|Assessing Needs in the Health Sector after Floods and Hurricanes (PAHO)|
Not all disasters cause food shortages and nutritional problems. Floods can destroy crops, but the population of the area may not be significantly affected-there are few communities today that depend exclusively on their own crops for food.
Serious nutrition problems are caused mainly by isolation, distance to markets, and socioeconomic problems created by the floods, such as loss of income. The latter may be attributable to the inaccessibility of workplaces, to the fact that they themselves have been destroyed or damaged by flood, or to crop destruction that has reduced family purchasing power. Floods may also damage food stored in warehouses, shops, and family larders or barns.
When large areas are flooded, when the floods are expected to be prolonged, and when communities are isolated, it can be assumed that food assistance is needed. The assessment team should determine the percentage (or absolute amount) of the expected food crop damaged by the flood and estimate the effect on energy intake. It should also do a rapid inventory of damaged stocks in stores, shops, and warehouses and compute the implications in terms of weeks or days of supplies lost for the community. To plan assistance, the team should have a rough idea of the number of families affected, the socioeconomic problems created by the flood, the extent of isolation, and the food habits of the population. The latter are often overlooked, with the result that foreign food assistance goes unconsumed because it is unfamiliar.
Sources of Information
The evaluator(s) should work in close contact with local agencies. Civil defense or its local equivalent usually has information about the size of the flooded area, crops destroyed, and population affected. This information may be completed with figures from the ministry of agriculture or its local representative (which may be the local agricultural extension officer). These officials will know how the flood has affected the present crop and whether it is likely to damage the next one. Agricultural cooperatives are common and are sometimes very well organized, with up-to-date and reliable data that may be quite useful.
The Red Cross and other voluntary organizations usually make quick surveys to determine the number of affected families, their location, and their needs.
Information on the population's food habits and nutrient intake may be available at the nutrition division or department of the ministry of health.
Most Latin American countries have at one time conducted a nutrition survey but the information may be outdated. The local (regional or provincial) nutritionist or nutrition officer (if there is one) may have recent information. They usually carry out small-scale nutrition surveys that may shed some light on the nutritional status and food habits of the community. The representativeness and scientific validity of these surveys should be interpreted cautiously, however.
Other sources of data about the size of the affected population and the socioeconomic impact of the flood may be the local officers of the ministry of social security or its equivalent, and social workers.
To determine sources of food supplies, their cost, means of transportation to or within the country and to the flooded area, and the distribution system among the people, the assessment team will have to meet and coordinate with civil defense, the armed forces, the World Food Program, Red Cross, and other voluntary organizations and international or government agencies. In many countries a food aid agency already exists and may be the most logical coordinating body.
EVALUATION OF NUTRITIONAL STATUS
A sudden-onset disaster does not cause an immediate deterioration of the nutritional status of the stricken community. It takes some time for the results of the food shortage to be reflected in the physical status and in the anthropometric parameters by which undernutrition can be objectively measured. However, if the disaster has long-lasting effects on food supplies or on the socioeconomic statue of the community, the incidence of undernutrition may increase. Physical evidence of undernutrition is noted first among vulnerable groups such as pregnant and lactating women and small children. The team needs to investigate how the flood has affected or is likely to affect the nutritional status of the community, and ascertain whether changes in nutritional status can be detected early.
Sources of Information
Although most health centers weigh and sometimes measure pregnant women, the practice of assessing nutritional status by using weight-for-height tables per week of pregnancy is not widespread (Gueri et al., 1982a). As result, it is unlikely that measurable and objective data will be found on the nutritional status of pregnant and lactating women.
