How Ladakh Is Battling ‘Hidden Hunger’

For the second time, doctors had refused to remove her sister’s gallbladder--they had diagnosed that the patient had disturbing anaemic levels despite being on iron supplements for six weeks now.

“We are disappointed as doctors refused to operate on her,” says Norbu, member of a pastoralist tribe of eastern Ladakh. “They are saying she is anaemic. Why should that be a problem? All of us are, and it cannot be changed overnight. It is difficult and costly to travel 100 km over and over again.”

Norbu, like her sister, has never taken iron and folic acid supplements. As pastoralists, the siblings seasonally migrate with their tribe, and receive little formal medical attention. “ASHA [accredited social health activists] workers mainly focus on pregnant and lactating mothers,” Norbu said. “Young girls hardly receive any care.”

In the cold mountains of Ladakh, beyond the tensions along its borders and the ongoing political struggle to preserve its culture and identity, its population is facing an acute deficiency of nutrients, mainly iron--a phenomenon known as ‘hidden hunger’, where a person fills her stomach but does not meet the nutrient requirements of the body.

This condition adversely impacts the lives of the natives in this Himalayan region--unchecked, it can increase risks of complications during pregnancy and maternal death. According to doctors and medical journals, iron deficiency in the long-term results in fatigue, lightheadedness, shortness of breath, palpitations and increased sensitivity to cold temperatures.

In the twin provinces of Leh (population: 133,000) and Kargil (population: 125,000), 93% of the women aged 15 to 49 years are anaemic, according to the fifth National Family Health Survey (NFHS-5). Much of this has to do with the region’s geography and extreme climatic conditions.

The Sonam Nurboo Memorial Hospital in Leh--which Angmo Norbu and her sister from Durbok visited twice in a month for a surgery--caters to the district’s population of 133,000.

Nestled in the Himalayas bordering China and Pakistan, at 3,000 metres above sea level, the region freezes with under -40°C temperatures during winters, and receives scant rainfall of about 10 cm annually as it falls in the Himalayan rain shadow. These extremes of climate breed a crisis from inadequate availability of food and a less than optimally nutritious diet consumed by the vulnerable groups in communities. The regional food production is insufficient to meet the local demand. The situation compels Leh district to import around 73% of food grains and 67% of vegetables from outside the region.

In 2020, a report published by the administration of the Union territory of Ladakh noted that this has resulted in “unbalanced diet”, and that micronutrient deficiencies including the lack of vitamin A, B6, B12 and folic acid are prevalent in the region.

In the cold desert region, vegetables don’t grow in sufficient quantities and the distances and closure of roads make the import of this perishable commodity difficult. Ladakh was connected with Central Asia through the various silk routes and received vegetables like potato, onion and other dried vegetables throughout the year, Sidiq Wahid, former vice chancellor, Islamic University of Science and Technology in Jammu & Kashmir, says.

Traders used to barter various kinds of dried fruits and food varieties, which people in Ladakh consumed in the winters. The 19th century explorer G.W. Hayward chronicled his journey from Leh to Yarkand in China in 1868, published in The Journal of the Royal Geographical Society of London. He writes of trade carried on ponies, Bactrian camels and horses.

It would take between 15 and 60 days to reach Leh from Yarkand and Central Asia, respectively, former ambassador P. Stopdan says. But the region would remain sufficient with different varieties of food. When the silk routes were closed, borders with China and Pakistan re-drawn, and security tightened, this changed, Wahid explained.

The Green House project

To fight this crisis, the government in 2021 introduced green houses in the region, offering 75% subsidy to potential beneficiaries. “Till now, we have set up 3,059 greenhouses in Ladakh,” says Thinless Dawa, Chief Agriculture Officer in Leh. These are designed to assist in cultivating limited quantities of vegetables in controlled conditions throughout the year.

