The solution to a complex problem like iron deficiency can be as simple as putting a Lucky Iron Fish in every pot #IronDeficiency #Soent
Iron deficiency anemia (IDA) is the number one micronutrient deficiency affecting close to 2 billion people worldwide. It is the only micronutrient deficiency that affects people in both the developed and developing world and it predominantly affects women and children, especially those living in poverty. Approximately 45% of women in India have IDA and it has been identified as the most important health challenge facing the country. Current attempts to alleviate IDA are not sustainable: iron pills are expensive, often culturally unacceptable and not consistently available. The Lucky Iron Fish offers a simple solution. Based on an ancient Chinese observation that cooking with cast iron results in iron being leached into the food, the fish releases a consistent amount of bioavailable iron during cooking. Originally, the iron ingot was shaped like a fish thought to be lucky in Cambodian culture where the project originally started but the company has developed a Lucky Iron Leaf for use by vegetarians. Regular use of the ingot improves iron status in women and reduces the prevalence of IDA by ~43%. Lucky Iron Fish Inc. is a for-profit social enterprise. Using a buy-one, give-one business model: people in the developed world buy a fish for themselves and provide a fish for distribution to a family in need in the developing world. The company has already distributed more than 100,000 fish. Working with local NGOs and organizations with credibility on the ground in the State of Maharashtra, India, the objective is to use crowd funding to accelerate the distribution of the fish/leaf to reach one million people with IDA and improve their overall health. Outcomes will include an improvement in iron status among the population with IDA and serve as a model for scale-up to other States in India.
What are the key outcomes and impact of your solution?
Health impact on the people using the fish/leaf: Based on the assumptions that there is an average of 4 persons in a family and that 1 million fish/leaf can be distributed over a 5-year period, the principal outcome from the proposal is to improve the lives of 4 million people by boosting their iron status determined by measuring hemoglobin levels in the blood. Previous work has indicated that IDA can be reduced by 43% in affected populations. Children with low levels of iron suffer from physical stunting, cognitive impairment and cannot concentrate for long-periods. In addition, they are more susceptible to disease. Therefore, a secondary outcome will be to reduce significantly infant and child mortality and morbidity, reduce stunting and improve educational outcomes in school. In adults, iron deficiency reduces the capacity to work a full week, and is associated with headaches, fatigue and fainting. Another secondary outcome will be to reduce the negative health consequences of IDA in adults and improve their capacity to earn money i.e., demonstrate a significant improvement in economic status among users. Part of the proposed accelerated distribution program is to work with HIV-positive patients and explore the impact of using the fish/leaf to boost iron levels in this population. HIV-patients are substantially at risk from low iron and the fish/leaf may present an alternative treatment option. If successful, the protocols developed could have widespread impact for the supportive treatment of HIV-patients worldwide.
Business impact: Lucky Iron Fish Inc. is a registered B-Corp with demonstrated and externally verified social and environmental impact included in every aspect of the business. The company will contract Industrial Metal Powders (IMP) to produce the fish/leaf locally in Pune. This will provide additional employment for at least 20 people in the region. The process of packaging, using products with minimal environmental impact, will engage another 30-50 local people. The majority of these workers will be women from a rehabilitation centre sponsored by IMP given transition opportunity to return to the workforce fulltime. To achieve the accelerated distribution of fish/leaf from the pool created from the BOGO business model, the company will sell one million units to people in the developed world. This will create a sustainable solution from a business perspective and address IDA in both the developed and developing world.
What actions do you propose to realize your stated goals?
A sustainable business model for sale of the iron ingots is already in place. Crowd funding will provide additional resources to accelerate sale and distribution of fish/leaf to people with identified IDA. The proposed accelerated distribution will also provide information for scale-up in other regions of the State.
