Fezile runs into the small, open yard of her home where carrots, potatoes and green beans grow in fertile soil in a corner. She is hungry and tired after a 2km walk home from school. For breakfast she ate a big plate of maize meal, with sugar and milk. Twice a week she gets a boiled egg as well. At school today they were given a thick, hearty vegetable soup with brown bread and butter. Her mother prepares a bean and cabbage stew in a big pot on the fire. She looks up and smiles at her daughter. An infant is tied to her back and cries for milk. She offers it quality formula feed from a sterilised bottle, both provided by the baby clinic nearby.
The above imaginary scenario would be preferable to the reality. Sadly though, undernutrition is rife for the majority of South Africans. It is unlikely such a family has all these food items, or a way to obtain them. For instance, it seems obvious that households should be able to grow vegetables for their own consumption. However, many, such as those in the Western Cape informal settlements of South Africa, are often unable to grow food because of a lack of soil or the space in which to do so. Feeding bottles may not necessarily be sterilised and the formula may be overdiluted with contaminated water.
It is a miracle that Fezile, who represents the standard young schoolchild, has reached a school-going age and the chances are that her baby brother won’t. Insubstantial meals are likely to dull the mind of a child like Fezile to perform at school. Evidence abounds worldwide on this very subject. A poor diet leads to suboptimal work performance, in this case, at school.
While food is acknowledged as a basic human need, it is nutritious food that is the key to good health and wellbeing throughout life. The World Food Summit of 1996 defined food and nutrition security as:
“When all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active life.” This definition has been taken further to always include physical and economic access to sufficient, safe and nutritious food to meet dietary needs and food preferences for an active and healthy life.
Few South Africans have food and nutrition security.
It is likely then that few South Africans have food and nutrition security. A great many people in South Africa rely on a monotonous diet where maize meal is the only affordable staple. Maize meal may be eaten to a point of satiety, yet, even when fortified, it will not meet daily dietary requirements. Perhaps a prime point to be made is that food availability in a country does not ensure access by all for various reasons, including a lack of purchasing power and entitlement to agricultural land. Food preferences, too, may not necessarily favour good nutrition. This last point is contentious, simply because individuals may not necessarily buy healthy foods as a first choice.
So we know a little about the necessity of good nutrition in general. However, eating healthy food is specifically essential for a young mother-to-be. Specifically, the so-called critical window period of establishing the quality of a child’s health for life occurs during the first 1,000 days of life, i.e. from conception through to the child’s second birthday. This is the time when optimal nutrition is of utmost importance.
UNICEF sums this up in a nutshell: “It means that mothers are empowered to initiate breastfeeding within one hour of birth, breastfeed exclusively for the first six months and continue to breastfeed for two years or more, together with nutritionally adequate, safe, age-appropriate, response complementary feeding starting at six months. Maternal nutrition is also important for ensuring the good nutrition status of the infant as well as safeguarding women’s health.”
Obviously, exclusive breastfeeding for the first six months would be ideal, but there will undoubtedly be exceptions such as the mother being ill or her not producing milk and so on. After that first six months, evidence shows that breast milk alone is inadequate in terms of meeting the nutritional needs of an infant. This is where complementary feeding plays a role in the form of other foods and liquids to be given alongside breast milk.
The popular Lancet Series (2013), a source of literature on the subject of maternal and child health, describes the consequences of undernutrition, which are dire: stunting (low height for age), anaemia, proneness to infectious diseases because of a compromised immune system, impaired cognitive development to name just a few. Beyond two years of age, much of the damage is irreversible.
In 2011, the Tshwane Declaration for the Support of Breastfeeding in South Africa was realised. Was this an answer to many a prayer? According to the Declaration, the SA government declared itself a country that supports exclusive breastfeeding and complementary feeding and pledged to take action to implement devised strategies such as food-based dietary guidelines. It pledged to scale up the supply of antiretroviral drugs to prevent HIV through breastfeeding and to improve the health of HIV-infected mothers. Formula feeding was strongly discouraged in a country where it has led to an increase in the number of deaths of children from malnutrition and various immune disorders. Understandably, this Declaration seemed like a beacon of hope.
Perhaps “seemed” is a tad harsh a judgement? In May this year, UNICEF SA reported in Independent Online that every year approximately 75,000 children do not reach their fifth birthday, and 75% of newborn babies die in their first week of life in South Africa today. This infers South Africa is far behind in meeting the Millennium Development Goals first pledged in 2000, its fourth goal being to reduce under-five child mortality by two-thirds worldwide.
Efforts to educate young mothers and girls about optimal breastfeeding, including suitable breastfeeding for those with HIV and the necessity of good sanitation and hygiene, abound.
These statistics come as a shock to those working tirelessly to change the status quo. Efforts to educate young mothers and girls about optimal breastfeeding, including suitable breastfeeding for those with HIV and the necessity of good sanitation and hygiene, abound. Consider the number of maternal health and baby clinics springing up nationwide and greater support for mothers being provided in the workplace. Yet with all the right strategies in place, why is it taking so long to see positive change? Perhaps therein lies the answer? Perhaps suitable strategies are not in place at all.
Referring to the stipulations of the Tshwane Declaration, Du Plessis says: “There is a need for adequate monitoring and evaluation processes at all levels of implementation, using the [above] strategies to drastically improve exclusive and continued breastfeeding, and to advance the health and survival of children in South Africa.” It would seem the trouble lies in inadequate planning and implementation at the various levels, including district and municipal levels.
Du Plessis identifies the need for suitable training of all healthcare workers. As it stands, poorly trained health staff means poorly implemented strategies. Du Plessis draws on evidence from Brazil that indicates that progress lies in effective communication between those imparting information and providing support to young mothers. There are clear signs this is happening, at least on a small scale. Fairly recent studies, as in the last five years, reveal that South African staff at a particular clinic in the province of KwaZulu Natal managed successfully to get local mothers with HIV to use suitable breastfeeding practices to prevent transmitting the virus to their infants.
The future need not be bleak. What is evident is that suitable policies alone do not count for much unless they are suitably implemented. But this is easier said than done. The challenges faced by healthcare workers countrywide are likely to be overwhelming. Many are poorly trained, and poor comprehension and communication greatly impede matters. Little education in general, current food practices and a lack of female power in the household in making decisions around food may be also responsible. Of course, a lack of disposable income, poor access to suitable foods to meet mothers’ nutritional needs and to provide for complementary breastfeeding are at the heart of the matter. Only then can food-based dietary guidelines be of benefit.
More than anything, the answer lies in ensuring food security. Certainly, progress already exists with non-governmental initiatives such as SOIL FOR LIFE, an organisation committed to teaching individuals techniques to grow their own vegetables regardless of how small or dry the environment. Those trained are then proudly equipped to provide their own families with healthy food. Until a great many more people are entitled to land and to cultivate it, changes in food security, hence better nutrition, will be slow in happening. Let us hope and believe that more families will be able to support themselves significantly better, just like Fezile’s.