Years have passed since the devastating 2010 earthquake in Haiti, but the remnants of destruction remain. There are toppled homes, broken streets and contaminated waterways. One of the longest-lasting effects, though, will be the developmental damage to Haitian children who remain malnourished as a result of the disaster.

Before the earthquake, the malnutrition rate in Haiti was staggering – more than 29 percent of children under five years old were stunted, according to the World Bank. Following a massive humanitarian response that included a specific focus on child nutrition in the wake of the earthquake, that rate dropped to 22 percent. But it remains one of the highest rates among Latin American and Caribbean countries. Meanwhile, four years after the crisis, USAID was still warning that nearly a third of the population remained food insecure.

“The earthquake exacerbated the challenges of combating malnutrition in Haiti,” said Skyler Badenoch, the chief executive officer of Hope for Haiti. The community-based organization helped delivery emergency food rations for months after the earthquake. “Haiti suffered from extreme food insecurity and our attention for a long period following the earthquake was on the provision of immediate relief.”

Disaster relief may ease immediate hunger, but the threat of malnutrition lasts long after the aid tents are taken down. Flying in boxes of food may work in the short term, but it does not address the structures that were already contributing to malnutrition, and which might be further exacerbated by the emergency. Experts wonder if there was a missed opportunity, in the wake of Haiti’s earthquake, to address these issues. And if they had, whether malnutrition rates might not be much lower than they are now.

The situation in Haiti offers a window into an unfolding debate about whether – and how – to integrate long-term nutrition programming into a disaster response.

The Typical Response

“Regardless of in a developed or developing country context, if there are considerable pre-existing food insecurity or malnutrition [issues], they are most assuredly going to be exacerbated by a natural disaster,” said Regine Webster, vice president of the Center for Disaster Philanthropy.

But the typical response, which the actors in Haiti largely followed, focuses on quickly trying to ease global acute malnutrition (GAM) rates by delivering food and responding to immediate health needs. GAM tracks the rate of moderate and severe acute malnutrition among children between 6 and 59 months old, using that as a proxy for the health of the larger community.

In the years after the earthquake, Haiti’s GAM rate actually began to climb, jumping from 5.1 percent in 2012 to 6.5 percent in 2013, according to the United Nations. It has since fallen, though individual communities have experienced spikes following recent droughts and hurricanes.

New research out of Tufts University indicates that the existence of persistent GAM in the aftermath of a crisis, like the Haiti earthquake, “indicates that food security may not be the main driver.” And their conclusions have the potential to recalibrate the traditional responses to malnutrition following an emergency.

The researchers behind the report, Dr. Helen Young and Anastasia Marshak, studied 25 countries with persistent GAM rates above 15 percent, including Somalia, Ethiopia and South Sudan. They wanted to find out why rates remained high despite both humanitarian and development responses.

According to Young and Marshak, the current model, which focuses on delivering food, improving care and fighting disease, overlooks more systemic problems, particularly in communities that were already experiencing malnutrition. They argue there are four “cross-cutting themes” that also need to be addressed in any response: gender; livelihood systems; the history of vulnerability and long-term trends driving acute malnutrition; and seasonal fluctuations in acute malnutrition.

The 1983 famine in Ethiopia, for example, was the result of a civil war and the government withholding food supplies from rebel areas. Also, local gender norms played a role by narrowing land and employment opportunities for women. The traditional “food-first” model of relief – delivering food boxes to stop hunger – struggles to reverse the causes of these types of crises. It also doesn’t address the ways a more traditional emergency, like Haiti’s earthquake, might exacerbate existing food security issues, such as poverty, land degradation and social inequalities.

The traditional response, the researchers argue, is a silo-ed approach that focuses on treatment without factoring in long-term prevention. With a better understanding of what long-term interventions work, they could be used in tandem with immediate relief efforts to reverse malnutrition trends.

“We’re often very focused on short-term indicators of the severity of the problem,” said Dr. Daniel Maxwell, a professor of food security at Tufts. “We’re often more focused on the immediate outcomes,” such as food consumption rates. Now experts are eager to try something different.

The Challenges that Remain

That won’t be easy, though, in part because the current approach, with its focus on food, health and hygiene in the aftermath of a crisis, has been in place for a long time. But it also points to a broader difficulty in trying to coordinate across organizations with very different missions.

Convincing organizations to research causes of malnutrition and take a diverse approach to resolving it can be difficult, said Dr. Jessica Fanzo, associate professor at Johns Hopkins University. “When you start getting into measuring growth and micronutrients, you need expertise and funding so a lot of people decide not to do that. You need that evidence base to influence policymakers.”

Fanzo co-chaired the 2017 Global Nutrition Report, which advocates for further promotion of nutritious diets and increasing the building of food infrastructure during humanitarian assistance efforts. “Linking immediate humanitarian relief interventions with longer-term development approaches is important for this resiliency,” the report concludes.

There is also the issue of funding. Young and Marshak note short-term funding cycles, which is how most humanitarian responses are paid for, are unable to take on in-depth analysis of existing causes of malnutrition. And like the organizations fighting malnutrition, there is a problem of siloed information, in which it is difficult for researchers to compare various findings to look at information across time.

There are some changes happening, though, on a small scale. Maxwell pointed to “weather index-based insurance schemes” in Kenya that fight droughts and give farmers confidence to invest in technologies that could boost their production.

Much research and work remains, though, he said, beginning with a better understanding of what other factors contribute to persistent GAM. “There are still some puzzles out there with regard to what drives these high levels of malnutrition.”