Historical Perspective

Current advances in transportation and communication permit relief workers to respond to international emergencies within hours rather than days.  As a consequence, emergency response managers can make decisions about implementing relief activities in less time, a fact that intensifies the need for timely and accurate information.  The critical element, is early on-site collection of key information about representative populations in order to provide adequate public health information on which to base emergency relief decisions (10).  To this day, the data collection activity remains a labor-intensive field process.

In the area of nutritional assessment, over time, a variety of papers, reports, and manuals provided the foundation for construction and execution of nutritional surveys and assessment of nutritional status.  From the late 1950s and 1960s, manuals describing nutritional surveys and their use in the field, were comprehensive and extremely detailed (11-18).  Many  multiple analyses and tests were not practical for rapid assessment situations as they are indeed time consuming.  However, upon close observation, one can see that the essential elements of an effective nutritional field survey had begun to take shape.

The development and adoption of nutritional indicators and general nutritional survey standards has a long, yet guided history and evolution.  During the 1970s and 80s, interest in the epidemiology of disasters accelerated (papers and guides for this time period can be found in references 4, 19-44).  New professional societies and scientific forums for the presentation of original work in this field appeared.  However, not all relief organizations placed a high priority on the early and rapid evaluation of the health status of the affected population as a management tool of emergency response.  As a consequence, the lack of objective information concerning the effect on the population at the disaster site consistently lead to poorly applied relief efforts.  This deficiency in disaster response was exacerbated by several other factors including lack of time in which to organize a disaster assessment strategy, reluctance of relief workers to keep records, and movement of populations from and into disaster affected areas.  In addition, many countries or regions devastated by a disaster lacked public health personnel with the epidemiologic expertise or the supporting data handling and communications resources necessary to conduct a disaster assessment.  Up until the early 1980s, there were few institutions or government agencies to which disaster managers could turn for experience and expertise about conducting an emergency health assessment of a disaster site.

In the 1980s, a positive turning point occurred.  Manuals developed by the World Health Organization (WHO) were published providing a summary of indicators of malnutrition, body measurements, organization of individual screening, organization of nutritional surveillance, and other indicators for the evaluation of relief programs (4, 41).  The indicators of malnutrition were compared with those obtained from an international reference population.  The recommended data for this purpose were those collected by the United States National Center for Health Statistics.  The comparison enabled national medical authorities to diagnose the problem of malnutrition in an epidemiological sense (prior to requesting assistance for supplementary feeding).

The positive trend toward development of key manuals continued into the 1990s.  In 1990 the Food and Agriculture Organization of the United Nations published, “Conducting small-scale nutrition surveys – a field manual” (9).  This manual is a “how to” for developing customized nutritional surveys.  Although it does not concentrate on rapid assessment, it does provide a good overview of methodologies, statistical methods, and definitions of the most basic and useful concepts.  The customized aspect is significant and describes a flexible approach which can be useful for adjusting to different cultures, situations, and time availability. 

Later, in 1992, a group of experts from WHO, UNICEF, UNHCR, Centers for Disease Control (CDC) Atlanta, FAO, Save the Children Fund (SCF) UK, and representatives from countries of the Eastern Mediterranean Region met in Alexandria, Egypt  to review the minimum amount of information needed to determine nutritional status in an emergency (for first decisions on nutritional relief and for its planning), and to develop a field guide for obtaining such information.  This resulted in a set of standardized procedures presented in a guide entitled, “The Management of Nutritional Emergencies in Large Populations” (2).  It was written for use by the various agencies and to allow comparison of results from different surveys.

To facilitate the task of those in charge of obtaining information on nutritional status, the group made a number of decisions on issues such as minimum sample size, survey participants, and the level of analysis needed, striking a balance between the methodically appropriate and the logistically feasible.  Decisions were based on scientifically sound methodologies and were meant to assist individuals with little statistical or epidemiological knowledge to carry out a survey that will yield reliable data for first assessment and for planning.

The relatively simple protocols could be modified or incorporated into disaster pre-preparedness and response activities at the local level.  This flexibility was extremely important because despite the development of an international humanitarian relief network, the local community continued to bear the principal responsibility for disaster preparedness, mitigation, and response.  Furthermore, relief workers who used assessment protocols containing a degree of standardization could contribute to a common data base that allowed disaster researchers to better compare the health effects of one disaster with another.  A predictable assessment process also enabled field personnel to communicate verifiable information to managers of relief operations.

In 1995 the report, “Physical Status: The Use and Interpretation of Anthropometry: Report of a WHO Expert Committee, Geneva, 1995” was made available (6).  This report gives a comprehensive summary of anthropometric measurements, indices, and indicators, its uses in populations, and the determinants and consequences of malnutrition.  Guidelines for use of anthropometric indicators (BMI with cut off points; arm circumference, etc.) and a summary for which the guidelines may not be appropriate were especially useful additions.  Also published by WHO in 1995 was a compact and handy field guide entitled, “Field Guide on Rapid Nutritional Assessment in Emergencies” intended for those who are faced with the need to make rapid but reliable estimates of nutritional status in emergencies as a basis for subsequent action (7).

In 1999 WHO published 10 protocols designed to help those involved in rapid assessment determine the immediate and potential health impact of a broad range of emergencies and assist in planning appropriate responses (8).  These protocols are available in one booklet entitled, “Rapid health assessment protocols for emergencies,” and includes a protocol dedicated to nutritional emergencies.  The original protocols were the joint effort of three WHO Collaborating Centers for Emergency Preparedness and Response, with feedback from Member States of six WHO regional offices and other WHO partners including nongovernmental organizations, for extensive field-testing.  On the basis of written comments, the protocols were reviewed and updated by experts from intergovernmental and nongovernmental organizations with broad experience in the field of emergency management.  The protocols are useful for both experienced and non experienced personnel.

It is evident from published literature that attempts to administer quality nutritional surveys based on key and scientifically accepted references and methodologies  had evolved from simply citing key papers (e.g., in the 1960s and into the early 1990s, Jelliffe et al. was most often cited for their methodologies).  Attempts toward providing standards and guidelines came in the 1980s then a final push in 1995 to provide WHO standard methodologies which are easy to understand, easy to customize to situations and cultures, and straight-forward to carry out.  Core surveys of the bare minimum information needed to rapidly assess a nutritional situation, and agreed upon by international experts, now exist.  References currently representing the basic essentials for developing and customizing a nutritional survey are found in references 2-9.