The Transkei’s infant mortality rate speaks volumes about the poverty of the people and their services, writes Trudy Thomas
One in 10 infants in the Transkei dies during its first 12 months of life, mainly from starvation, according to a study carried out earlier this year by the Health Systems Trust. It is a startling figure in the new South Africa, especially in the light of the following experience which is offered as a small ”triumph of memory over forgetting”, as Minister of Education Kader Asmal has dubbed history.
In 1961 migrant labour was wreaking some of its worst havoc, breaking up and impoverishing homeland families. At that time, as a new doctor, I was working in rural area deep in the Ciskei, where malnutrition was as prevalent as it now is in the Transkei. There was a difference, however. Instead of the current Transkeian hospital death rates for kwashiokor of up to 50%, in ours it was 6%, which was the same as at Baragwanath, the teaching hospital from which I had just come.
This was not being achieved through any heroic or complicated methods, but directly and simply through the meticulous application of routine nursing procedures captured in two terse instructions on the child’s bedletter: ”Two-hourly feeds please” and ”two-hourly temperature, pulse and respiration measurements”.
These were based on the established knowledge of the time, much of it researched in South Africa, 40 years before its current ”transformational” importation, packaged in workshops, from the World Health Organisation. Medical students of the Sixties were taught that kwashiokor damaged the liver, making it unable to do its usual job of supplying a steady flow of sugar to the brain, and that this could quickly result in convulsions, coma and death. It was therefore important to give children frequent feeds so that the necessary nutrients could be sucked directly from the stomach into the bloodstream and on to the brain. Failure to do this could disrupt your sleep when a panic-stricken nurse’s voice came over the phone at 2am: ”Doctor, Thembisa is fitting.”
The remedy was to inject a strong glucose solution into a major neck vein when you might be rewarded with a child waking up, looking around a little bemused and then saying: ”Hullo, Doctor.” But speed was of the essence. If you did not reach the bedside quickly enough or could not find a vein because of the child’s state of collapse or your ineptitude, the child often died or suffered brain damage.
Standard textbooks of the time also taught that malnourished children could not regulate their body temperatures. This was the reason for the common and gruesome finding of a small, cold corpse in the small dark hours of the first night after admission, when the baby had been removed from the warm blanket on his guardian’s back and placed in a clinical cot.
To pass their examinations students were also expected to know that these children were prone to infections and low blood potassium levels, which slowed their pulses as a harbinger to a full heart stop. I still have protocol hand-outs now being peddled by overseas consultants that were given to nurses in the Seventies, designed to help them monitor and prevent all these catastrophes.
Disconcertingly, despite our good cure rates and a policy to discharge babies only when they were active, smiling and growing fast, many relapsed as is now the case in the Transkei. They had to be readmitted and their last state was often worse than their first. This prompted a quick survey of children discharged in good health. It showed that within 10 weeks a third were still fine, a third were slipping and a third had died.
More in-depth research was undertaken that clearly implicated migrant labour as the culprit. It showed that if babies were cared for by their mothers and supported by their fathers they were fat and fit. In contrast, mothers of malnourished children were mostly destitute, usually due to desertion by fathers. As one woman put it on being harangued and ”nutritionally educated” in time-honoured medical fashion on the miserable state of her child: ”Doctor, I have no man, no money, no milk.”
About 60% of mothers of malnourished children had, in desperation, left their babies with makeshift guardians sick or senile or psychotic, or even young children to look for work in the cities. I recall one grandmother, bent under the weight of her charge, even though it was pathetically slight, having to crawl up the last three steps to the clinic.
Unsurprisingly, these babies sickened. Equally unsurprisingly, if such a baby was discharged after ”cure” in hospital into the same circumstances that had caused the hunger in the first place, the child relapsed.
