SECOND CARNEGIE INQUIRY INTO POVERTY

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CapeTown

SECOND CARNEGIE INQUIRY INTO POVERTY AND DEVELOPMENT IN SOUTHERN AFRICA

Dietary silWlenentation

as

preventative

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health treatnent

in needy populations by

M A KibeI, A 0 M:xldie and I Ibbertson

Canlegie O::mference Paper lb. 220

13 - 19 April 1984

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ISBN 0 7992 0843 4

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DIET4RY SUPPLEMENT4TION AS PREVENTIVE HEALTH TREATMENT IN NEEDY POPULATIONS

1 am presenting for discussion an overview of nutrition policy as it applies in the Cape Town area from which all examples are drawn. I hope that this will have some general relevance.

There are two opposing attitudes towards responsibili ty for the health and welfare of children. The one decrees that i t is the State which must ensure that optimal development of its future citizens is possible; the ,other that parents themselves are respo~sible for the children they produce. It is well to accept that the latter is the policy adopted by the State in South 4frica. Thus any intervention ,in the field of nutrition, necessitated, by special circumstances, is viewed, as an erosion of that philosophy and m'ust be hedged

~ith restraints. The failure of the fortified bread scheme and the abuse of the School Feeding Scheme are considered to justify such caution. So-called

"hand-outs" are not acceptable but preventive measures milY be justifiable.

Cert~in_ statutory provision:;; for, pr:eventing ~alnutri tion do ¢'xist tn the form of both direct and indirect intervention.

Direct Intervention

i. ,The issue of, skimmed dried milk.

The Department ,~f ~eal th'cand Welfare is not legally empowered to undertake any feeding schemes as such, but it does supply free skimmed dried milk as a form of preve,ntive treatment to infants and, pre-,school children who attend clinics and are considered to be at, risk of severe !lutri tional

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breakdown.

ii. Hospital care

This j5 widel'y availabl.e to victims of sev<ere malnutritic.c, and nutrition-r'elated conditions as outpatients and in-pa~ients ane ... in "' resLlscitation war'os. The latter have been a life-saving innovation and treatment is followed by special care.

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Indir'ect InterventJon

Various indi reet measures hA.ve come :ntCl exist:.~cce ~~hr~')ugh 3Vlareness of . he multifactorial c'llsation of child eJalnutt'ition which is well-established, viz.

Depressed economic circumstances:

due to low earning power and a variety of other f~ctors.

A serious housing shortage:

causing overcrowding, poor hygiene, ,"aternal exhaustion and recurrent and mul tiple infect ions in children, ;Ihieh interac t wi th malnutri ti on and aggravate i t .

Widespread l~noranc~:

whi.ch implies beth 3 low ~Jar~ental standard of sc~col (1tt0inment and a deficient k!10wlRdge of ctlild care, breast feeding, family-planning, hygiene, food values, bud~eting, faulty cultural practices, etc.

General social disorganisation:

including breakdown of family life, non-support, over-large famil ies, illegitiMacy, ..,coholism, delinquency an(1, .in Many populati:Jn grJups, the effects of a migrant labour system - which are dealt with in other reports.

Thus, ind i rec t measures to comb;] t the above, aim at 1 on,;- term preven ti on of malnutrition and take such forms as:

1. wide network of Chilli 1·,1elfaf'{~ Centres, (or r.'lobile slaffed by Community Health Nurses, to supply aoviee, immunizalion, full-Ct'eam milk at cost price 3nd sllbsi.jised ski'Tv''l'je(~ ,jr.ied fI'Iil.k, :::part fr~om th?t ' ... :·d-::h IS supplied fl'ee to severe c;]ses. The introduction of Ihe Growth Canl, a Ilome-based medical and growth record of the infant's progress from birth, has grAat potential as a preventive ~easure.

ii. ~ Care Centres, run by local au thcwi ties (and volun tar·y organisatLms I which provide, where available, good car·? for the pre-school children of working mothers.

