Nutritional Assessment of the West Bank & Gaza Strip

from CARE
Published on 02 Jan 2003
Gaza Strip faces a distinct humanitarian emergency; CARE International Assessment finds high levels of Malnutrition, Anemia and Micro-nutrient Deficiencies in the West Bank and Gaza Strip
JERUSALEM (January 2, 2003) - CARE International today released a 67-page report with findings of a Nutritional Assessment carried out in the West Bank and Gaza Strip. The survey indicates that Global Acute Malnutrition (GAM) for children aged 6-59 months stands at 13.3% in the Gaza Strip and 4.3% in the West Bank. In a normally nourished population, the figure would be 2.3%. Global Chronic Malnutrition (GCM) for the same age group is 17.5% in the Gaza Strip and 7.9% in the West Bank. These findings are based on a survey of 1,004 households randomly selected in the West Bank and Gaza Strip. Preliminary assessment results were released in August 2002.

The Assessment's other findings provide important data regarding household level access to food, the ability of the market to provide various products and the ability of clinics to respond to the rising levels of malnutrition and anemia. These findings reveal that the current nutritional crisis is exacerbated by market disruptions from curfews, closures, military incursions, border closures, and checkpoints; decreased caloric and micronutrient intake by preschool aged children; and the fact that healthcare providers may not be adequately identifying and diagnosing malnutrition in their communities.

Unlike the levels of malnutrition, the prevalence of anemia among children 6-59 months of age varies little between the West Bank (43.8%) and the Gaza Strip (44%). Four of five children in both areas have inadequate iron and zinc intake, deficiencies which cause anemia and immune deficiencies, respectively. In both areas over half the children have inadequate caloric and vitamin A intake while half the children have inadequate folate intake. Non-urban areas of the Gaza Strip fared worse in all categories of intake. A large percentage of reproductive-aged non-pregnant women have deficiencies in energy, iron, folate, and zinc consumption, critical for healthy fetal development. Reproductive-aged women also show a 15-20% decrease in per diem calorie and protein intake compared to 2000.

The clinic portion of the Assessment reveals the inability of clinics to properly and accurately diagnose and treat malnutrition and anemia. The survey found that attention to growth and monitoring of children declines as the age of the child increases, so that only 18% of children 25-36 months had had their weight recorded in the previous six months prior to the interview. Despite the objective prevalence of malnutrition from the clinics' own records, clinic managers subjectively estimated only 1% of preschool aged children were malnourished. The clinic survey covered a sample of 68 clinics, half of which did not have protocols or guidelines within the clinic setting to standardize the diagnosis and treatment of malnutrition and anemia, or the guidelines for counseling or follow-up for such cases. Further, 27.9% of all 68 clinics (19) and 40.7% of the 27 rural clinics (11) lack supplemental iron for children.

Finally, the market portion of the Assessment documented sustained major market disruption of infant formula and other high protein foods critical for growth. For West Bank retailers, incursions/curfews were cited as the major reason for disruption (53%) followed by road closures/checkpoints (38%). For West Bank wholesalers, road closures/checkpoints were cited as the major reason for disruption (52%) followed by incursions/curfews (34%). For both Gaza Strip retailers and wholesalers, border closures were cited as the major reason for disruption (60% and 63% respectively) followed by road closures/checkpoints (20% and 15% respectively). The market survey was a representative sample of 660 retailers and 140 wholesalers stratified by urban wholesale, urban retail, large village and refugee camp, and small village.

The report concludes with 6 pages of recommendations aimed at policymakers, donors and the humanitarian aid community. The authors caution against large bulk food distribution programs which would undermine functioning markets and further deflate prices and recommend instead limited targeted supplemental feeding programs. Other recommendations include micronutrient supplementation and health provider education.

The Assessment was funded and supported by CARE International with a grant from the US Agency for International Development (USAID). The survey was implemented by Al Quds University (Jerusalem) and the Global Management Consulting Group (Ramallah) with technical assistance from Johns Hopkins University (Baltimore). The report is available on the following websites: and

Media Contacts:

Jerusalem: Lucy Mair,, +972-(0)54-542-751
Atlanta: Lurma Rackley, CARE USA,, +1-404-979-9450


Table of Contents

Tables and Graphs
Executive Summary

  • Introduction
  • Objectives
  • Methods
  • Summary of Findings
  • Conclusions
Household Survey
  • Objectives
  • Methodology
  • Results and Discussion
  • Conclusions
Clinic Survey
  • Objectives
  • Methodology
  • Results
  • Discussion and Conclusions
  • Recommendations
Market Survey
  • Objectives
  • Methodology
  • Results
  • Discussion and Conclusions

Executive Summary


In December 2001, the Palestinian Minister of Health requested the U.S. Agency for International Development West Bank/Gaza (USAID WB/G) Mission to undertake an assessment of the nutritional status of preschool aged children and women of reproductive age throughout the West Bank and Gaza Strip. USAID WB/G accepted this task and added it to the portfolio of the Emergency Medical Assistance Program (EMAP), a cooperative effort of USAID and CARE International (CARE)/American Near East Refugee Aid (ANERA).

