Targeting anemia in rural China, Stanford economist tries to shape country's health policy

By Adam Gorlick

A fourth-grader in rural Gao Lou eats a hardboiled egg. Government officials began feeding kids eggs in this poor, rural area after Stanford researchers found high rates of anemia among schoolchildren. The academics are now studying the effectiveness of the egg program. (Photo by Adam Gorlick / Stanford News Service) 

GAO LOU, CHINA – Dong Laifang says there isn't enough food in her house for breakfast before going to school. When the 11-year-old makes the half-hour walk back home for her lunch break, her mother usually has a bun for her to eat. Dinner usually means noodles, sometimes with a few vegetables that barely grew in the parched dirt of Gansu Province, one of China's poorest places.

Meat?

"Never," she says.

But schooldays bring a treat. At about 9 every morning, she and the 55 other fourth-graders at her school – the name of which translates to "Iron Dragon" – scoop a hardboiled egg out of a metal bucket placed at the front of their classroom.

The school breakfast – if a single egg really qualifies as a meal – is part of a study being conducted by Stanford economist Scott Rozelle and his colleagues at the Rural Education Action Project (REAP), who are trying to convince Chinese officials of the best way to reduce anemia rates among China's rural schoolchildren.

Eggs aren't the answer

It's unclear if Laifang is anemic, but there's a good chance she is. Nearly 40 percent of kids in this area have the iron deficiency, which often leads to lethargy and developmental problems that can impede their school performance and hurt their chances of leaving this desolate area for well-paying jobs in the city.

Those weighty concerns are almost certainly far from Laifang's mind. The girl is hungry. She and her classmates peel the eggs quickly at their desks and pile bits of shell on their textbooks. The insides are devoured within seconds.

Rozelle and his colleagues are sure that eggs are not the answer to rural China's anemia problem because they contain very little iron. They also take a long time to prepare. Laifang's teacher, Bao Zhiyou, starts washing the eggs at 6:30 a.m., then boils the water for them. The process is still under way when his students arrive just before 8. After the eggs cook and cool, he brings them to his classroom by 9.

After REAP conducted research in 2008 that showed giving vitamins to fourth-graders in neighboring Shaanxi Province lowered anemia rates by about 35 percent and pushed test scores up from the equivalent of a C-plus to a B, officials there mandated that every kid would get an egg a day.

"We give the kids vitamins and get great results. Then, for whatever reason, the government gets this fixation with passing out eggs," Rozelle says. "They can procure them locally and eggs don't go bad easily. But we've had no idea if giving a kid an egg has any impact."

That led to the need for more experiments.

Vitamins, education or money?

Because every child in Shaanxi started eating an egg a day, Rozelle looked next door to Gansu, where no eggs were given and he could directly compare the effects of giving students either an egg or a vitamin.

Early results from two tests involving about 1,600 children show the eggs did nothing to lower the anemia rates in Gansu. Enough data hasn't been analyzed to tell whether the eggs had any impact on grades. But in villages where kids received a chewable vitamin every day, anemia usually went down by as much as 45 percent.

Rozelle is hopeful that those results will prompt the government to give at-risk children vitamins. It's a cheap fix – about 3 cents a day – to a problem that could have big societal costs.

To stay in the countryside means being left behind by China's breakneck economy, a risk that could lead to a disenfranchised generation that becomes a stumbling block in the country's increasingly important role in the global market, Rozelle says.

"Part of the issue is that the government thinks nutrition is something that should be dealt with at home," Rozelle says about China's reluctance to incorporate vitamins into a daily regimen at school. Another hang-up could be that principals and teachers are reluctant to pass out pills they think are medicine.

So in another round of experiments in a province to the northeast, REAP is designing a package of financial incentives that might motivate school officials to find ways to reduce anemia rates among their students. The researchers are also studying what effect parent and teacher training may have. Although other REAP studies show that informational sessions on nutrition and anemia haven't made a dent in the problem, Rozelle has a few more ideas up his sleeve to see if an education program would work.

The week before arriving in Gansu he struck a deal with Madhouse, a mobile advertising company based in Shanghai. The company agreed to send 200,000 text messages, aimed at increasing anemia awareness, to the cell phones of 8,000 randomly selected parents during the upcoming academic year.

Half of those parents already will have received information about what anemia is and how to deal with it, while the others will receive only the text messages. REAP researchers will then compare the anemia rates of children before and after the texting begins to see whether the messages helped.

For now, the best bet for solving anemia seems like implementing a vitamin program, but just handing a child a chewable caplet isn't a cure-all.

Stashed in a pencil case

In a village a few hours' drive from the school where Laifang and her classmates get an egg a day, 46 fourth-graders wearing green or blue uniforms are handed chewable vitamins by their teacher. Some gobble them like candy, but others grimace at the sweet taste. Those who hate them the most have found a way to deal with the nuisance: One girl admits to spitting out the pill or hiding it in her pencil case.

"I don't think other people like it either," she says.

While REAP's latest test shows that anemia rates dropped overall in schools giving kids vitamins instead of eggs, this particular school actually saw a slight rise in iron deficiencies.

Still, parents say they've seen changes for the better in their children's health since the vitamin program began last year.

Lei Shuangping can't tell if her 11-year-old son has more energy, but she has noticed he doesn't get colds as often.

Working as a cucumber farmer while her husband lives in the city where his job is, Lei says she doesn't think the noodles she serves her son and 14-year-old daughter are very nutritious. But it's all she can afford. She serves vegetables once in a while and gives her kids meat on special occasions – the last of which was the Chinese New Year, about five months ago.

She says she'd like to buy vitamins once her son stops getting them through the REAP program, but there's a hitch: She doesn't know where she'd get them, and she has no idea how much they would cost.

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