Experiences in addressing malnutrition and anaemia in Gaza

By Dr Bassam Abu Hamad and Erik Johnson

Dr Hamad is Palestinian Public Health Professional with a PhD in health management, and works at the School of Public Health, Al Quds University, Jerusalem. He has extensive experience in health research, particularly health services research and nutrition. He is widely involved in strengthening the health care systems with particular interest in quality management, using health information systems and nutrition research. He performs consultancy services to the NECCCRW Nutrition Programme.

Erik Johnson is Humanitarian Response Coordinator with DanChurchAid, based in Denmark.

Special acknowledgements are extended to the Near East Council of Churches for their commitment, dedication and sincere efforts to help the Palestinian people, especially women and children. The Management Board of the organization and its Executive Manager played a vital leadership role is making the life of many Palestinians much better. Special thanks to Mr Constantine S. Dabbagh, the Executive Secretary/manager of the NECCCRW, Dr. Salim Al Abadlah, the Medical Coordinator of the NECCCRW and to the project teams and the administrative support teams for their great efforts and sincere commitment. Finally thanks to the support of DanChurch Aid, especially Mads Schack Lindegaard, Regional Representative DCA Palestine, and the support of the Danish people through DANIDA.

Household food security in the Gaza Strip has deteriorated significantly since the inception of the Israeli blockade in June 2007, with extremely severe restrictions on the entry of goods and the virtual halt of movements of Gazan people in and out of the territory¹. Acute malnutrition rates amongst children under 5 years are low, but the rate of chronic malnutrition has risen over the past few years, reaching 14 percent stunting of the population in the area of Shajia, Eastern Gaza.²

The Near East Council of Churches Committee for Refugee Work (NECCCRW)/ DSPR (Department of Service to Palestine Refugees) has been successfully providing maternal and child health care to populations in the Gaza Strip for the last 42 years. A key component of service delivery in NECCCRW's clinics includes a 'well baby' programme, which has long included the screening and referral of moderately and acutely malnourished children. In the past, moderately malnourished children were treated through a combination of nutritional counselling, micronutrient supplements, and intense follow up, with satisfactory results. Rarely identified cases of severely malnourished children were referred for in-patient care.

Following the commencement of the economic blockade of Gaza, NECCCRW staff witnessed two changes; an increase in moderate child malnutrition, and the inability of its prevailing treatment protocol to address the moderate malnutrition in the face of lack of household food availability. In the project area, 80% of households live under the poverty line (2 USD per person per day), with a full 70% living under the absolute poverty line of 1 USD per person per day. The staff of NECCCRW and its partner organisation, DanChurchAid, have also witnessed a direct impact of the deteriorating food security on the time required for malnourished patients to revert to normal weight for height curves. Recovery was taking an unacceptably long 12 to 14 months.

Throughout the Gaza Strip, stunting rates due to chronic malnutrition have been increasing. Data show that chronic malnutrition increased from 8.3% in 2000 to 13.2% in 2006³. It can be speculated that given the current state of food security in Gaza, stunting has risen further since the inception of the blockade. In NECCCRW's operational area, the prevalence of stunting is 14%. In December 2008, the effects of the ongoing crisis were exacerbated by the Israeli launch of a three week military operation in Gaza (Operation Cast Lead).

Given the chronic deterioration in childhood nutrition, a project was designed by NECCCRW to adjust the existing treatment to the worsening environment. This article describes a programme to respond specifically to acute malnutrition and anaemia amongst children under five years in the eastern area of the Gaza Strip. The programme coincided with but was not a direct response to the 2008/09 conflict.

