D. Malnutrition and Growth Stunting
A growing body of evidence shows that Tibetan children suffer from growth stunting as a result of severe malnutrition. In February 2001, the New England Journal of Medicine published a study based on an examination of 2,078 Tibetan children under the age of seven and drawn from '11 counties, which contained more than 50 diverse urban and nonurban . . . communities' throughout [the TAR].
The study found that, contrary to popular belief, Tibetan children's short height does not reflect the consequences of Tibet's environment (high altitude) or any genetic predisposition. Rather, 'stunting was linked to malnutrition . . . and was often accompanied by bone disorders, depigmented hair, skin disorders and other diseases of malnutrition.' More than fifty-six percent of Tibetan children between the ages of two and seven manifested severe growth stunting.
This recent study corroborates prior research. In 1997, the ICJ noted that children in the TAR tend to be unusually short for their age. Roughly sixty percent fell below
accepted international growth reference values. Data indicates that this shortness is the result of nutritional stunting chronic malnutrition during the first three years of life rather than a result of genetics or altitude . . . . Chronic malnutrition renders children vulnerable to the common fatal diseases of childhood in the developing world: diarrhea and pneumonia.'
An earlier study similarly found that 'over half of Tibetan children examined are affected by malnutrition: nutritional stunting, micronutrient deficiencies, and a subsequent high incidence of life-threatening childhood illness. . . . Malnutrition has been identified as a major contributor to mortality in children under 7 years of age in the T.A.R.'
Growth stunting results from malnutrition, which itself can be conceived in lay terms as a combination of a poor diet, high incidence of infection and poor hygienic conditions. Again Tibetan children in rural and nomadic regions appear to suffer from the most serious malnutrition problems. According to one study, for example, a 'nutritional urban elite,' a control group comprised of children from a Tibetan-run daycare center in Lhasa, fell within international standards in all growth indices, but non-urban Tibetan children often manifested growth stunting, with the most severe damage occurring between the ages of one and two. Dechen Tsomo, a nurse at TCV who examines newly-arrived refugee children, noted that many suffer from growth stunting. At the age of nine, she said, many appear about six. Others show thin limbs, distended stomachs and reddish hair, all indicia of malnutrition. While the causes of malnutrition and growth stunting are diverse, poor diet and the absence of a clean water supply play a major role.
1. Availability and Adequacy of Food
Tibetan children reported widely divergent food intake. Most said they ate tsampa, the traditional roasted barley meal that remains a staple for Tibetans from all regions. Dr. Norbu commented that tsampa is often the only food that remains plentiful in Tibet. But it does not, by itself, meet children's health needs.
The children of farmers reported a more diverse diet, consisting not only of tsampa, but also meat and animal products, such as milk and butter, and a variety of vegetables, including turnips, greens, cabbage and cauliflower. Nomads tend to have greater access to meat and dairy products but less vegetable matter. In the cities, more affluent Tibetan parents can buy or trade for a good variety of these foods. Thus, the diet of most urban children tends to be adequate, though several experts commented on the increase in 'junk food' in cities.
Most children said there was an adequate amount to eat most of the time. A few, however, reported instances in which they went without food: 'Sometimes,' one boy from Kham told us, 'I would go for three days without food, and when they would bring the food, I didn't even feel hungry.' Another thirteen-year-old girl from Kham said that, as 'children we [me and my two sisters] always ate, but I'm not sure about my parents.' One twelve-year-old girl, from a particularly poor family in Lhasa, related that sometimes the family subsisted on 'tsampa mixed with lots of water' and tea that a neighbor contributed. A sixteen-year-old girl from Lhoka likewise said that, while the family ate daily, they typically had 'barely enough' food from their own fields because of disproportionately high taxes on her family's 'excess grain.'
