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Stakes of Life: Science, states, policies, publics and ‘the first thousand days’

This article is part of the series:

Welcome back to the “First Thousand Days of LifeSomatosphere series. Here we continue to explore the ways that a global health initiative driven by new findings in epigenetics and neuroscience and by a reframing of theories about health and disease in terms of developmental origins shape ideas about (global) health and population futures, invigorate campaigns, and take form and settle in localized contexts. Understanding the links between science, biomedicine, policy, population, well-being and relationship as simultaneously both meshed and contingent, our series posits questions about what affordances and limitations lie in new modalities of understanding human illness and well-being. It examines how policy is made and with what effects for its recipients, how states are implicated in health and its others, what forms of the everyday materialize under the lens of new findings in epigenetics and epidemiology, what modalities of knowing emerge and how they settle with older forms, and how ethnography might contribute.

Describing the research programme driven by the Thousand Days research group at the University of Cape Town, I noted that,

The emergent field both synergises a range of disciplines in the bio- and social sciences and develops new sites of humanitarian intervention, reframing current debates about population, well-being and ‘the best interests of the child’ in newly biological ways. As these findings are taken up in policy and practice, we are witnessing the making of a social object with material effects’ (www.thousanddays.uct.ac.za).

Our project has explored that making, its prior conditions and its effects.  As Michelle Pentecost noted in her opening to the Somatosphere series, the framing ‘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.’  We have traced both the ways that medical and scientific knowledge about life come to be interpolated in everyday worlds and the ways that people engage with, respond to – or indeed, ignore and subvert – it as they grapple with the possibilities that reproductive worlds afford. Our stance is deliberately invested in how everyday lives are made, and how scientific knowledge and the policies it enjoins are folded into those lives. We have traced how new knowledges, particularly in epigenetics, are rendered into policy and state practice, and come to shape imaginaries not only of individual lives but of population futures. In the process, they materialize certain kinds of relations (embodied, physiological, maternal) as more significant than others, and these in turn have the effect of producing a powerful and sometimes punishing discourse of, among others, the good mother, the responsible citizen and the expert.

Earlier contributions to the series trace questions of birthing, medicalization, nutrition and care. They offer grounded accounts from Southern Africa of the ways that different forms of knowing take root in everyday practices associated with reproduction. Contributors explored the formation of the field (Pentecost); worlds of birthing (McDougall, Rogerson, Ferreira); nutrition, nourishment and care (Truyts, Waltz, Ncube). These projects demonstrated the interwoven nature of imperative; the ways that the state understands and frames the imperative to act, to care, to intervene. They spell out the ways that ordinary practices of child-bearing and rearing are shaped by knowledge practices and histories that produce certain populations as sites for medical and pastoral intervention and run the risk of replicating older colonial practices even as they institute new forms of power.

In this second part of the series, we deepen these themes.  The framing of the first thousand days of life is, above all else, a way of imagining individual and population futures. Intervention during pregnancy and early childhood is anticipated to have lasting impacts on individual well-being and to carry those through to the next generation. Laudable in their intention, the interventions we have traced in South Africa have not fully grasped the uneven terrain on which sociality is built; the historical shaping of individual lives and collective futures. The effect is that policy imagines an ahistorical individual who will receive and implement the ministrations of experts in particular kinds of knowledge. By contrast, we have been concerned to show the ways that understandings about life are multivectoral, drawing on a range of repertoires that include but are not limited to biological notions. Our work suggests that it is important to understand the ways that ‘the biological’, its pasts and futures, is constituted as a social fact through a range of agencies; states, educational institutions, scientific imaginaries, technologies, policies and the everyday encounters that shape both how we come to inhabit a shared form of life and how we understand it.  It suggests also that it is critical to understand the stakes of life for different players.

As the global campaign around the First Thousand Days deepens and is taken up in a variety of sites and states, we continue to explore the meanings that are generated in specific locales, always understanding these to be globally inflected (and sometimes to be global nodes themselves – cf. Pentecost 2017).  We are committed to developing modes of analysis that are reflexive and reflective of Southern African contexts.

This series extends work on reproductive and birthing worlds. It also takes up the theme of the state, asking how and in what ways the state is implicated in reproduction and population futures. In so doing, it asks us to consider how the state materializes (for) families, women of childbearing age, those responsible for reproduction and care, and so forth. It also asks us to consider the ways that state and population are imbricated in contemporary African postcolonies.  Drawing inspiration from Poole and Das’s (2004) interrogation of ‘the margins of the state’, we ask how life is constituted in domains in which the state imagines itself – or is imagined – to have considerable sway and responsibility even as its reach is limited or fractured. Our commitment remains to fine-grained ethnographic accounts that draw from and may put pressure on theories ‘from the north’ by offering accounts from and of Southern Africa.

