At the recent 7th Social Justice Summit in Cape Town, President Cyril Ramaphosa questioned why the rate of stunting is still so high in this ostensibly food-secure country. Stunting means that children are too short for their age due to poor nutrition and is linked to poor brain development. It limits their ability to learn and to contribute to the economy when they grow up. One in four children under the age of five is stunted which, according to the World Bank, is one of the main reasons for South Africa’s weak human capital formation and low GDP growth.
At first, I was frustrated by the President’s question, because we know what causes stunting. Pregnant women who can’t afford enough nutritious food nor access to good healthcare and those who drink alcohol are likely to give birth to babies lighter than 2.5kg. These “low-birth weight babies” have three times the risk of becoming stunted than babies of normal weight. Exclusive breastfeeding for the first six months mitigates this risk by providing all the nutrients infants need and protects them from viruses and bacteria. But poorly nourished and highly stressed mothers battle to breastfeed and wean their babies prematurely – onto low-protein diets that lack essential vitamins and minerals. Poor living circumstances and a nutrient-deprived diet make them susceptible to frequent infections which damage their gut and further reduce nutrient absorption. From the onset of life, this vicious domino effect of one insult after another compounds the odds of stunting, setting off a chain reaction that shapes the course of an individual’s life, and collectively, the trajectory of our nation.
The irony is that babies are designed to thrive, simply given the right ingredients. Post-conception, the first 1,000 days offer the opportunity of a lifetime, where enough love, food, safety and brainpower unlock exponential human potential. Yet from their first moments of life, children in South Africa are assigned either a set of dominoes generating cumulative virtuous impacts or a set with vicious knock-on effects. It’s not just the unlucky few that are dealt a bad hand, and the 2024 Thrive by Five Index found the split to be about 50-50.
We now need to catalyse a national chain reaction to accelerate child nutrition. If all our children are to thrive, the vicious dominoes must be replaced with virtuous ones – starting from conception and positioned close enough together to trigger a dynamic cascade.
Fortunately, we already have two pieces in hand. The first is the Child Support Grant (CSG), with the odds of stunting among children who receive it one-third (31%) lower than among those who should get it but don’t. The second is access to early learning where, according to the 2024 Thrive by Five Index, the rate of stunting is two-and-a-half times lower among four-year-olds who attend programmes compared with those who don’t. The government’s plan to subsidise another 1.2 million children in early learning programmes by 2030 – providing both food and brain stimulation – could give powerful impetus to more upstream interventions.
However, we should be cautious about these claims: Eligible children excluded from these benefits are more likely to be exposed to other factors that cause stunting as well, and neither of these dominoes (CSG and early learning) starts early enough to activate the full benefit cascade.
Restricted foetal growth accounts for a fifth of all stunting, yet the CSG only starts after the birth of a child, missing the crucial nine months of pregnancy.
The domino effect we need
A new domino within immediate grasp is multiple micronutrient supplementation – replacing iron and folate for pregnant women with a mix of 15 minerals and vitamins. This composite product has been shown to be 13% to 19% more effective in reducing low birth weight and should cost the state only fractionally more to procure.
Another promising domino is currently being tested by the government of the Western Cape, together with civil society, academic and business partners. Khulisa Care identifies pregnant women at risk as well as mothers of low-birth weight babies and provides monthly cash vouchers, redeemable for 10 protein-rich “best-buy” foods, until the baby is six months old. They also receive more intensive support from community health workers. Fully implemented, Khulisa Care will cost the province R60-million a year, but this targeted intervention should pay for itself several times over.
There are more virtuous dominoes available at low or no extra cost to the state – such as supporting local production and preventing food waste – if it were to apply its mind to them. We know how to stop stunting, but there doesn’t seem to be the national will or mindset to do so. In the main, we continue to play a game of toppling dominoes designed in the apartheid era, doling out to children the same virtuous or vicious sets that their parents and grandparents got more than 30 years ago.
As I contemplated this image, it struck me that the President’s question was less about the playing pieces than the mindset of the players themselves. He spoke of the irony of supply chains stocking supermarkets with enough good food for everyone but priced out of reach of a substantial part of the population. He could have mentioned the decision of the Northern Cape legislature to extend liquor trading hours late into the night and all day on Sundays, spurring greater consumption in poorer communities that already have the highest rates of foetal alcohol syndrome in the world. Or the absurdity of paying the high costs of intensive care and prolonged hospital admissions for small babies with preventable neonatal complications instead of providing a Maternal Support Grant to pregnant women, which could generate savings of R13.8-billion from averted health costs alone.
In his letter from the Desk of the President, spurred by the Social Justice Summit, Ramaphosa notes that “we need to gain a deeper and honest understanding of what is driving food insecurity in our society and the measures that need to be taken to overcome them”. Specifically, he speaks of the need to confront “market factors that are making the cost of nutritious food increasingly out of reach”. “Ultimately,” he says, “the success of all efforts will rely on deeper collaboration between government, business, labour and civil society.”
Over the past two years the DG Murray Trust and its partners have pushed for exactly that – the idea of a “double-discounted” range of 10 protein-rich staples which would require everyone to come to the table. If manufacturers and retailers were to forfeit their profit on just one label of each of the 10 “best-buy” foods – and if the government matched their contribution with a retail subsidy – the price of a basket of essential proteins could be 20% to 25% cheaper. Civil society and labour would be then mobilised to promote them as part of a balanced, nutritious diet.
Some retailers have indicated that they would consider such a proposal, if the government were to meet them halfway. Their openness to conversation must be seized. The question now is to whom they should talk, because no other leader in the national government has stepped up to drive better nutrition. At this point, we’re unlikely to spark a chain reaction without the President’s active leadership and he should declare zero stunting a national priority and appoint a trailblazer to drive all of society towards it. Their first task should be to convene the key players and line up enough of the right sort of dominoes to eradicate stunting, giving both players and pieces a concerted push. DM