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.”
“Food security has become a national crisis,” he added. “Roughly 50% of our population” (almost 30 million South Africans) are “food insecure or at risk of food insecurity”.
There are a multitude of reasons why the Covid-19 crisis and the lockdown measures have increased those numbers so dramatically. They include, a lack of funds for food relief, the Department of Social Development’s (DSD’s) cautious, controlling and rigid approach to the crisis and its seeming inability to map and coordinate food interventions, the inexplicable closure of the National School Nutrition Programme (NSNP) and ECD food programmes, the shutdown of the informal economy during lockdown, increasing food costs cancelling out grant top-ups, and the exclusion of foreigners from food interventions.
In the same portfolio committee presentation, Netshipale reported that in conjunction with the Solidarity Fund and myriad NGOs, the DSD had delivered more than 788,000 food parcels to meet the needs of almost 3.2 million South Africans. It is a commendable achievement but should raise some concerns. The first is that estimates suggest we actually need at least two million food parcels per month, and while government is relying on a mixed strategy of grants and food relief to ensure that people don’t go hungry, anecdotal evidence (and maths) reveal that it isn’t coming close.
The Social Relief of Distress Grant, which was widely welcomed, has had two unfortunate consequences. The first is that the complexities of applying for the grant and Sassa’s stringent checks meant that by the third week of May (two months into lockdown), only 10 applicants had received the grant. Secondly, to avoid “double dipping”, applicants cannot receive the grant if they are getting any other governmental support. Applicants, therefore, risk swapping a R700 food parcel for a R350 grant, which most have not yet received.
Equally, while creditable, the initial top-up of the Child Support Grant in May only took the quantum of the grant to the food poverty line. And according to the NGO Pietermaritzburg Economic Justice & Dignity (PMBEJD), the increase in food costs cancelled out the top-up: “From 2 March 2020 to 23 April 2020, the cost of the household food basket increased by R252.75 (7.8%)”. These costs included a 12% increase in rice, 8% in sugar beans, and a 9% in cooking oil. Staples like onions and cabbages also increased, the latter by 10%.
Disturbingly, cost pressure is likely to grow for families receiving the child support grant over the next five months when the grant top-up is given “per caregiver” rather than “per child”. This caveat means that the more children you need to feed, the less relief you will receive.
Increased costs were exacerbated by the closure of informal traders, and the yo-yoing “open-again, closed-again” regulations about spaza shops. Merwyn Abrahams of PMBEJD explains that poorer shoppers traditionally buy their vegetables, fruit and eggs from informal traders where they are able to buy food quantities based on how much money they have. Associate Professor Jane Battersby, of the African Centre for Cities at UCT, who bemoans the fact that lockdown regulations favoured formal food providers, agrees:
“The informal sector provides food in affordable unit sizes, provides food on credit, sells fresh produce at lower costs than supermarket fresh produce, and sells prepared foods appropriate for households that experience income, time, storage and energy poverty.”
The closure of the informal economy had the compounding effect of making thousands of previously self-sufficient people dependent on the state. One of the least explicable lockdown regulations was allowing commercial fishing to continue in crowded boats, but prohibiting subsistence fishing which, according to Desmond D’Sa of the South African Fisherfolk, epitomises physical distancing.
Another key question is, did the government understand the impact of NSNP and ECD-based feeding programmes being closed during lockdown, and factor this into its food relief efforts? Equally, why has it failed to reopen them despite advocacy groups stressing the impact on children of their closure?
According to the Department of Basic Education (DBE), the NSNP was due to resume for all learners on 1 June (now 8 June), when schools reopen for Grades 7 and 12. However, there are currently no plans for how to manage the logistics of safely feeding growing numbers of learners in need. Worse still, the minister drove child activists to threaten litigation after her 1 June press conference when she reneged on her commitment to reopen the NSNP, saying that “there is intention to start the nutrition programme, but we just need to find our feet in this new environment before we can get into new programmes”.
Confusion also reigns over ECD after the DBE and DSD presented diametrically opposing plans for ECD (the DBE gazetting that they will reopen in July, and, on the same day the DSD issuing a release saying that they must remain closed). As a result, there’s presently no plan for feeding the small children previously dependent on ECD food programmes.
The need is undoubtedly greater than the department estimates, and as the DDG correctly pointed out in his portfolio committee briefing on 21 May, food parcels aren’t a once-off intervention. Troublingly, he stated that people who received parcels on 1 April should now be receiving their second food parcel. Given that studies have shown that the nutritive value of these parcels is insufficient for a whole month, this seven-week lag between deliveries is of huge concern, as is his statement that future food parcels will be even smaller to “help funds stretch further”.
Nor is there any certainty that the DSD will continue distributing food parcels. According to the minister of social development, the department has no funds to keep feeding hungry people. And the Solidarity Fund, which assisted with immediate crisis food parcel and voucher provision, has completed its first tranche of food delivery, and senior personnel report that it has no further mandate for food provision.
It may be left to NGOs to bear the load. But many are at breaking point (as are the donors that fund them). And although court action and Human Rights Commission opposition has forced the DSD to rethink its food regulations (new regulations will hopefully allow hot food and remove the worst bureaucratic restrictions, like the 48-hour advanced application for permits that expire daily, and the requirement to work through centralised food distribution points run by the DSD), some onerous criteria like “knock and drop” rather than centralised food distribution, are likely to remain. This, along with the DSD’s lack of agility, inefficiencies, and inability to coordinate feeding interventions, and its confrontational statements about the “noise” around food distribution, have resulted in its relationship with NGOs becoming strained.
