Skip to content

Posts tagged ‘kwashiorkor’

Starved Out

Two years ago today, police opened fire on a group of striking mineworkers encamped on a koppie outside of Marikana. Mainly rock drill operators doing some of the most basic and difficult work on the mine, these men demanded that Lonmin – in whose platinum mine they worked – raise their salary to match that of literate, better skilled miners, to about R12,500 per month.

After weeks of sporadic violence on both sides – during which policemen, shop stewards, and workers were injured and killed – mine bosses urged the police to end the standoff. Jack Shenker writes:

It was the police who escalated the standoff at Marikana mountain, bringing in large numbers of reinforcements and live ammunition. Four mortuary vans were summoned before a single shot had been fired. Lonmin was liaising closely with state police, lending them the company’s own private security staff and helicopters, and ferrying in police units on corporate buses. Razor wire was rolled out by police around the outcrop to cut the miners off from Nkaneng settlement; pleas by strike leaders for a gap to be left open so that workers could depart peacefully to their homes were ignored.

Police opened fire as workers approached them. In the end, thirty-four were killed, seventeen of them at a nearby koppie where it appears that they were shot at close range. The Marikana massacre has been described as post-apartheid South Africa’s Sharpeville. As the inquiry into the events near the mine has revealed, police arrived not to keep order, but, rather, to end the strike through any means possible.

Miners-Shot-Down-March-finalweb-450x640

The poster for Rehad Desai’s documentary on the Marikana massacre, Miners Shot Down.

The killings were followed by a strike – the longest in South African history – until May. Of all the details to emerge in the coverage of life in the platinum belt, the one that seemed to encapsulate the desperation of striking miners and their families was in a 2006 report commissioned by Lonmin: researchers had discovered children suffering from kwashiorkor near the mine.

Although already identified in 1908, kwashiorkor was named by Dr Cicely Williams, a Colonial Medical Officer, in the Gold Cost during the 1930s. Tom Scott-Smith explains:

she noticed a recurring set of symptoms amongst children who were aged between one and four: oedema in the hands and feet, darkening and thickening of the skin followed by peeling, and a reddish tinge to the hair in the worst cases. There was a clear pattern in the incidence of this disease, since it occurred in children who had been weaned onto low-protein, starchy foods such as maize, after being displaced from the breast by a younger sibling. Williams’ description first appeared in print in 1933, and two years later she identified the condition by its name in the local language: kwashiorkor, the ‘disease of the deposed child’.

Williams diagnosed kwashiorkor as a from of inadequate nutrition – similar to pellagra, which is caused by a diet insufficient in vitamin B3 – related specifically to an intake of too little protein. Williams had noticed that newly weaned babies and young children – the ‘deposed’ children referred to by the word kwashiorkor – were particularly vulnerable to the condition, and surmised that longer breastfeeding or a diet rich in the nutrients non-breastfed children lacked – protein especially – would eradicate kwashiorkor.

By the 1970s, though, doctors argued that this emphasis on protein supplements – which had driven United Nations and other organisations’ efforts to address kwashiorkor – was incorrect. Kwashiorkor, they argued, was the product of under nutrition: of not consuming enough energy. Scott-Smith writes:

Evidence from the 1960s demonstrated that a less protein-rich, more balanced diet could cure kwashiorkor equally well, and by the 1970s a number of other causes for the disease were suggested – even today, the details of kwashiorkor are still not fully understood.

Had scientists paid closer attention to the name ‘kwashiorkor’ they may have come to this realisation sooner. It is a disease of poverty where adults are unable to provide weaned children with adequate nutrition. As a result, its solution is distressingly simple: better and more food.

If there is any indicator of the extent of poverty in the platinum belt, then it is the fact that children suffer from kwashiorkor. While Lonmin has ploughed some of its profits back into communities surrounding the mines – opening schools and running feeding schemes, for example – it remains the case that mineworkers and their families are still desperately poor.