CARE had a pre-established contractual relationship with Johns Hopkins University (JHU) to provide technical assistance in health. Within that context, JHU developed a comprehensive three component nutritional assessment to evaluate the extent and causes of malnutrition and anemia and to identify areas for strategic programmatic interventions. The assessment contained: 1) a household interview and examination survey; 2) a survey of market places; and 3) a survey of maternal child health (MCH) clinic practices and capabilities. The surveys of the Nutritional Assessment for West Bank and Gaza Strip (NA/WBGS) were field tested and carried out during June-August 2002 by Al Quds University and the Global Management Consulting Group under sub-contracts with CARE.


Populations affected by conflict will experience food insecurity and undernutrition. The escalation of the Palestinian-Israeli conflict which commenced September 2000, and increased in intensity during the Spring of 2002, has led to a deterioration of the household economies in the West Bank and Gaza Strip, interfered with food availability and accessibility, and raised the probability of a significant problem of undernutrition.

Furthermore, clinics responsible for recognizing and treating undernutrition-related problems face budgetary constraints and travel restrictions for staff and patients. Thus, principal questions to be addressed included:

  • What is the prevalence of undernourishment among children (male and female) aged 6-59 months as determined by conventional and internationally recognized anthropometric measures;

  • What is the prevalence of undernourishment among reproductive age women 15-49 years as determined by body mass index (BMI);

  • What is the prevalence of iron deficiency anemia as determined by hemoglobin measurement amongst these two populations;

  • What is the consumption of selected macronutrients and micronutrients for the women and children as determined by a 24 hour food intake;

  • What is the status of food security at the household level;

  • What is the availability of staple foods in the marketplace and does the market remain continuously functional for these food types; and

  • What are the growth monitoring practices at MCH clinics and do these clinics have the capacity to properly and accurately diagnose, treat, and follow-up cases of undernutrition and anemia?
Each of these questions will be addressed separately for the West Bank and Gaza Strip.

The NA/WBGS will, by means of accepted scientific methodology, inform the Palestinian Ministry of Health, the international and local donor community, and key public health professionals on the state of nutrition in WB/GS (see Figure S1). In so doing, the findings should be used to aid in pinpointing areas for targeted interventions and for the thoughtful implementation of short and long term nutritional programs and policies. It should also serve as a baseline for ongoing nutritional surveillance and any follow-on impact studies or further nutritional assessments.


Through a competitive tendering process, Al Quds University in Jerusalem was chosen to partner with Johns Hopkins University for the household (HS) and clinic surveys (CS). Also chosen was Global Marketing Consulting Group in Ramallah for the implementation of the market survey (MS). Al Quds and Johns Hopkins faculty members jointly designed the questionnaires and jointly trained the data collectors. Likewise, Global and Johns Hopkins personnel jointly designed the MS tool. Field work was carried out under the supervision of the Palestinian partners with Johns Hopkins consultation and was subject to data quality assurance protocols. The Palestinian institutions were responsible for primary data entry, cleaning, and analysis with secondary review carried out by Al Quds University primary investigators and Johns Hopkins University faculty.

Traditionally, women and children have been the most vulnerable groups during periods of food insecurity worldwide. The HS involved a representative sample of 1004 households in WB/GS, equally stratified between the two regions to ensure greater precision and to reduce sampling error. The sample size was based on required levels of precision and the sampling distribution on the population figures from the official 1997 census carried out by the Palestinian Center Bureau of Statistics (PCBS) and the mid-2002 population estimates. Urban and non-urban stratified primary sampling units were randomly selected in all 11 districts of the West Bank and all 5 districts of the Gaza Strip; households were randomly selected within each primary sampling unit. The 1,004 households yielded 936 children between 6 and 59 months of age (485 males, 451 females) and 1,534 non-pregnant women between 15-49 years of age. The assessment's nutrition parameters included:

  • Iron deficiency anemia of women and children by hemoglobin determination and classified by severity using World Health Organization (WHO) criteria;

  • Acute malnutrition of children defined by the ratio of weight for height classified by severity using WHO criteria;

