Imagine if all our political leaders said: “We have our differences, but we agree that if you want to grow a country, grow its children. On our watch, no child will be stunted because of poor nutrition”. Some solutions are pivotal to the future of this country and must be endorsed by all leaders in every sector and political party. A commitment to zero-stunting is one of them.
The physical height of our children is a leading indicator of the future health of the nation, its social stability and its economic prospects. Yet we are trapped by poor nutrition that damages children before they go to school and erodes human capital all along the way.
Stunting is defined as height-for-age that is two standard deviations below the middle of the growth curve of a normal population. Some children are normally short and, statistically, 2.3% would fall into the lower tail. It would be abnormal if five times as many children fell below the second standard deviation of the growth curve. That would imply that a nation’s nutrition is chronically inadequate — that many pregnant women do not have enough energy and protein to share with their growing babies, households have insufficient food, foods that are affordable have low nutritional value, children get diarrhoea from dirty water and that those who fail to thrive are not identified and rehabilitated through the health system.
South Africa’s last national anthropometric survey was in 2016. It found that 27% of our children under five fell below the second standard deviation.That’s almost 12 times as many children as should be expected to be there. When only one in 40 of our children is short-for-age, and not one in four, we will have achieved zero-stunting.
A year into his presidency, Nelson Mandela noted that “there can be no keener revelation of a society’s soul than the way in which it treats its children”. His government was serious about it. It introduced free health care for women and children in 1994 and the child support grant four years later. But on his departure, children became invisible to politicians.
It is now up to activists for child nutrition to step into the political space, to forge a coalition with all who understand that the slow and interminable depletion of a child’s physiological well-being leeches away our country’s potential too.
This week, the national zero-stunting campaign, Grow Great, held a national summit to galvanise concerted action. When it first approached the presidency to see if President Cyril Ramaphosa would open this event, his team was responsive and helpful. The president was unavailable, but we should approach the minister of social development.
Minister Lindiwe Zulu has a critical role to play in social relief of distress and curbing hunger. Last year, more than a fifth of respondents to the General Household Survey said their household’s access to food was inadequate in the previous month.
The problem is not just that caloric and protein intake is insufficient, but that not knowing how and when you will next feed your family creates stress and despair among parents. This anxiety further damages their ability to provide the care and support that their children need to grow. A 2017 study in Cape Town found that food insecure mothers were five times more likely to report depression and suicidal behaviour.
Grow Great would have wanted Zulu to announce a support grant for pregnant women without delay, because properly nourished mothers have bigger babies who are much less likely to become stunted.
In sub-Saharan Africa, children with low birth weights are nearly 70% more likely to be stunted. This is defined as babies weighing less than 2.5kg at birth. South Africa’s rate of low birth weight is about 14%, nearly double that of most middle-income countries. So extending our child support grant backwards into pregnancy could be a powerful accelerator of child growth over the next five years. Yes, Minister Zulu should have been invited.
We wanted Ramaphosa to say that stunting is a national priority and that the cabinet is determined to eliminate chronic undernutrition among children. Finance Minister Enoch Godongwana would accompany him with a ball and chain around his ankle to illustrate the effect of nutritional stunting on the country’s economy. He would acknowledge that stunting accounts for at least 1% of GDP lost to South Africa every year and point to Peru, Brazil and China as examples where better nutrition accelerated human capital development and productivity. In seeking high returns on investment in social security, he would declare his commitment to maternal support grants and food supplementation for all underweight children younger than two years of age.
Minister of Basic Education Angie Motshekga would join to explain that stunting in very young children is associated with cognitive deficits that affect their ability to learn. IQ is just one metric that must be interpreted with care, but it does give a sense of the deficit. A birth cohort study in India published this year showed that children who were stunted had an average IQ 4.6 points lower than children with normal growth. That’s one third of a standard deviation in a normal IQ distribution – contributing to the 1.2 million children in South Africa who fail their grade each year and the 300 000 learners who drop out annually.
If we are to reset our economic path, we need to change the life trajectories of the 2 800 children born each day in South Africa. We cannot allow them to become stunted. For those children who already are, there is still — at least for the next few years of their lives — a real prospect of catch-up growth, both physically and mentally.
Motshekga would draw on the experiences of Peru, Vietnam, India and Ethiopia that show that a combination of nutrition support and early learning opportunities allows children to get back on track. She would be seized with the possibility that the million or so children under five who are stunted could still enter school with better prospects. This would mean reaching most of them in informal early childhood development (ECD) centres, childminder groups and other spaces through programmes that provide quality early learning and electronic food vouchers redeemable at retailers and spaza shops. She would mobilise the vast network of ECD resource and training organisations and other NGOs to identify children at greatest risk.