Keith Breckenridge argues that the wealth generated by workers operating in exceptionally dangerous conditions is channelled largely to a small group of beneficiaries. He adds:

Under the current arrangements in the platinum belt there is almost no movement of resources from mining to the wider problem of maintaining the physical and emotional well-being of the general population working in the mines. Mine managers have retreated from maintaining order and health in the hostels, and they have ceded control over the key human resource questions – employment and housing – to union officials and their allies. Like foreign shareholders and local royalty owners, these union leaders, using their monopoly over jobs and housing, have tapped into the demand for employment to enrich themselves (often at the expense of the working and living conditions of union members). Local government – caught between the mines and the prerogatives of tribal authorities – has all but abandoned the project of regulating the living spaces around the mines.

Where once miners were coralled into the prison-like conditions of single-sex hostels where their food, accommodation, and other expenses were covered by mining companies, now meagre housing allowances are meant to support these workers and their families in the otherwise badly provisioned and serviced towns and villages in the platinum belt. Salaries tend to go straight to pay interest on loans granted by micro lenders, charging exorbitant interest rates.

As the incidences of kwashiorkor reported to Lonmin suggest, these men were not earning enough to feed themselves and their children. While under cross examination at the Farlam Commission of Inquiry into the Marikana massacre, Cyril Ramaphosa – current Deputy President and Lonmin board member who had emailed the then-Police Minister, demanding an end to the workers’ strike – remarked:

The responsibility has to be collective. As a nation, we should dip our heads and accept that we failed the people of Marikana, particularly the families, the workers, and those that died.

I dispute the ‘we,’ Mr Deputy President.

Further Reading

Keith Breckenridge, ‘Marikana and the Limits of Biopolitics: Themes in the Recent Scholarship of South African Mining,’ Africa, vol. 84 (2014), pp. 151-161.

Keith Breckenridge, ‘Revenge of the Commons: The Crisis in the South African Mining Industry,’ History Workshop Journal Blog, 5 November 2012.

Creative Commons License
Tangerine and Cinnamon by Sarah Duff is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.

The President’s Vegetable Garden

There are very few countries, I think, where a satirical news site is frequently mistaken for being entirely serious. Hayibo – the South African equivalent of the Daily Mash or the Onion – must, occasionally, point out to its readers that its stories are made up, rather than real.

Readers can be forgiven for wondering if a report about striking Marikana mineworkers being charged for the Helderberg plane crash is true, when the ANC announces an official policy on the serving of cake at party celebrations. Or if Cosatu officials really did believe they could move into Cape Town stadium, after the ANC Women’s League decided to march against a rude painting of Jacob Zuma, rather than protest the circumstances which allowed for the serial abuse and gang rape of a seventeen year-old mentally incapacitated girl.

A Hayibo post from this week suggests that the ANC’s national conference to be held in December in Manguang, will be replaced by an episode of Come Dine with Me. Instead of conference delegates voting to choose the new leader of the party – and, thus, by default, the next president of South Africa – four contestants will compete in a series of dinner parties:

The cookery show…will feature President Jacob Zuma take on rival Kgalema Motlanthe, former ANC Youth League leader Julius Malema and Proteas batsman Hashim Amla.

When asked why Amla, a cricketer, was suddenly a contender for the top leadership position in the ANC, BBC producer Cokey McLush shrugged and said ‘Everyone loves that geezer, yeah?’

The four will each host a dinner party on successive nights, and after each dinner will rate the host on his evening. ‘The winner walks away with Pick ‘n Pay vouchers worth R5000, as well as obviously the complete control of South Africa’s political space, so there’s a lot to play for,’ explained McLush.

It would all be much more amusing were it not so very, very serious. I was thinking about food and South African politics this week, after the Mail and Guardian produced a handy interactive guide to the development of Nkandla, the village in which Zuma’s private residence is based.

The Nkandla scandal has rocked South African politics and civil society over the past few weeks, as the City Press revealed that the Department of Public Works has committed to spending R203 million – about US$23 million or £14 million – of public money, not only in developing this village in rural KwaZulu-Natal, but in building Zuma’s increasingly elaborate home.

South African Wonder Woman-incarnate Thuli Madonsela, the Public Protector, has announced an investigation into the development. Despite her interest and increasing public outrage, the government remains unrepentant: it has declared Nklandla a ‘national key point’, meaning that it comes under security legislation and can’t be reported on; the Minister for Public Works, Thulas Nxesi, declared at a press conference that ‘questioning the need for spending hundreds of millions of rands in Nkandla showed insensitivity to the cultural diversity of South Africa’; and the state has launched an investigation into how the City Press got hold of the documents which revealed the scale of the spending at Nklandla.