The authors consider the programme unique in its approach of comprehensive household screening and referral, integrated health care management for children under five, and sophisticated management of patient data. The methodology developed by this programme may be relevant for other agencies implementing nutrition programmes in urban environments during protracted complex political emergencies. It may have particular relevance for agencies implementing nutrition and feeding programmes in the Gaza Strip, where household food insecurity is expected to continue to deteriorate.⁴

Project overview

The project was implemented in Shijaia area, which is served by the Shijaia clinic located in the east of Gaza City. The area contains around 80,000 inhabitants and is regarded as vulnerable. The project started on April 1st 2008 and was planned for one year initially. Project activities were suspended during the war on Gaza, when the clinic was demolished. Activities resumed after approx 2 months and were continued until 31 July 2009. The care of outstanding enrolled cases was integrated into the regular operations of the Shijaia clinic.

The project aim was to improve the health and nutrition status of targeted mothers and children under 5 years in the project area during the programming period. Target indicators for the intervention included ensuring that at least 95 percent of children identified as malnourished receive supplementary feeding (or are referred to other agencies in the case of those with severe malnutrition), and decreasing the percentage of malnourished children presenting to the health centre is by 30% from a baseline of 10.6 % in children under 5 years.⁵

The project operated in one of NECCCRW's four clinics. The NECCCRW staff continued to identify malnourished children in the clinic's 'well baby' programme as per the prevailing methodology of nutritional counselling, micronutrient supplementation and follow-up. This new programme had three significant new features:

• Household screening and diagnosis/referral
• Supplementary feeding through the supply of infant formula to malnourished children
• Development of a new database to enhance the management of patient data and follow up

A flow chart of the workplan to manage malnutrition is shown in Figure 1.

Key programme features

Comprehensive household screening and diagnosis

This element of the programme aimed to increase coverage and participation in the 'well baby' programme. However, the staff feared that inviting all mothers of children under 5 years to a series of community 'weigh-ins' might not succeed in engaging the most marginalised families. Therefore they planned to visit every one of the 13,799 households in their catchment area, with a total population of 82,464 residents.⁶ Six community workers visited the houses in pairs (each team composed of two workers). Each team visited around 20 houses every day. Coverage proved high, since not a single household was missed.

The household visits had additional benefits. These visits afforded an opportunity for the clinic staff to engage in one-on-one dialogue with the mothers about their children's nutrition. Because of the sensitive nature of child malnutrition for many families, women may find it easier to discuss the issue on a one to one basis in their own home rather than in a large public setting.

These visits also presented an opportunity to assess weight for height, mid-upper arm circumference (MUAC), and anaemia status of children. Anaemia was tested using a portable hemocue kit⁷. Children identified with anaemia were immediately given iron supplements on the spot, and these and all other acutely malnourished children were referred to the NECCCRW clinic for admission to the programme.

Expanded treatment of acute and chronic malnutrition

Supplementary feeding using infant formula

Children were admitted to the supplementary feeding programme based on anthropometric indices (z score). Moderate underweight, wasting and stunting were all included in the target group (weight-forage -3> to <-2, weight-for-height -3> to <-2 and height-for-age -3> to <-2 in z scores, respectively). Whilst typical 'emergency' interventions target cases of wasting, this programme elected to expand the admission criteria to include underweight and stunting. This decision was based in the context of a broader programme to address maternal and child health and to encourage healthy breastfeeding, hygiene and nutrition practices amongst mothers. Discharge was based on achieving >-2 z score. Severe cases of malnutrition were referred to Ard El Enssan specialised nutrition centre and/or to Ministry of Health facilities.

The new treatment protocol introduced in this project period used infant formula as a take home ration and targeted children 6 months - 3 years of age⁸. Malnourished infants under six months of age received no infant formula and exclusive breastfeeding was promoted. Children between six and 12 months of age received one type of infant formula in conjunction with promotion of breastfeeding and healthy eating practices. Children between one to three years received another type of infant formula, in addition to promotion and support of healthy eating practices. The infant formula was provided for up to a maximum of four months. In addition, initial examination and screening of children was complemented by a range of laboratory tests for parasitic infections and other diseases. Identified malnourished cases were seen monthly at the NECCCRW clinics.