Background preparation: Lucky Iron Fish Inc. is an established for-profit social enterprise based in Canada. Internet-based sales with the buy-one, give-one (BOGO) model have reached 66 countries and the sustainability of the model has been demonstrated. Industrial Metals Powders (IMP) in Pune (India) using a currently produce the fish/leaf from electrolytic iron using a patented process. The World Health Organization approves electrolytic iron for use in fortification of food for human consumption. The fish/leaf releases ~7mg bioavailable iron when cooked for 10 minutes, does not release any contaminants that could be deleterious to human health, and is approved for sale in Canada and elsewhere. Packaging is made locally through a women’s cooperative set up to provide transitional employment for women. Through the BOGO business model more than 100,000 fish have been sold to date and arrangements made to “give-away” another 100,000 fish to families in need from this program. Originally, the Lucky Iron Fish was specifically developed to be culturally sensitive to users in Cambodia where the company first started working. Although focus group work has shown that the fish would be acceptable to some communities in India, there is a significant population of vegetarians and vegans in Maharashtra who would prefer a different shape to use in their cooking pot. Therefore, an alternate iron ingot has been developed in association with IMP and communities in Pune. The design of the new ingot is based on the “tulsi leaf” – a leaf that is thought to possess medicinal properties in Hindi. This new ingot is called the Lucky Iron Leaf and was designed to release a consistent amount of iron each time it is used in cooking similar to the Lucky Iron Fish. Supply chain management developed by the company working with IMP is sufficient to meet current and predicted demand for the accelerated production and distribution of the leaf/fish.
Sales of the fish in the developed world: The current business plan for Lucky Iron Fish Inc. predicts sales in three areas: internet-based sales using the BOGO model; retail sales also using the BOGO model and direct sales to NGOs, governments and health clinics in the developing world. The company expects to sell at least one million units using the BOGO model within three years providing an adequate supply of fish to be distributed from the “fish tank” to the developing world in the predicted five-year goal for the scale-up in Maharashtra.
Distribution of the BOGO fish/leaf: With a predicted target of distributing one million fish in the proposed accelerated program, it will be necessary to increase personnel and crowd funding will support the accelerated distribution. Partnerships are already in place with a number of local organizations. These include: (1) the Sahara Foundation – a charity working to support underprivileged communities in Pune including people with HIV infections; (2) the Maher Foundation – an NGO supporting women seeking shelter for a variety of reasons; (3) the Foundation for Mother and Child Health working to improve the nutrition and health care for mothers, pregnant women and young children among depressed communities in Mumbai; and (4) a number of smaller charitable organizations providing support for villages in the outskirts of Pune. Together, these organizations have access to more than 500,000 families in need. To accelerate the opportunities for distribution, it will necessary to identify further potential partners and assess their capacity to distribute the fish/leaf effectively. This process will be managed by the Social Engagement and Impact specialist currently employed by Lucky Iron Fish Inc. but it will be necessary to employ additional personnel locally in Maharashtra to expand partnership opportunities and liaise with local government officials to support this distribution. The additional personnel will also be responsible for identifying opportunities and potential barriers for scale-up to other regions of the State.
Accelerating distribution of the fish/leaf: The current business model for the company is based on the gradual distribution of the BOGOfish to partners. Crowd funding will enable the company to focus on distribution in a phased and deliberative strategy across a geographic location. Starting with the capital Pune of the State and the City of Mumbai (population of ~25 million people), and working with local partners we will accelerate the rate of distribution, carry out the research to demonstrate impact, and identify the barriers and opportunities for distribution across the rest of the State of Maharashtra – one of the most populous states in the Indian sub-continent.
To achieve these goals, Lucky Iron Fish Inc. is seeking crowd funding at ~$100K per year for a five-year period to: (1) support additional personnel on the ground to facilitate distribution; (2) support efforts to carry out research on impact and outcomes; and (3) liaise with governments and organizations that can facilitate use of the ingot as one of the strategies to combat IDA.
Lucky Iron Fish Inc. has a record of success in achieving fund-raising goals: the company completed a first phase of raising capital from private equity and has already obtained more than $1 million in funding from organizations such as Grand Challenges (Canada) and Saving Lives at Birth Round 5 (supported by the Gates Foundation, USAID, UKAID, Grand Challenges (Canada), Norwegian Foreign Aid and KOICA).