Not for nothing has Nkandla been nicknamed ‘Zumaville’. The M&G’s guide reveals how the village will be transformed with new roads, housing, and a shopping centre. Zuma’s own residence will have two helicopter landing pads, a football pitch, tennis court, and underground bunkers. (Remembering, of course, that he has two official houses, one in Pretoria and the other in Cape Town.) I was intrigued by the fact that a vegetable garden has also been included in the development.

The M&G explains:

The vegetable garden is outside the main security zone, but still inside the outer fence, making it accessible for the people who tend it without a need for them to use the front entrance of the compound. The public works department says food security was identified as a potential security threat for President Jacob Zuma and visiting dignitaries, which means the establishment of the garden may have been state-funded.

I am all for heads of state planting vegetable gardens: I think it’s an excellent idea, particularly as a means of encouraging people to grow their own food. I wish more presidents and prime ministers would plant vegetables to show their commitment to feeding their families healthily and relatively cheaply. But I have a couple of reservations about this garden.

Firstly, the Department of Public Works justifies funding the garden on the grounds that food insecurity could pose a threat to Zuma and his guests. What do we mean by ‘food security’? As a paper published in the Bulletin of the World Health Organisation, and cited by the M&G, explains:

Food security as an umbrella term includes: (i) the availability of food that is nutritious and safe; (ii) an assured ability to procure and acquire food of good quality in a socially acceptable way (e.g. without resorting to emergency food supplies, scavenging, stealing or similar coping strategies). In contrast, food insecurity exists when food is not easily accessible and households have difficulty securing adequate food.

The authors of the paper argue that although food insecurity declined in South Africa between 1995 and 2008 – due partly to the social grants system and the work of the National School Nutrition Programme – one third of South African children do not eat an adequately varied diet, and 18% of them are malnourished:

Our findings show that the nutrient density of the diet consumed by South African children is insufficient to meet their nutrient requirements. Similarly, they have shown alarmingly low food variety and household dietary diversity scores, both of which have been positively related to children’s nutritional status. … Hence, stunting still affects a large proportion of children.

One of the main reasons for food insecurity in South Africa is poverty and, partly as a result of this, the country’s population is at risk of becoming even more insecure. A 2009 report on food security published by the Human Sciences Research Council notes:

Rising food prices, particularly of maize and wheat which are the staple diet of the poor in South Africa, pose serious problems for the urban and rural poor as most are net buyers of food. Recent information from the Food and Agriculture Organisation…suggest that food prices will increase steadily over the next decade even if there are some fluctuations and the occasional drop in prices. Given increasingly strong linkages between the local level and national and international commodity chains and economic networks, even remote rural households in South Africa are affected by changes in these networks. Unless there are new policy directions, poor households will increasingly be forced to allocate a greater proportion of their expenditure to food, with the result that diets will become less diverse, lower in quality, and energy intake (calories consumed) will drop as people try to cope with the situation. Most severely affected will be the chronically urban and rural poor, the landless and female headed households.

Although the government deserves praise for reducing levels of hunger in South Africa, far too many people, particularly children, don’t have adequate access to food. Indeed, it would appear that with rising food prices internationally, there is a risk that the country may become more food insecure.

To justify the public funding of a vegetable garden for the president’s private residence on the grounds of ‘food security’ is deeply offensive to the numbers of South Africans who can’t afford to feed themselves and their families properly. If the president and the Department of Public Works were genuinely interested in reducing food insecurity in the region, it would make far better sense for them to plant a larger, communal garden for all of Nkandla’s residents.

My second problem with Zuma’s vegetable garden is the very dubious way in which it’s been funded. There is a link between poor governance and food insecurity. One of the best recent examples of how corruption impedes food distribution occurred in Uttar Pradesh. Throughout India, only 41 per cent of the food intended for the very poor by the Food Corporation of India – the government agency established in 1965 to ensure India’s food supply – reaches households. This is due partly to wastage, but also to corruption.