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iii. Health education

Trained health educators are employed by the Department of Health & Welfare and certain local authorities (and voluntary organisations) to give instruction in dietetics, budgeting, family planning, etc. Limitation of family size is recognised as having an important bearing on child nutrition.

iv. Housing

Although the housing problem has been compounded by group removals, considerable sums are devoted to providing homes at sub-economic rates, to meet the natural increase of populations.

v. Trained Staff

The sal~ries of trained welfare workers in many organisations are subsidised by the State, and certain of these organisations are extremely active in social and prev~ntive care.

vi. Maintenance Grants

These are paid tc unsupported mothers of pre-school and SChool-attending child,'en where tl1",re is mar", than one child and lep;~l compulsion of the f::>ther is impossible. This is a very valuable protective measure as the mother .1s not com~elled to leave yOlJng children and fjo ~o Hark.

vi i. Education

The wideninf, availability of education facili Lies should ensure improved enr'ning ani1 i:..y 3.m0nt; SCh001 leavers and more adequate peporat.ion for furt!"ler education and training wher'e desir'ed. Thus good school educa:ion is a lcng-ter'm prev'?ntlve mensure of the utmost importance.

V J ij . Rese~;ch

The .5taT:e promc":es important and high-lpvel rese~rch In nutrition and p3ec: 2.t r'ics.

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The aim of this report is to bring fcrward for' d15Cusssion certain needs WhiCh have not been met in f,he cou!"se of the ad hoc '-~evp.l.:'!'r.~nl. ou:.lined above ::If:d ^I.:)

~~ke sllgp:,est.ions for amendment within ~he '2xjsling :~r'a~ewcrk:

~'llure to delineate the problem

The basic problem of child nutri t:.on in i.he lowes~: socio-ecJr~0fTlic gt'OUpS In

South Africa is one of r,rOl-lth failure.'

j ncidence of the more dramat j c f:Jrms of breakdC'wn, such as mar3.srJus 3nd k~."ashiorkor, which is not, in ::"tself, statis~ically jm~r·essive. The mistake is still being f'lade of r"'garding ilS imp',c'tant,'nly the tip of the ic-eher,g and of disr~gar'ding the broader' case. ~hGsJ ~rl1y when 3 child's growth has reached danger'ously l~w levels is ther~ inter'venllon e.g. by the provision of ::;ki[T']med ciried m.ilk, or ski.11ed hCS~'l!..?l cnre, and only for

1~hnl child. 1n the context of ~r1e pl'2sent Car'negi~ pr'cject it is Jmport2nt

'_0 restate thRt r;rowth failure has been Sr~own to corre.late sigrdficanLly .:. s

possible to identify communities which may Hell be at risk ami, within these, to pinpoint those familles which most probably ac'e at rlsk.

i l . Failure to recognise the importance of the enlire spectr'um of grcw',h, !'r'e>m conception through adolescence, viz.

( al Pregnancy:

available,

Although good antenatal and obstetric services are they do not include riletar'y 5upplement2tion for' underweigtlt mothers or the·se that. show i!~adt~quate welght g<1in .!.n pr"gnancy, Jeliffe descci'Jes the cumda:.:ve nutr'itional drain of in a 'rn::.J.ter'nal depletion syndrome f • SLJch moth2r's h~ve been shown to be at risk of producing low weight infants with high morb!dlty in early life. In general, there is a rljg~l incidence of low !)irthweight in socL,lly depressed communities and, i f this is followed by ineffiCient lactation, infection and malnutritlon readily supervene,

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Apart from the effects on morbidity there is a risk of intellectual impairment if brain growth is affected during its fastest growing period, i.e. in late pregnancy and early infancy. Stoch

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Smythe in a controlled 20 ·year follow-up study (jf severely marasmic young infants found biological evidence ·of organic changes linked to early undernutrition.3 The effects of such impairment may be compounded by the physical inactivity and unresponsiveness of malnutrition itself.