One such polycarbonate greenhouse has been established by Kunzes Dolma from Kharu village, around 50 km from Leh. On a small patch of land, Dolma grows tomato, brinjal, turnip, cabbage and spinach for household consumption. The gradual rise in temperature from changing climate has helped her grow vegetables during the autumn and winter season. But, she says, increasing water scarcity has become a major challenge.

In her village, Dolma says, the farming season used to end in September but due to climate change it has extended to October now. “In March, the season of sowing saplings, there is an acute shortage of water for irrigation,” she says. “My husband is part of ongoing protests to create awareness on climate change.”

Ladakh and its mountain ranges of the Hindu Kush-Karakoram-Himalayan system (HKKH) known as the Third Pole--so called because the region’s glaciers and snowfields--store more frozen fresh water than anywhere outside the Arctic and Antarctic polar caps. HKKH is also known as the Asian water tower, and it provides fresh water to 1.3 billion people and 10 river systems with a vast combined footprint and complex ecosystems.

Kunzes Dolma walking along with her grandson. To fight the crisis of malnutrition stemming from unavailability of fresh produce, the government green houses in the region so that people can cultivate vegetables in limited quantities in controlled conditions throughout the year.

A study done by the United Nations Environment Program (UNEP) to assess the Third Pole found that glaciers are melting due to the rise in temperatures, and that in a decade's time, this may lead to water shortages across South and East Asia.

The Leh Nutrition Project (LNP) is an NGO based in Leh working on ecology, environment and nutrition since the 1980s. LNP published a report in 2022, which shows that 40% of villages in Ladakh are vulnerable to water scarcity and among these, 12 are ‘highly vulnerable’.

A study published this April in the Journal of Water and Climate Change, on groundwater resources of the Ladakh region, says that the region has been significantly affected by the climate change, population expansion, urbanisation and increase in tourist inflow. It states that 40% of glacier area has been decreased so far.

“During spring, farmers shift the direction of the canals to their fields for irrigation purposes, which ultimately damages the crop when the water level increases in these canals during summers due to melting of glaciers,” says Chotak Gyatso, managing director of LNP.

Gyatso says Ladakh is witnessing water scarcity for several years now, and that they have introduced the concept of artificial glaciers in 15 villages so far to tackle the issue to some extent.

The water glacier, or ice stupa, was pioneered by engineer and environmentalist Sonam Wangchuk. A large pipe, with small holes drilled at one end, is installed near a village. Water is pumped up the pipe under high pressure; this water comes out through the small holes at the top, and freezes in the sub-zero temperature. As more and more water is pumped through the pipe, the frozen water takes the shape of a large cone, creating an artificial glacier that, in summer months, melts slowly and provides water to meet the requirements of the village.

Vegetables both expensive and hard to procure

Approximately 90% of vegetable and fruit sellers in Leh market are from the Kashmir Valley, wholesalers in Leh’s Sakara market told us. During winters, these migrant sellers prefer to go back to their homes, returning to Leh only in April-May. Thus, during the winter months, only two wholesale suppliers of vegetables operate in this Himalayan freezer.

“The remote location of Ladakh makes vegetables and fruits costly for locals during summers as well,” says Mohammad Amin, a vegetable wholesaler in the Sakara market. “And during winters, prices skyrocket as fruits and veggies have to be airlifted for local consumption. Not a single vegetable is sold below Rs 200 per kilogram, as we have to pay Rs 120 as freight charges. Last winter, the cooperative society did not buy any vegetables after private players sold the airlifted veggies in the market.”

Given the rising cost of vegetables brought in from elsewhere, the younger generation of farmers have taken to producing their own greens during summer months, and selling their surplus in the market.

Ladakhi women selling vegetables produced in Ladakh. The remote location means fruits and vegetables are expensive even in the summers. But during winters, prices skyrocket as they have to be airlifted for local consumption.

In Leh arcade, scores of vegetable vendors--who themselves are battling anaemia--are now selling tomatoes, spinach, cabbage and cauliflower. “Earlier I used to sell vegetables brought from outside Ladakh,” says Spazas Chondaol, a woman vegetable seller, “but now I am selling locally grown vegetables. It’s the end of the season of open field farming in Leh. Growers only sell their produce during summers. Not every farmer has a greenhouse to grow vegetables for winter consumption.”