In Uttar Pradesh, though, nearly all food aid was stolen by corrupt officials over the course of three years, as Bloomberg reports:

The scam itself was simple. So much so, that by 2007 corrupt politicians and officials in at least 30 of Uttar Pradesh’s 71 districts had learned to copy it…. All they had to do was pay the government the subsidized rates for the food. Then instead of selling it on to villagers at the lower prices, they sold to traders at market rates.

The irony is that India’s food reserves are full – and there’s more than enough food to go around:

While the Food Corporation of India is required to keep about 32 million metric tons of rice and wheat, bumper harvests have left the country with a stockpile of more than 80 million tonnes, according to the corporation. Stacked in 50-kilogram sacks, the food would reach from Sitapur to the moon, with at least 270,000 bags to spare.

To stop food rotting, the central government lifted a four- year ban on exports of wheat last year. In June, India donated 250,000 tons of wheat to Afghanistan.

But with corrupt officials, there’s no way of guaranteeing that this food will reach the poor. When distribution systems fail, people go hungry – and more than half of India’s children, and 21 per cent of adults, suffer from malnutrition.

This is, admittedly, an extreme example of the implications of corruption for food security, but it demonstrates particularly well how poor governance can impact the lives of the very poor. Given the rising levels of corruption in South Africa, it’s not too much of a stretch to conclude that the government’s good work on reducing hunger has the potential to be reversed if systems are corrupted through bribery, theft, and mismanagement.

It’s an obvious point, but the R203 million set aside for Zumaville could have been used to build roads, railways, food silos, and other infrastructure to improve the distribution of food to rural areas.

Six years ago, Lonmin commissioned a report into the health of the communities in seven villages – including Marikana – around its platinum mines. One of the main findings was that malnutrition was a major problem, and that children had been discovered suffering from kwashiorkor:

an easily prevented condition that occurs when there is insufficient protein in the diet. Kwashiorkor is more common in countries in a state of political unrest, or where there has been a drought or natural disaster.

Why the president feels that he and his guests deserve a state-funded vegetable garden when South African children are suffering from a condition associated with failed states, is utterly beyond me.

Further Reading

Miriam Altman, Tim Hart, and Peter Jacobs, Food Security in South Africa (Human Sciences Research Council, 2009).

Creative Commons License
Tangerine and Cinnamon by Sarah Duff is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.

No Sweeteners

One of the best things about being an academic is the stuff that people send you in the – usually entirely correct – belief that you’ll find it interesting. I’ve had emails about pink slime (for the blog) and on programmes about children’s literature (for my research). Recently, my friend Elizabeth, who’s a lawyer, forwarded me this from Legalbrief:

New draft baby feeding regulations will forbid formula manufacturers from ‘aggressively marketing’ their products to mothers and from sponsoring meals and professional development courses for healthcare practitioners, says a Weekend Argus report. It adds the standards set in the draft regulations, which the Department of Health has released for public comment, intend to promote safe nutrition for babies and young children and restrict inappropriate marketing practices. The department stressed that the regulations would not stop baby formula and complementary foods from being sold at retailers. ‘Although breastfeeding is best, government recognises that some women cannot breast-feed or decide not to breast-feed. These regulations do not in any way compel women to breast-feed against their will,’ the department is reported to have stated.

The proposed regulations, which fall under Section 15 (1) of the Foodstuffs, Cosmetics and Disinfectants Act, 1972, make for fascinating reading. Other than banning trans fats and artificial sweeteners in baby formula, their emphasis is on curtailing the advertising and promotion of artificial foods.

For instance, the packaging of baby formula may not have pictures of infants, young children, or any other ‘humanised figures,’ except for those included in instructions for preparing the product. Tins and containers may not ‘contain any information or make any negative claim relating to the nutritional content or other properties of human milk’, and they’re not allowed to include toys or gifts. Packaging must include in English, in bold letters at least 3mm tall, the message: ‘Breast milk is the best food for babies.’

The regulations will also radically limit the advertising of baby formula shops, in print and online, ban the distribution of gift packs and free samples, and prevent formula manufacturers from sponsoring or donating equipment bearing the logo of their products. These manufacturers may not

provide research grants or any other financial assistance relating to infant or young child nutrition to health care personnel working in a health establishment or health care personnel linked to a health establishment.

