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I believe it was after my third or fourth conversation with vaccine hesitant individuals that I began querying people’s lifestyle choices.When a 19 year old mother is standing there at a community visit with a cigarette in her mouth, a beer in one hand and nursing bub with the other and says she doesn’t want to vaccinate her kid because her social media mothers group says it will cause autism. I get professionally annoyed.Out comes the pamphlets, the primo medical articles, the health and safety guidelines and a risk assessment form. We go over how her recreational drug use and poor child nutrition will cause bigger issues than anything she can provide regarding vaccines.Then we get to vaccines; the seat belt analogy generally works best but if all that fails and we have a true diehard ANTI-VAXXER then I get her to sign a form that I explained everything and that she still declined to vaccinate.Because if the thirty or so points I politely made prior didn’t change her mind nothing will and child services can have a crack at the problem. Now if I was required by law to have a similar conversation with an individual regarding smoking, you’d hear about it.

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 girlsThe 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 intakeDietary 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 absorptionMore 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 includePolyphenols. 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 girlsThe 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 includeLower income, lower access to income and resources.Higher rates of infection due to poor sanitation.Factors found to be protective against anemiaBelonging 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.BibliographyRaman, L., A. B. Pawashe, and B. A. Ramalakshmi. "Iron nutritional status of preschool children." The Indian Journal of Pediatrics 59.2 (1992): 209-212.Yip, Ray. "Iron deficiency: contemporary scientific issues and international programmatic approaches." The Journal of nutrition 124.8 Suppl (1994): 1479S-1490S. Page on nutrition.orgBalarajan, Yarlini, et al. "Anaemia in low-income and middle-income countries." The Lancet 378.9809 (2012): 2123-2135. Page on indiaenvironmentportal.org.inNair, 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.inRammohan, 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.comGoyal, 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.comChiplonkar, 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.comSeshadri, 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.Gautam, Virender P., et al. "Dietary aspects of pregnant women in rural areas of Northern India." Maternal & child nutrition 4.2 (2008): 86-94.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.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.eduHallberg, Leif. "Does calcium interfere with iron absorption?." American Journal of Clinical Nutrition 68.1 (1998): 3-4. Page on nutrition.orgSamuel, 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.orgKulkarni, 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.comPage on unicef.orgSharma, Vridhee, et al. "NUTRITIONAL ANAEMIA AMONG CURRENTLY MARRIED FEMALES IN THE REPRODUCTIVE AGE GROUP IN RURAL JAMMU." Page on jemds.comApte, S. V., and P. S. Venkatachalam. "IRON LOSSES IN INDIAN WOMEN." The Indian journal of medical research 51 (1963): 958.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.inBharati, Susmita, et al. "Temporal trend of anemia among reproductive-aged Women in India." Asia-Pacific Journal of Public Health 27.2 (2015): NP1193-NP1207.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.inBentley, 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.comGhosh, Saswata. "Exploring socioeconomic vulnerability of anaemia among women in eastern Indian States." Journal of biosocial science 41.06 (2009): 763-787.Turnbull, A. Iron Absorption. pp369-403. In Jacobs, Allan, and Mark Worwood. Iron in biochemistry and medicine. Academic Press Inc.(London) Ltd., 1974.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.Hallberg, Leif, and Lena Hulthén. "Prediction of dietary iron absorption: an algorithm for calculating absorption and bioavailability of dietary iron." The American Journal of Clinical Nutrition 71.5 (2000): 1147-1160.an algorithm for calculating absorption and bioavailability of dietary ironBalarajan, Yarlini S., Wafaie W. Fawzi, and S. V. Subramanian. "Changing patterns of social inequalities in anaemia among women in India: cross-sectional study using nationally representative data." BMJ open 3.3 (2013): e002233. cross-sectional study using nationally representative dataLee, Jinkook, et al. "Education, gender, and state-level disparities in the health of older Indians: Evidence from biomarker data." Economics & Human Biology 19 (2015): 145-156. Education, gender, and state-level disparities in the health of older Indians: Evidence from biomarker dataMaiti, S., et al. "Prevalence of anaemia among the male population aged 60 years and above in rural area of Paschim Medinipur, West Bengal, India." Health Renaissance 11.1 (2013): 23-26. Page on www.nepjol.infoRajan, S. Irudaya, and K. S. James. "Third national family health survey in india: issues, problems and prospects." Economic and Political Weekly (2008): 33-38. Page on environmentportal.inThompson, Brian. "Food-based approaches for combating iron deficiency." Nutritional Anemia. Sight and Life Press, Switzerland (2007). ftp://ftp.fao.org/ag/agn/nutrition/Kapitel_21_210207.pdfUpadhyay, Ravi Prakash, C. Palanivel, and Vaman Kulkarni. "Unrelenting burden of anaemia in India: highlighting possible prevention strategies." International Journal of Medicine and Public Health 2.4 (2012): 1-6. Page on researchgate.netAnand, Tanu, et al. "Issues in prevention of iron deficiency anemia in India." Nutrition 30.7 (2014): 764-770.Thanks for the A2A, Kritika Gupta.