Tashi Chospol, Councilor in charge of Agriculture Department in Ladakh Autonomous Hill Council, said that there is scarcity of vegetables during winters, but added that people cannot depend on vegetables as the sole source of required nutrients. “People can take other foods like meat, milk and barley,” he says.

“We cannot distribute vegetables village to village,” Chospoi said. “We can help them through schemes like greenhouses, and they can grow their own veggies. We have also brought drip and sprinkler irrigation. This year we are also introducing artificial ice reservoirs, each costing Rs 20 lakh. They are fully automatic, and reduce water stress to villages. These artificial glaciers cannot replace natural ones, but they can help alleviate the impact of global climate change impacting the Himalayas and our health.”

The efforts to tackle anaemia

The Union government’s Anaemia Mukt Bharat programme is being implemented here to tackle the crisis through iron and folic acid supplements. The scheme is being implemented for six categories of people: infants (6-59 months), children (5-9 years), adolescents (10-19 years), pregnant and lactating women, and women of reproductive age (15-49).

The administration in Ladakh says it is working hard on the first five beneficiaries, while the last beneficiary age group is being provided iron supplements, but without regular testing and monitoring of anaemia levels.

“Within a few months we are going to work for this age group as well,” says Iqbal, nodal officer of the Anaemia Mukt Bharat programme in Ladakh. “In Kargil district, the anaemia rate has come down to 40% in 2024 compared to 54% in 2023. So, we are fighting the menace with unrelenting strength and strategy.”

The last mile delivery of supplements is in the hands of young health workers like Tresing Norzon. As an ASHA worker, Norzon campaigns door to door, raising awareness of the dangers of anaemia and distributing iron and folic acid tablets to pregnant women. “We don’t want another anaemic generation in Ladakh,” says Norzon, her cold-flushed face full of resolve.

Haemoglobin tests carried out at a primary school in Igoo Leh. About 93% of women and children in Ladakh are anaemic, according to data from the National Family Health Survey.

However, a study reveals that the iron and folic acid tablets are not distributed on time, and sometimes, a lack of funds worsens the situation. The study recommended that the ASHA workers be provided training, and capacity building programmes put in place so that they can follow the guidelines and protocols while practising their work.

“But the problem is beyond training and capacity building,” says Noor Jahan, Block ASHA Coordinator in Durbuk. “The thing is, the area in Ladakh is huge and the population is very small. It’s very difficult to travel a distance of 20-30 km to reach out to just a few families of nomads.” These nomads mainly consume barley and meat and hardly any vegetables and fruits. “This is the main reason for anaemia among these women in Changthang,” she said.

In a bid to map the nutritional crisis across the country, the Indian Council of Medical Research-National Institute of Nutrition is set to release a report on Diet and Biomarker (DAB-1), including for Ladakh. “This is the first of its kind study through which we can get insight about what India eats,” says Subbarao M. Gavaravarapu, scientist at the National Institute of Nutrition, Hyderabad.

“At present we have data on cereal-based foods, but the diversity of foods consumed by the population will be available only through this study we are now undertaking.

“We need to understand that only by iron supplements we may not be able to combat the problems of anaemia,” Subbarao adds. “For iron to be absorbed we need other micronutrients, protein and good hygiene, food safety environment and then there are concerns of accessibility and affordability.”

India’s nutritional security at risk

In 2024, India ranked 105 of 127 countries on the Global Hunger Index, with 13.7% of its population classified as undernourished. Although human populations worldwide are vulnerable to nutrient deficiency due to the decrease in nutrients in plants caused by increased carbon dioxide levels in the atmosphere, the challenge is exacerbated in Ladakh with the non-availability of even basic food stocks and vegetables.

In 2023, scientists from the Indian Council Agricultural Research published a study that found that the Green Revolution in India had helped in achieving sufficiency of high-yield varieties, but that it compromised the nutritional quality of minerals, particularly in rice and wheat, the country’s two staple crops.