Whilst programme staff were aware of guidelines and standards surrounding provision of breast milk substitutes, they determined that its use in this context was to complement rather than substitute breastmilk intake. Infant formula was classified as an 'enriched milk based food' and so considered by the programme and ministry colleagues and advisors to concur with WHO guidelines⁹. Other organisations were providing complementary food and NECCCRW referred poor cases to Social Welfare organizations providing complementary food, such as Ard El Enssan and the Ministry of Social Affairs. Financial and logistic difficulties were also contributing factors to not supplying food; due to Israeli blockades, only commercially available foods are available for use as supplementary foods. Given the considerable logistics of food procurement and provision and the fact that food was more likely to be shared by the wider family but milk restricted for use in children, it was considered more cost effective and practical to use milk. As per Sphere standards, caregivers received advice and support on its safe use. For more discussion of use of infant formula, see Box 1.

Table 1 shows the change in the status of children illustrated by different periods. Almost 60% of the wasted children recovered within 3-4 months since the diagnosis. Additionally, 82% recovered within a period between 4-5 months.

Table 1: Change in the status of malnourished cases admitted to the programme per period of enrollment
Change period	Change period		Improved		Remained the same		Deteriorated		Total
	No	%	No	%	No	%	No	%
Wasting
Less than 60 days	10	35.7	2	7.1	13	46.4	3	10.7	28
60 - 90 days and more	13	59.1	1	4.5	4	18.2	4	18.2	22
91 - 120 days	13	61.9	0	0.0	5	23.8	3	14.3	21
121 - 160	14	82.4	0	0.0	1	5.9	2	11.8	17
More than 161 days	61	83.6	2	2.7	8	11	2	2.7	73
Under weight
Less than 60 days	19	21.6	1	1.1	64	72.2	4	4.5	88
60 - 90 days and more	36	59.0	0	0.0	23	37.7	2	3.3	61
91 - 120 days	48	62.3	2	2.6	22	28.6	5	6.5	77
121 - 160	57	85.1	4	6.0	6	9.0	0	0.0	67
More than 161 days	125	69.1	7	3.9	48	26.5	1	0.6	181
Stunting
Less than 60 days	63	22.3	8	2.8	193	68.4	18	6.4	282
60 - 90 days and more	50	29.9	4	2.4	100	59.9	13	7.8	167
91 - 120 days	49	28.2	9	5.2	108	62.1	8	4.6	174
121 - 160	62	30.0	6	2.9	128	61.8	11	5.3	207
More than 161 days	150	33.7	28	6.3	148	55.7	19	4.3	445

 

The large scale conflict in Gaza in late 2008/early 2009 led to an interruption in treatment plans for two months on average (range 37 to 90 days). Table 2 shows both the average and median times for recovery for two periods: the project period which covers the entire project life including the suspension period (2-3 months) and the period after the war starting from March 1st (when there as no service disruption). The suspended service increased the average length of stay recorded and the median time for recovery. The 'post war' period therefore gives a better indication of recovery time.

Breastfeeding status was not assessed in children enrolled in the supplementary feeding programme. Information on breastfeeding status was available at from the NECCCRW's clinic-based database found that the prevalence of exclusive breastfeeding at Shijiaia clinic amongst children aged under 6 months was 45%, more than double the prevalence at the national level. Among children less than 2 years old, 55% were breastfed in combination with other foods. At UNRWA clinics, the NECCCRW supervising Public Health Specialist supervised a study on weaning practice in the summer of 2009 which showed that the median cut-off for breastfeeding in all of the Gaza Strip was 14 months.¹⁰

Anaemia and micronutrient deficiencies

Anaemia is highly prevalent amongst under 5 year olds across the region. In a study conducted in 2006, 57% of children aged 6 - 36 months of aged were found to be anaemic¹³, well above the 40% threshold considered as a severe public health situation according to WHO standards¹⁴. Of the 14,796 children screened by the NECCCRW programme, 5,795 (43.3%) were identified as anaemic, 56.5% suffered from mild anaemia, with the remainder suffering from moderate anaemia.