The First Thousand Days: A South African Example

South Africa has not yet met its MDGs or SDGs in relation to maternal, infant and under-five morbidity and mortality (StatsSA 2015), which remain very high despite the (uneven) medicalization of reproduction. Critical of a formulation that focuses on child survival as ‘a health issue’, while ‘ignoring the wider social and economic determinants of health’ (2015:17), the StatsSA report on the MDGs notes, ‘There has … been insufficient recognition and operationalisation of a multi-sectoral response designed to address the social and economic, and not only medical, determinants of child survival’ (2015: 18).

As of 2013, nutrition policy in South Africa explicitly focuses on ‘the first thousand days of life’.  Derived from the SANHANES report (2013), a nationwide health and nutrition survey which found that while decreasing, rates of infant malnutrition and stunting remain unacceptably high, with devastating consequences for individual well-being, ‘national development’ and population developmental outcomes, the policy aims to put in place mechanisms to intervene in population malnourishment.   In the Western Cape, the province in which I work, this policy has been augmented by a campaign aimed simultaneously at medical practitioners in public health facilities and at their clients.  The First 1000 Days campaign, launched on 17 February 2016, by the Western Cape Department of Health, in partnership with the Department of Social Development (see Figure 1), is an attempt to develop the kind of a multi-sectoral approach envisaged by the critique of the MDGs.  It seeks to ameliorate maternal and infant well-being and to augment existing policies on health care provision for these categories with a wider campaign that will, among other things, teach beneficiaries proper nutrition, offer support for early childhood development, provide parenting skills, and address apartheid’s legacies that continue to manifest in poor infant and maternal outcomes.

Figure 1: Campaign Logo. Source: https://www.westerncape.gov.za/general-publication/first-1-000-days-campaign

Figure 1: Campaign Logo. Source: https://www.westerncape.gov.za/general-publication/first-1-000-days-campaign

The campaign extends the 2013 nutrition policy, adding two further elements: ‘love and attention’ and ‘play and stimulation’. The campaign website states: ‘We believe that the first 1000 days in a child’s development, starting from conception, moving through pregnancy, birth, and after the first 2 years of life, are crucial for securing a child’s bright future.’  The slogan, replicated here, is a directive and injunction. Its dense imagery, resonant with some of the SDG symbols symbolizes nutrition, love and learning within a directed period. It has moral force and offers a clear set of temporal framings.  The poster on which it appears foregrounds the mother-child dyad as the site of intervention while also drawing on wider networks, such as fathers and ‘communities’.  It includes the logos of both Departments of Health and Social Development, along with hotlines for substance abuse, violence and abuse, early childhood development, and health-related queries. In other words, this intervention clearly stages the state, particularly in its manifestation as those sectors responsible for health and social well-being, as a key agent in what is often imagined as the private work of social reproduction, and it simultaneously positions the state as arbiter of expert knowledge and source of advice.

I suggest that, like other campaigns elsewhere in the world (Thurow 2016), this project seeks to instantiate a new form of life; a new set of agreements about what it is to be properly human. It has two key objectives, temporally-oriented; the goal of improved population health beyond the individual, or indeed, this generation – thus, an orientation to the future – and a recognition of the pasts that continue to shape access to health care and to produce inequitable health outcomes. An implicit assumption is that people need to be educated, and that the people who need to be educated are mothers.  While the campaign has worked to include ‘fathers, families, and the community’ in its remit, and has initiated an advertising campaign (for example, offering signage in commuter taxis), the maternal-child dyad is nevertheless the core target and most interventions are targeted at women. There are several reasons for this. This focus on the maternal body and the mother-child dyad has diverse origins: a highly medicalized birthing sector (see Rogerson, Ferreira, McDougall in earlier contributions to this series); the impact of HIV/AIDS and, vertical transmission in particular, on health care policy; and, more broadly, the ways that here, as elsewhere (see Richardson 2015), the maternal body is envisaged as an ‘environment’.  It is influenced too by the gender normative framing of family that pervades South African policy implementation, despite the 2012 White Paper on Family’s commitment to recognizing the diversity of families in South Africa. Another, in the fact that the maternal body is the state’s closest point of contact with ‘family’, both through health policy and in the de facto distribution of the state’s Child Support Grants.

