2 Big is Beautiful

Although some of the women in the lower-income neighbourhood of Masiphumelele, south of Cape Town, South Africa, are quite comfortable in their heavier bodies, many have taken on board the messages about the health implications of being overweight. Yet their efforts to trim down are often in vain, which shows that making healthy food and lifestyle choices for people living on the breadline is about more than whether they have the strong willpower and all the right information. This story shows the complex political, cultural, and market forces that drive a kind of ‘food apartheid’ in developing communities, where poor people, as Oxfam South Africa says, “have good access to bad food, and bad access to good food”. The upshot is that people are often heavy, sick, and over-burdened with blame.

At 05:00 a.m., the main road running into Ocean View is pretty in name alone. Before sunrise, there’s no sight of the breathtaking seascapes that make Cape Town’s southern peninsula so famous. It’s just a long stretch of hard asphalt washed in acid orange from the streetlights that dot-and-dash the pavement, which at least offers pedestrians some protection from the cars that thunder past at dawn. A row of eucalyptus trees lean slightly, turning away from the fierce gales that howl from the southeast for most of the summer.

It’s certainly no place for a cushy Park Run.

This is the route that some of the women from nearby Masiphumelele use from time to time, when their guilt gets the better of them and they try, once again, to build an early-morning ‘constitutional’ into their day.

Well-intentioned as they are, these bouts of discipline often don’t last. A ‘small’ crisis will come along and disrupt the women’s attempted routine: one of them might have the water supply to her home cut off, meaning she has to wake up at 03:00 a.m. to use a neighbour’s tap to wash the laundry by hand; an unexpected expense will blow the family’s budget and the stress of it will just be too much; or someone might say she stopped because she is ‘lazy’, when what she really means is that she’s feeling worn out.

Then they’ll fall back into their old ways, their weight will creep back up, and they’ll fret that when they go back to the clinic for their next checkup, they’re likely to be told off for letting their blood pressure get out of control again. It is a pattern of ebbing motivation, followed by a spiral of guilt and self-recrimination that so many people struggle within a world where being overweight and obese is outstripping the old infectious diseases that were once the main health worries here in southern Africa – illnesses associated with HIV or tuberculosis.

These women are mostly charwomen, or home carers, or they work in local grocery stores. Some may have a gig on the side selling second-hand clothing or offal picked up at a meat market about an hour’s drive away. Some take seasonal jobs on nearby farms. Most eke out an existence in the cashlessness that comes with being between jobs, or trying to get by on the pittance of a social grant. Their stories show what it is like to live on the breadline for people who are somehow expected to take charge of their health and their unruly bodies when they have little means to do so.

Mostly, these women are really comfortable in their own skin, despite the extra weight they carry. They say that being curvy and well-padded makes them feel like they belong, that they are part of their community. It shows the world that they are healthy and that their marriages are thriving. It means satiety and wellbeing to them, not cloying hunger and want. It might also be an unspoken message to the world that they are not poor, even though they may be, or a way to show that they don’t have that virus.

But they are also not deaf to the messages they’re hearing about the risks of weight gain and blood pressure and diabetes. These messages might come from the local clinic nurses, or a doctor at the hospital; or maybe their suburban- mum boss is bullying them into going ‘on a diet’. You can imagine them setting their alarms a little earlier each day, pulling on whatever shoes might be suitable to exercise in, and shuffling their stiff early-morning bodies out onto the road that heads towards Ocean View to put in a few kms before the sun comes up.

This is how Dr Jo Hunter Adams from the School of Public Health and Family Medicine at the University of Cape Town (UCT) describes the way that some of the women from Masiphumelele have tried to take charge of their health in a cityscape that makes it so hard for them to do so.

‘Masi’, as the locals call it, is situated about 50 kilometres south of Cape Town’s city centre. It’s a mishmash of state and privately built bricks-and-mortar homes, dotted with backyard Wendy houses and informal shacks. It’s a lower-middle-class-meets-informal settlement, and the people who live here are likely to be the lowest income earners, if they are lucky to have work at all.

