Opinion: Urgent course correction needed on NHI, climate change, and economic policy
Kedibone Mmupele (27), her two children Onkarabile (2) and Nkune (6), and her younger siblings Mapule (7) and Sebengu (9) had not had a decent meal in weeks, media reports at the time showed. It was 2011. There was no food in their home near Verdwaal, a small place in the North-West Province. So she decided to walk to a farm 18 kilometres away to find food. On that Thursday in October 2011, the temperature rose to 32 degrees Celsius.
When Kedibone returned later, the four children were missing. The dead bodies of the two younger children were found in a field three days later. Two weeks later, the older children were found. A post-mortem examination showed that all four had died of hunger and dehydration, made worse by the sweltering heat.
The greatest risk to human health is neither communicable nor non-communicable disease – it is climate change. – Fiona Godlee
In the same year, Fiona Godlee, editor-in-chief of the British Medical Journal (BMJ), wrote that “the greatest risk to human health is neither communicable nor non-communicable disease – it is climate change”. She writes further, “Saying this – putting climate change at the top of the list of things to worry about is hard when faced with the daily challenges of clinical care.”
Godlee’s editorial and the tragic story of the Mmupele children bring into stark focus the most critical challenges humanity faces today – enormous injustice and inequality in the context of rapid global heating, human-induced climate change, and fossil-fuel pollution.
Climate change makes all our failures worse
Climate change intensifies a range of global and local emergencies that we have known about for decades but have not addressed effectively. These intertwined emergencies include growing inequality within and between nations; unemployment; poor physical, spiritual, and mental health; inadequate access to education; homelessness; growing food insecurity, and interpersonal conflict and violence against children and women.
Drought, intense heat, floods, loss of livelihoods, and conflict over resources force millions of people to migrate. At the time of writing, a prolonged drought across Somalia, Ethiopia, and Kenya threatens the lives of over 20 million children through hunger, thirst, war, and food insecurity. Climate change exacerbates political instability and war, turning many thousands into refugees. New parts of the planet will become uninhabitable by people within the lifetimes of children born today.
Climate change intensifies a range of global and local emergencies that we have known about for decades but have not addressed effectively.
Closer to home, two reports commissioned by the Centre for Environmental Rights (CERI) in 2021 indicate that Southern Africa is particularly vulnerable to climate change and that warming in the interior is advancing at about twice the global average rate. South Africa will experience “enormous negative physical, socio-economic and ecological impacts”. These include severe heat stress, extreme weather events, sea-level rise, coastal damage, water stress, and crop failures. This will reduce food security, the availability of fresh water, and increase the risk of severe storms, droughts, and heatwaves. In addition, we can expect more disease outbreaks, various forms of economic collapse, social conflict, and mass migration to informal settlements around urban areas, the report stated.
Due to biological, developmental, and socio-economic factors, children are highly vulnerable to these impacts throughout the life cycle.
Children are highly vulnerable
Due to biological, developmental, and socio-economic factors, children are highly vulnerable to these impacts throughout the life cycle. The health risks start before they are born, with complications of pregnancy. Later, the environmental crisis aggravates health risks across the spectrum of childhood disease, including allergies, heart disease, skin disease, immune disorders, infections with new organisms, acute and chronic malnutrition, kidney disease, mental health problems, respiratory disease, neurodevelopment problems, and violence.
Around 12 000 children will be born in South Africa this week (based on Stats-SA numbers). Fifty-six percent of them (about 7 500 children) will be taken into households living below the upper poverty line of R1 227 per month. Around 380 are expected to die before their fifth birthday. On average, however, the life expectancy of children born in South Africa today is around 64 years. This means many will still be alive in 2080 unless things change.
But things will change.
As we have seen, climate change is changing the world dramatically in many ways. And this is happening with a temperature increase of 1.1 degrees Celsius since pre-industrial times. The aim of the UN Framework Convention on Climate Change (UNFCCC) process to limit the warming to 1.5 degrees Celsius is unlikely to succeed. The impact on today’s children and future generations will be profound. In the years to come, the tragic story of the “Verdwaal” children will be repeated many times in many forms.
Could the NHI have prevented the death of the four Verdwaal children?
The answer depends on action in two interconnected areas – what kind of health service the National Health Insurance project delivers and whether the government effectively addresses the inequalities and social injustices that lead to poor health.
First, regarding the health service, the process must deliver universal health care through an equitable, green, and sustainable national health system. To achieve Universal Health Coverage (UHC) as intended in the NHI Bill, it must interpret the “C” as the right to care rather than market-driven insurance coverage. This is the only way to reverse the currently operating Inverse Care Law, where those who need health care most have the least access.
It is also essential to move the central focus of health services from hospitals to high-quality team-based care in community settings, extending to the household level. For example, if a well-trained, well-supported community health worker who knows the community around Verdwaal had visited the Mmupele home, identified the problems early, and taken appropriate action to relieve the family, these children’s deaths could have been prevented. It’s not hard to imagine that their life course would also have changed substantially for the better.
Moving the focus of healthcare to communities should make healthcare more accessible and allow for community participation in issues related to health. Meaningful community participation, where local health services are accountable to the community, could improve the service, make it more relevant to the specific community, reduce corruption, and build trust. More community-based health services should also reduce the system’s greenhouse gas emissions.
Second, improving the health services alone will not entirely prevent more Verdwaal deaths because it will not change the underlying conditions under which children live, fail to thrive, and die. Concerted, collaborative intersectoral action beyond the health department is necessary to ensure equitable access to the social, economic, and commercial determinants of health.
Improving the health services alone will not entirely prevent more Verdwaal deaths because it will not change the underlying conditions under which children live, fail to thrive, and die.
Human and children’s rights must be at the centre. These are laid out clearly in the UN Convention on the Rights of the Child and in our Bill of Rights, as in other legislation. Economic justice and social solidarity are central. We have to make a decisive break with neoliberal capitalism and trickle-down economics. We need a wealth tax to pay for a universal basic income as a citizens’ right.
All of this depends on whether the NHI project achieves what it originally intended. An opportunity like this to develop the health system we need comes around about once in a generation. But the process is non-transparent and appears to be bogged down in conflicts of interest, poor governance, political stalemates, endemic corruption, and a deep trust deficit.
This time, we don’t have the luxury of time. Unless we get ahead of both the climate crisis and the current levels of pervasive injustice, we will never be able to catch up.
Finally, we have to recognise children’s agency. Young children around the world are becoming more active in this, sometimes in ways we might not like. But they need our endorsement and support. No one has a bigger stake in dealing with climate change than those born today.
*Reynolds is a retired paediatric respiratory and ICU specialist and Associate Professor in the Department of Paediatrics and Child Health at UCT, where he is a member of the Advocacy Committee. He is a member of the Steering Committee of the People’s Health Movement.