What’s also disturbing is the xenophobic approach to food relief. It’s common knowledge that most foreigners have been excluded from government initiatives, and while the government may argue that it needs to focus on South African citizens only (hence the need for IDs when food is distributed), the approach is not only ethically problematic, but also myopic given the number of South Africans who also don’t have IDs.
So, what can be done? The first step to combating hunger is to admit that we have a problem and take proactive steps to address it. Coretta Jonah, a researcher and coordinator at the DST-NRF Centre of Excellence in Food Security at the University of the Western Cape confirms that “challenges in global and local food supply and demand”, as well as the “consequences of job and income loss” means that “food insecurity, especially for children, will extend beyond the lockdown period”.
According to a World Food Programme projection, the “number of people facing acute food insecurity has risen by 130 million from the 135 million in 2019”. The UN concurs: “the coronavirus crisis will push more than a quarter of a billion people to the brink of starvation unless swift action is taken”. In the forward of the Global Report on Food, António Guterres, the UN secretary-general wrote, “We must redouble our efforts to defeat hunger and malnutrition. We have the tools and the knowhow. What we need is political will and sustained commitment by leaders and nations.”
Political will begins with government accepting that without intervention, an increase in child malnutrition will be a foreseeable consequence of the Covid-19 crisis. Chantell Witten explains that it only takes six weeks in a child’s life to move from normal weight to wasted: “A one-year-old weighing 10kg (normal weight) who loses 10% of her weight per week, which is plausible in this crisis, will deteriorate as follows: In week one, she will weigh 9kg, in week two, 8.2kg; in week three, 7.4kg; in week four, 6.6kg; in week five, 6kg. At this point, she will be less than 60% of expected healthy weight,” which is equivalent to being severely malnourished.
Given that this crisis is already in its 10th week and may continue, it will most certainly result in an increase in malnutrition-related deaths and the worsening of our already shockingly high stunting levels.
The theme for Child Protection Week this year is “Let us all protect children during Covid-19 and beyond”, so it’s time to accept that one of the biggest threats to children is food security, and that we’re failing to protect their constitutional right to food. To do so, experts believe that we urgently need:
- Finance, either from Treasury, the Solidarity Fund or donors, to continue assisting those experiencing food insecurity, and a targeted plan for its use. While no one would argue that South Africa has money to spare, food provision for our children isn’t just a moral obligation, it’s also an act of self-interest given the cost to the country in healthcare, and loss of economic potential that not addressing malnutrition will bring.
- A strategy to identify and map those experiencing hunger (this should include consulting community-based organisations and leaders to find out where the needs are).
- The DSD to find innovative ways to make food provision financially viable, for example, harnessing successful strategies like Food Forward’s use of “wasted food.”
- A coordinated plan for government to partner with key role-players (NGOs, faith-based organisations, community soup kitchens, and the Solidarity Fund), to run food programmes for those in need.
- The DSD to acknowledge its inability to anticipate or react quickly to immediate needs, and use strategic partnerships with NGOs to improve its crisis-response times.
- Government to disclose who is advising it on the composition of the food parcels, and ensure that parcels are optimally nutritious (an option is the World Food Programme’s household food package which provides 60-80% RDA for five people for 30 days), and delivered with appropriate regularity.
- The DSD to draw on the expertise of NGOs and the SACC to swap food parcels for vouchers, preferably usable at spaza shops. Vouchers for food relief will minimise the risk of corruption and patronage, remove the cost of transportation and the logistics of food distribution, support the informal economy and uphold the dignity of the beneficiaries.
- Appropriate sanction for those guilty of patronage and misappropriation of food parcels.
- Government to develop a logistical plan for the reopening of the NSNP and the ECD food programmes, and to prioritise the use of the ring-fenced funds allocated for feeding children at school to address the increased food insecurity of school-going children.
- Increased ECD subsidies, and revised parameters for registering ECDs to ensure that more ECDs can be registered and subsidised.
- Schools to become key distribution points for food initiatives for children who aren’t at school and their families.
- Support and enabling legislation for the informal food economy now that it has reopened.
- A proactive plan from the Department of Health to ensure the continued promotion of healthy practices like breastfeeding, monitoring of children’s health and growth, identification of children at-risk for malnutrition (including completing mid-upper arm circumference screenings for all children under five during Covid-19 household screenings), and intervening when children are malnourished.
- Education for community members so they can identify risk signs of SAM and seek help.
- A plan for food provision for foreigners.
- A permanent change to the quantum of the child support grant.
It’s been 100 years since Alfred Henry Lewis’s famous statement, “there are only nine meals between mankind and anarchy” and yet, globally, hunger remains a pervasive and increasing problem. Even in the absence of statistics to prove it, child malnutrition has undoubtedly increased during lockdown, and numbers will continue to grow in months to come.
Ignoring child hunger, or weaponising it as part of a political agenda, detracts from the urgency of the need, and the desperation of the outcome if we don’t act.
Ultimately, failure to address intensified wasting and stunting will have a lifelong impact on children’s development, school performance and economic potential, and result in many more child deaths. DM