In the style of those days, the response to these findings was direct and commonsensical, and untrammelled by any rhetoric of ”integrated development”, ”intersectorality” or ”community participation”. This is not to say that these concepts were not recognised or applied. In fact, our research concluded that childhood malnutrition was merely a medical manifestation of social disorganisation and extreme impoverishment, both mainly politically determined a finding that the Carnegie Poverty Enquiry of the Seventies amply confirmed.
There were also no workshops to teach nurses and doctors things that, if their qualifications were anything to go by, they were supposed to know. Instead, the response consisted of the employment of a suitably trained village woman and an all-purpose driver with a bakkie and a loudhailer. With plenty of community involvement, they did the rounds of 72 ”milk stops” at clinics, shops, churches, homes and even under trees, weighing and checking children and handing out powdered milk, and even climbing hill and dale if a granny and her baby did not turn up. At any one time this team was looking after up to 3000 children and 95% were thriving.
The infant mortality rate (IMR) is the number of babies out of every thousand born alive each year who die before reaching their first birthday. It is one of the most sensitive indicators of the state of health not only of infants but of the community in which it is being measured. It also speaks of the state of health services, notably antenatal, obstetric and paediatric care and primary healthcare services.
The IMR in the Transkei 100 out of every 1 000 live births is more than double the national average of 41 and compares with 57 in the Northern Province, its closest runner-up, and 27 in the Western Cape, the healthiest province for babies in South Africa.
The IMR is not only a health indicator but a much-used and accurate socio-economic one. With literacy and income levels, through life expectancy, it contributes substantially to the Human Development Index, which provides one of the best markers of prevailing levels of the economy and development and their potential for growth. Ten is tops. In 1991 Canada scored 0,932, Gauteng 0,818, Brazil 0,756, South Africa 0,677 and the Eastern Cape 0,507. In the Transkei it is below 0,5 similar to many troubled Central African countries.
Examples of IMR down the years and across societies abound: when humans were at the mercy of wild animals and the vagaries of nature, or more recently during unchecked epidemics such as measles and smallpox or plague, and now in places of civil wars, famine and Aids, less than a third of live-born children may live to blow out their first birthday candle.
Currently, in the Scandinavian countries only seven out of 1 000 children will succumb in their first year, all due to conditions that we do not yet know how to prevent or cure. In the United States the rate is 12 and in Bolivia 77. In South Africa the IMRs are colour coded: 10:25:54 per 1 000 white, coloured and black live-born children respectively. In the Ciskei in the 1980s it ranged around 50.
So in this the third millennium, in the seventh year of transformation in the new South Africa, an infant mortality rate of 100 out of 1 000 in the Transkei is shocking. It speaks volumes about the poverty of its people and their services.
Although shocking, these figures which emanate from work being undertaken by researchers and trainers from the University of the Western Cape in the Mount Fletcher district of the Eastern Cape will come as no surprise to many nurses and doctors working in poor rural communities. They reflect conditions that drove many old-timers, while doing what they could to ameliorate its effects, to join the struggle to oust apartheid. It saw them standing on the threshold of a brave, new land in April 1994, eager to offer their energy, experience and passion to help bring about ”Better Health For All”.
Many doctors have been trying to raise the alarm, especially since 1997 when the country opted for rapid apartheid debt repayments and the ”fiscal discipline” of structural adjustment to woo Western financiers. This was meant to attract foreign investment that in turn was meant to stimulate the growth, employment and redistribution strategy (Gear).
Unfortunately, where these doctors were working this was not occurring. It was translating, instead, into direct suspensions from social services: no petrol to send supplies to clinics; no money for food supplements to prevent and treat kwashiokor; no dip for cattle so that in one year 60 000 died with the milk that could have kept babies healthy no money to top up the 350 social workers for the more than six-million people in the Eastern Cape; and no cars for them to reach starving, rural children and arrange poverty grants for them.
