By Veronica MarianIn the southeastern Indian state of Tamil Nadu, an estimated 70 percent of children under the age of 5 (approximately 22 million) suffer from iron deficiency and anemia. Beyond well-known symptoms like lethargy, persistent anemia can significantly impair children’s cognitive development, leading to less education and a lifetime of lower income - and a greater chance of impoverishment.The state government has taken steps to curb this widespread problem. In the past decade, state-sponsored community and school programs have aimed to educate the public about the dangers of anemia and ways to alleviate it. The government has also heavily emphasized distributing vitamins to at-risk populations. Yet these efforts have failed to produce significant results on a large scale.For three years, Stanford Associate Professor of Medicine Grant Miller has collaborated both with colleagues at other universities and the government of Tamil Nadu with the goal of introducing a more impactful alternative strategy, fortified rice (the main food staple of the region) provided through the state’s Public Distribution System with iron and other essential micronutrients.Miller’s collaborators includes economists from UC Berkeley and Universitat Pompeu Fabra in Barcelona; a nutrition specialist from Emory University; and food industry executives, food scientists, and health experts spread across India, North America, and Europe.“A fundamental starting point for us was that this is a clear priority identified by the government of Tamil Nadu,” said Miller. Drawing on past research insights, including work Miller and colleagues had done on vitamin supplementation programs in China similar to those used in India, was also key. “From this research foundation, we designed an intervention and study to push the boundaries of what has been tried in India and in Tamil Nadu using the best available evidence and past lessons learned,” he added.Miller, who directs the Stanford Center for Global Poverty and Development, points out that countries with low levels of anemia generally fortify food staples enriched with micronutrients, including iron, on a large scale. In the United States, for example, the breads, cereals, and cookies we consume are almost all made with wheat flour fortified with iron, folic acid, and thiamin, among others.“I can buy my kids a box of Froot Loops and they will still get a healthy dose of iron and many other basic micronutrients that they need,” Miller pointed out.What if Tamil Nadu’s children could get micronutrients in a similar way, eating a fortified food staple that they would consume anyway, requiring no additional effort by parents and children?This is exactly Miller and colleagues’ focus – fortifying a large share of the rice that the poorest and the most vulnerable children eat every day. This rice is already distributed free of charge by the Tamil Nadu government to approximately half of the state’s population through its Public Distribution System.For Miller and his collaborators, it was crucial that their strategy require as little change in behavior as possible – unlike existing vitamin supplementation programs. “Changing behavior is always hard and has a mixed history of success,” Miller emphasized. “Expecting tens of millions of children in low income countries to take vitamins regularly as a strategy against malnutrition seems unrealistic.”The government of Tamil Nadu has been a vital partner in this project, funding a third of Miller and colleagues’ research.“Although this type of project is never easy, collaborating directly with the government is essential for navigating the regulatory hurdles that come with a project like ours,” Miller stressed.But other challenges have been daunting. Collaborating with domestic Indian manufacturers of fortified rice proved to be an enormous undertaking given lack of previous large-scale commercial experience with fortified rice. Moreover, the team has been immersed in long chain of technical processes, from rigorous laboratory testing of cooked samples, evaluation of micronutrient retention across various forms of cooking, and taste testing.At last, three years after beginning the collaboration with the Tamil Nadu government on this project, the team is prepared to begin field operations in earnest.In the winter of 2017-18, Miller and his colleagues will begin work in hundreds of villages across Tamil Nadu, conducting a large survey of households with small children and adolescents. Among other things, they will measure levels of anemia present before the program starts. Soon after the survey, they will distribute fortified rice to randomly selected villages, and after eighteen months, the team will once again measure anemia levels both in villages which received the fortified rice and those that did not. The results will give insight into how a fortified diet impacts levels of anemia, children’s cognitive development, and other aspects of basic welfare.The Government of Tamil Nadu anticipates that, if the project’s results are promising, it will expand the approach state-wide, providing fortified rice to about 80 million people.Miller’s collaborative approach ensures “buy-in” for the project that only comes from working with a state government from the beginning. “Although it means that the start-up of a project can take a long time,” Miller said, “it is essential for its success and for two-way learning between researchers and policymakers – and ultimately, for policy impact.”