Demonstrating outcomes: The fundamental model for distribution of the fish/leaf requires effective partnerships with local organizations and NGOs that have access to and credibility with local people. Part of the partnership agreements with each of these local organizations and NGOs include arrangements for qualitative and quantitative assessment of the outcomes from using the fish/leaf. For example: demonstrating sustained improvement in iron status among users; demonstrating changes in the perceptions of health among adults; and improving anthropometric data and cognitive function among children. The results from these studies will complement studies already underway on the efficacy of using the Lucky Iron Leaf in Bihar State, northern India in a research program funded partly by the Bihari State Government, Saving Lives at Birth and by the universities of Göttingen (Germany), Guelph (Canada) and Harvard (USA). The Sahara Foundation (Pune) works with a number of people living in marginal conditions but also includes a significant number of people who are HIV-positive. This offers the opportunity to work closely with HIV-positive patients to explore the impacts of using the fish or leaf as a means of boosting iron status among these people. People infected with HIV have a significant challenge maintaining and balancing their iron levels: low levels of iron materially affect their abilities to cope with antiretroviral treatment. This population will be studied intensively in collaboration with the Foundation. The data could represent a significant breakthrough in the support of people suffering from HIV infection and may have worldwide impact.
Government organizations: The National and State governments of India have declared that alleviating iron deficiency is the number one health goal for the next five years. Lucky Iron Fish Inc. will work closely with government officials to ensure that the introduction of the fish or leaf is eventually assimilated into the overall nutrition improvement strategy in the State.
Capacity development: As part of the social mission of Lucky Iron Fish Inc. efforts will be focused on capacity development through local training and employment. Production of the fish at IMP will increase the workforce for IMP by at least 20 people and a further 30-50 people will be employed in production of the packaging and packing the fish/leaf. In addition, working in partnership with the Symbiosis International University in Pune, the project will undertake to support graduate students engaged in the research on the efficacy of the fish/leaf and, through partnership with the University of Guelph (Canada) offer opportunities for international training of graduate students and the possibility of student and faculty exchanges. This will be formalized with a Memorandum of Agreement between the two universities and the impacts reported as part of the overall outcomes of the proposed accelerated distribution program. The project will also engage and help train local nutrition educators to support distribution of the fish/leaf and to work with the distributing partners to train their staff in the care and proper use of the fish/leaf. Finally, local expertise will be used to engage and liaise with government departments and officials to ensure that use of the fish/leaf is integrated in the longer-term into the iron deficiency alleviation strategies of the State government.
Overview and review: The final stage of the project will be conducted in the final year of the proposed program. This will include a formal impact assessment of the accelerated distribution identifying the successes, challenges, obstacles and opportunities of the project in Maharashtra. This review will generate a body of knowledge to inform decisions about scale-up to other parts of the State of Maharashtra. The review will include an in-depth review of the opportunities, demand and levels of potential opportunities for support for scale-up in other States in India.
Who will take these actions?
As Lucky Iron Fish Inc. is an established company, a number of costs will be borne by the company and the BOGO program, but a number of costs will have to be funded to support the accelerated distribution program.
Overall management: the CEO and VP Operations, as the senior team at Lucky Iron Fish Inc., will oversee and manage the strategic issues of the proposed scale-up. This will include the recruitment, hiring, and management of additional personnel necessary to support the accelerated distribution program. The senior team will also have overall responsibility for fiscal control and management of the project. The company will cover these costs.
Supply chain management: The VP Operations at Lucky Iron Fish Inc. working with Industrial Metal Powders (Pune) will be responsible for supply chain management and distribution of the fish/leaves. Again, the company already covers these costs.