Hunter Adams hasn’t formally counted how many people are overweight or obese in Masiphumelele, but the figures are likely to be similar to those across southern and South Africa, and in many other rapidly urbanising developing countries around the world (see State of the (heavy) nation). But she has been working in the Masiphumelele community since 2016, trying to gauge the cultural attitudes towards ‘fatness’, and thinking about how the environment in which these women live shapes their food and lifestyle choices.

What she’s found is a complex interplay of factors that are so much bigger than the individual women’s lives, something that international public-health discussions are now finally beginning to recognise: the problem is not the individuals themselves, it’s the environment in which they live that makes it so hard for them to stay lean and healthy.

Yet, during her research, Hunter Adams encountered the stubborn attitude that emanates from society in general – also still evident in the public-health discourse, and amplified by the media and employers – that bad dietary choices, and the resulting health fallout, are simply a matter of individual choice and behaviour among poorer people.

If people are fat, this storyline goes, it’s because they’re ill-disciplined and lazy, and so the onus is on them to eat and exercise their way back to good, lean health.

The policy response to this is to push education as the main ‘fix’, in the hope that it’ll drive individual behaviour change: if you simply give people enough information, and if they’re strong-willed and motivated, they’ll pull themselves up by their bootstraps and save themselves from themselves.

The lived experience that Hunter Adams has captured through the stories of the women in Masiphumelele is confirmed by sociology Prof Gerardo Otero from Simon Fraser University in Vancouver, Canada. In his searing critique of the modern industrial food system, he points out that this attitude, in its “crudest form… amounts to ‘blaming the victim’”, which stems from an ideological position that ignores the powerful political and market forces, both locally, nationally, and internationally, that shape the food environment in communities like this.

Otero and colleagues point out that, in reality, poorer people are becoming obese because the food they have most easy access to is cheap and highly processed, but also mostly nutritionally dead. They’re simply unable to access good, healthy food because it is either too expensive, or not sold in their local shops. They may also not have enough time to prepare food at home, or their kitchen might not have the basics like a working fridge, or electricity, or a sink with running water (see Cheap ‘junk’ and the rise of ‘Big Food’). The result is that the working classes or unemployed are unfairly shouldered with the responsibility for their diet and health in a wider structural context in which they actually have limited agency to help themselves.

Leading medical journal The Lancet debunks this dusty old ‘blame the victim’ narrative in its 2011 special report on obesity, saying that today’s problems of overweight and obesity are not the fault of the individual, but rather they are the “normal response by normal people to an abnormal environment”.

After recording the life stories of 20 women in Masiphumelele and sitting with 57 other women in various focus groups, Hunter Adams saw the kind of bind they find themselves in. “That some of these women are waking up at 05:00 a.m. to exercise shows they’re taking the health advice from clinicians on board. But the burden of this expectation, and the guilt they feel when they can’t manage it and fail, just doesn’t seem to improve their quality of life.”

Most people are well aware of the health problems relating to food and diet, she says, but in reality, the priority for these women is finding and keeping a stable job, rather than getting healthy.

There are bigger challenges in the wider food environment that are shaping their bodies but which are often overlooked.

Telling them to eat or run themselves thin in such an abnormal environment is like asking a drowning swimmer to save herself from a rip current simply by swimming faster towards the shore, when what she really needs is some other way to free herself from the pull of the current.

‘Fast or feast’ in the abnormal food environment

The hungry season for some of the Masiphumelele women usually creeps in towards the end of each month. The first week of the month usually starts well for those who collect a wage or social grant. They can eat meals with plenty of vegetables, and maybe even treat their families to the luxury of a two-litre bottle of their favourite fizzy drink. Week two might still be alright, with a good mix of different fresh foods on their plates. But this will tail off as their cash starts to dwindle until, by month-end, many women say they are down to eating just maize meal and white bread.

