Swimming to Safety: Community health researchers in Cambodia are in the final stages of testing ‘lucky’ fish that could alleviate a life-threatening form of anaemia.

Story and images by Kenneth Ingram, Southeast Asia Globe Magazine – Oct 2011

Midway through the rainy season in the small village of Preak Khmeng, Kandal Province, a team of researchers paddle their wooden boat on the murky waters, visiting Cambodian
homes one by one. Their purpose, as part of a three-year scientific study known as the Iron Fish Project, is to develop an effective, low-cost remedy for people who suffer from dietary iron deficiency. A key factor in malnutrition, low iron can lead to a condition known as iron deficiency anaemia, a disorder of the blood that affects over two billion people worldwide and is the most common nutritional deficiency in the world.

Although widespread, this form of anaemia is more prevalent in developing countries and, in the Asia-Pacific, segments of the Cambodian population are among the highest at risk. Studies show one in three women between the ages of 15 and 49 in Cambodia are anaemic, as well as 62% of children under the age of five. Pregnant women are also susceptible, as 60% are estimated to have anaemia – a rate that triples  those found in more developed countries. The most common symptoms of anaemia are general fatigue and weakness. More severe cases, however, carry a risk of death due to haemorrhaging and bleeding during childbirth. It has also been linked with lower birth weights, diminished learning abilities, reduced immunity and, overall, poorer quality of life.

From an economic standpoint, the World Bank estimates Cambodia loses over $134m each year as a result of mineral and vitamin deficiencies. A variety of health reports identify anaemia as a ‘major health problem’ in Cambodia despite a number of initiatives that are attempting to alleviate the problem. A national nutrition programme was established
in 1997 by the Cambodian Ministry of Health to reduce the prevalence of iron-deficiency anaemia. Following a few revisions, the programme now subsidises folic acid (iron) supplements for pregnant women but shows limited effectiveness.

According to the most recent Cambodian Health Survey, released in 2010, less than 20% of women in Cambodia were receiving the recommended number of tablets
during their pregnancy. “People don’t like taking supplements,” says Christopher Charles, a Canadian biomedical scientist who is leading the Iron Fish Project. “It’s a pain in the butt to take a pill every day, and they can give people stomach problems,” he says. It is also unsustainable because people have to rely on external funding to cover the monthly $2-$3 cost per person. In an effort to design a more effective treatment, the Iron Fish Project’s team of international community health researchers developed a substance that releases iron when cooked in soup or water. It has assumed a variety of forms since it was first introduced to Cambodia in 2008.

“The first prototype was a dark disc,” explains Charles, who acknowledges that, initially, the villagers were reluctant to use it when cooking. “We tried a lotus flower design, followed by a few fish shapes,” he continues, explaining that the team eventually settled on the current design: a smiling fish, which has become popular in the Preak Khmeng
community.

“It’s a native species of fish that Cambodians identify with as being lucky,” he says. “It was familiar to them, and that is important because they were happier to use it.” Produced in Kandal Province for $1.50 a piece, about 500 of the palm-sized fishwere given to villagers in the pilot study. “By using the iron fish and boiling it for 10 minutes with citrus juice, which is a well known iron enhancer, we were able to show that it meets 75% of the daily [iron] requirement,” explains Charles. It is unknown how long the iron fish will
last but Charles says there are no signs of reduced effectiveness thus far in the study – with one exception. “One woman said she didn’t have the iron fish any more because her son was
playing with it and he had set it free in the river,” recalls Charles with a smile. While he is reluctant to speak in absolutes about the project until all the data has been assessed, Charles says preliminary results “look promising” and that the fish may work as a nutritional intervention.

Researchers are also gathering information from the Cambodian participants using a method known as 24-hour food recall because there is limited knowledge of what the villagers eat on a daily basis. Assisted by researchers from Resource Development International (RDI), an NGO located about six kilometres from the village, Charles is recording their feedback regarding food consumption, including variety, preparation and cooking practices. The intent is to determine other possible underlying causes of anaemia in the village.
For example, tea and coffee are both regularly consumed and can limit the absorption of iron, which highlights the need to provide the villagers with nutritional education.

“We support prenatal women with vitamins while also teaching them about proper nutrition and cooking,” explains Ann Hall, RDI community health director.
The final results of the project, funded through grants by the government of Canada, will be published by the end of the year. Portions of the iron fish nutrition programme have been published in scientific journals. While it may sometimes seem like swimming upstream, these little fish are working to help turn the tide of malnutrition in the Kingdom.