(On behalf of the First Thousand Days Research Group (University of Cape Town))
“Good nutrition in the first 1000 days between a woman’s pregnancy and her child’s second birthday sets the foundation for all the days that follow.”
“The First 1,000 Days of being a parent are now accepted to be the most significant in a child’s development.”
“Researchers have identified the first 1,000 days of a child’s life—from pregnancy through a child’s 2nd birthday—as a critical window of time that sets the stage for a person’s intellectual development and lifelong health.”
— Lucy Sullivan, National Healthy Mothers, Healthy Babies Coalition
The focus of this series is the “the first thousand days”, a new field of enquiry that is radically reshaping understandings of health and heredity, with material consequences for policy, publics and concepts of life. The thousand days between conception and a child’s second birthday is presented in contemporary epidemiology and public media, shaped by new knowledge in neuroscience, epigenetics and Developmental Origins of Health and Disease (DoHaD) research, as a critical period that determines future health and potential. This imaginary – as captured by the excerpts from non-governmental organizations above – has been the object of study for The First Thousand Days Research Group at the University of Cape Town, chaired by Professor Fiona Ross, since mid-2013. Under the rubric of “the first thousand days”, we have conducted ethnographic research across a set of inter-related themes to interrogate the logics and implications of this imaginary. The sites of our research include antenatal clinics, soup kitchens, laboratories of reproductive technologies, places of worship, neonatal units, breast milk banks, middle class settings and informal settlements. The work currently spans research across Southern Africa, and draws on historical and contemporary accounts of parenting, reproduction and social relations particular to this context.
Our work has benefitted from thinking with a range of analytic frames including STS and postcolonial approaches as well as conventional ethnographic and historical research methods. Thus far we have found that “the first thousand days” offers fertile ground for careful thought about contemporary concepts of life, life-giving and care, offering spaces for critically assessing not only how states and people understand and enable health and well being but also how life is conceptualized by different disciplines. This Somastosphere series will speak to the complex questions that new attention to the early life period within epigenetic framings provokes, particularly in contexts of the global South.
This first installment offers a brief introduction of the First Thousand Days as a contemporary global health project. Later articles will highlight findings from our ethnographic and other explorations and suggest areas for future research.
Global health and visions of the future: the first 1000 days of life
The 1000 days campaign is a transnational project orchestrated by a diverse set of actors within the “global health” framework. The focus on “the first thousand days” originates in the 2008 Lancet Series on Maternal and Child Undernutrition, which presented the rationale for the thousand-day period in a review of cohort studies from India, the Philippines, South Africa, Brazil and Guatemala. This data, based on World Health Organization (WHO) indices for child growth standards, suggested that future human capital – captured in “height, school achievement, economic productivity and birth weight of offspring” – is best predicted by height for age at two years, hence the focus on the period from conception until age 2, or (more catchy) the first thousand days (Victora et al. 2008). The Lancet’s 2013 follow up series adds that in addition, “the first thousand days” impacts potential future burdens of overnutrition and chronic disease. These recommendations formed the basis for the United Nations’ (UN) Scaling Up Nutrition (SUN) program and the 1000 Days: Change a Life, Change the Future campaign. The one thousand day span has become the critical window for intervention for both improved nutritional outcomes as well as cognitive development. Today, this is an explicit focus for the post-2015 development agenda, directing policy in fifty countries and supported by a network of public and private partners, the largest of which is the Bill and Melinda Gates Foundation. Corporations like Nestle and Nutricia have also readily taken up the project.
The first one thousand days concept is based on life course epidemiological models that incorporate epigenetics, DoHaD, and nutrition transition theory. Developmental programming theory has its origins in a series of studies that recognized the role of poor socio-economic status in early life in predicting for adult disease. Most famously, Barker and Osmond linked poor childhood nutrition in poor English counties to an increased risk of heart disease in adulthood (1986). This work produced the ‘thrifty phenotype hypothesis’ (also known as the fetal origins hypothesis), which contends that intrauterine nutritional constraints cause fetal adaptations that constrict growth and prepare the fetus for a restricted food environment. This confers a fitness advantage if the external environment is as predicted, but confers increased disease risk if the environment turns out to be abundant (Hales and Barker 1992: 599). Hales and Barker defined ‘programming’ as a long-term effect on morphology or function that results from conditions during critical windows of development (ibid: 596). Animal models and epidemiological studies in many settings have since supported developmental programming theory (Delisle 2002). This phenomenon has also been described as “fetal impression” (Paneth 1994), “genomic imprinting” (Signorello and Trichopoulos 1998), “metabolic imprinting” (Waterland and Garza 1999), and “induction” (Bateson 2001). This growing field is now referred to as “Developmental Origins of Health and Disease” (DOHaD) research.