“The women in Masi budget carefully. They usually have just enough money to cover food and things like rent. But there is invariably an unexpected expense that throws them for a loop,” explains Hunter Adams. “To call it a ‘crisis’ sounds acute but for many of these women it takes a really small thing, like a child needing something unexpected for school, to disrupt their budget. So they run out of money, and food is often the first thing they cut. But they don’t want to talk about this because there’s an element of shame for them.”

The reality of surviving in an urban food system is that it’s not enough for residents to simply have calories moving through their neighbourhoods (see Chapter 1: The Hungry Season). They also need to be able to access those calories, which usually means having money in their pockets, either from a salary, a small business, a loan, or a social grant. But when families like those in Masiphumelele are living on the economic fringe, even those who are employed are on a chokingly tight budget. The poorer a family is, the harder it is for them to absorb even the smallest economic shock, such as having a phone pick-pocketed on the taxi ride home after work, an unexpected medical expense, a day’s wages lost because they have to spend a few hours at the clinic waiting for treatment, or a sudden hike in food prices in response to drought.

Many of the people in Cape Town’s lower-income communities, including Masiphumelele, are migrants from the Eastern Cape. Their journey to the city is typical of urban migration trends around the developing world, when people often shed the traditional diets of their rural roots and adopt what’s sometimes called the ‘Western diet’ (see Cheap ‘junk’ and the rise of ‘Big Food’). This nutritional transition generally means a switch from homegrown greens and unrefined cereals, to a diet packed with ultra-processed, packaged foods that are low in fibre and high in refined carbohydrates, sugar, salt, and unhealthy fats. These are mostly cheap, because of the economies of scale that apply to factory-processed foods and the way the manufacturers of these products are able to dominate the market. There’s a direct cause-and-effect link between this dietary shift and the obesity pandemic in the developing world, as well as the cascade of non-communicable diseases (NCDs) that goes with it: heart disease, certain cancers, strokes, and the many illnesses associated with Type-2 diabetes.

Diabetes is the second biggest killer of women in South Africa.

The disease is merciless: when there’s a high concentration of sugar in the blood, it becomes ‘sticky’ and the flow sluggish, particularly through the smaller vessels. It clogs the vessels and damages their walls, and over time this cuts off blood flow, starving nerves and outer limbs of oxygen.

Damage to tiny vessels in the eyes can eventually pull a shutter of darkness over them, blurring vision and even bringing on blindness. Without oxygen reaching important nerves, someone might not feel pain when they bump a foot or leg, for instance, and so an important survival feedback message becomes muted, increasing the chances of further injury. Without a good flow of oxygen to the extremities, a minor injury to a hand, for example, might not heal, possibly leading to serious infection, gangrene or amputation. Clogged blood vessels in the kidneys means these organs can’t filter out the toxins in the blood, and as a result, the body won’t flush out excess fluid and waste. Damage to vessels in the brain can lead to dementia (dementia is now being called ‘Type-3 diabetes’ in many medical circles). If you are a man, the stickiness in your veins can even steal your erection.

This is the cost of long-term exposure to sugar, and the loss of wellbeing and income for a poorer person who can no longer work due to blindness, the loss of a limb, or kidney failure is a burden that she and her family have to carry alone.

Today, sugar is added to food in large volumes, sometimes as a bulking agent, and it is often concealed in savoury foods. Sugary drinks are now pervasive in our diets and make a lethal contribution to the diabetes pandemic. The cost of treating these diseases is carried largely by the state, but the firms that sell this cheap, addictive substance, are pocketing the profits without being held accountable for the burden on society at large.

This is the era of ‘Big Food’ – the media’s catch-all term for the multinational and national food and beverage corporations that dominate the global market.

Their sugary, starchy, refined products have largely replaced ‘small food’, which is usually locally produced, often fresh and highly diverse, and was once the bedrock of our diets. In the new, industrialised food system, ‘product’ replaces ‘food’ on the shelves and on our plates, says Otero. These products have even taken centre stage in an image-conscious world: a Big Mac has more social currency than a no-name-brand green apple.

