This chart, too, I notice, has curves that snake across it.
Our pediatrician measures our son’s height and weight, and plots both on a growth chart. The curves are percentiles. They tell us that at nine-but-closer-to-ten, our son is taller than 97 percent of kids his age, and heavier than 75 percent of them.
“Ideally,” the doc says, “those two numbers should match better.”
Because they don’t, our son is the tall slender child he is. “But there’s nothing to worry about,” he adds quickly, though I’m not worried at all. The kid is active and healthy. Given that, percentiles interest me little—this mismatch even less.
There are, however, some lines of fine print at the bottom of the chart. I’ll return to them. For now, this experience—chart, curves, numbers plotted—reminds me of something. Later that day, I put my finger on what: Joda, just a few years ago, which I visited with doctor Ramani Atkuri.
Joda is a small iron mining town in the eastern Indian state of Orissa. We arrow inland from the coastal plain, then the road winds through mute hills and somber stands of sal trees. Joda sits in a shallow bowl of a valley, surrounded by more hills. Some of them, I realize with a start, are great heaps of slag from the mines.
Everything is in shades of ochre. The roads, the cars and buses, even assorted menacing stands of mining machinery are coated with this, the leavings of mining. Yet Joda is not as chaotic and grubby as many Indian small towns are. Where we stay, on a rise above the bowl, the view is dramatic, the air is crisp and flowers abound. Looking up at Orion in a brilliant night sky, I can believe this is one of the country’s fabled hill stations, destination for hordes of honeymooners.
It isn’t, of course. The people on Joda’s streets are not honeymooners. They are migrant tribals, come to work in the mines—men and women alike, at jobs ranging from digging out the ore to filling railway wagons with it. Hard labor, it earns them 2,000 rupees ($40) per month and up. Nowhere else in this area, in Orissa or the neighboring states, can they get paid as much as that.
Most mine workers live in a mud hut colony, Banspani, on the edge of town. One morning, I visit a day-care center run by a local organization for the workers’ children. About two dozen bright-eyed and skinny kids play and sing around me as I pore over a sheaf of charts, weight records for a child’s first five years, which I am reminded of, years later, in our pediatrician’s chamber. The government of Orissa prints and distributes these charts, and requires day-care centers like this to fill them in. There’s one for each child who has ever passed through the center, maybe 100 in all. It’s meticulously recorded data, and it tells some grave tales.
First, every single child in this sheaf is seriously malnourished and underweight. The chubbiest on record was 13 kg at five. At that age, my son weighed 21 kg.
Second, several kids were actually normal at birth. Yet by six months, every single “normal” child had sunk into malnutrition, to stay. Padmabati, the woman in charge, has a one-English-word explanation: “Neglect.” Pressured to work and earn, both parents leave home for long hours, neglecting their children almost from birth. “Mothers don’t breastfeed,” says Padmabati. “The slightly older kids look after their little brothers and sisters and bring them here.” Malnutrition in such circumstances is inevitable.
Third, the charts show frequent sharp weight loss from one month to the next, from bouts of diarrhea or malaria. In already malnourished children, such attacks are devastating. Sometimes, going by plots that end abruptly, they are fatal.
Fourth, the charts have curves marked on them which represent four grades of malnutrition: “1” goes from 2.75 kg at birth to 15 at 5 years old; “4,” from 1.5 kg to 9; grades “2” and “3” lie in between.
Four grades of malnutrition, actually preprinted on these sheets. Preprinted, because the government presumes that the children of migrant tribal workers will be malnourished. The government is wise to presume: every child here is indeed malnourished. In fact, most hover between grades “3” and “4,” and several have spent spells chugging along below “4.”
The four curves narrate a story about my country. Last November, the International Food Policy Research Institute told that story differently. They called Indian hunger levels “alarming.” Their annual Global Hunger Index ranks India as the world’s 23rd most malnourished country. Only the likes of Mali, Eritrea, and Sierra Leone are hungrier.
If that’s dismal, it may get worse. Atkuri tells me that if we returned to Joda today, we’d see higher levels of malnutrition. From the rural clinic where she now works, she sends me some Government of India data on nutrition levels, with this comment: “You can see that the proportion of children wasted (indicating acute hunger) has increased.” (“Wasted,” meaning too thin for their height.) Her colleague, Yogesh Jain, calls with this reminder: “Malnourishment is just a medically sanitized term for hunger.”
Whichever term you use, it’s on the rise. At their clinic, Atkuri and Jain are seeing a steady increase in TB cases, always a good indicator of chronic and acute hunger.
Back in our pediatrician’s chamber, our son’s chart tells another kind of story about my country. Its curves are not labeled for malnutrition. But the 5 percentile weight line nicely matches the grade “1” line from Joda, meaning that 5 percent of the children who use the chart are at or below that least serious level of malnutrition. (95 percent, then, are above).
Yet most children plotted on that chart in Joda—I would say over 90 of the 100 or so whose records I examined—were far more malnourished than that. So much more, that it would make no sense to use my pediatrician’s chart for those kids. Their plots would creep along the bottom of the grid.
So what’s going on here? Why do 90 percent of the children in a Joda day-care center fall below the 5 percentile level on our pediatrician’s chart?
The answer is in those lines I mentioned far above, on the bottom of the chart from our pediatrician. The percentile curves, says the fine print, are adapted from a 1994 paper in the journal Indian Pediatrics: “Physical Growth in Affluent Indian Children.”
Reading that paper, I find this sentence: “The objective of the present study was to investigate the growth performance of Indian children below six years of age, not subject to any obvious socio-economic constraints that could be expected to impair growth, [and thus] only children [from] affluent population segments … were selected.”
I’m in an affluent population segment. My son, my 97 and 75 percentile son—his growth chart tells me so.
|A computer scientist by training, Dilip D’Souza now writes for his supper in Bombay. His main interests are social and political issues in India.|