It seemed that in its services Gear was in reverse and, as usual, its teeth were biting deepest into the poorest. Instead of growth, employment and redistribution, the new financial policies were associated with increasing unemployment, poverty and deteriorating services. Between 1994 and last year the Eastern Cape dropped from the second poorest to the poorest province. Its operational costs for core health services decreased from R787-million in 1997/1998 to R350-million in 1999/2000. The per capita operational health rands for people without medical aid last year was R70 to Gauteng’s R292 and a national average of R147.
A declining economy, deteriorating health services and a tattered social safety net provide the circumstances for an entirely predictable, rising and unacceptably high IMR. Unfortunately the pleas of health workers about this crisis have fallen on deaf ears or worse been labelled anti-transformational. And so the babies die of hunger.
The infant mortality figures released by the Health Systems Trust have added little new information, but have helped to confirm trends. They have also succeeded in engaging the media and so finally stung the attention of politicians. The provincial health MEC has said that with his welfare counterpart he will visit affected areas to see this tragedy for himself. He has also opined that ”malnutrition is the end of the line. It is a manifestation of poverty, unemployment, lack of education social factors that all contribute to parents being unable to adequately care for their children.”
Many would agree, but if so should he not be inviting those MECs responsible for agriculture, public works, education, economic development and finance to see first-hand the hunger and poverty of the people? For just as in the bad old days of apartheid and migrant labour, childhood malnutrition is merely a medical manifestation of social disorganisation and extreme impoverishment mainly determined by (current) political decisions.
But while politicians are making sage statements, their remedies are less convincing. Minister of Welfare and Population Development Zola Skweyiya, who does have a kind heart in the right place, donated R2-million from his department for families of starving children. In addition he has sent out a 16-person team of home affairs and social welfare workers to sort out documents needed for impoverished people to access child-support grants of R100 a child a month. He is very pleased with their work in organising 280 grants in a matter of weeks.
Very good, but Mount Fletcher is only one area, and not even the poorest, in the Eastern Cape. Visit any of scores of hospitals in the province where they admit ”kwashiokors” and you will see two or three babies per shabby iron cot; stick-legged, gaunt-faced listless old men of two, winged shoulders slumped over bloated bellies, or waterlogged, pale faces staring at you with ancient resignation.
Once-off token aid, however well intentioned, is not the answer. The problem is enormous and pervasive, deeply structural and systematic, and the systems and structures through which help must flow in these places are grossly dysfunctional, if they exist at all. Child support grants (CSGs) were introduced in 1998 and in its policy statement of April that year the Eastern Cape Department of Welfare announced that ”75 000 children will benefit from CSGs in the first year of implementation”. By March 1999 only 12681 had been registered, but in March last year the department was pleased to note although the figure was still well below half the target they had set themselves two years earlier ”a considerable improvement”, up to 32515. The conservatively estimated need is 200 000.
Reasons given for ”blockages” were the lack of barcoded identity documents and computerised birth certificates, over-stringent qualifying requirements, staff attitudes and poor physical infrastructure.
This is also the department that five judges of the Supreme Court of Appeal recently accused of ”going to war with its own citizens” because it unlawfully removed thousands of disabled people from their registers and then persistently argued against reinstating and paying them, with savage consequences for many. While the judges cannot be faulted, it is also worth noting that the repeated ”savaging” reviews that removed these pensioners were done, under the guise of ”cleaning the database”, as a cost-cutting exercise at the behest of the provincial Department of Finance as part of its enthusiastic deficit-reduction drive.
This drive has also prevented the welfare department from appointing staff or developing infrastructure and systems that could deal more effectively and less chaotically with pension administration, including the processing of child-care grants.
Many people in the Transkei have never seen a social worker and in extensive areas there are no offices, telephones or vehicles. Only the introduction of properly resourced and staffed systems and infrastructure will begin to have useful, sustainable results. It will require a loosening of the fiscal stranglehold, but there is no other answer consistent with serving the poorest people.
