This year is likely to be tumultuous in South Africa, with social unrest aggravated by electoral politicking, and rapidly growing food insecurity – and cases of severe acute malnutrition – likely to exacerbate the situation.
Mortality rates are the ultimate bottom line in gauging the success of the healthcare system and are well-documented in South Africa, but morbidity, on the other hand – the extent of suffering from diseases or other health conditions – does not get as much attention in our society.
These terrible twins of death and disease are typically consigned to the health sector, but the Covid pandemic made stark the connection between health and broader socio-economic development, write Mvuyo Tom and David Harrison in Daily Maverick.
While this link is inevitably amplified during epidemics, it is constantly there, shaping our collective ability to learn and participate productively in the economy.
Economist Robert Fogel speaks of the national asset of “physiological capital” that endows the size and distribution of human capital. To some extent, variation in individual endowments is shaped by genetics, but the differences in our stocks of “healthiness” are mainly determined by external factors, like access to nutritional foods and the degree of exposure to infections, alcohol and drugs, both before and after birth.
This link between human vitality and economic development must be taken up seriously by all members of society, including the government, the business sector and scientists.
It’s a link that works both ways: poor health of the nation leads to poor educational and economic outcomes, and the economic machinery of the government and business can perpetuate poor health. The latter is a form of structural violence.
In his presentation of the Presidential Advisory Panel on HIV/Aids in 2000, Professor Malegapuru Makgoba described the mortality rate from HIV/Aids as akin to that of a country engaged in a major war.
Are we now witnessing a low-grade civil war in the country, against our own children, manifested in childhood mortality and morbidity rates related to malnutrition?
At the peak of Aids denialism in South Africa, an average of 777 people died from Aids daily.
In 2006 alone, a similar number of people died from Aids as the total number of excess deaths during the Covid pandemic – roughly 290 000.
Both epidemics were fulminant, filling hospitals and mortuaries and obvious to all but those who would not see.
In both cases, the blinkers were ideological, fuelled by false science. In the former, the reality of Aids conflicted with former President Thabo Mbeki’s view of an African Renaissance and he clutched on to the assertion of Aids denialists that acquired immunodeficiency was due to nutritional deficit.
In the latter, the ultra-libertarianism of conservative evangelicals and politicians stoked an endless parade of conspiracy theories.
Compared with these numbers, the deaths of 30 children a day from malnutrition-related causes seem insignificant. The equivalent of “only” one classroom full of children dies from malnutrition every single day – about 10 000 a year.
This includes the 1 000 children who die directly from severe acute malnutrition (SAM) and the 9 000 or so more under five for whom SAM is an underlying factor in their deaths (Department of Health District Health Information System – written reply to Parliament Question No. 2501, 30 June 2023.)
That’s not to mention another 10 000 a year who are underweight-for-age at the time of death, and whose nutritional status also makes them more susceptible to infections.
If the equivalent of 10 to 20 schools of malnourished children dying a year isn’t unsettling enough, we might add the 1.5m children under five whose brains are damaged by chronic malnutrition, evidenced by the fact that they are stunted (short-for-age). If they weren’t stunted and if international experience is anything to go by, as adults they would add at least another R90bn per year to the economy.
Instead, today’s stunted children are eventually more likely to join the ranks of the unemployed, trapping South Africa in a job-scarce, low-growth environment. According to the World Bank, a child born in South Africa today is likely to achieve only 43% of their potential human capital. Those who don’t are more likely to engage in criminal and other high-risk behaviour.
During the years of Aids denialism, it seemed baffling that Mbeki could not accept the obvious fact that HIV causes Aids. Contemporary commentators wondered what a sentient extra-terrestrial creature would have thought, landing in a township on a Saturday and watching one cortège after the other making their way to overcrowded graveyards while the President turned a blind eye.
Although the mortality from malnutrition is far lower than that of Aids at its peak, the long-term societal and economic consequences are ultimately just as destructive, systematically corroding the country’s social stability and economic potential.
The failure of the government and business to fully acknowledge and seek to avert the devastating impact of malnutrition is reminiscent of the Aids denialism of the early 2000s.
While malnutrition often involves more than the lack of food, national food security is the starting point for good nutrition. What is so difficult to understand? Without sufficient food, children cannot grow well. If children don’t grow well, the economy doesn’t grow well and society suffers.
Yet one in five households in South Africa say their access to food is insufficient. This is in a country that produces more than enough food for everyone and where the right to sufficient food is enshrined in section 27(1)(b) of the Constitution. It goes further in section 28(1)(c) to guarantee children the right to basic nutrition – guaranteed, not subject to progressive realisation.
It is ironic that many countries of similar socio-economic status that don’t have the same explicit constitutional obligations take the right to food more seriously than we do.
In 2008, Peru had a stunting rate among children under five of 28%. Eight years later, it was down to 13%. Yet the closest Peru’s Constitution comes to securing the right to food is the right to physical integrity, development and well-being.
Similarly, Malaysians can lay no claim on the state for food security, yet their country has used a combination of price caps and food subsidies to protect the population from food inflation. Some economists maintain that this is one of the main reasons that Malaysia’s overall inflation rate is the lowest among Asean countries.
Compared with South Africa’s torpor, the apparent difference in Peru and Malaysia is their strong political will, forged through the sustained efforts of an activist coalition of national and local organisations, and the participation of the food industry in ensuring availability of nutritious foods.
Here, expressions of political concern have yet to translate into concrete action, while industry simply chooses not to engage except to point to their contribution to food gardens and distribution of meals. These gestures have value, but the fundamental issue of food affordability is not being addressed.
In 2023, and in an effort to improve access to basic nutritious foods, the DG Murray Trust (DGMT) and Grow Great zero-stunting campaign proposed a double-discounted list of 10 “best buy foods”.
Food retailers and manufacturers were asked to waive their profit on just one food label of 10 highly nutritious staple foods, with the government providing a matching subsidy.
In this way, these foods could be double-discounted to the consumer.
The practicalities of this proposal still need to be fully interrogated and we remain open to alternative proposals that could achieve the same aim in a simpler manner.
The Competition Commission has given its conditional approval for industry engagement on this matter. Yet the corporate sector simply refuses to engage.
This year, 2024, is likely to be tumultuous, with social unrest aggravated by electoral politicking. Growing food insecurity is likely to further exacerbate this situation. International evidence is that food riots are not due to high prices per se, but to the public’s conclusion that governments are not doing anything to help them directly.
The alarm bells from grassroots activists and clinicians are growing louder – in each successive month, food purchases are lasting for a shorter and shorter time and there are more and more reports of severe acute malnutrition.
History has harshly judged Mbeki and the political leadership that accompanied his Aids denialism.
History will similarly judge today’s political and business leadership if they don’t make the right to food a reality in South Africa.
We also challenge more academics – especially clinicians, economists and political scientists – to join community-based activists as vocal and persistent advocates for food as the basis for health, prosperity and social stability.
Mvuyo Tom and David Harrison are, respectively, the chairperson and CEO of the DG Murray Trust.
See more from MedicalBrief archives:
SA’s malnutrition crisis: 15 000 hospitalised in 2022/23
Free State infant malnutrition and deaths from starvation on the rise
Surging malnutrition data under-reported, say experts
SAHRC gives government deadline to address Eastern Cape malnutrition crisis
DoH tells Parliament: Thousands of SA’s children have died of malnutrition