Dr. Dorji Damdul, a resident physician at the TCV Health Centre in Dharamsala, conducted a study of recent refugee children arriving in India and found that most suffer from some form of malnutrition, typically vitamin and mineral deficiencies. According to several studies, iodine deficiency is a major problem among Tibetan children. A May 1995 study of 557 subjects in twelve villages in the Lhasa Prefecture found that sixty-six percent had urinary iodine value indicative of severe iodine deficiency; and forty-six percent suffered from goiter.
Several researchers described how nomadic Tibetan families increasingly face food shortages that result from high taxes and price-fixing. Chinese regulations require that nomads limit the size of their herds by killing any animals beyond a stated quota and selling them to the government at prices significantly below market value. A fourteen-year-old boy from Ngari, for example, explained that Chinese regulations required his family to slaughter twenty sheep and goats annually. The remaining animals would be taxed. A girl from Kham recalled that her family owned twenty animals that the government taxed yearly. Failure to pay this tax, she said, resulted in their confiscation. Similarly, many nomads traditionally collect a special plant - yatsa gongbu, or 'summer grass, winter worm.' But they are now required to sell it to the government at fixed prices, earning them a smaller profit than they could obtain on the open market. For large nomadic families, this combination of quotas, high taxes and the forced sale of 'excess' animals at below-market cost can result in food shortages.
For example, a twelve-year-old boy from Amdo recalled that, once each year, when the family had to pay the annual 'yak tax,' he did not get enough food. The family ate only once a day during this time: 'The Chinese authorities required my family to pay them five yaks per year or a fine. If you don't pay, they have many punishments, such as sending you to prison or beating you.' On one occasion, his father could not afford the 'yak tax' and failed to pay it. As a result, he said, Chinese authorities took his father away for one month. When the father returned, he was extremely thin: 'My father didn't tell me anything except that the Chinese were bad. If he told me more, there is a risk I could be caught.'
Farmers, too, are subject to excessive taxes and price controls. One girl, for example, recalled that the Chinese authorities collected a revenue tax at the harvest and also compelled a sale of grain at below-market value. For this reason, among others, she joined a demonstration in 1993. An eleven-year-old boy from Lhasa who arrived in exile in 1999 recalled that, when the price of barley and grains went up, his mother and some other Tibetan women participated in a hunger strike. Chinese police responded with tear gas, dispersing the demonstrators. A twelve-year-old boy from Kham who arrived in exile in 1999 estimated that his family paid 200 yuan plus a portion of their grain in taxes annually. Excessive taxes thus appear to deprive some Tibetan children, particularly those of farmers and nomads, of the quantity and quality of food that they require.
2. Access to Clean Water
Most children reported access to clean water, particularly in the winter, when an abundance of snow and rain provide a clean, fresh water supply. But some said they were plagued by unclean water for most of the year or had to travel substantial distances to obtain clean drinking water. The absence of gas in some rural regions makes it impossible to boil the water as a means of purification.
A former aide at a Chinese medical clinic in central Tibet commented that water supplies generally are not treated, leading to problems with parasites, particularly during the summer. An eleven-year-old boy from Kham said that the water in his village contained parasites, which he believed caused many people stomach problems. Another twelve-year-old nomadic boy from Kham reported that when he drank, his intestine would hurt. One twelve-year-old girl from Lhasa reported that her family's drinking water had an odor. Its source, she said, was a Chinese bathing pool at a higher elevation. This bath water would run down pipes to the inhabitants below. She believed that wealthier residents benefited from a separate pipeline carrying clean water.
Official data issued in 1998 shows that in 1997, among China's rural populations, the TAR ranked last in improved access to clean drinking water: only eighteen percent of the TAR's rural population enjoyed improved access to drinking water. The next-lowest ranked province in China, Chongqing, showed an improvement of almost forty-two percent. Here again, it is difficult to generalize on the basis of limited data. But our research indicates that some Tibetan children suffer from the absence of a stable clean water supply. Contaminated water leads to chronic gastrointestinal infections and malabsorption syndromes, which contribute to the severe growth stunting among Tibetan children.