Concern about child malnutrition made national news in mid-May following what became a public, politicised, and likely unintentional spat between Professor Glenda Gray and the Health Minister, Dr Zweli Mkhize, about lockdown regulations and malnutrition figures.
In an interview with News24, Gray stated that “We are seeing children with malnutrition for the first time [at Chris Hani Baragwanath Academic Hospital]. We have not seen malnutrition for decades and so we are seeing it for the first time in the hospital.”
The Minister of Health countered with a diametrically opposing view: “there has been a reduction in the number of cases of malnutrition that have been seen at Chris Hani Baragwanath Academic Hospital POPD and the total admissions during the month of March and April 2020, when compared to the previous four years,” he stated.
The truth seems to lie somewhere between these positions. Although national figures for severe acute malnutrition have declined year-on-year in South Africa (from 12,107 admissions and 1,589 deaths in 2011/2012 to 11,280 admissions and 806 deaths in 2018/2019), Bara has continued to see between 15 and 25 cases per month, a fact that Gray acknowledged in her clarifying statement:
“The Chris Hani Baragwanath Hospital still sees admissions for malnutrition, the increase in the cases seen in the first week of May needs to be closely monitored.”
And while she was correct that there was a spike in cases at the beginning of May, they still amounted to less than the monthly hospital norm.
However, the health minister’s interpretation of Bara’s statistics is also misleading. Although the hospital’s malnutrition figures were two-thirds less than commensurate figures in 2019, they mirror a two-thirds decline in overall hospital admissions. Globally, health professionals have warned that fewer people are seeking hospital care during the Covid-19 crisis.
The only thing that we should accurately conclude from the April statistics is therefore that fewer children are being hospitalised for malnutrition. But that doesn’t mean that they aren’t starving at home. A lack of up-to-date statistical evidence about malnutrition increasing doesn’t negate the likelihood that it is present. And since undernutrition increases children’s risk of dying at birth and from infectious diseases, including Covid-19, dismissing Gray’s claim about an increase in child malnutrition as “anxiety provoking” seems shortsighted.
Growing numbers of Covid-19 cases in Level 3 and fear of contracting it at health facilities may make families even more unwilling to seek medical care. It’s why Professor Haroon Saloojee, head of the Division of Community Paediatrics at Wits, fears that the crisis is reducing children’s access to medical care, and that child mortality statistics, which won’t be available for months, will confirm the devastating effect of the current food crisis on child nutrition.
This rise in mortality due to malnutrition seems inevitable. A recent Lancet study predicts that lack of access to health care, combined with food insecurity, will result in a dramatic increase in childhood wasting (another term for severe acute malnutrition (SAM) – when the child’s ratio of weight to height drops below 60% of expected weight) which will account for 18-23% more child deaths globally.
For South Africa, the prediction is devastating. Lori Lake, communication and education specialist at the Children’s Institute, explains that “even before Covid-19, a quarter of child deaths in South African hospitals were associated with severe acute malnutrition, and a further quarter with moderate acute malnutrition.”
Nor should death be the only concern. “For those who survive,” says Saloojee, “malnutrition can still cause lifelong impaired cognitive ability (learning and thinking skills), neurodevelopmental and behavioural problems that result in poor school performance, and lower adult work performance and earnings.”
Unless urgent interventions occur to manage children’s lack of access to food, sanitation and healthcare, the Covid-19 crisis threatens to undo any progress we’ve made in combating childhood malnutrition as a nation, and to have multi-generational consequences.
It’s why the politicisation of the debate between Gray and Mkhize is so troubling. And making child malnutrition a fulcrum in the dispute about lockdown is likely to have two other disturbing effects. Firstly, it negates the fact that child malnutrition is an ongoing problem which the country has historically dealt with inadequately. And secondly, it leads to magical thinking that ending lockdown will end child hunger. But, nothing could be further from the truth.
According to Vishwas Satgar from the SA Food Sovereignty campaign, prior to the Covid-19 crisis, 30 million South Africans lived below the poverty line and
14 million were hungry. This amounted to a quarter of urban households going hungry. In rural areas, that figure was over 30%. The impact was evident in children. The 2019 Child Gauge reported that 11% of children lived in households that experienced hunger, and although the country’s wasting levels have been at their lowest in recent years (2.5% in 2016), a shocking 27% of South African children were stunted (a measure of height per age). This percentage has remained static for the past two decades.
Saloojee explains that stunting, which results from a persistent inadequate diet and lack of basic amenities such as water and sanitation, particularly affects children between the ages of six months and two years, and leads to developmental delays, decreased IQ, poorer school performance and lower income in adulthood.
In response, South African has used social grants and the Early Childhood Development (ECD) and National School Nutrition Programmes (NSNP) to combat childhood hunger. These initiatives have had some impact, but there are some significant problems with them.
The Child Support Grant is too low, falling as it does below the food poverty line, and only 81% of children under six, and 64% of eligible infants under one receive the grant, meaning that it’s failing to reach many vulnerable children. And although the NSNP, which caters for nine million learners daily, is intended to provide 35-40% of a child’s daily nutrients, anecdotal reports suggest that meals provided in many schools are nutritionally poor, and that many schools have to use their own funds to top up the money provided by government.
Chantell Witten, from the University of the Free State and nutrition lead for the South African Civil Society for Women’s, Adolescents, and Children’s Health (SACSoWACH) argues that the schools’ programme more typically only provides 15-20% of a child’s nutritional needs. Saloojee concurs that the programme’s benefit is educational, not nutritive. It only gives children enough calories to concentrate and learn during their schoolday, but not enough to compensate for the effects of established stunting, or to provide the nutrients children need to continue to thrive.
For smaller children, the picture is even more concerning. Thirty-one percent of children between the ages of 3-5 don’t attend an ECD programme or Grade R. Only 626,574 children are subsidised through registered ECD centres. Even so, Lizette Berry, senior researcher from the Children’s Institute, argues that at only R17 per child, per day, subsidies are too low to cover running costs, and only a small portion is allocated for food provision. In addition, more than 1.5 million children attend unregistered ECDs, a common problem within the sector because registration criteria are so difficult to meet. These receive no government subsidies.
Researcher and writer Camilla Thorogood explains that many unregistered ECDs are reliant on external food programmes for meals. But coverage is patchy, and donor requirements can mean that feeding schemes are limited to feeding children in registered ECDs. And disturbingly, although stunting is established by age three, there are no national food interventions directly targeting children between six months and two years of age.
Equally concerning has been the government’s top-down and somewhat opaque approach to the country’s food security strategy. Even before the Covid-19 crisis, multiple food and health advocacy organisations considered legal action against the government over the right to food. They were protesting the state’s inability to take the right to food seriously following its failure to implement the 2002 Integrated Food Security Strategy, failure to do adequate public participation for the 2013 Food Security Policy, and failure to develop and implement a strategy for this policy. The Food and Nutrition Security Coordination Committee has been tasked with the management of SA’s current food crisis, but none of the experts who contributed to this article knew who was on the committee, or what proficiencies qualify committee members to manage the food requirements of millions of vulnerable South Africans.
The upshot is that the country’s efforts to combat food insecurity for children were flawed prior to the Covid-19 crisis, and Covid-19 has resulted in its rapid escalation. April 2020 surveys by the University of Johannesburg and the Human Sciences Research Council (HSRC) indicated that up to 55% of informal settlement and township residents had no money to buy food during lockdown. In a 29 May presentation to the Portfolio Committee on Social Development, the department’s DDG, Peter Netshipale, confirmed that: “There’s been evidence suggesting high incidences of food insecurity, hunger and malnutrition recently in South Africa.”