Anaemia in Gaza is generally attributed to the lack of iron sources in the diet and exacerbated by the high presence of nitrate in the groundwater, which can lead to methemoglobinaemia¹⁵. Following Operation Cast Lead in 2008 - 2009, the ability to treat sewage and prevent seepage of nitrates into the ground water has significantly deteriorated. This has lead to speculation that a higher level of nitrates in the groundwater has resulted in some areas.

Table 2: Time for recovery (days) for malnourished cases for the entire project period (1 April 2008 - 31 July 2009) and for the post conflict (1 March - 31July 2009 period only)
Variable	Mean (days)		Median (days)		SD(days)
	Project period	After the war	Project period	After the war	Project period	After the war
Wasting	83	45	55	35	79	35
Underweight	79	41	55	40	70	26
Stunting	102	61	68	61	93	34

Figure 2 outlines the project work plan to treat anaemia. Anaemia is treated according to the Palestinian protocol through providing iron supplementation of 6 mg per kg body weight for three months followed by prophylactic dose (3 mg per kg body weight) for additional an three months after the haemoglobin reaches 11 mg/kg body weight. Children with anaemia are examined for the existence of other conditions, such as infections and bleeding, and treated accordingly. During iron supplementation, haemoglobin levels are assessed at least twice to monitor the progress. For non-responsive cases, multivitamins are provided, including vitamin A and D. Due to lack of its availability in Gaza and its high cost, Vitamin A is not give routinely.

Around 70% of anaemic children recovered and returned to normal within 2 months of starting treatment. These figures climbed to 80% after 3 to 4 months in the programme. Those children who had not recovered after 3-4 months continued under treatment after the end of the project. Currently, most of these children have now recovered.

Nutritional, health, and hygiene counselling

A key feature behind the success of the programme has been the degree of follow up with patients and the close engagement with them by NECCCRW staff in their child's health and growth progress. The programme started with introductory meetings with community leaders and community members to gain their commitment, ownership, and support.

Health education was provided during home visits to every caregiver, followed by targeted focused sessions to caregivers of anaemic and malnourished children. Health education sessions were also provided to community based organizations while individual counselling sessions were provided for specific cases - mostly for non responsive cases. The key messages of the counselling were healthy nutrition, hygiene and sanitation, as well as breastfeeding, feeding practices, and how to ensure an iron-rich diet.

In addition, two health awareness brochures were developed for mothers, one on anaemia and one on malnutrition and 15,000 copies were printed and distributed via home visits.

Database for managing patient data

The project developed a database to capture the following information:

• Demographic data
• Socioeconomic data
• Anthropometric data, which are automatically converted to z scores
• Haemoglobin levels
• Data pertaining to confounders, such as enrolment in other programmes
• Computerized automated appointment system
• Health education related data
• Type of medication and treatment modalities
• Built in quality control measures for outlier values

The newly developed data based served many functions, including automatically generating charts to show the progress of cases according to z score. The system also automatically generated appointments, organized the work through 'smart enquiries,' and provided reminders for health providers about the measures to be taken according to the treatment protocol. Other facilities included automatically generating patients' prescriptions, organizing patient flow, showing workload, planning and staffing level needs, requesting medications and supplies, follow up of field work and showing overall impacts in a timely manner. No forms or paper work are used at all - data is inputed directly by staff.

The database also shows the measures taken to follow up defaulters. Every day, staff are provided with the names, addresses, and contact information of those who didn't present for follow up. The results of efforts to address defaulters are presented, as well as reasons for their non attendance. Outcomes of measures to get defaulters to return to the programme are presented and response comparisons are made between those who remain in the programme and those that default.

Presentation of household screening data

Of the 82,464 persons in the catchment area, 14,976 were children under 5 years (18.2%). Through household screening, 1,307 children (8.7%) were identified as malnourished (wasting/underweight/stunted¹⁶). Underweight accounted for 2.3% and wasting for 1.1% (n=159) of children under five years. The prevalence of stunting in the under five population was 7.7% (n=1160). A total of 263 children (1.7%) were identified as severely wasted/underweight/stunted.

