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Field ArticleA mother prepares foodin a makeshift tent.Leah Richardson works as aPublic Health Nutritionist inthe Nutrition Service of theWorld Food Programme (WFP)headquarters. Her currentinterests are survey methods,nutrition in emergencies, andmeasuring mortality.Moazzem Hossain is anAdvisor at UNICEF NYHQ,Nutrition Section. He wascoordinating NutritionAssessment and responses inthe earthquake affected areasof Pakistan during October2005 – January 2006. He hasvast experience in conductingNutrition Assessment in differentemergencies likedrought, floods, conflicts andnow the recent earthquake.Kevin Sullivan is an AssociateProfessor in the Departmentof Epidemiology, EmoryUniversity, Atlanta. His areasof expertise include epidemiologicmethods, micronutrientdeficiencies, anthropometry,and survey methods.On October 8, 2005 a strong earthquake- said to be the most powerfulin the region in 500 years -hit the northeastern part ofPakistan. The result was massive destructionand catastrophic mortality, primarily inthe upper Northwest Frontier Province(NWFP) and in Azad Jammu Kashmir(AJK). Emergency relief was initiated withindays of the earthquake to deal with themost immediate needs and within weeks ofthe event, a Rapid Food Security andNutrition Needs Assessment was conductedby WFP and UNICEF (with support fromOXFAM). The results indicated that amongthe affected areas, most were rural. Nearly2.5 million had lost their homes and themajority of the population was living inmakeshift tents. More than half reportedloss of all grain stock and 15% reportedcomplete dependence upon charity/aid.The rice and maize harvest had been interrupted,livelihoods had been severely curtailed,and morbidity rates were high.Prior to the earthquake, acute malnutritionhad been a major public health problem(at national level 13% global acute malnutrition)and in light of the aggravating factors,the situation was expected to deteriorate.Various agencies involved in the responsewanted a more specific and accurate figureof the malnutrition prevalence along withrelevant health and vulnerability informationthat would assist in designing appropriateinterventions in affected areas.Therefore, a nutrition and health surveywas planned by UNICEF/WFP/WHO incoordination with the national Ministry ofHealth (MOH). A technical working groupof the implementing agencies was formedwith representation from all partners tooversee the survey implementation – fromdesign to data analysis through to reportwriting. In this context, the partnershipworked extremely well and was a valueaddedstep in the process. It could serve asa model for future assessments.The principal objectives of the surveywere to assess the nutritional status of children6-59 months and their mothers, to estimatethe crude mortality rates for the day ofthe earthquake as well as the pre/postearthquake rates, to determine the prevalenceof morbidity, and to investigate foodconsumption patterns and household foodsecurity. Sample sizes were calculated foreach of the survey populations using estimatesof global acute malnutrition andcrude mortality rates. Clusters were selectedusing the probability proportional to sizemethodology. Households were selectedusing systematic random sampling andhousehold lists. Data were collected in thefour surveys by six trained survey teamsbetween 21 November and 25 December2005.Methodological Lessons LearnedAssessments conducted in times of crisishave limitations and problems broughtabout by (among other things) a lack ofready information, time constraints, andharsh/dangerous working conditions. Thissurvey in Pakistan was no exception. Someof the problems encountered, mistakesmade, and solutions found are just as valuableas the results. In sharing these experiencesand lessons learned, the goal is toimprove the quality of future assessmentsand to provide a platform from which togrow.Lesson 1: At what level do you want yourresults to be representative?The first challenge the technical workinggroup faced was to create a study designthat would capture separately the conditionsof both the stable and moving populationsaffected by the earthquake. Creating apopulation sample frame was extremelydifficult considering the ongoing migrationand that those displaced (camps) weremuch more adversely affected than thosewho remained in their homes (communities).Additionally, the affected areas fellinto two major political and geographicalzones, Azad Jammu and Kashmir (AJK) andNorth West Frontier Province (NWFP) ofPakistan, which had different pre-disasterconditions and had not sustained damageproportionally. With these issues in mind,the struggle was to create a sampling framethat would translate into survey results representativeof the different populationsinvolved. Since the earthquake had affectedthe provinces unequally, and since theS Sharif, T Shah (Eycon Solution), Pakistan, 2005Scenes of destructionpost earthquake in northeastern Pakistan26