Barry Popkin developed nutrition transition theory (1993) as an extension of demographic (Thompson 1929, Caldwell 1976) and epidemiological (Omran 1971) transition theories to illustrate how diet and energy expenditure, and their correlating disease states, have shifted in concert with population and economic changes. Many developing countries display a “nutrition transition paradox” (Doak et al. 2005) that is characterised by a dual burden of obesity and undernutrition at the national, community and even household level (Popkin et al. 2011: 10). Developmental biologists posit that nutrition transition sets up the conditions that program for adult chronic disease. Under-nourished mothers give birth to infants programmed for an environment of restricted nutrition, but as the nutrition transition unfolds, this generation develops obesity and chronic disease as a result of environmental mismatch (Gluckman and Hanson 2006). Maternal diabetes and obesity in the second generation predict for the same conditions in their offspring via overnutrition pathways (Gluckman 2010: 14).
DOHaD researchers have readily taken up epigenetic theory as a means for explaining these observations. Conceived by Waddington (1942), the term epigenetics is a synthesis of genetics and the Aristotelian concept of epigenesis, which emphasized the qualitative and continuous nature of development. Waddington’s understanding of the developmental trajectory is best illustrated by his “epigenetic landscape” (1957). This consists of a network of valleys and hills on an inclined plane that must be negotiated by a marble that rolls through the landscape via a series of binary options. The marble represents the developmental outcome; the final path taken is a function of gene-network interactions modulated by environmental factors (Slack 2002: 891). Waterland likens nutrition to the “wind” that blows over the epigenetic landscape to influence the final developmental pathway (2006). The merging of DOHaD research and epigenetics has thus given rise to an “epigenetic epidemiology” (Waterland and Michel 2007) that is increasingly framed within life course perspectives (Godfrey et al. 2010). Contemporary epidemiological life course theory thus employs theories of nutrition transition and developmental programming to understand the aetiology of noncommunicable disease in developing settings. Intervening in early life promises gains in both early childhood – lower rates of undernutrition, stunting and infection – and long term gains via developmental programming mechanisms – lower risks of obesity, cardiovascular disease, diabetes (non-communicable diseases or NCDs).
The appeal of the “first thousand days” thus lies in its perceived dual impact on a present and future disease burden, and its measurable outputs in economic indices. As one epidemiologist described it to me, intervening in the first thousand days offers “bang for your buck.” The one thousand days focus on human capital formation is captured in indices including adult height, educational achievement, income, and offspring’s birth weight. One can consider this choice of indicators, following Didier Fassin, as “qualitative data offering political insights as to how societies produce and reproduce themselves” (2012: 109; Canguilhem 1978). The perceived cost-effectiveness of interventions aimed at the early life period expresses an economic logic that appeals, in Siddiq Osmani and Amartya Sen’s assessment, to “hard-nosed economic calculus” (2003), a worthy rationale in a political and scientific milieu which privileges measurable economic outcomes and the creation of capital. As such, the “1000 days” global health project might be viewed as an instantiation of how the epistemology of market logics comes to bear on the life sciences and the public health interventions they inform – what Kaushik Sunder Rajan terms “the capitalization of life” (2012: 1). In addition, “the first thousand days” represents a present-day articulation of a longstanding focus on mothers and infants in public health frameworks – a group which carries significant currency in the humanitarian imagination.
Close ethnographic enquiry is warranted to examine how changing notions of life and value come to bear on the ordinary, and “the first thousand days” offers one prism through which this might be viewed. An emerging literature across philosophy, STS and anthropology engages new forms of life and its governance (Merry 2011, Sunder Rajan 2012), and the implications of DoHaD and epigenetic science for politics and policy, and concepts of life, health, nature and nurture (for excellent overviews, see Pickersgill et al. 2013, Meloni and Testa 2014; for a comprehensive edited volume see Richardson and Stevens 2015). Less attention has been paid so far to the intersection of these in what we might label “epigenetics and the everyday”. What do DoHaD and epigenetic discourses – captured within the rubric of “the first thousand days” – mean for reproductive technologies, for nutrition interventions, for the law, for understandings of time and inheritance, for the making of families, for the meaning of food security, for understandings of health and life in all its imbrications?
More specifically – what is revealed when such questions are localized? How do understandings of, and interventions in early life, reflect a local milieu, and how might we attend to this? Our research group approaches this question from multiple perspectives across southern African contexts. In these settings, the logics and implications of the 1000 days’ imaginary must be read in conjunction with colonial histories and postcolonial concerns, regional political economies, and the economy of images of mother and child so central to humanitarian reason in Africa (Vaughan 1991, Fassin 2012). The first thousand days construct offers one window onto the ways in which new understandings of the neuroscience of cognition and the developmental origins of health and disease – now commonly framed as epigenetic – come to bear on, and interact with, existing framings of health, to reconfigure policy and healthcare across global and local networks, and to remake temporalities, citizenship and relationships. Across the work of our research group, the first thousand days is a fruitful object of study for considering the everyday ways in which new science and technology comes to bear on life and life-giving in the postcolony. We hope that our reflection and contributions make for an enjoyable and thought-provoking series.
Michelle Pentecost is a DPhil candidate in Anthropology at the University of Oxford (Green Templeton College) under the supervision of Professor Stanley Ulijaszek, and an affiliate of ‘The First Thousand Days’ research group at the University of Cape Town. She is currently completing her doctoral thesis, titled “The First Thousand Days: Global Health and the Politics of Potential in Khayelitsha, South Africa.” Michelle is a practicing clinician with special interests in perinatology and internal medicine. On completion of her doctorate, she aims to practice at the intersections of medicine, public health, anthropology, and medical education.