Partnership development and impact assessment: The Impact and Engagement Specialist currently on staff at Lucky Iron Fish Inc. will be responsible for overall partnership management and impact assessment. However, it will be necessary to provide an additional person to work with the organizations and NGOs on the ground
Local partnership management and development: A local management officer will be appointed in Pune. Responsibilities of this position will include; direct interaction with the partners on the ground; training on the use of the fish and to ensure maximum of impact on the local communities and organizations; liaison with the head office and liaison with the employees responsible for research and for interactions with government organizations. The local manager will also be responsible for identifying further potential partners to expand the reach of the scale-up.
Research management and activities: The Interim Research Director for the company will manage research activities, obtain funding for research through research grants to demonstrate efficacy of the fish. Funds will be sought through the crowd sourcing to support locally employed graduate students (in partnership with graduate programs at Symbiosis International University) and graduate students studying in Canada to partner on the outcomes assessments of the scale-up among people in Maharashtra and the impact on their lives.
Local government liaison: Liaison with local government officials is key to the success of the program. Crowd sourced funding will be used to employ an individual with intimate knowledge of the various ministries and branches of the state and federal government in Maharashtra and India respectively to ensure support from the governments, and to work to integrate the Lucky Iron Fish into state and national government initiatives to reduce iron deficiency.
Overview: The purpose of the project is to accelerate the distribution of the iron fish/leaf to families suffering from IDA in Pune and Mumbai. Working with local foundations, not-for-profit and for-profit organizations, government agencies and local universities, the target is to distribute one million fish/leaf to families over a five-year period. Based on the estimate that average family size in these urban regions, the project will reach and improve the lives of four million people over the proposed five years time-frame. The impact on health and earning capacity of the people using the iron ingot will be quantified to demonstrate the efficacy of this strategy. In addition, there will be a specific research program carried out on a population of people infected with HIV to determine whether or not the fish/leaf is an appropriate intervention to support maintaining and boosting the iron status of HIV-infected people.
Overall target population: The State of Maharashtra is the third largest state in India with a population of an estimated 115 million. It is the world’s second most populous sub-national entity. Approximately 20.7 million people living in Mumbai and a further 4.5 million are concentrated in the capital, Pune. Over the last decade there has been a significant migration from rural to urban areas in the State. Although Maharashtra is the wealthiest and one of the most developed states in India, there is a high prevalence of iron deficiency among the population. It is estimated that 45-55% of the population are iron deficient: the majority being women and children especially those of the lower the economic status. Iron deficiency affects physical and cognitive development in children leading to stunting and permanently reduced opportunities to raise themselves out of poverty and reduces the capacity of adults to work by about 20% per year. Therefore in additional to negative health outcomes from iron deficiency, being iron deficient permanently affects people’s abilities to achieve their potential – effectively consigning them to perpetual poverty.
There are five geographical regions and six administrative districts in the State. A district collector and local administration, appointed by and responsible to the Indian Administrative Service, report to the State government. The proposed scale-up would begin in the Pune District (which includes the State capital) and Mumbai with the vision of expanding the distribution of the fish/leaves to other regions of the State as funding and fish from the BOGO model permit. A number of local partners for distribution of the fish/leaf and the methods of distribution are already in place for Pune and Mumbai. However, to meet the demand of the proposed accelerated distribution, the number of partners will need to be increased in the two cities and will need to be developed for the other geographically distinct regions of the State.
As iron deficiency predominantly affects women and children, especially those living in poverty and affects people with chronic illness, these groups will be the primary focus on distribution of the fish/leaf. Initially, accelerated distribution will be concentrated in Pune and Mumbai using the partnerships that are already established and working to expand the network. Working with effective partnerships on the ground and with established networks is essential to ensure effective distribution and use of the fish/leaf.
Almost 80% of the population of the State are Hindu with smaller proportions (less than 5% each) of Buddhists and Jainists so that majority of the people in Maharashtra are vegetarian. A vegetarian diet is lower in dietary iron than an omnivorous diet, which exacerbates iron deficiency among the population.
