Bread originated in Egypt. Egyptians today are fiercely protective of the quality of their bread, and deeply suspicious of any attempts to tamper with it. This presents a headache for government ministers trying to persuade their countrymen of the benefits of fortifying their bread with iron – a staple practice in Western countries for over 50 years.The most common nutritional deficiency in the world, iron deficiency is a severe health problem that affects hundreds of millions of people around the world – causing a range of problems, from extreme lethargy to low birth weight, stunting, maternal mortality and loss of productivity on a national scale. More than half the population of Middle Eastern countries are iron-deficient – yet fortifying flour with iron costs just US$2 per person, per lifetime.
Basma is not quite 6 years old, but she is suffering from anaemia which will stunt her life and affect her education and mental development if it is not treated. She has no appetite, she’s tired and she can’t concentrate. There’s not enough iron in her blood to allow it to carry enough oxygen to her body and her brain. Young children are especially vulnerable to iron deficiency and need a constant supply of iron to grow properly.Basma is lucky. She is getting specialist treatment from Dr Ibrahim, a nutritional expert at a clinic in Cairo. He finds that she is below average height and weight: “This child is not growing well even physically or mentally and this will affect her in the school age… She will get some educational problems if she is not well treated now.”
Over half the population of some countries in the Middle East suffer from iron-deficiency anaemia. It stunts the health of entire populations and slows down productivity. Dr Anna Verster of the WHO Eastern Mediterranean Regional Office says that this anaemia has a very real economic effect. “When you translate this iron deficiency – this lack of productivity – into actual money terms there’s a huge loss. You come up with amounts of up to four to eight dollars per capita per year.”
One of the most effective ways to combat iron deficiency anaemia is to add iron to staple foods everybody eats – usually flour. Western countries have been fortifying bread and cereals for the last 50 years but in the Middle East the idea’s still quite new and the process has thrown up a number of problems.
Cairo baker Ramdan Fawzy is suspicious of plans to add anything to the flour: “We shouldn’t put anything into our flour, it will affect the bread – any small changes will affect our work. We shouldn’t play around with things that God gave us, changing nature will give us a lot of problems.”
Dr Farouk Shaheen of the Cairo Nutritional Institute is aware of the problem. “In Egypt, bread is very precious, and sacred since ancient, ancient times. And we are keen on the fortification of the bread, but the process will be done in a very cautious way. We decided that we have to do a pilot study in one of the regions – not universal for the whole nation.”
Dr Ibrahim explains that adding iron is only putting back what the milling has taken out. In Al-Fayoum in the east of the country he is training nutritional educators to teach people about fortification and iron-rich foods. Basma is fortunate. As well as eating an iron rich diet she is receiving iron supplements: with luck, she won’t suffer any long-term damage.
Across the Red Sea, Yemen is also launching a national flour fortification programme in the near future. As in Egypt bread is Yemen’s staple food but here the challenges are different: fortifying flour is just one part of the need to address basic health issues compounded by extreme poverty, primitive infrastructures and a mountainous terrain. Yemen faces major problems of malaria control and eradication of intestinal parasites, both of which can make anaemia worse. Obstetric care and family planning are woefully inadequate. Eight out of 10 women are illiterate, most families have at least seven children and women who suffer from iron-deficiency anaemia are much more likely to die in childbirth.
Dr Rachel Chandiru of the Adventist Development and Relief Agency teaches midwives to discuss primary health care and nutrition with their patients. Rachel emphasises the key role midwives can play in persuading women to take iron tablets during pregnancy, but the women sometimes refuse, saying that the tablets will make their babies too big. “But we have to teach them, train them what iron tablets does for the baby and for the mother.”As women are not allowed to go out, men shop in the one-weekly market and do not buy the most nutritious foods, and there is a lack of facilities for food storage. This adds to nutrition problems. But now the Yemeni government has issued a decree that all flour will be fortified. As Dr Magdi Yacoum of Unicef says: “The challenge now is how to enforce this law.”