I’ve just got back from
Johannesburg, where I attended the
26th Congress of Paediatrics, held
at the Sandton Convention Centre,
above. This International Paediatric
Association congress was held for
the first time in Africa on the
occasion of the IPA’s 100th
anniversary, making this particular
congress very special.
So I would like to share with you my
highlights of the congress and some
lessons I learnt in the course of
those six days in South Africa. I
call them ‘my highlights’ because
the congress was so huge that
individual highlights will be
different. Also different
professions have different
viewpoints, and I am not a
paediatrician but a public health
nutritionist.
The Convention Centre is located at
the heart of Sandton City, shown
above. Opposite the Centre is
Mandela Square which has a massive
statue of Nelson Mandela, below, the
size of which I have not seen in my
entire life.
It’s easy to understand why Mandela
is honoured in such a way. He has
the health of children and the world
at heart. His initiatives to prevent
the spread of HIV infection, to
reduce mother-to-child transmission
of the virus, and to make
anti-retroviral drugs available for
those infected, attest to this fact.
He once said: ‘Wasting words and
energy in worthless ridicule
distracts us from our main course of
action, which must be not only to
develop an AIDS vaccine, but also to
love, care for, and comfort those
who are dying of HIV/AIDS. A vaccine
shall only prevent the further
spread of HIV/AIDS to those not
already infected; we must also
direct our concern towards those who
are already HIV-positive’. He
deserves all the honour bestowed on
him by South Africans and the world
at large.
Locals told me that what draws
people to Sandton is shopping. The
city has many huge buildings,
including the Sandton twin towers.
Shopping malls are everywhere.
Sandton is known as the shopping
paradise of South Africa, and you
can get everything to buy if you can
afford. Even though the World Cup is
over, vuvuzelas were still on sale
when I was there. I think they have
come to stay.
Level of commitment
The 26th IPA congress was the most
attended, in terms of the number of
countries from which delegates came
from, and also the number of
participants – around 3,500 in all.
The number of countries reflected
the number of national paediatric
associations represented. The number
of delegates signified the level of
engagement within this group, its
unified front, and one large voice
proclaiming: ‘Healthy children mean
a healthy world’. .
I was also impressed by the number
of delegates from lower-income
countries, especially within Africa,
and specifically Nigeria which had
over 120 delegates. These numbers
show the level of importance that
paediatricians and trainees within
the country attach to continuous
professional development and seeing
the need to engaging the world body.
The large representation from Asia
and Africa is also important
considering that the burden of
disease and death of children is
greatest in these countries. For
instance in Nigeria, under-5
mortality is still about 176 per
10,000 live births, and progress
over the years has been extremely
slow. The Millennium Development
Goal of reducing under-5 mortality
by two thirds by 2015, at global
level or in most countries, is not
likely to be achieved in most
countries in Africa, including
Nigeria, judging by the rate of
progress. The level of interest and
participation at the IPA congress
may indicate renewed zeal and hope
to turn the situation around.
Severely malnourished children (1)
Core competencies needed
One of my highlights at the IPA was
the pre-congress workshop on 4
August organised by the
International Malnutrition Task
Force. Its theme was ‘Caring for
children with severe malnutrition as
a core competency’. The aim was for
paediatricians to resolve to make
the care of severe malnutrition
fundamental to their work. This
implies that paediatricians and
trainees need to appreciate the
magnitude of malnutrition (in the
sense of undernutrition) and the
impact it has on child survival.
Health workers, especially those to
whom the care of children is
entrusted, should also understand
that prevention and treatment of
severe malnutrition in children will
contribute immensely to reduction of
under-5 mortality.
Scale and urgency
The workshop included presentations
made by renowned paediatricians and
nutritionists such as Ricardo Uauy
(picture above), Alan Jackson,
Zulfiqar Bhuta, and Tahmeed Ahmed,
who all showed that the problem of
malnutrition is still massive
globally. But malnutrition can be
controlled and prevented. Evidence
of effective interventions exist.
There are basic principles for
treating severe malnutrition in
hospitals. Treatment can be scaled
up at the community level to include
the wider population, and deaths
from severe malnutrition can be
reduced with effective case
management.
Front line experience
Later on, presentations were made by
front line paediatricians. From
Africa these included Adenike
Grange, past president of the IPA
and former Minister for Health of
the Federal Republic of Nigeria
(picture below), Ruth Nduati from
Kenya, Alamin Osman from Sudan, and
Beatrice Amadi from Malawi.
There are immense opportunities to
improve child survival and provide
better opportunities for children
and infants, if nutrition issues are
properly addressed. But there are
also immense challenges, some caused
by the HIV-AIDS epidemic, some
caused by lack of trained staff and
resources, which influence the
quality of care and thus the
outcome.
High prevalence of HIV infection in
many African countries means that
more children are presenting on
admission with severe malnutrition,
and end-stage AIDS, tuberculosis or
persistent diarrhoea. Lack of
adequate staff and supplies and even
health facilities also plague the
system of health delivery in Africa
and caring for these children. One
of the presenters showed a picture
of a ‘health centre’ whose
‘building’ and ‘beds’ were just an
open tent and mats. Such challenges
can be addressed with a strong
political will.
The workshop resolution
The final highlight of this workshop
was a resolution agreed by all
participants, and presented to the
IPA, that the care of malnourished
children should indeed be a core
competency for every paediatrician.
This is a major achievement. We rely
on paediatricians to care for sick
children, among whom some are
malnourished. They need to know how
to recognise and treat malnutrition,
and also how to prevent it. Our job
as nutritionists is to provide basic
training. If we really want to make
a difference then we need to engage
all stakeholders, and paediatricians
are among these stakeholders.