Thus any help that can be given t.o the malnourished pregnant woman, must contribute to the wellbeing and resistance of her child and should be regarded as an important preventive measure.4

Infancy: The advice, immunisation and assisted feeding at infant clinics are only available ·to those who are able to attend there.

Although the Community Health nurses attempt to seek out the non_attending infants of negligent or workihg mdthers, or those that are for some reason in the care of child-minders, nutri tion failure frequently occurs among these.

A certain number of mothers wean their babies early because maternity ben~fit is only payable for two months a(ter birth, but experience in the field has not shown this to be the major cause of early weaning among the poorer mothers. There appears rather to be a widespread lack of encouragement and direction in the establishment of lactation during the crucial post-partum weeks, a period which may well represent the gap betweer. the outgoing obstetric tea:n and the incoming health team.

Shortage of staff and distance from clinics are thus factors that limit the practice of breast-feeding, which is the most important preventive measure in infancy, and the full utilisation of clinic fac i l Hies.

leI The ~toddler" and pre-school age: A grave shortcoming of Day Centres is that these are for infants over the age of 24 - 30 months because of the additional care requlre~, yet the age group of 10 ~ 30 mont~s is notoriou~ly vulnerable ~2 infection and malnutrition.

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More:wer the l'8sultlng 8palhy and l'edlic2ci md,lli'-:, "ffee\. early learnIng and ~xploratcry experience. We fed infants in homes where a sibl ing had previously had kwashiorkor. Initially the fed infants grew very well but, after assis\.ed feeding stopped at about 30 months, they slowly reverted to the family pactern. However, intellect,ual asses.sments at 6 & 12 year's of age, shOl,ed them to be signlfic8ntly superior to their sibling controls. Not only had they been well nouri.shed when young but they had been alert and active in their early 18acnin8 period.5

It needs also to be emphasised that, in spite of recent cievelopments in city areas, the Day Centres that do exist for toddlers over 30 months of age are totally inadequate in number for the children who need to make good their early deprivation before school age is r'eached.

Surveys of school en trants ar'e cons idered Impot'tant because resul ts reflect 'he ~,revious 5 years of growth of " cohor't of children. In one such study Power (1982) found that 24% of the ctlildren were below the 5th percentile for weight and 20% for height.6

He considered it to be of particular concern that probably many of these, I.e. those who weee unde r'we ight for age but had a normal h", 19tH /we ight ra t j 0,

had probably experienced sub-optimal growth during the critical per'lods of brain development.? ,8

Scl,ool age: Between 1949 and 1960 the State through ItS Edllcation Dep8.'tments, sponsored the feeding of school children. This was a measure supported by the findings of the CUli e Repor·t (I g')O I 3nd was found to be a great benefit to needy children. Since its dis(()ntinua .... ion such diet.ary .5upplemf-'ntat,ion for Sr:110Cl children as does exist has been in the hands of voluntaey organisations, such as the Peninsula School feeding organisation which currently assists 269 schools in the Cape as far afield as Robertson and Saldanha.

The report 9 of the authoritative Theron Commission (1976) recommended that well-organised, selective school-feeding be re-introduced by the State wi th possible community participation: also that the School Medical Services be made more comprehensive and effecti.ve.

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EVIDENCE FOR THE EFFECTI'JENIOSS OF SCHOOL FEEDING --

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The effectiveness of school feeding is always questioned because there is no cle3r evidence that it improves growth or school performance.

Large scale studies, after the first world war, by Orr in Britain.and Lininger in Philadelphia produced strongly suggestive evidence of benefi ts derived.

After the second world war investigations, using more refined techniques, confirmed that the nutritional status of the study children did improve over a period of time. The more successful resul ts were tied to the nutri tional deficits of the cildren being served, Le. the most nutritionally deficient children would show the mos t marked improvemen t. This confirmed the view of Roberts (1935) that a mid-morning snack would be likly to accelerate weight gain in underweight children.