There are three distinct populations that will be targeted in the proposed accelerated distribution of the fish/leaf: (1) women and children with identified IDA in urban areas; (2) men, women and children who are HIV-positive and are challenged balancing their iron levels; and (3) individuals living on marginal diets in abject poverty on city garbage dumps in Pune and Mumbai.
Women and children in need: The Maher Foundation, the Foundation for Mother and Child Health and a number of smaller NGOs in and around the City of Pune, offer support to women of reproductive age and their children from lower socioeconomic groups. They provide counselling, nutrition and reproductive health advice and offer protected shelter. They also offer training programs to enable the women to earn money to support their children, provide them with adequate nutrition and to train them to develop employability skills so they can support themselves and become independent. Through their activities they offer the opportunity not only to improve health but also to raise the women and their families out of poverty. Providing an adventitious source of iron by distributing the fish/leaves to women served by these organizations will help boost their iron levels and improve their health and their abilities to earn a living wage.
Women, children and men with chronic infection conditions: The national AIDS Control Organization of India reports that the prevalence of AIDS has reduced to 0.27% of the Indian population in the last decade with a 50% decline in new HIV infections. Nevertheless, HIV infection rates are still a serious issue especially in urban areas and among the poor. The Sahara Foundation in Pune reports that among the migrants to the City who cannot find work and end up living on the garbage dumps HIV infection rates may be as high as 5%. Iron has a complex relationship with HIV, affects the progression of the disease and is deleterious to the overall health of the individual. High iron stores in the body or high doses of iron (similar to those provided by iron pills) are associated with faster progression of HIV-1 infections as iron is involved in several steps in the HIV cycle. At the same time, low levels of iron are deleterious to the overall health of the individual because iron deficiency anemia results in fatigue, failure to thrive, fainting, susceptibility to secondary infections and even death. To maximize health and to provide a stable base for antiretroviral treatment, it is important to balance iron levels in HIV patients and boost iron status to levels that can help the body combat other infections and maintain a regular lifestyle. However, HIV patients do not tolerate traditional iron supplementation – iron pills. It is likely that the episodic boost of iron to the body from taking iron pills temporarily overloads the system, increases the speed of various parts of the HIV life-cycle and negatively affects digestive function which further exacerbates the draining effect of the infection. Many people living with HIV, especially those on anti-retroviral therapy, have perilously low levels of iron and are severely anemic. Preliminary evidence suggests that the Lucky Iron Fish or Leaf may provide a sufficiently low, but consistent, boost to iron in the diet that it may be helpful for these patients. Working with the Sahara Foundation, who have access to over 4,000 HIV-positive men, women and children in Pune, part of the proposed scale-up would be a phased approached to testing whether or not the fish/leaf is effective at improving the iron status of HIV-positive people. If it is possible to demonstrate a positive outcome in clinical trials, this would be important information for the arsenal of weapons supporting HIV-infected patients, not simply among a wider population in Maharashtra but to HIV-positive patients worldwide.
Families living in abject poverty: The Sahara Foundation works with people living in abject poverty around the garbage dumps of the cities of Pune and Mumbai. It is difficult to estimate the populations in these shantytowns but the Sahara Foundation is currently working with three villages in Pune with ~25,000 families, known as ‘transition villages’. As part of their mission, Sahara provides clean potable water for the people in these transition villages and offers health care and nutritional advice. The diet of the people in these settings is impoverished and the majority of the family members suffer from IDA. The iron fish/leaf will be distributed to these families to complement the fresh potable water and advice will be given to the families about how to use the ingot effectively to boost their iron status.
What do you expect are the costs associated with piloting and implementing the solution, and what is your business model?
Background: Lucky Iron Fish Inc. has an established and sustainable business model providing fish/leaf to people suffering from IDA in the developed and developing world. The purpose of the proposed work is to accelerate and focus the distribution of iron ingots from the BOGO business model to people in Pune and Mumbai over a five-year period. The information from these processes will then be used to develop strategies for accelerated distribution across Maharashtra State and provide recommendations on strategies for distribution to other States in the country.