The rise of Big Food in recent decades has created a kind of ‘food apartheid’: an “inequality in access to quality food”, as Otero describes it.

Wealthier families can afford ‘luxury’ foods such as meat, nuts, and fresh fruit and vegetables. Better-off households also usually own a car, so can easily drive to supermarkets to stock up on these foods and enjoy the discounts that come with the bulk buying power of big retailers. Meanwhile, residents of lower-income neighbourhoods have too little money to meet their day-to-day expenses, including food.

For a long time, food systems thinkers described the food environment in lower-income communities as food ‘deserts’: places where there was not enough healthy food available at affordable prices. The notion was that supermarkets would enter these neighbourhoods and fill this food gap. This largely has not happened (see Chapter 3: Cinderella Markets.) Now, however, a different term is coming through to describe the kind of food environment that’s evolving in these communities: the food ‘swamp’. It is not that there’s a lack of food in these neighbourhoods, according to the Lexicon of Food, but rather that they’re “flooded with unhealthy, highly processed, low-nutrient food combined with disproportionate advertising for unhealthy food compared to wealthier neighbourhoods”.

A lot of the food here is cheap, packaged, ultra-processed, and ultimately nutritionally ‘dead’. Carless, these families depend on their nearest food-store owner, whose shelves are stocked with mostly non-perishable food- like products, rather than real, fresh foods. For some spaza shop owners and roadside traders, it might make economic sense to stock their shelves and stands with foods that have a long shelf life and can withstand manhandling. It’s financially more risky to buy spinach leaves and tomatoes that bruise and wilt in a matter of days, compared with maize meal, crisps and biscuits. This is particularly true for stallholders who don’t have refrigeration or running water to keep their food safe and sanitary.

Even though there are plenty of vegetable vendors in Masiphumelele, Hunter Adams says it’s still often financially risky for people to buy healthier perishables.

“These foods are available in their communities, and people often want to buy fresh produce, but the economics might not add up,”

CUP lead researcher Dr Jane Battersby goes on to explain. There is the risk of fresh produce spoiling before a family can get to use it all up, which adds more risk to the equation. “That’s why ‘long-legged’ vegetables sell well, veggies like onions, butternut, carrots, or potatoes,” she adds.

In slowly weaving together the story of these women’s lives and their decision-making around food, Hunter Adams found another underlying reason why many of them didn’t want to take the time to prepare good food: because they were cooking and eating alone. And, although some of the older women still hankered after the ‘small foods’ they’d grown up eating in the Eastern Cape and said they did not really like the processed foods that typify their life in Cape Town, many seemed to be developing a taste for the sugary, fatty, flavoured foods that come in glitzy sealed packages with recognisable brand names.

The bottom line is that, in the ‘food swamp’ of Masiphumelele, poorer families are buying what they can afford within their budget, and what’s available in their neighbourhood.

When civil society group Oxfam looked at what South Africans were eating in 2014, it concluded that poorer families have “good access to bad food, and bad access to good food”. The food that is most readily available is cheap, highly refined, packed with starch and sugar, but with very little nutritional goodness. When the CUP researchers visited Kitwe, Kisumu and Epworth, they found that the diets in these neighbourhoods were still fairly traditional compared to those in South Africa’s cities, and that while there is evidence of a shift in the direction of the so-called ‘Western’ or ‘industrial’ diet, this hasn’t gained the same momentum as it has in South Africa.

In trying to explain why the Masiphumelele women are eating maize meal and white bread at month-end, rather than vegetables, Hunter Adams says the reasons are complicated.

“Multinationals expand their brands into developing markets by giving small, independent shop owners free fridges and vending machines or signage. In exchange, the shop becomes a billboard for the multinational’s corporate branding”

“It’s partly because vegetable calories are quite expensive, relative to many other kinds of calories. Many of these communities come from a background where they’d get vegetables free from their back yard, so it’s hard for them to get their heads around paying for veggies. It’s also partly because of the mixed messages they’re getting about what constitutes healthy food.”

