause. Usually lack of absorption because of inflammation of gut from worms, ongoing bleeding, infestation, allergic disease of stomach and upper part of the intestine. There are many other cause of iron deficiency like hemolysis or breakdown of red blood cell from artificial heart valve, sometimes soldiers get broken red blood cell from long march, the red cell in foot get crushed and lose iron inside the vascular system instead of external blood loss like epistaxis, stomach ulcer, colon cancer, hemorrhoids, kidney stone, cancer of genitourinary system, bladder infection , heavy menstruations or other female organs related issues where person is losing blood.

What are other nutritional causes of anemia?

Iron deficiency is the most common in India as well as everywhere. However concomitant Vitamin B12 deficiency, folic acid deficiency as well as sometime other vitamin deficiency also may be responsible for anemia. Vitamin B6 deficiency causes a special type of sideroblastic anemia. Most of the Vitamin B12 deficiency in vegetarian is because very little B12 is available in vegetables. Milk and other animal sources can help. Folic acid is coming from green leafy vegetables so people with poor access to vegetables in diet suffer from this deficiency specially poor and migrant people who have very low income and their diet is more from staple food. Among Indian there is very high prevalence of vitamin B12 deficiency. One should not forget that Vitamin B12 is very important for brain and nervous tissue and sometime it can cause irreversible damage to nervous system called neuropathy or brain damage. If person has borderline deficiency and when we start treating anemia there is spurt of red blood cell production and it will use more iron and vitamin and that can go from borderline to full fledge deficiency and disease. In our practice we try to get iron, folic acid and Vitamin B12 level before starting anemia treatment. However these tests are very expensive in India compare to treatment. So if one does not know the blood level of various important blood forming nutrients, it is reasonable to treat with iron, folic acid and Vitamin B12 for first 3 months and hopefully that will replenish those storages. Than one continue with iron therapy.

Is there any other disease can cause anemia?

Anemia means decrease red blood cells in body. This can be happen if any form of systemic disease affects bone marrow. This called bone marrow suppression. Any form of bone marrow disease like aplastic anemia, leukemia, myeloma, granuloma, chemotherapy, radiation therapy or many of the drugs used for different conditions can suppress the bone marrow. This may be the reason people look weak, tired, emaciated and chronically sick appearing during these treatments. There is other systemic disease like chronic infection, tuberculosis, rheumatoid disease, lupus, cancer and many more can affect red cell survival or red blood cell production and these are usually called anemia of chronic disease. Many times these patients have normal nutritional elements so treating with iron or other vitamins does not help. Kidney disease is also special class because kidney produces hormone called erythropoietin. In chronic disease person cannot produce this we cannot stimuli red cell production factory. Some of this patient can be treated with erythropoietin therapy. Anemia from chemotherapy, chronic disease or other conditions where vitamins and iron level are normal and still patient has anemia they can benefit from erythropoietin therapy. Erythropoietin has also some of side effects and issues so before starting this treatment one should discuss these issues with your doctors of specialist who understand this medicine.

Always think simple thing first if person has bleeding correct that through medicine, surgery, hormone treatment or with other intervention and cure the condition rather than opting for long term treatment. Sometime like thalassemia when person has hemoglobin 8 to 10, they can tolerate reasonable well, if it goes down than treatment available is transfusion or chemotherapy. In this situation cost benefit ratio of treatment should be assessed before treating. Bone marrow transplant can cure thalassemia and many other diseases but it is expensive and this process is hard and person can die or can have long term complications. I like to recommend every thalassemia patient should check for iron deficiency and we see these two diseases together and iron treatment makes tremendous difference in quality of life for these patients.

Is it always better to have higher and higher hemoglobin?