There have been persistent reports from teacherS and others, of lessened fatigue and improved powers of concentration with school feeding and of better school attendance. I n the 5 tudy by Reddy (1977) on school failure among coloured children in Cape Town, 90% of the teachers cited absenteeism 'as the chief cause.10 ~s regards mainutrition, 75% emphatically agreed that "the child who is hungry and ill-fed lacks the energy and enthusiasm to apply himself tb his school work".

This lends weight to the differentiation which Read makes between malnutrition as a state of nutrient deficiency which is chroniC, and hunger, as a psychologic and physiologic state resulting from deficiency to meet immediate energy needs.11

The claSSic study on hunger and starvation by Keys et al (1950) after the second world war, clearly indicated a pattern of irritability, disinterest, apathy, etc., which was completely reversed on re_feeding.12

In schools where a fai r percentage of children from the surrounding communi ty show stigmata of malnutrition, especially in the form of retarded growth, there is likely to be a much larger percentage who are hungry although not growth retar'ded.

THE COMMONLY ACCEPTED AIM IN SCHOOL DIET~RY SUPPPL.EMENTATION IS TO PROVIDE ONE THIRD Of THE DAILY ALLOWANCE Of ENERGY, PROTEIN AND VITAMINS IN AN INEXPENSIVE

AND ACCEPTABLE FORM.

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D. RECOMMENDATIONS

The long-term objective must re!Tlain the removal of the underlying causes of malnutr1tion.13,l~ In the meanwhile, much is being achieved by the close involvement of ttle health team with the community and by fostering self-help whenever possi ble. Nevertheless, there is an urgent need for the State to expand its preventive measures to make good certain present deficiencies, viz.

Assisted nutrition for malnourished women with inadequate weight gain in pregnancy.

Increased staff facilities for the promotion of breast-feedinr, and the supervision of non-attending infants and toddlers.

Provision of Day Centres for younger age groups.

DIETAfi', SUPPLEMENTATION AT SELECTED SCHOOLS by the Depar~ment of Health anej Welfare.

EXPAN::';ON OF THE SCHOOl., MEDICA!" S~P\'lCE to in'elude res;>onsibili' 'I fer the selection of scho:)ls t.e· l)e servt"c1, OJ! the basis of system3tjc grcHU-, r'(·cordinP.'_

A D Moe,die Ro!),;,: !'tson M A KibeI

CHILD HEALTH UNIT Marct', 1984

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E:V IDENCE FOR THE EFFECTIVENESS OF SCHOOL FEEDING

The effe::tiveness of school feeding is AIHays questi0ned because there is no clear ev idence that it improves gr'owth or school performance,

Larg~ scale studies, after the first 'world war, by Orr in Britain and Lininger in Philadelphia produced strongly suggestive evidence of benefits derived.

After the second world war investigations, using more refined techniques, confirmed that the nutritional status of the study children did improve over a period of 'time. The more successful resul ts \,ere tied to the nutri tional deficits of the cildren beinp; served, Le. the most nutritionally deficient childrel" would show the most marked improvement. ,This, confirmed the view of Roberts (1935) that a mid:morning snack Hould be likly to accel~rate weight gain in underHe ie;h t children.

There have been persistent reports from teachers and bthers, of lessened fatigue and improved povlers of concentr?tion Hith school feedir'Jg and of better school attendance. In the study by Reddy (1977) on school failure among coloured children in Cape Town, 90% of the teachers cited absenteeism as the chief cause.¹⁰ As regards malnutrition, 75% emphatically agreed that "the child who is hungry and ill-fed lacks the energy and enthusiasm to apply himself to his school Hork".