Costs of accelerating change: Funds are required to accelerate distribution in three principal areas: (1) personnel working with partners on the ground to support the distribution of the fish/leaf – it is important to complement the activities of the NGO partners, taking advantage of their networks and credibility within the communities they serve without disrupting the work that they do. Therefore, it is necessary recruit personnel to work closely with the NGOs to schedule and implement distribution of the iron ingots and to work with the local people to ensure its correct use and care; (2) provide stipends for locally appointed graduate students to support and complement the research activities of student researchers from Canada in determining health, social and cultural impacts and outcomes from distributing the fish/leaf. Partnership with the nutrition program at Symbiosis International University will facilitate recruitment of qualified Indian graduate students and support their studies associated with the program; and (3) it is vital to work closely with the District Administrator’s Office and the bureaucracy to integrate the provision of fish/leaf into government-led initiatives to alleviate iron deficiency and to promote inclusion of the Lucky Iron Fish/Leaf in the regional government strategy. Therefore, an individual with experience of liaising and working with government will be support for the five-year program to facilitate effective interaction and support from government. In addition, costs for travel and general operating will be included in the proposed fund-raise.
Summary of costs per annum for the five-year period: Lucky Iron Fish Inc. will provide administrative, management and oversight support for the project estimated to be equivalent for about $120K p.a. In addition, the company will supply the fish/leaf from the BOGO program for distribution.
Costs to be funded from the crowd-sourcing will include:
- Full-time local liaison officer to manage distribution of the fish/leaf and education about effective use of the ingot $20,000
- Graduate student stipends for 3 x Indian Graduate students @$10,000 p.a. each $30,000
- Local government liaison officer $35,000
- Travel $10,000
- Operating expenses $5,000
Total per year $100,000
Year 1 milestones:
- Contract Industrial Metal Powders to produce 100,000 fish/leaf in year 1
- Confirm Memorandum of Agreement with Symbiosis International University for graduate training and faculty exchange with the University of Guelph
- Confirm partnership arrangements with the Maher Foundation, Foundation for Mother and Child Health, and Sahara Foundation including commitments for the distribution and impact assessment for delivery of 100,000 fish/leaf in year 1 to people with IDA
- Appoint local personnel (Distribution Coordinator and Government Liaison Officer)
- Develop educational material in pictorial form which will be customized to the specific groups
- Appoint graduate students
Years 2-4 milestones:
- Contract Industrial Metal Powders to produce ~225,000 fish/leaf per year in years 2-4
- Identify at least 3 local organizations/NGOs willing to partner on distribution of fish/leaf
- Distribute ~250,000 fish/leaf per year of during years 2-4 to people with IDA
- Set up research protocols to provide evidence on impact on women, children and individuals with HIV
- In year 4, develop and impact an overall impact assessment including health, social and economic changes among the people using the fish/leaf
- Work closely with local and State government organizations to promote use of the Lucky Iron Fish/Leaf as part of the multiple strategies for addressing IDA
Year 5 milestones:
- Contract Industrial Metal Powders to produce ~225,000 fish/leaf per year in year 5
- Distribute ~225,000 fish/leaf in year 5 through partnerships with local organizations and NGOs to people with IDA
Implement the impact assessment and develop recommendations including barriers and opportunities for scale-up in other States in India
No links found
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Armstrong, G.R. & Summerlee, A.J.S. (2015). Scaling up a health innovation using social enterprise to alleviate iron deficiency in women and children in Cambodia. Maternal and Child Nutrition Special Issue: Nutrition and Nurture in Infancy and Childhood 10-12 June 2015 (in press).
Armstrong, G.R., Dewey, C.E. & Summerlee, A.J.S. (2015a). Iron release from the Lucky Iron Fish™: safety considerations. Asia Pacific Journal of Clinical Nutrition (accepted for publication August 25, 2015 ID APJCN-2015-0188).
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