  • Chronic malnutrition of children defined by the ratio of height for age classified by severity using WHO criteria;

  • Undernutrition of women defined by the Body Mass Index (BMI), a ratio of weight for height squared; and

  • Nutrient deficiencies of critical macronutrients (energy and protein) and micronutrients (iron, vitamins A and E, zinc, and folic acid) by a 24 hour dietary recall on the youngest child in the household and their mother.
Al Quds University developed the 24 hour dietary recall survey adapted for the Palestinian diet. An Al Quds 24 hour recall database of reproductive age women developed in calendar year 2000 provides a basis for comparison in nutrient consumption for this target group. The 24 hour recall for preschool aged children presented here is the first ever such body of information collected in WB/GS.

The CS covered a sample of 68 clinics each of which was the most frequently visited for child growth monitoring as reported by the households in each of the clusters of the HS.

Investigation of the following parameters included:

  • Qualitative recognition, prevalence, and etiologies of malnutrition in the community based on interviews with senior health providers;

  • Prevalence of growth monitoring and malnutrition in children 6 months to 36 months of age by a random sample of 24 clinic records in each clinic;

  • Prevalence of hemoglobin checks and anemia in children 6 months to 30 months of age by a random sample of 24 clinic records in each clinic; and

  • Capacity and adequacy of care in the clinical management and treatment of malnutrition and anemia based on interviews, on-site inspection, and a random sample of 24 children's records in each clinic.
The chart review gave an indication of how well malnutrition and anemia were "discovered" at the health care level in comparison with the HS which would be considered the more accurate method for determining the true prevalence of malnutrition and anemia in the community.

While the household component of the NA/WBGS describes the capacity of families to provide food for their own household consumption, the market component (MS) assesses the capacity of the market to supply that food. The MS was a representative sample of 647 retailers and 153 wholesalers stratified by urban wholesale, urban retail, large village and refugee camp, and small village. Specifically, the MS examined:

  • Frequencies of major disruptions in the marketplace of staple (non-luxury) food items that contribute to the nutritional intake of the population;
  • Reasons for such disruptions; and
  • Trends in food prices.
"Disruption" was defined as three or more consecutive days over the course of a month in which retailers and wholesalers regarded food products in a state of significant shortage (not available as usual or severely diminished in stock) and were unable to replenish them during that three day period.

Summary of Findings

A. Household Interview and Examination Survey (HS)

A nutritional disorder or condition resulting from faulty or inadequate nutritional intake is defined as malnutrition. Acute malnutrition or wasting reflects inadequate nutrition in the short-term period immediately preceding the survey. The ratio of a child's weight to height (or in the case of an infant, weight for length) is the commonly used and most accurate indicator of wasting. Chronic malnutrition, or stunting, is an indicator of past growth failure, thus implying a state of longer term (weeks to months to years) undernutrition. Chronic malnutrition may lead to serious irreversible growth and developmental delays. The ratio of a child's height for age is the most useful indicator for chronic malnutrition.

The difference between the value for an individual and the median value of the population for the same age or height divided by the standard deviation of the population defines the Z score, the conventional statistic measured for acute and chronic malnutrition. The World Health Organization (WHO) has classified the severity of acute and chronic malnutrition based on the U.S. National Center for Health Statistics (NCHS) standards. The measure of greatest interest (and the one most commonly referred to by donor and humanitarian agencies) is that segment of the population below -2 Z score, classified as moderate (between -2 and -3 Z) and severe (below -3 Z) combined. This combination of moderate and severe is applied to both wasting and stunting and is termed global acute malnutrition (GAM) and global chronic malnutrition (GCM), respectively. Table S1 below reflects the distribution of GAM and GCM in the population of Palestinian children ages 6-59 months.

Anemia reflects a decrease in the oxygen carrying capacity of the blood due to a decrease in the mass of red blood cells. Hemoglobin, the oxygen carrying protein of red blood cells is the most useful indicator of anemia. Iron, folic acid, and dietary protein are necessary for hemoglobin and red blood cell production. Iron deficiency in particular is the leading cause of anemia worldwide. Thus, malnutrition or inadequate nutrition can lead to anemia and subsequent impaired learning and growth development (children), low birth weight infants and premature delivery (maternal anemia), fatigue and diminished physical and mental productivity (all ages), and decreased immunity from infectious diseases (all ages). WHO classifies the severity of anemia by hemoglobin levels in gm/dl of blood. The widely accepted combined categories of mild, moderate and severe is most commonly used as the reference values: below 11gm/dl for children ages 6-59 months, and below 12gm/dl in nonpregnant reproductive age women.

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