This lends Height to' the differentiation which Read makes between malnutrition as a state of nutrient deficiency Which is chronic, and hunger, as a psychologic and physiologic state r~sulting from deficiency to meet immediate energy needs.¹¹ The classic study on hunger and starvation by Keys et al (1950) after the second world war, clearly indicated a pattern of irritability, disinterest, apathy, etc., which ~3S completely reversed on re_feeding.12

In schools where a fair percentage of children from the surrounding community sho\.[ stigmata of malnutrition, especially in the, form of retarded growth, there is likely to b'e a much larger percentage who are hungry although not growth retarded.

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REfERENCES

1. Hansen, JDL, Buchanan, Nand Pettifcr JM (1982) Protein energy

2.

malnutrition. In Textbook of Paediatric Nutrition. Second edition. Eds.

MCLaren, OS and BUI'man, D. P114. EdinbtJl'gh. Cllurchill Livir!iostonf'.

Wittmann, W, Moodie AD, fellingham, S, and Hansen, JDL (1g67).

evaluation of the relationship between nutritional status and infection by means of a field study. S Afr Med J 41, 664.

3. Handler, LC, Stoch, MB, and Smythe, PM, (1981). CT Brain Scans: Part of a 20 year developmental Study following [';1'055 undernutrition during infancy.

British Journal of Radiology 54, 9~3.

I; . Raoult, (1972) • The Nu tri tional cc'ncii tion of school c:h i ldren. In MRlnlltrjtion and endemic diseRsPS: their effects an education in llnescu Institute for' Ecucatio:l.

developing countries.

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Ed Smart, KF.

5. F.V?lIlS, D, 80\4ie, MD, Hensen, JDL, Moodie, AD, 3nc.J van de! .spuy, HiL Int~lJ~rtual deve18pment and nutrition. JournRJ of PediaLric~ 97, 3S2.

6. PO\,e r, D. (1 q82 )

araa rf Capo Town. S Afr Med J 61, 303.

8. van Rensbuq;~:, CFW,':, Bc)(',yens, J, Ga.:rlJ.ram, F, an" f<a:II~, _{(1977) •} _Tri"

S Afr Med J 52,,6~~.

9. Report of the Commission of Inqulr~y into matters l~ela'ini3' '_,= nl'? ::C.1Ul~~''':'ci

pop;)}::1tjon Groll;-' 1.1976) Govern;'1-?nt Pr~r'.ting Off1(,'::> RP 38/1Q'7G.

10. R(-'dt1:,,' , eN (197 (1). l;r: i!1\'~sti~ati:Jr. ir;t,c th,:- prc~!er~ of fRilure n.:"l;.'.~-

pupils in CC1')tlred primAry .'3ch~)01s. Unjversi ty Qf the Westerr, CapfO.

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11. Read, MS. (1973) Malnutrition, hunger and behaviour. J Amer. Diet. AsSoc.

63, 386.

12. Keys, A, et al ( 1 950) . The biology of hUman starvation.

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University of Minneapolis Press.

Vol 11.

13. van Rensburg, HCJ, and Mans, A, (1982) • Profile of disease and heal th care in South Africa. Academica. Pretoria.

14. Moodie, A (1982) Th Social background of child:'riutri·"tion. In textbook of

, ~; ... ~

Paediatric Nu trition op. cit. 1'385. .'

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These papers constitute the preliminary findings of the Second Carnegie Inquiry into Poverty and Develop- ment in Southern Africa, and were prepared for presen- tation at a Conference at the University of Cape Town from 13-19 April, 1984.

The Second Carnegie Inquiry into Poverty and Develop- ment in Southern Africa was launched in April 1982, and is scheduled to run until June 1985.

Quoting (in context) from these preliminary papers with due acknowledgement is of course allowed, but for permission to reprint any material, or for further infor- mation about the Inquiry, please write to:

SALDRU

School of Economics Robert Leslie Building University of Cape Town Rondebosch 7700

Edina-Griffiths