If hemoglobin goes above 17, than we need to investigate. This can happen when bone marrow produce very high number of red blood cells and hemoglobin. This is condition like leukemia where white cells are unnecessarily produced here red cell are unnecessarily produce. This is usually treated by frequently removing blood called phlebotomy. High hemoglobin is also seen in smokers because of higher carbon monoxide level, drinkers because of decrease plasma level where hemoglobin is not elevated but it is perceived so. Some people have abnormal hemoglobin which cannot release oxygen so to maintain normal oxygen level bone marrow produce more red cells. As mentioned above some people take erythropoietin injection unnecessarily to get more competitive and that is why hemoglobin may be elevated and that is how sport authorities find Epo Doping athletes. Hemoglobin above 18 starts interfering with blood circulation because blood becomes thick. Then there is increased risk of blood clot and stroke so once this condition is diagnosed we try to keep hemoglobin below15 in men and 14 in women by removing extra blood. This blood even you cannot donate to others.

How easy to find other causes of anemia exist beside iron?

When we measure red blood cell indices like mean corpuscle volume which gives us size of red blood cell from which we can start differentiating various conditions. Usually iron deficiency have small red cell and cell looks pale under microscope we use the terminology hypochromic red cell. So when we find person has microcytic and hypochromic red blood cells we think of iron deficiency and thalassemia. If person has high hemoglobin A2 level that goes in favor of thalassemia. Iron deficiency red cell also has increased red blood cell width (RDW) so one can differentiate from thalassemia. When we treat usually hemoglobin does not go above 12 in thalassemia while iron deficiency patient can improve hemoglobin above 15 and that might be very good number. Person’s heart and lung has to work less so shortness of breath after run or hard work is less. On the same token if red cell size is large it is called macrocytic anemia and this happens with B12 and folic acid deficiency or thyroid disease. That is why when person comes with anemia doctors write all the three drugs at the sometime and hope that everything will be corrected. This avoids cost of ordering blood test and sometimes test may be more expensive than medicine. Macrocytic also seen with chronic alcoholic drinker and when thyroid gland produces less thyroid hormone this is called hypothyroidism. There is many other abnormal shape of the red cell and looking expert can make diagnosis however this seems outside of the arena for this article. In medicine doctor always thinks more common thing as first and after treatment if person does not respond than order more test to find out the cause of anemia. It is always very important to find a good family physician and follow their advice for your condition or disease and when they are not able to diagnose or treat they will refer you to the expert.

What are the issues with iron and other nutrients?

Nature has made very nice system for their need. So if you have enough iron, your body will not absorb unnecessary and do not cause iron overload. In last few years there is a tremendous progress in understanding iron absorption, metabolism and removal. Lots of iron is consumed in the food in ferric state, after mixing with acid in stomach it is converted in to ferrous. Body can only able to absorb in ferrous state. In intestine mucous membrane ferrous is absorbed with the help of the other protein inside cell it is converted in ferric form. From where that can be transferred to blood by ferroportin protein and then enter to the needy cell with help of transferittin receptor. It is stored in ferritin form and when needed it is mobilized. A protein called Hepcidin helps to mobilize iron back and forth. Hepcidin level in future might important for diagnosis of iron deficiency and iron storage disease. There is lot to learn by scientist and research community about this important element and I will hopefully appraise you about the progress periodically.

After we examined more than 35,000 people in Upleta Taluka we started brain storming how can treat these patients. Unfortunately government machinery has no power to tackle this issue. However when I started talking to the doctor who was conducting this survey he told my wife had hemoglobin 10 and she cannot take iron and I cannot improve. At that point I contacted Dr. Suresh Patel in Dhoraji who is an eminent physician and we had invited 30 doctors from surrounding area and we had lots of nice discussion and interaction, Other person I met was Dr. Rabadia who is family physician but has one of the best understanding about anemia and various nutritional issue and through Rabadia Charitable Trust has taken important mission to cure each and everybody’s anemia

From this interaction I also learn lot. In India we have usual practice to tell patient take tablet after meal and do not eat sour and salty. Unfortunately iron needs to talk if possible at empty stomach and as I said earlier we always encourage taking with orange or lemon juice. We also learn that many patients take antacid; calcium, drinking tea and many other food and medicine does not let iron absorb. Timing of iron and various food and medicine intake is very important. Dhoraji doctors took a challenge they called about 700 patients from community, measured their base line hemoglobin, started deworming tablets and taught about iron therapy. We repeated hemoglobin again in six months. There was very good enthusiasm and interest in patients as well as local doctors. In this experiment the response to iron therapy was somewhat lower than as we expected. This was quite a puzzling issue for me.