Some of the women she worked with are cleaners in middle-class homes, where they’ve been given the impression that processed cereals, sweetened yoghurts, and fruit juice are healthy. As a result, they may spend a disproportionate amount of their food budget on these foods, which are high in sugar and not, in fact, terribly nutritious.

They might also be wooed by the marketing and advertising messages of the food industry, whose tactics have been described by leading public-health thinkers as persuasive and pervasive. The Lancet’s special report on obesity in 2011 goes so far as to say they are even predatory, particularly in terms of how they target children.

Big Food has its brand names everywhere, and their packaging is often misleading: the names of crisps or savoury biscuit snacks might contain the words ‘cheese’ or ‘beef’ because they’re flavoured to that taste, but creating the impression that they contain dairy or beef.

Maas is a big favourite here. These days, this traditional sour-milk drink is also made and bottled by dairy manufacturers for the formal retail sector. A bulk-produced modern spin on the old favourite now includes sweetened and flavoured versions, as well.

“The packaged food industry is implicated here. They market deliberately to the poor and take advantage of people with clever messaging,” says Hunter Adams. “People tell me they buy strawberry- or banana-flavoured maas, rather than plain maas, because they say it has fruit in it.”

A similar story comes from a state primary healthcare clinic in nearby Fisantekraal, a lower-income neighbourhood about 30 kilometres northeast of Cape Town, where a nurse was instructing young mothers to wean their infants onto a ginger-flavoured sugary drink, because the billboards in her neighbourhood associate the brand with a strong, lean champion boxer.

“The mind boggles,” the research coordinator from the Red Cross Children’s Hospital, who discovered this, said a few years later. “This nurse influenced an entire generation of babies, because we came across several mothers in that community who reported weaning their infants onto ginger beer.”

A nutrition and health consultant with the World Food Programme in Zambia also told of one mother’s reason for giving her weaning infant baked maize crisps: the product’s name referred to cheese, and she thought it must contain dairy.

With its massive profits, Big Food is able to use its global power and expert strategies to push brands into developing world markets in a way that has come under heavy fire in public-health circles, including the World Health Organization (WHO). Writing for the WHO in 2012, food policy expert Prof Corinna Hawkes from City, University of London, notes the extent of the reach of some of these multinationals, partly owing to fortunes they are able to spend on public relations, including “service-related marketing, television and movie tie-ins, sports sponsorship, music, event and product sponsorship, educational competitions, and philanthropy”.

Sponsoring global sporting events, such as the FIFA World Cup or the Olympic Games, and buying in sports stars to endorse their products, creates the myth that many of these food-like products are associated with fitness, leanness, sporting prowess, high social status, and desirability.

Hawkes’ critique gives a bird’s-eye view of the way in which these multinationals carefully strategise to expand their brands into developing markets. They do this through helping out small, independent and often informal shop owners by giving them free fridges and vending machines or signage. In exchange, the shop becomes a billboard for the multinational’s loud and visible corporate branding. The evidence of how effective they are is visible right here on the streets of Masiphumelele.

Deep in the settlement, where Pokela Road crosses Masemola Road, the neglected tar surface begins to crumble, petering out into a muddy dirt track that leads towards the last rows of houses. The pavement is lined by a moat of muddy water because the storm-water drains have clogged up with rubbish that escaped the municipal garbage truck’s last collection run.

Yet where the state is struggling to meet the needs of its citizens, a multinational is managing to do its work. There’s a two-storey zinc building on the corner, its baby-blue and pink painted walls faded by the sun and weeping streaks of rust here and there. The building is part home, part business. Hand-painted signs advertise the services of a local barber and announce that there’s second-hand furniture for sale inside.

The sign immediately above the shop, crowing loudest of all from the second-storey wall, tells the neighbourhood that this is the spaza shop Mogadishu*. The shop’s name is printed in white text against a red background. Stamped immediately below Mogadishu is the name of the entity that gave this sign to the trader who would otherwise not have been able to afford it: one of the most recognisable personalities on the planet – Coca-Cola.