Ebrahim Patel, the minister of trade, industry and competition would declare a subsidy on a limited basket of nutritious foods. He would challenge the manufacturing and retail parts of the food industry to match that subsidy by foregoing their mark-ups on these products. Of course, there must be a quantity cap per customer, but this could be a critical step (well beyond zero-rating of value-added tax) in securing the nutrition of the most vulnerable.
The size of public funding for social grants equates to 30% of the total food retail market in South Africa, and poor households spend more than a third of their income on food. The implication is that part of the profits of the big supermarkets is subsidised by taxpayers. Admittedly, margins on basic foodstuffs are already low and the food industry will point to its commitment to food parcels. Still, it cannot be right that 20% of households do not have enough food while shareholders and management extract profits from social security.
The passage of the Liquor Amendment Bill in Parliament this year also rests in Patel’s hands. Heavy drinking leads to gender-based violence, maternal stress and substance abuse that are associated with foetal damage and low birth weight. In South Africa, the adult per capita consumption of alcohol is twice the global average. We know that restricting liquor advertising, reducing the density of liquor outlets and regulating their hours of opening can reduce harmful consumption. In the past two decades, Russia has halved the harmful use of alcohol through these strategies and through minimum unit pricing.
Our wish is that Patel would also announce a new generation of black economic empowerment alternatives to specifically promote local production of food and the diversification of markets. Large retailers should be rewarded for stimulating local food enterprises, especially in bringing resource-poor producers into their supply chains. This would require collaboration between Patel and his counterpart in the agriculture, land reform and rural development, Thoko Didiza. She would point to the critical role that these strategies played in improving food security in China, helping to drive rapid economic growth. Didiza would announce a major new collaboration between the government, the agricultural sector, trade unions and civil society to extend food production across the country. She would root her vision in the success of projects like Thanda near Umzumbe in southern KwaZulu-Natal that hires local facilitators to support small-scale farmers through an agri-hub for seedlings and chicken feed, develops their skills, provides fencing, tools and irrigation, and links them to ECD and school feeding schemes and local spaza shop owners.
The minister of water Affairs and sanitation, Senzo Mchunu, would also be there to declare that piped water and proper sanitation can reduce stunting by 15 to 20% through the prevention of recurrent diarrhoea in children. He would warn that our crumbling municipal infrastructure will pose a big risk to health and nutrition over the next decade unless this decay is halted. Minister of Human Settlements Mmamaloko Kubayi would commit to child-nurturing social housing, because formal housing improves child health and reduces the frequency of infectious illnesses that lead to stunting.
The minister in the presidency, Mondli Gungubele, would be there to ensure that Government Communication and Information Services promote the value of nutritious foods. That communication cannot be trite – telling an unemployed mother whose only source of monthly income is the child support grant of R480 that she must provide balanced meals is insensitive when the absolute food poverty line is R663 per person a month. Public communication can work when there is genuine discussion about breastfeeding, alcohol consumption during pregnancy and the best complementary foods when money is tight.
Health Minister Joe Phaahla would declare that the work of community health workers (CHWs) will centre on maternal and child health to improve child outcomes in the near-term and prevent chronic diseases like diabetes and hypertension as they grow up. Currently, CHWs are viewed as auxiliary workers in the health system, yet they exercise their greatest power in homes, not in clinics. The experience of the Philani Health and Nutrition Programme is that families visited by trained community health workers before and after birth are 25% less likely to be stunted. This shows the importance of mentorship and support in reducing maternal stress and in providing medicines like Vitamin A and deworming. Phaahla would also give CHWs with lightweight scales to ensure that growth faltering is detected early and properly managed.
The minister of justice, Ronald Lamola, would remind his colleagues that the Constitution gives the right of access to sufficient food to everyone and the right of basic nutrition to every child. He would explain that, within available resources, the progressive realisation of socioeconomic rights is an obligation on the state. Given that South Africa has a prevalence of stunting among children under five that is double that of most countries of similar per capita income, he would have to conclude that we already have enough resources to allow at least 90% of our children to grow to their full potential, if only we spent our money wisely.
Until there is a radical shift in the mindset of the government, Grow Great won’t get all the ministers to attend its summits.
Some government departments have shown a commitment to improving household food security. They include the departments of social development, agriculture, and planning, monitoring and evaluation. But it can’t just be one ministry or the other that takes the matter seriously, because the power to stop stunting rests in combined action.
Private funders need to support a prototype agency for nutrition to work with government, civil society and the private sector. All that is needed is a small, nimble entity to build impetus behind the work of the National Nutrition and Food Security Committee (which is spearheaded by the planning, monitoring and evaluation department) and synergise its work with the NGO sector.
The government must galvanise its efforts, but zero-stunting will also require an extraordinary coalition of activists from across all sectors of society. This coalition must be able to articulate the critical paths to food and nutrition security and demand a set of urgent actions to stop stunting.
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