These malnourished children were more likely from large families, not refugees, and from economically disadvantaged families. (Refugees typically receive food distribution from UNRWA, the UN Relief and Works Agency). Other studies have found that stunting is closely associated with low levels of maternal education with the highest stunting rates found amongst families where the mother has had no education¹⁷.

More than 80% of children who were underweight or wasted improved and/or returned to their target weight after 3 to 4 months since their enrolment in the programme. This is a dramatic improvement over earlier performances. Thirty three percent of stunted children recovered from this acute episode and/or improved after 3 to 4 months of enrolment in the programme, a figure which climbed to 40 percent with more time spent in the programme.

The recent escalation of conflict in Gaza led to interruption of treatment plans and to increased numbers of defaulters. There were clear variations in defaulting patterns across the different areas. More defaulters were reported among children from areas far away from the NECCCRW clinics. No gender related variations were noticed among defaulters. Defaulters identified towards the end of the project period, when follow-up was no longer possible, constituted a higher proportion than those identified early in the programme and from more accessible areas. Reasons for not coming are explained below.

Challenges, areas for improvement and next steps

• Operation Cast Lead: Destruction of the Maternal - Child Health Clinic by Israeli Missiles

The major challenge during the last programme period was the total destruction of the NECCCRW clinic by Israeli missiles. The clinic was targeted by the Israeli air force which fired missiles during a night time operation.

Therefore none of the clinic staff were present. However, the event led to complete disruption of programme activities, loss of valuable equipment, and contributed to the psychological trauma already experienced by clinic staff and patients as a result of the war. This resulted in a cessation of treatment for 2 months, and the loss of some important baseline public health data regarding levels of diarrhoea, parasitic infections, and skin diseases. Some key target indicators for the project could not be calculated due to loss of records. A new clinic building was subsequently identified and renovated following the war, and activities resumed.

• Analysis of defaulters

Approximately 70% of defaulters were reenrolled in the programme following telephone contact or home visits by project staffs. Only 4% of children who defaulted did not return. The most frequently reported reasons for not coming included forgetting the appointments, family issues, geographical distance of the clinic, sickness of the mother, follow up with other health care providers, waiting time, crowdedness of the clinic, and children's distaste for the iron supplements. Furthermore, as it takes time to recover from chronic malnutrition some families felt discouraged and so discontinued treatment. Also, as stunting affects the poorest and marginalized sections of the population who usually live relatively far away from the clinic, accessibility and transportation were noted as significant issues.

• A psychosocial component to malnutrition

Malnutrition has acknowledged and well documented psychological dimensions, and in Gaza, the effects of the recent war on the mental health of young children and their families were particularly significant. Whilst the primary cause of malnutrition amongst Gazan children is still believed to be household food insecurity, the next phase of the programme will look at the psychosocial status of the children together with DCA partner, Youth Education Centre (YEC).

• Coordination, including better linkage with therapeutic feeding programmes

Provision of health care in the occupied Palestinian territories is extremely fragmented, with a number of different agencies providing a patchwork of services that covers the territory. Through its activities, NECCCRW was able to positively identify families entitled to assistance from the Ministry of Social Affairs based on socio-economic criteria. This assistance may help to prevent future cases of malnutrition.

NECCCRW spends significant energy in coordinating with other actors, including the Ministry of Health and Health Cluster in Gaza. They found that the national protocol for treating malnutrition is generally effective, and that proper implementation of the protocol can lead to positive outcomes.

Severely malnourished children identified through the NECCCRW programme screening are in this case referred to Ard El Enssan specialised nutrition centre, which provides in patient care. Whilst the collaboration with Ard El Enssan has been excellent, the fact that there are two different organisations - with two different sets of data management protocols, teams, and follow-up methodologies - has proved a challenge with respect to ensuring that patients discharged from in patient care continue to maintain their normal weight/ height growth curve, and do not relapse.

