ALARMING FACTS ABOUT THE HEALTH AND NUTRITION OF CHILDREN
IN TIBET
ANY people view Tibet as an exotic region
where people live in rugged circumstances yet
perpetuate values that are noble and mysterious. The
study reported by Harris et al. in this issue of the
Journal
1 reveals a harsher reality. In this study, the
overall prevalence of moderate or severe stunting of
growth in Tibetan children who were 84 months of
age or younger was 51 percent. Compared with the
prevalence of stunting in other populations, this prevalence
would be classified as very high,
2 and it is well above that for China as a whole (17 percent).
3 It is interesting to note that in Tibet the prevalence of wasting
(a low weight-for-height z score) was very low
and within the acceptable range, indicating that the
children, on average, were not thin.
Stunting of growth in children is a consequence
of multiple adverse events, including poor nutritional
status of pregnant mothers and children, exposure
to infection and other disease, emotional stress, and
perhaps the stressful physiologic effects of high altitude.
Being shorter than average may not seem to
be an important clinical problem or public health issue,
but the factors that cause stunting have adverse
consequences, including impaired development, lower
intelligence, poorer academic performance, and a
reduced capacity for work in adults; these factors, in
turn, have a negative effect on economic productivity.
Shorter women are at greater risk for obstetrical
complications, and there is an intergenerational effect
of stunted growth.
4,5Harris et al. 1present evidence
not only of a very high prevalence of stunting
but also of micronutrient deficiencies that constitute
a double insult to the developing brains and bodies
of Tibetan children, further limiting their ability to
reach their genetic potential.
Does high altitude cause stunting in children? This
question is complicated, because people living at high
altitudes tend to be of lower socioeconomic status
than those living at low altitudes. However, several
studies have suggested that children raised at high altitudes
(around 2500 m or higher) tend to grow more
slowly than children raised at lower altitudes and
therefore are more likely to have stunted growth,
6,7
but other studies have revealed no such association.
8
Thus, although growth in children living at high altitudes
may be affected by the body’s adaptation to
a hypoxic environment, Harris et al.
1
found no linear
relation between stunting of growth and altitude (divided
into three categories: less than 3000, 3000 to
4000, and more than 4000 m); however, children living
at the highest altitudes had the highest prevalence
of stunting.
Early childhood is the focus of the United Nations
Children’s Fund (UNICEF) report
The State of the
World’s Children 2001.
3
This report underscores the
now well-established fact that the early years of children’s
development are the most critical. Some investigators
from nations in which stunting of growth
has been reported have argued that different growth
references need to be established for their regions on
the basis of the unique ethnic backgrounds of the populations.
There is a solid body of literature to refute
this claim. International growth references based on
well-nourished, healthy children vary little among
countries throughout the world.
2
There has also been
a myth that children whose growth is stunted are
“small but healthy.” This is no longer an acceptable
concept and, in fact, represents a denial of their basic
human rights to adequate nutrition and access to
health care, as defined by the UNICEF Convention
on the Rights of the Child.
9
It would be easy to conclude from the data presented
by Harris et al. that their cross-sectional study
of Tibetan children had some epidemiologic limitations
and then to recommend more studies. This
conclusion may be valid; however, the larger view is
that as each day passes, the children of Tibet are suffering
from a silent calamity that causes many to die
and that inhibits the development of the survivors.
This calamity will have a negative effect on the people
of Tibet for generations to come. Investment
bankers have estimated that a national investment in
early childhood is very worthwhile, with a strong
economic return. One wonders how many more
studies the children of Tibet will have to endure before
those with the resources make the political and
economic commitment to say that enough is enough;
it is time to make things better.
GLEN E. M ABERLY, M.D. KEVIN
M. SULLIVAN, PH.D.
Emory University
Atlanta, GA 30322
N Engl J Med, Vol. 344, No. 5
•February 1, 2001
•
www.nejm.org•
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