Anaemia in a Maize-Dependent Village
A health team screens 240 people in a rural Angolan village where maize porridge is the staple and fresh fruit is rarely eaten. Blood tests show 96 people with haemoglobin below 11 g/dL. Dietary recall shows average daily iron intake near 18 mg, but almost all of it is non-haem iron from maize, and most meals include strong tea. Twelve of the anaemic people are adult men with no visible bleeding; the rest are women and children. The team has a small budget: either iron-folate tablets for everyone with low haemoglobin, or a food-based programme promoting beans, dried fish and citrus fruit at meals.
1. Explain, using the absorption data in the setup, why iron intake of 18 mg can still coexist with widespread anaemia.
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Intake alone does not determine iron status; absorption does. Non-haem iron from maize is poorly absorbed, and tea contains tannins/polyphenols that further inhibit its absorption, while the absence of fruit means little vitamin C to enhance it. So of 18 mg, only a small fraction is absorbed. The population is therefore in negative iron balance despite apparently adequate intake. The fix must address absorption and bioavailability, not just milligrams in the diet.
2. The team finds 12 anaemic adult men with no visible bleeding. What does this suggest, and how should it change the plan?
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Anaemia in adult men without obvious blood loss is a warning sign. It points to occult blood loss (e.g. hookworm infection, peptic ulcer, intestinal parasites) or another underlying cause such as chronic infection or haemoglobinopathy. These men should be investigated rather than simply given iron, because iron supplementation could mask a serious condition and will not treat the cause. The plan should combine supplementation or food-based measures for women and children with deworming and clinical referral for the men.
3. Compare the two budget options and recommend one, justifying with the biology.
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Tablets give a reliable dose of absorbable iron and act quickly, but they do not change the diet and stop working when the supply ends; they also do not help people whose anaemia is not due to iron deficiency. The food-based programme improves bioavailability (beans and dried fish add protein and haem iron; citrus adds vitamin C; less tea at meals reduces inhibition) and is sustainable, but takes longer to show effect. A defensible recommendation: use tablets as a short-term measure for the most severely anaemic, especially pregnant women and young children, while investing in the food-based programme and deworming for the long term. Either choice must be justified by absorption biology, not by cost alone.