The 1000 Days Campaign makes human ends (such as love, play, social interaction) the means through which population well-being is secured. In other words, social worlds and human relations are instrumentalised to population ends.  The campaign is a classical illustration of neoliberal risk discourse: it identifies a population, duratives, a set of tools and an effect. However, despite economic policies that are broadly neoliberal, South Africa is not a neoliberal state and its health policies are not fully biopolitical.  (National government holds a welfarist stance, as evidenced, for example, in the allocation of state grants to more than 16 million people.) Nevertheless, there are aspects of surveillance and intervention that social scientists have come to identify as having biopolitical roots, in particular, a re-responsibilising of women as bearers of life and as mothers.  I say ‘re’-responsibilising here because there is a far longer history of holding women, particularly African women, responsible for reproductive well-being (see Pentecost and Ross, n.d.; Pentecost 2017); a history that traces its origins to concerns about kwashiorkor in urbanizing areas in the 1950s, and more recently to the problem of mother-to-child (vertical) HIV transmission. Meloni and Testa (2014: 445) have noted that, as a field, epigenetics gives rise to ‘an expansion of the concept of responsibility’, ‘fostering the materialization of new bonds among generations’ (italics in original).  Given the disruption to generational relations caused by HIV and the state’s dilatory response to it until 2004, the nature, form, capacity and power of responsibilisation to re-generate kinship remains to be seen.

Our work shows that ‘new’ epigenetic findings continue to rest on understandings of the maternal body that have longer histories, and that embed normative Eurocentric ideas of both the body and the maternal role, and that increasingly instrumentalise human relations, including affects, desires and play, to population ends. This suggests to us that ‘the maternal’ as it appears in policy is ‘a knowledge effect’; a product of a specific way of thinking about an issue or problem. Here, the problem is the future well-being of the population and the means to accomplish it. It seems to us that it is materializing in what Andrew Hartnack (2016) has identified as a form of biopolitics characterized by maternalism; a form of power that has a long (although relatively under-acknowledged) colonial genealogy. Such modes of governance are unevenly distributed and mesh with intense forms of patriarchal control in different contexts. These produce uneven effects across provinces and national boundaries.

In the introduction to their recent book, Living and Dying in the Contemporary World, Clara Han and Veena Das (2015: 2) make the critical point that questions of life, once the domain of philosophy, humanities and related fields, have become reductionist in their material focus. They argue that narrowing down the notion of life to biological life alone has drawn a boundary between more classical questions about life… and the so-called new questions that assume that unless the prefix bio- can be added to a concept, that concept becomes irrelevant to our contemporary conditions.

Their examination seeks to undo the privileging of biology in understanding ‘newness’. They suggest that the new is ‘embedded in and transforms ‘older forms’ and, offer, through an exploration of singularity, a way to arrive at the question of how to pay attention to the fragility of life – including the forms of agreement we make in and of it. We hope that the next contributions to the series does justice to their call.

 

References

Han, Clara and Veena Das. 2015.  Living and Dying in the Contemporary World: A Compendium.  University of California Press. Berkeley.

Hartnack, Andrew. 2016.  Ordered Estates. Weaver Press. Zimbabwe.

Meloni, Maurizio and Giuseppe Testa. 2014.  ‘Scrutinizing the epigenetics revolution’. BioSocieties, 9:431-56)

Pentecost, Michelle and Fiona C. Ross.  The first thousand days: temporalities of motherhood in South Africa. (under review).

Pentecost, Michelle. 2017. The First Thousand Days: Global Health and the Politics of Potential in Khayelitsha, South Africa. Unpublished PhD dissertation, University of Oxford.

Poole, Deborah and Veena Das. 2004. Anthropology in the Margins of the State. School of American Research Press. Santa Fe.

StatsSA. 2015. Millenium Development Goals Report. Statistics South Africa. Pretoria.

Thurow, Roger. 2016.  The First 1,000 Days: A crucial time for mothers and children – and the world. Public Affairs. New York.

 

Professor Fiona C. Ross holds the AW Mellon Chair in the Anthropology of the First Thousand Days of Life and is the Head of Section in Social Anthropology at the University of Cape Town. Her research explores the making of children as social beings; the crafting of childhoods; and the constitution of the child’s social world in Southern Africa. Her previous publications explore the effects of violence and redress in South Africa and include Bearing Witness: Women and the Truth and Reconciliation Commission in South Africa (2002. Pluto Press: London) and Raw Life, New Hope: Decency, housing and everyday life in a post-apartheid community (2010. UCT Press: Cape Town). For more information click here – See more at: http://www.thousanddays.uct.ac.za/1000days/people#sthash.UzaHrQ0q.dpuf


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