Nor may they give doctors, nurses, and health workers gifts, and ‘heads of health establishments, national, provincial and local health authorities shall take measures to promote, support and protect breastfeeding.’

It’s an ambitious piece of legislation, but one which is entirely in line with the World Health Organisation’s International Code on the Marketing of Breast Milk Substitutes. The Code was adapted in 1981, and places stringent regulations on how baby formula is advertised: it advises that baby milk formula should not be allowed to market products directly to pregnant women and mothers with young children, including handing out samples. Products should also state that breast milk is superior to formula.

Implementation of the Code has been slow, and there is evidence to suggest that it has been particularly poorly policed in developing nations where oversight of the activities of powerful multinationals is often lax. The South African regulations are far stricter than the Code, particularly as regards the relationship between the pharmaceuticals industry and academic research, but address a problem which campaigners have long identified: that there is a link between the way in which formula is advertised and how women feed their babies.

This isn’t to suggest that women should have their choices about how they feed their babies curtailed – or that it’s only advertising which causes women to choose to use baby formula. Far from it. The problem, though, is that, particularly in poor nations, advertising or other promotional methods encourage breastfeeding mothers to switch to baby formula when it’s unlikely that they’ll be able to afford to buy more formula, and where they may dilute formula with too much water to make it go further. This water may not be clean, and it’s difficult to keep bottles and teats sterile without electricity or plumbing.

The purpose of these regulations is to ensure that formula manufacturers don’t use the often less than ideal conditions in which mothers in developing nations raise their babies, to their own advantage.

We tend to associate the WHO’s Code with the Nestle Boycott, which was launched in 1977. The Boycott was based on a pamphlet published by War on Want in 1974, titled ‘The Baby Killer’ and, in Switzerland, ‘Nestle Kills Babies’. The charity alleged that Nestle’s advertising strategies were responsible for high rates of child mortality. After a legal tussle as well as an attempt to refute the Boycott’s allegations, Nestle agreed to implement the Code in 1984, although there remains some scepticism as to Nestle’s, and other companies’, commitment to this.

But concern about the advertising of baby formula predated the 1970s, and even the 1940s, when breastfeeding began to decline globally. As I’ve sat in the National Library over the past few months, reading Child Welfare and other child health magazines from the first half of the twentieth century, I’ve been struck by the number of advertisements for baby formula. They all feature fat, healthy babies and testimonials from relieved mothers who claim that the child was fed from birth on Lactogen or whichever other patent food.

Even Truby King, early twentieth-century breastfeeding evangelical and founder of the global mothercraft movement, developed artificial baby food which was produced in New Zealand and then shipped all over the world. Kariol, Karilac, and Karil were meant to be prescribed for babies who were not, for whatever reason, breastfed either as a supplement to cows’ milk, or to be taken on their own.

Although King’s patent foods seemed to contradict his enthusiasm for breastfeeding – and he came under enormous criticism in New Zealand and Australia for his promotion of Kariol and Karilac – there was a certain logic to his decision to manufacture wholesome baby formula. During the early decades of the twentieth century, doctors in Britain and the United States noticed that bottle-fed babies were considerably more likely to die during early infancy than those who were breastfed. Artificial foods – which ranged from thin porridges and condensed milk to baby formulas – were often nutritionally inadequate, particularly in poor families who could not afford better and more expensive substitutes.

But they also identified a link between bottle feeding and diarrhoea, then, as now, one of the main causes of death in infancy. William J. Howarth, the Medical Officer of Health for Derby

arranged in 1900 to receive weekly lists of the births registered during the past seven days from the local registrar. From November of that year until November 1093 women inspectors enquired into the feeding method of each registered child by personally visiting the mother and infant at home.

The results of the study, published in 1905, were telling. Of the infants surveyed, 63% were breastfeed, 17% were partly bottle-fed, and 19% entirely bottle-fed:

The mortality rates from ‘diarrhoea and epidemic enteritis’ in addition to those from ‘gastritis and gastro-enteritis’ were as expected: 52, or 10 per 1,000 of the breastfed, 36 or 25.1 per 1,000 of the mixed-fed, and 94 or 57.9 per 1,000 of the bottle-fed babies died. In other words the mortality rate of the bottle-fed infants was nearly six times greater than that of the breast-fed babies.