Bateson P. 2001. Fetal experience and good adult design. International Journal of Epidemiology, 30, pp.928-934.
Delisle H. 2002. Programming of chronic disease by impaired fetal nutrition Evidence and implications for policy and intervention strategies. Geneva: World Health Organisation.
Barker D.J.P., Osmond C. 1986. Infant mortality, childhood nutrition and ischaemic heart disease in England and Wales. The Lancet, 1, pp.1077-1081
Fassin, D. 2012. Humanitarian reason: a moral history of the present. Berkeley: University of California Press.
Caldwell J.C. 1976. Toward a restatement of demographic transition theory. Population and Development Review, 2, pp.321-66.
Canguilhem, G. (1978) On the normal and the pathological. Boston: D Reidel.
Doak C.M., Adair L.S., Bentley M., Monteiro C., Popkin B.M. 2005. The dual burden household and the nutrition transition paradox. International Journal of Obesity, 29, pp129–136.
Fassin, D. (2012) That Obscure Object of Global Health. In M. Inhorn & E. A. Wentzell, eds. Medical Anthropology at the intersections: histories, activisms, futures. Durham: Duke University Press Gluckman P.D, Hanson M. A. 2006. Developmental origins of health and disease. Cambridge: Cambridge University Press.
Gluckman P.D., Hanson M.A., Buklijas T. 2010. A conceptual framework for the developmental origins of health and disease. Journal of Developmental Origins of Health and Disease, 1(1), pp.6–18.
Godfrey K., Gluckman P.D., Hanson M.A. 2010. Developmental origins of metabolic disease: life course and intergenerational perspectives. Trends in Endocrinology and Metabolism, 21(4), pp.199-205.
Hales C., Barker D.J.P. 1992. Type 2 (non-insulin-dependent) diabetes mellitus: the thrifty phenotype hypothesis. Diabetologia, 35, pp.595~601.
Lock, M. 2005. “Eclipse of the Gene and the Return of Divination.” Current Anthropology 46 (S5): S47–S70. doi:10.1086/432452.
Meloni, M, Testa G. 2014. “Scrutinizing the Epigenetics Revolution.” BioSocieties 9 (4): 1–26. doi:10.1057/biosoc.2014.22.
Merry, S.E. 2011. “Measuring the World.” Current Anthropology 52 (S3) (April): S83–S95. doi:10.1086/657241.
Omran, A.R. 1971. The epidemiologic transition: a theory of the epidemiology of population change. Milbank Memorial Fund Quarterly, 49, pp.509-538.
Osmani, Siddiq, and Amartya Sen. 2003. “The Hidden Penalties of Gender Inequality : Fetal Origins of Ill-Health.” Economics and Human Biology 1: 105–121.
Paneth N. 1994. The impressionable fetus? American Journal of Public Health, 84, pp.1372-4.
Pickersgill,M, Niewöhner J, Müller R, Martin P, and Cunningham-Burley,S. 2013. “Mapping the New Molecular Landscape: Social Dimensions of Epigenetics.” New Genetics and Society 32 (4) (December): 429–447. doi:10.1080/14636778.2013.861739.
Popkin B.M. 1993. Nutritional patterns and transitions. Population and Development Review, 19(1), pp.138-157.
Popkin, BM, Adair LS, Ng, SW. 2011. “Global Nutrition Transition and the Pandemic of Obesity in Developing Countries.” Nutrition Reviews 70 (1) (January): 3–21. doi:10.1111/j.1753-4887.2011.00456.x.
Richardson, SS, and H Stevens, ed. 2015. Postgenomics: Perspectives on Biology and the Genome. Durham: Duke University Press.
Signorello L.B., Trichopoulos D. 1998. Perinatal determinants of adult cardiovascular disease and cancer. Scandinavian Journal of Social Medicine, 26, pp.161–5.
Sunder Rajan K (ed). 2012. Lively Capital. Biotechnologies, ethics and governance in global markets. Durham: Duke University Press.
Thompson W. 1929. Danger spots in world population. American Journal of Sociology, 34, pp.959-75.
Vaughan, M. 1991. Curing Their Ills: Colonial Power and African Illness. Stanford: Stanford University Press.
Victora, CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, Singh Sachdev H. 2008. “Maternal and Child Undernutrition: Consequences for Adult Health and Human Capital.” Lancet 371 (9609) (January 26): 340–57. doi:10.1016/S0140-6736(07)61692-4.
Waddington C. 1942. The epigenotype. Endeavour, 1, pp.18–20.
Waddington C.H. 1957. The strategy of the genes. London: Allen & Unwin.
Waterland R.A. 2006. Epigenetic mechanisms and gastrointestinal development. The Journal of Pediatrics, 149 (S5), pp. S137-42.
Waterland R.A.,Garza C. 1999. Potential mechanisms of metabolic imprinting that lead to chronic disease. American Journal of Clinical Nutrition, 69, pp.179–97.