Its going to be a bit lengthy. please bare with me :)Let's begin with some numbers. Industry estimates suggest India had 375 million Internet users at the end of October 2015, a number that was supposed to touch 402 million. Facebook has over 130 million users from India that log in at least once every month, which translates to roughly one in three connected Indians who access Facebook. If you throw in the more than 100 million monthly active users WhatsApp has in India, the number of users of Facebook-owned services is even higher — assuming there are many people who use WhatsApp but don't have a Facebook account.With Free Basics, Facebook said it wanted to bring more unconnected users online. At a town hall held at the Indian Institute of Technology (IIT) Delhi last December, Zuckerberg said Free Basics had already brought 15 million users online, of which a million came from India. And that's not all — he claimed half of people who came to Free Basics opted to pay to access the whole Internet.FB founder Mark Zuckerberg has argued that developers get to offer zero rated services through Free Basics. But access to mobile internet is more than connecting with social media. It can change and save lives. But just how far is Free Basics free or basic? Is it for the common good or just another virtual money making plan? Is profit the motive or welfare? Let us examine the pros and cons of Free Basics to assess if it is a hit or a miss.Pros1. Free Basics provides essential services: While many people use social media and the internet for entertainment, access to mobile internet can better lives. From times of civil unrest to natural disasters, social media platforms such as FB use the power of connectivity to find survivors and raise money for aid.2. Technology and internet create a powerful impact: Technology and internet can scale impact at a rate never noticed before and the power of connecting persons who want to take action is further enhanced through initiatives such as Free Basics.3. Affordable internet connectivity is a basic human right: Through projects such as Google Loon has been created to relieve victims during natural disasters, Free Basics offers the benefits and opportunities that other initiatives lack.4. Internet connectivity for more than a privileged few: Free Basics aims to expand the coverage of internet rather than be motivated by profit. This is noteworthy5. Cause of the common man: Free Basics seeks to uphold the cause of the common man and promote internet access for everybody and not just a select few.Cons1. Why would a company not want personal gain?: Facebook is aiming to get more users to login across the world, provided that Facebook app is one of the limited series that are part of free internet connection it aims to provide. Facebook attempts to connect the world for selling user data to advertisers worldwide through Free Basics.2. Lack of internet connections is not a serious problem: Lack of internet connection as a first world problem has been discussed by no less than Bill Fates, who feels that while improving lives, more basic things need to be addressed first such as child survival, child nutrition and access to potable, clean drinking water. Close to 768 million people had no access to clean water in 2011. Having a 3G signal on a cell phone should hardly be the priority.3. Full internet needs to be provided at prices people can afford: Privilege private platforms cannot be used to provide limited benefits for a chosen view. Free Basics raises questions about data privacy, global economics and net neutrality.4. 100 crore campaign to promote net neutrality: A 100 crore campaign has been unleashed to promote the idea that Free Basic is a gift for the Indian poor from FB. Moreover, FB is using the generic phase free basic internet in complete contradistinction with the notion that it is a private, proprietary platform which is a blatant violation of Indian rules on advertising. This is because generic worlds cannot be used for products and brands. Neither does FB pay taxes in India nor is it within purview of Indian law. Placing Free Basics in their hands is like giving them power they do not deserve.5. Rehash of controversial Internet.org: This initiative is just a reworded rehash of the controversial internet dot org floated earlier by FB. FB and India’s leading company Reliance, which is the sixth largest mobile service provider have joined hands for providing this free data services limited to just a few websites.6. Silicon valley seeks to subvert the state: Noted commentators on technology have discussed how Silicon valley seeks to subvert the rights of the state, promising people connectivity, transport and other facilities which they have no intention of delivering for free, unlike the state. Internet connectivity instead of education and private taxis in the place of public transport point to the hidden, mass scale privatisation of what should be public services7. Privacy concerns: Internet monopolies are being paid with data because personal data forms the essential currency of the online economy. Data as commodity is prized resource of the 21st century and FB as well as Google’s model is based on monetising this personal data. Consider that FB generates USD 1 billion from Indian subscribers which pays no taxes in return.8. Free basics is far from free: Free Basics is only a version of FB and is for those websites and services willing to collaborate with its proprietary platform. Consider that there are 1 billion websites and close to 3.5 billion users of the Internet which can become a powerful force for chance. This would stop if telcos become gatekeepers and this is what net neutrality is all about. Health demands doctors and hospitals, not a few websites in FB. The same holds true for education. Internet cannot become a substitute for schools and colleges.9. Regulating price of data: Free Basics has connected only 15 million people in different parts of the world so far. In India there are 60 million people joining the internet in past 12 months and close to 300 million mobile broadband users in the country. Another 600 million mobile subscribers need to be provided internet, according to estimated figures. Free internet or fill internet at prices people can afford would be a better option than FB’s Free Basics. This is because the main barrier to internet penetration is that India has expensive data services. This caused high price of data in the nation and leads to lowered internet access for the poor and those not financially well off. Free Basics is just a privilege platform attempting to take over the Internet.10. Just another digital divide: Free Basics also provides just another kind of digital divide rather than connecting people. FB does not equal internet. Free Basics would have us believe otherwise. Silicon Valley is exploiting space and the internet to extend its frontiers through this initiative.ConclusionFree Basics is not at all the solution that India needs right now. With cost of data being high and privilege platforms seeking to encash on billions of subscribers in India, Free Basics is just another wolf in sheep’s clothing. This internet platform seeks to capitalise on the lack of internet penetration in India and promote the cause of FB and its associated companies. It is certainly not a gift for India’s public to access internet at a reasonable rate. Will net neutrality become a crisis point? Can people see through Free Basics in time? Hopefully, the answer to those questions is yes or India’s digital divide will never be bridged.want to write more but its lengthy already.. will add on further, with comments.cheers :)