• Increasing the geographic coverage to all of NECCCRW's clinics

Currently, the project only operates in one of NECCCRW's three clinics. The next project phase aims to extend the geographical coverage of the programme to all three of NECCCRW's clinics in Gaza.

• Collaboration with the Emergency Nutrition Network (ENN) to ensure that the database includes relevant elements of the SFP Minimum Reporting Package

The project has followed the developments with respect to improving reporting on emergency SFP programmes¹⁸ and the subsequent efforts by ENN and others to develop a minimum reporting package. ENN and NECCCRW staff will be collaborating later this year to determine if there are elements of the newly developed MRP that have not yet been captured by the NECCCRW database.

Conclusions

The three key features which led to the positive outcomes of this programme - household screening and diagnosis, a comprehensive treatment approach including preventive child health care, and a computerised database to reduce paperwork and enable staff to proactively respond to changes in the patient's condition - are likely to be most relevant to programmes operating in complex political emergencies in urban or peri-urban environments.

Neither the prospects for household food security or the political and security outlook are promising in the Gaza Strip. The severity of the already dismal situation is masked by the fact that 71% of households already receive regular humanitarian assistance, mostly with food¹⁹. If the economic barricade of the Gaza Strip continues, or further deteriorates due to another war, further restrictions on the lifeline of humanitarian food assistance to Gazan households are likely to result in more severe deteriorations of household food security, and concomitant increases in child malnutrition.

For further information, contact: Dr Bassam Abu Hamad, email: ghsrcb@gmail.com, tel: 00 9705 99351515

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¹NECC final project report, July 2009

²As footnote 1.

³UN Food and Agriculture organization and World Food Programme. Food Security and Vulnerability Analysis Report, occupied Palestinian territory, December 2009

⁴As footnote 3.

⁵DanChurchAid. NECC/DCA application to Danida, 2008

⁶NECC final project report, July 2009

⁷This one step device uses a cuvette but does not require wet reagents, making it suitable or rapid but credible field work. It is easy to train non-laboratory personnel to operate the device and it does not require a source of electricity.

⁸As reflected in Figure 1, the infant formula was planned initially to be provided to acutely malnourished children aged 6 m-2 years. Later on, with the availability of extra support, the age was extended up to three years since the prevalence of malnutrition is high for this age category.

⁹WHO (2005). Pocket book of Hospital care for children. Guidelines for the management of common illnesses with limited resources. p272. This gives examples of local adaptations of feeding recommendations that includes milk in options for children over 6 months of age. www.who.int/child_adolescent_health/documents/9241546700/en/index.html

¹⁰Samour H 2009. Weaning practices among children less than 2 years attending UNRWA health centres. Master thesis. Al-Quds University, Jerusalem.

¹¹Increased diarrhoea following infant formula distribution in 2006 earthquake response in Indonesia: evidence and actions. Field Exchange, October 2008, Issue 34

¹²USAID, Maram Project (2004). Survey of women and child health and health services in the West Bank and Gaza Strip.

¹³DanChurchAid. Emergency Humanitarian Nutrition and Health Response for Vulnerable Children in Shijaia Area - Gaza Strip. 2009

¹⁴UN Food and Agriculture organization and World Food Programme, Food Security and Vulnerability Analysis Report, occupied Palestinian territory. December 2009

¹⁵This is a blood disorder caused by abnormally high level of methemoglobin, a form of haemoglobin that does not bind to oxygen.

¹⁶Weight-for-height <-2 z score; weight-for-age <-2 z score; height-for-age<-2 z score, respectively.

¹⁷Palestinian National Authoirity, Palestinian Central Bureau of Statistics, December 2007 - Palestinian Health Survey, 2006 Final Report.

¹⁸Navarro-Colorado, C., Mason, F., Shoham, J. Measuring the Effectiveness of Supplementary Feeding Programmes, Network Paper 63, Overseas Development Institute, September 2008

¹⁹UN Food and Agriculture Organisation and World Food Programme. Food Security and Vulnerability Analysis Report, occupied Palestinian territory, December 2009