The study also found that in the past 50 years, zinc content fell by 33% and iron by 27% in rice grains, while in wheat, zinc and iron content fell by 30% and 19%, respectively.

Ladakh’s experience with fortified rice

Tahir Hussian, Director, Food Supplies in Leh said that on average, between 40,000 and 50,000 quintals of wheat and 60,000 quintals of rice is being imported each year in Ladakh. In 2023, Tresing Stobdan from the Defence Institute of High Altitude Research in his study found that with the rise in population, the net crop area in Ladakh is only 0.4% under agriculture--enough to cover requirements of only 60,000 population.

This shifts the focus to fortified rice, which refers to rice to which vitamins and minerals are added in the post-harvest phase. India’s rice fortification programme started in 2019 as a pilot and was scaled up in three phases, and fortified rice contains iron, folic acid and vitamin B12. The scheme is being implemented through the Targeted Public Distribution System under National Food Security Act (NFSA) and Integrated Child Development Services (ICDS).

The National Institute of Nutrition, in its 2023 report on the efficacy and safety of fortified rice in India, found that fortification is a cost-effective strategy to improve the nutrition status of the population. The study says that fortification requires regular monitoring of dietary intakes, impact evaluation, and regular checks for adverse effects in different population groups.

Sylvia Karpagam, a doctor working in the public health space, says that in India the focus is on cereals only, and that food is being communalised and politicised. For a nutrient-dense plate, we need to have food like eggs and red meat and/or fish as well, she says. Red meat is rich in heme iron, a type of iron found in animal products like meat, fish and poultry that is easily absorbed by the human body. Cereals, she points out, contain non-heme iron.

“The Indian government is adding iron to cereals, but these have phytates and oxalates that actually prevent absorption of iron,” Karpagam says.

She said that to manufacture one molecule of haemoglobin you need Vit-A, Cilium, protein, and nutrients. “Iron is a most common deficiency but it is not the only deficiency, we have other deficiencies of multi-vitamins and minerals. Unless you replace all these deficiencies you are not going to overcome the anaemia,” she said.

IndiaSpend reached out to the Union ministries of health, and women and child development for comment on the lack of nutritious food, high levels of anaemia, and the government’s efforts to address this. We will update this story when we receive a response.

Iron phobia an impediment

In 2023, around 40 children from a local school were admitted to a hospital in the Drass sector of Kargil district after suffering from gastritis. It became one of the classic cases of what health workers call ‘iron phobia’ in Ladakh.

Medical officer Reyaz Lone blames guideline violations for the crisis. “The teacher at this school had given the children iron tablets in the morning hours, which is advisable as per the National Health Mission guidelines, but not recommended in the population with malnutrition problems as iron intake on an empty stomach can cause issues in people suffering from malnutrition. Because of this, the kids fell sick,” Lone said. “It was a scary moment as parents and security personnel rushed to the hospital to attend to the crisis. The situation normalised after months of relentless awareness campaigns.”

But while the ‘phobia’ in the school campus waned, the perception that iron tablets are bad prevails in the villages, which makes it hard for ASHA workers to normalise the consumption of iron supplements.

Students playing at Government High School, Igoo.

Around 20 km from Leh, in Thiksey village, two ASHA workers, Tashi Norzom and Rigzin Chordol, spoke of how pregnant women grapple with gastritis upon taking iron-folic acid supplements. The duo supplies supplements to Anganwadi centres, school teachers and pregnant women. “In this tribal population, the habit of having traditional food especially during pregnancy is hard to break. Also, the body takes time to adapt to iron, and during this period we have to push hard to get people to continue taking the supplement.”

Karpagam says that malnourished children have suppressed immune systems. “If these children are suffering from any infections, they may not show signs and symptoms but once you give them iron, other infections can flare up,” she says.

We welcome feedback. Please write to respond@indiaspend.org. We reserve the right to edit responses for language and grammar.