Therefore it is better to concentrate on data about the nutritional status of children under 5 years of age. Even within this group, the clinical diagnosis of "malnutrition" or "undernutrition" has very little value because diagnostic criteria vary widely from one doctor to another. In addition, when undernutrition compounds other pathological processes, it is frequently omitted in both the clinical history and the death certificates. Nevertheless, health professionals might be more inclined to diagnose undernutrition in the abnormal climate of a disaster, which encompasses the emotional issue of food shortages and the phantom of widespread starvation. For all these reasons, assessing the frequency of undernutrition from clinical diagnoses in the clinical histories, "admissions books," "daily registry of patients," or death certificates frequently leads to error. The nutritional status of the community affected by the flood can be evaluated accurately only by using objective and measurable evidence such as weight, height, arm circumference, and similar anthropometric parameters.
A. Health centers:
Most health centers in Latin America and the Caribbean hold regular "well-baby" sessions, in which the child's growth is monitored. Usually weight-for-height or -for-age is registered on a standard growth chart according to certain reference values. These registers make it easy to obtain data on the nutritional status of the child population. However, attendance at sessions may decrease markedly in emergency situations.
In many centers all children's weight (and sometimes height) is measured and noted in the clinical record (comparison of these measurements with the standard of reference and nutritional status recorded is not as regular). It is also likely that the health ministry will have established a nutrition surveillance system.
If the only reasonably reliable data are those on the clinical record, the team may have to survey the records. It should calculate the possibility of nutritional deterioration by matching the measurements against records from the previous year or months. This is a tedious and time-consuming exercise but may reveal changes in the frequency of undernutrition that may be attributed to the floods. A more important result would be the establishment of the baseline data for a surveillance system.
Common sources of error are incorrect measuring techniques, defective scales, and mistakes in calculating the children's ages (when using weight- or height-for-age as the parameter). Moreover, an unfortunate and well-known fact is that the worst cases of malnutrition never go to the clinics.
Frequently the weight and height of the child are entered in the admissions book of pediatric wards. Data obtained from this source will give very biased results, as the sample is hardly representative of all the children of the community. Nonetheless, the team can tell from this whether more cases of malnutrition have been admitted since the flood.
C. In the absence of information:
If no recorded information can be found, the evaluators should conduct a survey that is as detailed and statistically significant as time and resources allow. The easiest and quickest way is to measure the arm circumference of the children seen at the clinics. Within certain limits, arm circumference is relatively independent of age; it can be compared with the reference values suggested in Table 7.1. This method has been used to assess nutritional status of the community in emergency situations in the Americas (Gueri et al., 1982b) and on other continents (Guerney, 1969).
TABLE 7.1. Reference values of arm circumference.a
Value below which a child would be considered
Under 3 months
3 to 5 months
6 to 23 months
24 to 59 months
a For more details as to measurement techniques and reference values, see D.B. Jelliffe, "The Assessment of the Nutritional Status of the Community (Monograph No. 53), Geneva, World Health Organization, 1966.
· What percentage (or absolute numbers in tons or hectares) of the expected food crops (and cash crops) have been destroyed by the flood?
· What is its significance for energy intake?
· What is the loss of stored foods, and what does it imply in terms of weeks or days of supply for the community?
· How many families are affected?
· What is the extent of isolation? Its expected duration?
· What are the socioeconomic problems created by the flood?
· What are the food habits of the community?
· Destroyed crops
- Types of crops destroyed
- Amount destroyed as percentage of the expected crop
· Percentage of caloric intake from local sources
· Effect of flood on next crop
· Amount of stocks destroyed
- As percentage of total stock
- Energy equivalent
· Number of isolated families
· Degree of isolation
· Socioeconomic problems created by flood
- Loss of employment
- Isolation from workplace
- Destruction of workplaces
- Loss of earnings due to destruction of crops
· Food habits of the population
Sources of information
· Civil defense or equivalent
· Ministry of agriculture and local officers
· Agricultural cooperatives
· Red Cross
· Voluntary and social organizations
· Social workers
- Admissions book, pediatric ward (anthropometric measurements)
· Health centers
- Well-baby clinics (growth charts)
- Clinic records* weight-for-age
· In the absence of any data: arm circumference of those children present at centers