This time I came to India on September 8, 2011. Dr. Rabadia and I took to tours to large number of girls’ schools special which had sizeable population of girl’s students. With eloquent speeches and communication power of Dr. Rabadia it was so easy to explain and convince all the students about anemia issues. Unfortunately this was very hard to execute. Dr. Rabadia and his son Dr. Dhawal and his wife who is also physician and working very hard to find various protocols how we can treat least expensive way to the rural and most poor people.

This time I went to Junagadh and discussed this issue with Mola Patel who is an eminent educator and runs several institutions extremely well. He invited all community physician at one evening and after long discussion and debate we decided to go ahead with program which to implement when all the girls come after their Diwali vacation.

Dr. Jaman Jasani took a lead, he asked authority to purchase an instrument which cost 10,000 rupees and examined close to 2000 girls. As we expected 75% or more had anemia in spite good nutrition and prophylactic ferrous sulphate twice a week. This time we decided to give iron, B12 and Folic acid containing one tablet every evening prior to dinner in supervised condition.

As we started we noticed two important things. First there were no side effects as we have feared before many doctors have encountered this in various previous discussions and treatments, Second girl’s hostel started consuming 35 Kg more flour every single day. There were few parents tried to object this but it was negligible and this experiment went extremely well.

When we started this on December 9, 20111 we had gotten hemoglobin for everybody. If girl had hemoglobin less than 12 we gave Albendazole (Zentel) a deworming tablet, gave one week rest and started treatment as above. On Sunday March 11, 2012 when we repeated this test in first 500 girls the results were amazing. Girls with hemoglobin 10 went to 12 to 13. Few students with 10 had now hemoglobin more than 15. These results were beyond the wildest expectation. Before treatment average hemoglobin was less than 9.9 and after treatment it went 13.24 this time our point was proven. Still there were 15% students who were not able to improve their hemoglobin at all in 3 months and this was going to tackle in next projects.

After this successful pilot project we have treated more than 20,000 students in 2012 at various boarding school of Gujarat and more than 25,000 students in 2013. We also started similar awareness and education programs at various villages. We have done this in 9 villages. I recently received results from village name Buri where pretreatment average hemoglobin was 9.2 and post treatment hemoglobin was 12.4. This is remarkable difference and we are very excited that we can make such a difference in anemia. If I give and extreme example at Buri, Labhuben had hemoglobin 9.5 and in 3 months her repeat hemoglobin was 15.5. This can be done in less than one dollar!

We are still thinking treating all the anemic women in villages can be channeled through public health department. When we try to talk with authorities they feel they have many important public health issue like AIDS, malaria, vaccination, sterilization and many more and anemia or clean water or RO plant may not come in priority. We will show these results to various NGO, partner with them and hopefully we will be able treat each and every person from this disease which require nominal cost of the treatment and can solve so many symptoms and improve the quality of life. As we progress and become industrialize country our people will think differently.

Mr. Vijaysing Parmar from Times of India took very sincere interest in this subject and wrote very good article about our project and we started lots of inquiry. What also we have noticed that if people drink clean water and remain on that after 5 ears hemoglobin went to 12.3 in my home town Sultanabad and even before we have started anemia project.

We have recently working in villages about helping to build toilet by poor people and at present we have built more than 500 toilets and now working on about 20 villages. By WHO research we can reduce 25% disease from rural community if we teach them proper hygiene.

Providing clean water is a big challenge and we are looking various ways how we can provide clean water. We have donated more than 60 RO plants in villages and schools.

I hope this information will help you. With warmest personal regards,

Bhanji D. Kundaria, M.D. FACP