THE ALTAR 
AND THE CROWN 
THE INHERITORS 
A DOCTOR OF SOULS 
by MARIAN NIVEN 
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the Ptolemys, it is a compelling 
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changing life along the change- 
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and oxygen saturation in their blood is 
about the same as that of the Quechuas. 
Perhaps the answer lies in the way oxy- 
gen diffuses across the pulmonary mem- 
brane. Whatever the adjustments may 
prove to be, they must be remarkably 
effective. Sherpas are renowned for 
their ability to carry heavy loads (as 
much as sixty pounds, or half their body 
weight) at altitudes up to 23,000 feet. 
Furthermore, I found that their maxi- 
mum oxygen consumption equaled that 
of the Quechuas and was similar to 
levels achieved by highly active low- 
landers tested at sea level. 
We are now fairly certain that many 
of the Andean adjustments to high-alti- 
tude hypoxia are not genetic. A. Ro- 
berto Frisancho has demonstrated that 
nonnative children who migrate from 
sea level to high altitudes and remain 
there while growing up eventually attain 
the same lung volumes as high-altitude 
natives. Sukhamy Lahiri of the Univer- 
sity of Pennsylvania School of Medicine 
has also reported that neonates and in- 
fants have the same lung volumes at 
high and low altitudes, but that a differ- 
ence appears by adolescence. The large 
lung volumes of Andean natives seem, 
therefore, to be a developmental re- 
sponse. In addition, Lahiri has shown 
that the “blunted” ventilatory response 
to hypoxia only begins to manifest itself 
during adolescence and becomes irre- 
versible by adulthood. Again, this is 
strong evidence that the ventilatory rate 
of Andean natives is developmentally 
determined. Finally, Frisancho has 
noted that the maximum amount of 
oxygen that can be delivered to the 
tissues during exhausting work is also 
affected by age at migration. The youn- 
ger the age at migration and the longer 
the stay at high altitude, the greater the 
maximum oxygen consumption. These 
findings do not rule out the possibility of 
genetic adaptations but, as yet, no such 
adaptations are apparent. 
Having considered some of the ways 
in which Quechuas and Sherpas have 
adapted, culturally and biologically, to 
living at high altitude, it may be appro- 
priate to conclude by evaluating the 
degree to which environmental stress 
nevertheless takes its toll among these 
people. The impact of altitude on sur- 
vival begins even before birth. Because 
of the low amount of oxygen that dif- 
fuses across the placental membrane 
into the fetal system, all fetuses (even 
those at low altitude) develop in an 
hypoxic environment. Atmospheric hy- 
poxia may create an additional stress for 
high-altitude fetuses, despite their 
mothers’ physiological adjustments. 
Perhaps to maximize the amount of 
oxygen available to the fetus, the 
placentas of altiplano women are larger 
in diameter, thinner, and weigh more 
relative to fetal weight than is the case 
at low altitude. Nonetheless, both fertil- 
ity and birth weight appear to be lower 
at high altitudes. 
Although reduced, fertility in the alti- 
plano is still high. Completed family 
size (the total number of live births to 
women age 45 and over) averages 6.7 in 
Nunoa and is similar in other areas of 
the altiplano. In comparison, completed 
family size in one well-studied area of 
low-altitude Peru was 8.3. 
Sherpa fertility is much lower — com- 
pleted family size is about 5.1. Part of 
the difference may be explained by var- 
ious cultural factors that seem to lower 
Sherpa fertility. In the past, low iodine 
intake caused a significant proportion of 
the Khumbu population to suffer from 
hypothyroidism, which is known to re- 
sult in an extremely high level of sponta- 
neous abortions. 
Low birth weight also seems to be a 
consequence of gestation at high alti- 
tude. Jere D. Haas reports that children 
born of Quechua mothers at high alti- 
tude weigh about three-and-one-half 
ounces less than children born to Que- 
chua women at low altitude. And chil- 
dren born to non-Indian women at high 
altitude weigh more than a pound less 
than those born at low altitude. Fewer 
data are available for the Sherpas, but 
nineteen neonates weighed by physi- 
cians at the Kunde hospital between 
1967 and 1972 were, on the average, 
nearly one-half pound lighter than high- 
altitude Quechua neonates. The reduc- 
tion in birth weight is important because 
it is associated with inadequate respira- 
tory function, poor temperature regula- 
tion, poor resistance to infection, a high 
incidence of anemia, and inadequate 
renal function. Despite the apparent dif- 
ferences in birth weights, the altiplano 
and the Khumbu region have equally 
high infant mortality rates: between 1 50 
and 160 per 1,000 live births (about 
twelve times the U.S. rate). 
To a certain extent, these rates are the 
result of diseases (such as gastrointesti- 
nal disorders) that cause high infant 
mortality regardless of altitude. But oth- 
ers, particularly respiratory diseases, are 
more common causes of death at high 
altitude. Some studies show that the 
effect of altitude on infant mortality 
may be especially strong immediately 
following birth. In both Peru and the 
United States, deaths during the first 
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