Promoting Good Nutrition and Food Security in the Gaza Strip

by Jane Hanon (Terre Des Hommes, Gaza)

The Gaza strip lies on the Mediterranean Coast between Egypt and Israel. It has an area of 360 square kilometres and just under one million (Palestinian) inhabitants, over 50% of whom are under 15 years of age. Approximately one quarter of the strip is occupied by around 4000 Israeli settlers. Gaza was directly occupied by Israel from 1967-1994 and Israel maintains control over the Israel/Egypt border, the air, and the sea.

Waged labour in Israel and the export of manufactured and agricultural goods to or through Israel remain the main sources of income alongside overseas aid. Raw materials and parts for industry are also mainly imported from or through Israel. However, in recent years, Israel has carried out a policy of periodic border closures justified by concerns about security allowing fewer Palestinians from Gaza and the West bank into Israel and restricting the export and import of goods.

Around two thirds of the inhabitants of the Gaza strip are refugees, i.e., people whose families lived in what is now the state of Israel until 1948 when they were obliged to flee to live in the West Bank, Gaza Strip, Jordan, Syria and Lebanon. The United Nations Relief and Works Agency for Palestinian Refugees in the Near and Middle East (UNRWA) was set up to look after the interests of these people and has been providing health education and welfare services since 1948.

The other major health providers in Gaza are the Palestinian National Authority and a number of national NGOs which are supplemented by the work of international NGOs. Approximately 40% of the inhabitants of the Gaza strip live in refugee camps. These consist of housing of varying degrees of completeness ranging from corrugated iron shack-like structures to normal houses. Around 45% live in cities while 15% live in villages and small towns.

Terre Des Hommes:

Terre Des Hommes (TDH), a Swiss NGO, has been working on nutrition related issues in Gaza for 11 years. I am employed as a nutritionist by TDH. We have two centres in Gaza and one in Hebron. Each centre has the services of a doctor and offers nutritional advice and support for malnourished children, breastfeeding counselling and care and advice for the treatment of diarrhoeal diseases. Attached to each centre are community health educators who follow up children at home and provide nutrition and health education in the community. Simple supplements of a rice/lentil and a rice/groundnut/sugar mixture are given to help and encourage families with malnourished children.

Food Security:

Gaza has limited agricultural land in relation to the number of people who live there. Because Gaza does not have control over its own borders and is not self sufficient in important foodstuffs, food security is highly dependent on Israeli border closure policies.

As over ninety five percent of Gazans obtain food through purchase, income is the most important factor affecting food security. The average number of Palestinians employed in Israel declined from about 116,000 in 1992 to an average of about 32,000 in 1995. Total border closure days were 28 in 1992 and 125 in 1995. Per capita income has dropped 37% since 1992.
In May 1996, due to mounting concern about the effects of border closure on household food security, we at TDH carried out a survey of 300 households in city, village and camp areas in the north and south of the Gaza strip. The survey found that while most houses seemed to be managing to provide the bare essentials of flour, rice, sugar, vegetables and pulses, they were doing so by increasing debt and sale of possessions. The percentage of households in debt had risen from 28% to 57% and the average debt per household had risen by 154%. We concluded that the situation was not yet critical but needed close monitoring.

The Nutritional Context:

In 1995 we carried out a random cluster sampling survey of the nutritional status of 1500 children under five. The survey found that 14.2% of children were stunted (< -2 SD of the reference height for age) and 5.7% were wasted (< - 2 SD of the reference weight for height). Factors that were significantly associated with malnutrition were; educational status of parents, number of meals eaten by children each day, toilet facilities, and whether or not money was borrowed to buy food. A more recent survey by the Palestinian Central Bureau of Statistics, carried out in the second half of 1996, found no evidence of an increase in levels of malnutrition since the TDH survey.

Over 50% of malnourished children seen by us in TDH centres are under 6 months of age. The breastfeeding counselling programme offered by TDH has been greatly strengthened during the last year and the impressive results shown have emphasised the role of breastfeeding, or lack of it, in many of the nutritional problems seen in young children. Fifty two percent of mothers used formula milk with 62% of these using it below 3 months of age and 85% below 6 months of age. Other factors which appear to play an important role in causing malnutrition are parasitic infestation, diarrhoeal and respiratory infections, and poor weaning habits.

Deteriorating Nutritional Status:

Of particular concern to us in TDH at the moment is the fact that reduced food security now appears to be having an impact on nutritional status. We have recently seen a number of children at our centres who were readmitted after having been discharged with adequate nutritional status. Many of these children are not ill and appear to be malnourished because of lack of food at home. There have also been recent reports by doctors in government and IJNRWA clinics of an increase in the number of children seen with rickets (mainly under two years of age). Cases of rickets have also been seen in TDH centres. IJNRWA and the government are now planning a survey to establish prevalence of this condition. The problem is, that the questionnaire used as part of this survey doesn't ask questions about maternal diet during pregnancy, or ask the right questions about exposure of the child to sunlight. For example, there are no questions on child clothing or lengthof time the child spends in sunlight (children are often swaddled in clothing so only their faces-would be exposed to sunlight). These questions may however be addressed in a subsequent survey. To us, it appears likely that the reported rise in cases of rickets is due to worsening food security as there has been a marked reduction in consumption of animal products in recent months.