The MEC for Health is also going to intensify the training of nurses to feed babies at 2am so that they do not die of cold or convulsions. Surely what is actually needed here is to hold someone accountable for incompetence, negligence or malpractice. This might be a nurse who is sleeping in the bath instead of checking her patients, a matron who has allocated only one junior nurse to a ward of 40 babies, or politicians who do not allocate enough staff to care safely for patients or who, preferring to be applauded by International Monetary Fund-leaning financiers, resist releasing enough money to hire them.
The health MEC says more attention must be given to the integrated care of childhood illnesses. Another name for this is comprehensive consultation, which has been practised for at least half a century in many rural areas of South Africa. It simply says that when you see a child, in addition to attending to any medical condition for which he or she may have been brought, check the child’s weight, nutrition, immunisation and TB status and ask the mother if she has any contraceptive or social needs she would like addressed. Then respond effectively and comprehensively.
This is normal practice for all good health workers but it must be supported with the fundamentals: adequately resourced and staffed health services. To achieve this and bring it within reach of everyone in the Eastern Cape there is only one answer the loosening of the fiscal stranglehold that is currently obstructing the cash flow below critical operational levels.
Nor does this disregard the need for good management. On the contrary, it assumes the procurement of enough high-quality supervisory expertise to ensure best management practice and money use at all levels of service and strict discipline which should, of course, also be scrupulously fair.
There is a huge store of experience and expertise of effective and even visionary health models in the poorest rural areas of South Africa and, indeed, many informed the current health policies. Unfortunately, because they were practised in the old South Africa there is a tendency to regard them as non- or anti-transformational and to discard them. This seems to misunderstand the true meaning and domain of transformation.
Transformation simply means change and it can be for better or for worse. Systems and models can serve a particular purpose well or badly, but otherwise are neutral. If there were systems and models that served the health of the people better in 1961 than the ones we are using now, is it not time to transform back to them? True transformation would seem to lie not in changing a good system but in ensuring that everyone, not only a privileged few, benefits from it.
Infant starvation and death are among the most accurate indicators of poverty and poor services. The bodies of our babies are signalling to us. But this is not only a message to the soft-hearted, who are sentimental about the suffering of children. It is also for the hard-nosed and tough-minded for whom economic growth drives the world. They are increasingly being proved wrong, of course, and not only by Seattle hotheads but by an ever-growing body of respectable and cool-headed thinkers and doers.
Growth by no means guarantees job creation and redistribution and, arguably, structural adjustment particularly disadvantages underdeveloped societies that lack the skills, systems and infrastructure receptors to latch onto or disburse any largesse. The enthusiastic cooperation with this adjustment by the political bosses in poor provinces, manifesting as the suspension of money from services to pay back deficits instead of advocating for the minimum needs of their people, also does not help.
In practise any honey that collects tends to stick in the pots at the already rich centre that has the capacity to absorb it and a strong sense of entitlement to it, with a platoon of smooth-talking economic advocates to support its case. Add to this urban blinkers and blind spots for their church mouse country cousins and the honey trickles very sluggishly indeed to the periphery. Certainly the impoverished and rural Eastern Cape has not yet tasted much.
The Transkei was the poorest, most underdeveloped and under-served area in the country in 1994, the worst casualty of apartheid. It is poorer now. In the last analysis, transformation to that ”Better Life For All” will be able to be claimed only when it shares similar, acceptable conditions with the rest of South Africa. It provides the acid test of the success or failure of our policies.
The Transkei’s IMR of 100 is therefore of the gravest import and an urgent call to review our strategies. One of these is that it is being resourced in a way that is perpetuating and even increasing the inequalities of apartheid. We need to find a financing formula that focuses primarily on the poor rather than on bank accounts. We may well find that if we look after the health of the babies, the whole economy, and not only its growth component, will begin to grow healthier too.
Trudy Thomas was MEC for health in the Eastern Cape until she resigned earlier this year