How do we build a fairer, healthier world for everyone? In a world that has forever been changed by the COVID-19 pandemic, and are in many ways looking to be rebuilt, this is precisely the question World Health Day 2021 prompts us to consider, writes Liezel M. Engelbrecht.
Good nutrition is arguably the cornerstone of good health. Undernutrition, overnutrition and malnutrition have consequences ranging from poor growth and development in infants and children, weak immune defences, ill health, disability and overburdened health systems, to name a few. In turn, this precipitates suboptimal human potential, stunted economic progress, unemployment, premature deaths and struggling communities.
Food and nutrition security should thus be regarded as key for rebuilding communities and economies, and for supporting health.
Researchers from the Nourished Child Project, a study seeking to understand how the food system, urban system, and social services system shape the quality of diets among children under five and women of childbearing age, share their thoughts on the some of the key things they believe cities can do to promote a fairer and healthier South Africa.
Food sensitive planning
Gareth Haysom, food systems researcher at ACC and Nourished Child co-investigator, says that though South Africa is largely an urban country, food policies are still mainly focussed on rural production. This is of particular concern as food insecurity in urban areas become more prevalent.
“We have a food system that is largely an urban food system – most buy their food from a food retail outlet. Yet local government argue that they have no fiscal, and as a result, operational, mandate to engage urban food questions.”
Haysom says South Africa’s colonial, apartheid and industrial legacies have shaped our cities and our food systems to the detriment. “The agrarian, or production-oriented, focus on food and nutrition security perpetuates these legacies offering few alternatives, often amplifying the negative outcomes. The current levels of food and nutrition insecurity in South African cities reflect a deeply inequitable society.”
He says negative food system outcomes are however only in part the result of failures in the food system. “Multiple urban systems, from water to energy, from transport to waste, from food access locations, to time poverty, from the gendered nature of household food provisioning to livelihood generation strategies, all intersect to influence the food system outcomes for most urban residents, particularly the poor. Seeing food and nutrition outcomes as separate to these systems is short sighted.”
According to Haysom new governance and policy responses are required to address this. “There are multiple ways in which local government can, and needs to, engage urban food questions. One such approach is through an existing urban mandate, planning, and specifically Food Sensitive Planning.”
The Nourished Child project has reviewed over 100 policies and “interventions” that impact the nutrition, health and wellbeing outcomes of children and their mothers. These interventions span the urban system, the health system, the food system, the social or societal system, and the social services system. Planning is however a key tool to connect these systems, says Haysom.
“In a predominantly urban society, where local governments have an explicit planning mandate, Food Sensitive Planning is an area where such paradigmatic change can begin, where cities can proactively engage food system issues, and plan strategically to build a more equitable, fairer and healthier city.”
Ultra-processed foods and a narrative shift
Jo Hunter-Adams, qualitative researcher for the Nourished Child project as well as for the Nourishing Spaces project (a study looking at urban governance in the prevention of noncommunicable disease), says amidst the complexities of what makes spaces, context and economies more or less nourishing, it is understandably hard to write good policy.
From her work, two things however stand out in this complexity as areas where action can be taken to make spaces more nourishing, and they are the issues of ultra-processed food, and the narrative of personal responsibility.
“Though there is virtual consensus on the negative impact of ultra-processed food on health, these foods are nevertheless being consumed in huge quantities, and are palatable, available, affordable, and shelf-stable. This comes at great costs to both people and the planet, and must be part of the calculus if they are to be part of our future food system.”
Hunter-Adams say the purveyors of ultra-processed foods should however not be the people who make decisions on the future of the food system, as there is an inherent conflict of interest that has both economic and health impacts. “Rather, decision-making must somehow be returned to communities.”
The dominant narrative of “personal responsibility to create a nourishing space, and a nourishing diet, for oneself and one’s family”, which is prevalent in public health settings, in clinical settings, and even in the public discourse, is also deeply flawed according to Hunter-Adams. “This is nearly impossible for the urban poor, in a fast moving urban economy, where one has little extra personal energy to expend, and where issues of water, energy, and sanitation are at the forefront of the urban experience.”
She says for real change to happen, this narrative needs to shift. “Such a seismic shift in public discourse may move energy away from health education, and towards broader systemic actions.”
Equitable access to WASH
Jane Battersby, project co-investigator, Assoc Prof at ACC and senior lecturer in the Environmental and Geographical Science department at UCT, says ensuring that children are well nourished is critical to good health, both now and in the future, and believes water, sanitation and hygiene (WASH) lies at the heart of this.
Battersby says though their work on the Nourished Child project is demonstrating how important direct interventions like nutrition information at clinics and child support grants are, they are finding that this is not sufficient. “Caregivers struggle to provide their children with safe and healthy foods because of poor access to clean and reliable water. Poor water and sanitation also mean their children often suffer from diarrhoea, leaving the children vulnerable to malnutrition.”
She says poor water, sanitation and waste management also leave caregivers hesitant to buy from local vendors, who will sell food in affordable unit sizes and even provide food on credit because they worry about health risks.
“Access to safe and reliable water, and provision of sanitation are utterly essential to food and nutrition security and a health promoting, inclusive food system.”These ideas are however not new. “WASH has been a central component of UNICEF’s malnutrition conceptual framework since 1990. However, they have been largely absent from any food security and nutrition policy or programming work in South Africa.”
According to Battersby local government has conventionally argued that it does not have a clear, funded food security or nutrition mandates. “But water, sanitation and waste management are core local government functions.”
She believes that equitable access to water and sanitation must be central to city government efforts to promote good health and nutrition.
“Child nutrition is core to building a fairer, healthier world and reducing the stark inequalities in our society, and cities can have a major role to play.”