Anaemia:

Another worrying nutritional problem is iron deficiency anaemia. A survey in 1994 of mothers in the first and third trimester of pregnancy found prevalence rates of 33% and 44% respectively. A later survey in 1995 of children under nine months of age found 71% anaemia (11 gms/dl). Iron supplementation has been operative throughout government Mother and Child (MCH) centres. While the supplements used to be kept in the centres and given by the nurse, they are now available by prescription which has to be taken to the pharmacist. However, unless women are convinced about the value of the supplement, they arelikely to be discouraged, especially as the pharmacist's supplies are not always well stocked. A recent survey found that many women did not understand why they were being prescribed iron, reflecting inadequate health education messages. It also found that many mothers did not take the supplement regularly, again demonstrating a lack of understanding about its importance.

TDH is currently considering a pilot study to test the effectiveness of community-based distribution of iron supplements using mosques as a focal point. Friday prayers is thought to be attended by over 90% of men in Gaza, providing access to a good cross section of an influential part of the community. The idea is to provide a health education message for men after prayer about iron supplementation and to ask them to take away iron capsules if they have a pregnant woman in their family.

The main factors leading to anaemia appear to be poor birth-spacing, parasitic infestations, a wheat based diet, the effect of tea consumption on iron absorption and the gradual reduction in availability of animal sources of iron.

Targeting Food Aid: Past and Present

Right now we are particularly worried at TDH about the fact that there is no adequate system within Gaza to provide food aid support for the increasing numbers of families who may need it. Although WFP is active in Gaza it lacks, as does its implementing partners, the capacity for a large-scale targeted food distribution. Approximately one year ago WFP and TDH attempted to set up a targeted general ration system for breastfeeding mothers of malnourished children. However, at times, the TDH centres rapidly became inundated with families wanting the ration so that our normal work activities began to be compromised. We came to realise that we lacked the administrative capacity to implement this type of programme unless distribution took place away from the centres and that any larger assistance programme needed to be handled by the government.

A government system does exist but both IJNRWA and the Palestinian Authority (Ministry for Social Affairs) do not include unemployment of the fath~r as a criteria for assistance. This is because until recently, there was not a great deal of unemployment. Current criteria for assistance are therefore, absence of a main income eamer in the family (this includes widows, women whose husbands are in prison, divorced women, etc) or if the main earner is chronically ill or disabled.

The Way Forward:

How families can be better helped is difficult to say. It is always easier for donor nations to offer more money than to exert effective political pressure on Israel to end Gaza's state of siege. This is the only long term, development-oriented solution. In the meantime, while an unemployment benefit system would appear to be called for, such a system could badly damage the extended family system which has helped so many families survive this far. Also, before we could come up with better targeting systems we would need surveys to help improve understanding of the nature of food insecurity in the Gaza strip.

It is possible to imagine many problems in trying to establish a better targeted system. For example, how would it be decided whether or not a family had support from relatives? Also, while indicators like extent of debt or remaining saleable assets could be useful measures of food insecurity, it may be difficult to get accurate information, p5ticularly if people see the answers they give as influencing whether they receive food aid. For us in TDH there appears to be little information in the public domain on how to target general ration support to the type of population we are dealing with here in Gaza.

To close on a more optimistic note, we are encouraged by the increasing interest shown by the MoH and other health providers in food and nutrition issues over the past two years. Hopefully, this will eventually translate into improved nutritional well-being for the Palestinians who for many years have had to endure so many hardships.

We asked Marion Kelly from ODA to read this article. She welcomed the article saying that it raised important issues and questions. We have summarised some of her comments below.

It is astonishing that over half of the malnourished children in this population are under 6 months of age. This is markedly different to the majority of African populations in which wasting in infants under 6 months is very rare. It seems possible that most of the malnutrition seen in Gazan children under 6 months of age in 1995 was attributable to sub-optimal infant feeding practices. If these young infants had instead been breastfed the prevalence of wasting in children under 5 would have been about 3%, barely above the level in a Western reference population. Of course, this line of reasoning is speculative, but unless use of breastmilk substitutes has been reduced considerably relative to the levels cited earlier (i.e. 62% below 3 months and 85% below 6 months), the priority to be given to other forms of intervention e.g. targeting general rations, remains unclear.

If artificial feeding of infants is still common despite the breastfeeding counselling programme (as implied by the fact that 50% of malnourished children are young infants), it is possible that rising rates of malnutrition have something to do with the availability and price of breastrnilk substitutes (as well as with the prevalence of artificial feeding).

It would be interesting to know what happens to the availability and price of breastmilk substitutes when the border is closed. Do supplies drop and prices increase? Do families (especially those of workers directly affected by border closures) respond by reducing the amount of infant formula they buy?. Do people buy other (cheaper) milks instead of infant formula?