Howarth concluded: ‘In not one single instance does the death-rate in any class of disease among hand-fed children even approximate that recorded among children who are breastfed; the rate is invariably higher.’

The problem, in terms of the link between bottle feeding and diarrhoea, was not so much the nutritional content of artificial foods, but the difficulties in keeping them free from contamination, and particularly during summer when infant mortality rates soared.

Indeed, South African advertisements for Lactogen emphasised that the product did not spoil in warm weather. As criticism of artificial foods grew louder, so advertising became more subtle, and better adept at appealing to mothers aware of the potential problems of bottle feeding. Doctors were, though, also aware of the effects of advertising on mothers’ choices, as a medical officer based in Johannesburg wrote in 1925:

No one can deny the fact that the proprietary foods of today are a vast improvement upon those of twenty years ago. They all contain very sound instructions as to the preparation of the food and the amount to be given. The advertising of such foods is carried out on a most extensive scale and in a clever and attractive manner. No hoarding today is without a picture of a flabby and over-fat infant alleged to have been reared solely on the proprietary food advertised thereon. Many a mother who for one reason or another, is not satisfied with the progress of her baby, sees this advertisement, and immediately rushes off to secure this particular food for non-thriving infant.

But not only mothers were influenced by this advertising. He admitted that it was ‘only too true that many medical men and trained nurses are also gulled by such advertisements and circulars’. Dr Cicely Williams, best known for her identification of the condition kwashiorkor in the 1930s, worked in the Colonial Medical Service in West Africa and southeast Asia before World War II and became particularly interested in the treatment of the diseases of early infancy.

She was critical of the introduction of baby formula to Singapore and Malaya, where white-coated sales reps distributed samples of artificial foods to poor mothers. In 1939 she published a pamphlet, ‘Milk and Murder,’ in which she pointed out the benefits to both mothers and babies of breastfeeding.

Nevertheless, Nestle and other companies were still using the same strategies to convince mothers in developing nations to use baby formula in the 1970s, and there are still concerns that they are not fully compliant with the Code on breast milk substitutes. The new South African regulations, if passed, are aimed at remedying this.

The cause for these new regulations and other measures introduced internationally to encourage mothers to breastfeed for the first six months of life, is a concern that rates of breastfeeding remain low in comparison to what they were during the early twentieth century. For all the good that the Code and other laws have done, it remains the exception, rather than the rule, for women to breastfeed for such an extended period of time.

However true it may be that advertising does have an impact on women’s choices, it’s certainly not the only factor which influences how women feed their babies. What’s missing from these measures is any attempt to communicate with mothers themselves. As doctors in the early twentieth century believed that mothers, whom they characterised as emotional and irrational, simply followed any and all advice which they read or heard, so campaigners and governments today seem to be too quick to seek only one reason for women’s decision to breast- or bottle-feed.

In fact, we need to make it easier for women to choose to breastfeed: to eliminate the ridiculous prejudice against breastfeeding in public spaces; for work and childcare not to be mutually exclusive; and for sympathetic advice and information to be made available for all new mothers.

Further Reading

Texts cited here:

Linda Bryder, A Voice for Mothers: The Plunket Society and Infant Welfare, 1907-2000 (Auckland: University of Auckland Press, 2003).

Deborah Dwork, War is Good for Babies and Other Young Children: A History of the Infant and Child Welfare Movement in England, 1898-1918 (London and New York: Tavistock Publications, 1987).

Philippa Mein Smith, Mothers and King Baby: Infant Survival and Welfare in an Imperial World: Australia, 1880-1950 (Basingstoke: Macmillan, 1997).

Other sources:

Rima D. Apple, Mothers and Medicine: A Social History of Infant Feeding (Madison: University of Wisconsin Press, 1987).

Linda M. Blum, At the Brast: Ideologies of Breastfeeding and Motherhood in the Contemporary United States (Boston: Beacon Press, 1999).

Marulyn Yalom, A History of the Breast (New York: Ballantine Books, 1997).
Creative Commons License
Tangerine and Cinnamon by Sarah Duff is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License.