One thing that was remarkable was
the high level of interest of these
paediatricians in malnutrition,
evident in the number who attended
and participated in the workshop.
Maybe paediatricians are more
interested in malnutrition than
nutritionists! The full report of
the workshop is available at
www.imtf.org.
Severely malnourished children (1)
Deep causes and the MDGs
A symposium on severe malnutrition
was held on the final day of the
congress. Here I highlight one of
the presentations, on the role of
paediatricians in achieving the
Millennium Development Goals, by
Haroon Saloojee of the department of
community paediatrics at the
University of Witwatersrand.
He attributed failure in achieving
the MDGs in Africa to reasons such
as increased food prices, increased
fuel prices, global warming, and
global and civil wars. These are
outside the control of many poor
households, and countries where
malnutrition is high, poverty and
hunger are common, and where under-5
mortality rates are high. Many
countries are at the mercy of global
forces.
Look at the above picture and what
it indicates of living conditions
for many children in South Africa.
Any increases in food prices for a
household probably living below $US
1 a day means that the same amount
of money can provide less food. It
is not surprising that progress by
poor countries towards achieving the
MDGs is slow. The slum conditions
shown in the picture only make
things worse.
But sometimes it is not just global
forces at work. The most important
causes may be national neglect. Or
it may be public health
nutritionists forgetting to advocate
for better policies to protect the
health of the people. Or may be we
are not communicating well enough
the evidence which would influence
decision making and policies. Yes,
we too can be part of the problem.
Old, gold, bold strategies
Haroon Salojee described what he
called old, gold and bold approaches
for addressing malnutrition. Old
approaches include growth monitoring
and school feeding programmes. These
are still used but are not very
effective. There is no use in just
weighing the child, plotting on the
growth chart and giving it to the
carer to take home without going
further or tackling some real
issues. That carer may be going an
empty home without food. Hence the
child will definitely end up
malnourished.
Gold strategies are direct
interventions that have demonstrated
effectiveness on maternal and child
health. These include breastfeeding
initiatives, interventions including
legislation, food fortification
initiatives, and policies that
improve education, women
empowerment, birth spacing, hygiene,
and access to water, policies etc.
These work, but very few countries
are implementing them, and even
those that do, are not scaling them
up. There are excellent exceptions.
For instance in Ghana, exclusive
breastfeeding rates have increased
from 7 per cent to 54 per cent
following direct national
intervention in the form of
legislation, mass media campaign,
training of health staff, the baby
friendly hospital initiative, and
other activities. Gold strategies do
work.
Support for agriculture
Two of the ‘bold’ approaches caught
my attention. These are support for
agriculture, and cash transfers.
Agricultural interventions such as
land rights issues, crop
diversification, bio-fortification,
effective legislation of the labour
market, economic support such as
subsidies for agricultural inputs,
and improved access to markets
really make a difference in
nutritional health and well being.
The picture above (sorry it’s a bit
out of focus) helps to illustrate
the point that rich countries
provide large subsidies for farming
and food production. No wonder that
such countries are food-secure.
Cash transfers
Giving poor families some money has
also been showed to improve
nutrition and health of children. In
South Africa, cash transfers improve
the growth of children, benefit
health generally, and are associated
with increased heights in children.
Moreover, the parents or other
family members who receive the money
typically use it well, contrary to
what is often alleged.
These ‘bold’ strategies caught my
attention, because they show once
again that the underlying and basic
causes of malnutrition are crucial.
If these are not addressed, the
immediate causes cannot be dealt
with sustainably. A problem can be
addressed properly only by
addressing its root causes.
I noted with fascination that the
above issues, which are what public
health nutritionists should be
addressing, were a major discussion
topic in a paediatric medical
congress. We public health
nutritionists can be sure that the
multi-sectoral and multi-faceted
nature of the issues that affect
population health cannot be over
emphasised. We should not get tired
of talking about these issues. If we
neglect them, other professions will
take over our jobs.
The Millennium Development Goals
What for?
I have referred to the Millennium
Development Goals (MDGs) a lot in
this column. Some readers will be
interested to know more. What are
they? What indicators are used to
measure their success? Where does
nutrition fit in? What progress has
been made so far? What accounts for
the success of those countries that
are making most progress, and why
are others falling behind? What
lessons can we learn? What can our
Association and the whole profession
of public health nutrition do to
help achieve these goals? In my next
column I will address some of these
issues
.
The MDGs, set at the turn of the
20th century by governments around
the world, include quantified
benchmarks for tackling extreme
poverty by 2015. The eight goals
were adopted by 189 nations and
signed by 147 heads of governments
during the UN Millennium Summit in
September 2000 (1). They are the
most broadly supported comprehensive
and specific development goals the
world has ever agreed on. It is not
just paediatricians who are
interested in the MDGs. For example,
football stars such as Zinedine
Zidane and Didier Drogba are two
leaders in the global campaign.
The eight MDGs seek to eradicate
extreme poverty and hunger, achieve
universal primary education, promote
gender equality and empower women,
reduce child mortality, improve
maternal health, combat HIV/AIDS,
malaria and other diseases, ensure
environmental sustainability, and
develop a global partnership for
development. They are expressed in
terms of 21 quantifiable targets
that are measured by 60 indicators.
The MDGs are a path to achieving a
world free of hunger and extreme
poverty, which we all want to see.
Nelson Mandela has said: ‘If there
are dreams about a beautiful South
Africa, there are also roads that
lead to their goal. Two of these
roads could be named Goodness and
Forgiveness’.
References
- Millennium Development
Goals. Basic Facts. Accessed at
http://www.undp.org/mdg/basicfacts
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