Section 5 - The Biosocial in Practice

Chapter 20 Understanding Child Development: A Biosocial Anthropological Approach to Early Life

Emily H. Emmott and Sahra Gibbon

20.1 Introduction

A biosocial understanding of child development frames development as a dynamic process that influences, and is influenced by, childrearing environments [1]. This encourages a complex understanding of the determinants of development by considering both biological and socio-cultural factors, which in turn encourages cross/interdisciplinary approaches. There is strong evidence that the Developmental Origins of Health and Disease (DOHaD) is best understood from a biosocial perspective that acknowledges and seeks to better understand the dynamic interactions between the biological and social [1]; however, cross/interdisciplinary research often encounters barriers and challenges such as epistemological differences and misunderstandings [2]. Understanding how research around child development has been conducted may help inform and facilitate effective biosocial collaborations.

Anthropology, being a diverse discipline spanning biological and social-cultural studies, is well positioned to examine and inform biosocial approaches. There has been long-standing interest in the biosocial within and beyond anthropology [3] as well as established traditions such as biocultural approaches in US-based anthropology that have long sought to better align social and biological sciences [4]. Recently, there is an emerging biosocial agenda in anthropology, in particular, medical anthropology (cf. Singer et al. on ‘syndemics’ [5], Lock on ‘local and situated biologies’ [6], Roberts on ‘bioethnography’ [7], and Gibbon et al. on ‘biosocial medical anthropology’ [8]; see also Alvergne on ‘evolutionary medicine’ [9]). Anthropology is as a result particularly well placed to contribute to work within DOHaD to foster better biosocial frameworks of understanding child development.

Building on this previous work, in this chapter we reflect on how different disciplines have conceptualised ‘early life’ with particular insights from evolutionary, social, and medical anthropology to challenge and further expand the narrow framing of DOHaD focus and to show the scope of a biosocial perspective. First, we introduce how childhood and early life have been studied in anthropology, followed by a discussion on how early life has been conceptualised in public health, lifecourse, and development research. We then discuss how concepts of early life may impact caregiving practice and childhood environments, which in turn impacts research on early life itself, with longitudinal birth cohort studies as an example. While recognising that there are points of difference in approach and analysis in the disciplinary reflections brought together in this chapter, and also that our discussion and analysis are far from comprehensive, we nonetheless highlight the need for critical and reflective thinking about the ways in which we do biosocial research, and the impact it has on our understanding of DOHaD. Overall, we suggest that a more reflexively engaged biosocial anthropological dialogue around research on early life helps to broaden the scope of cross-disciplinary work that can more fully engage with the complex and dynamic process of childhood development and present a more nuanced framework of early life for DOHaD informed research and health practice.

20.2 ‘Early Life’ in Anthropology

Children, childhood, and child development have long been a focus of interest in anthropology, with some considering it as central to its foundation and disciplinary development [10]. By studying children across cultures, anthropologists in the early twentieth century directly challenged the notion of ‘childhood’ as universal or that child development is shaped solely by physiology, biology, or hormones, instead showing how early life is a period of both intense socialisation and cultural transmission [11–13]. Anthropologists continue to engage with early life by describing the variety of childhoods across cultures, examining how ecology and culture impact development, and testing processes of cultural transmission, to name a few [14–16].

At the same time, there is a great deal of heterogeneity in the way that children and childhood have been studied [17, 18], and how this period of the lifecourse is approached; a diversity that provides a particular resource for widening the lens of DOHaD research and perspectives on early life. This is reflected in a more psychologically informed focus on child development in US-based anthropology that draws from lifecourse theory [19]. A focus on childhood in anthropology is also informed by what is called ‘four field’ approaches that include physical and cultural anthropology as well as archaeology and linguistics [14, 16], as demonstrated, for example, in the classic work of Margaret Mead [12]. While European anthropology also attended to children’s lives, this was by contrast more as part of an evolving ethnographic tradition that aimed to examine wider social structures rather than child development per se (cf. Malinowski [20] and Richards [21]). A more explicit focus on childhood, however, emerged within a constructivist-situated paradigm that highlights personhood and agency in examining early socialisation [18, 22, 23]. While there are differences in the historical evolution of research in anthropology on children and childhood development, it is true to say that diverse traditions of anthropology (including those beyond a Euro-American context – see, for instance, work in South Africa such as Reynolds [24] and Ross and Pentecost [25]) have collectively helped to show how child socialisation is variably influenced by both culture and ecology, while also recognising that there are some shared mechanisms and processes.

Notably this broad landscape of anthropological work has led to directly challenging Eurocentric ideas in developmental psychology and beyond, including Bowlby and Ainsworth’s ‘attachment theory’, which not only fails to consider non-Western caregiving approaches [26] but sees intensive caregiving by a primary caregiver as biologically adaptive [27]. An evolutionary anthropological perspective highlights the importance of a wide range of caregivers beyond the mother, with humans evolving a cooperative childrearing system [28]. Cross-cultural, comparative research highlights how attachment to a single individual is not always observed nor optimal [26]. In summary, diverse histories of engagement with early life across different traditions of anthropology provide an important basis and resource in widening biosocial dialogue. This enables us to consider how DOHaD-informed research, policies, and practices might be expanded to encompass a broader range of factors and contexts in childhood development.

20.3 Concepts of ‘Early Life’ and Optimal Developmental Environments

In contemporary public health research and practice, child development is typically viewed as a process of growth where individuals gain socio-emotional, physical, and cognitive traits until they reach their ‘final state’ in adulthood [29]. Development is often represented in terms of trajectories, where there is an expected and optimal path of growth, or in terms of milestones, where development is sequential and additive. Taking physical development as an example, anthropometric measures are commonly mapped onto the WHO’s child growth standards, which describe ‘normal child growth [trajectories] from birth to 5 years under optimal environmental conditions’ [30]. Here, average development is often perceived as ‘good development’, and being under- or overdeveloped may potentially be problematic with an increased risk of negative health outcomes. Similarly, motor skills may be mapped onto expected milestones using the Ages and Stages Questionnaire, a threshold-based, age-specific global screening tool assessing developmental progress [31]. Here, development is conceptualised as hierarchical where later stages of development are ‘more advanced’ and often perceived as ‘good development’. For both trajectories and milestones, development is underpinned by biology, interacts with the environment, and builds through time. What children experience and how they develop in early life act as foundations for later life, framing the lifecourse approach as critical for developmental research. Combined with this is the idea of sensitive and critical periods, particularly in the first few years of life where ‘the brain is “tuned” by the input from the environment’ [32].

This view of early life, by default, places children as immature beings on their journeys to adulthood, with implications for how we research and engage with children and caregivers, and what we consider as optimal childrearing practices and environments. For example, in ‘Western’ countries such as the United Kingdom, United States, and Australia where such views are normative, children are typically viewed as being different to adults, and as highly sensitive to caregiver input and external environments [33–35]. Research findings recommend sensitive parenting practices that focus on understanding and responding to the child’s needs without frightening the child, and such parenting practices are argued to be crucial in constructing secure attachments to the caregiver, and a foundation for ‘good development’ across a range of socio-emotional and behavioural outcomes [33]. Consequently, there are social expectations to create child-centred, developmentally appropriate, and stimulating environments that are typically age specific and separated from the adult world, allowing ‘children to be children’ [33–36]. For instance, caregivers in England are encouraged to ‘read and look at books together’ because ‘it will help [children] with their future learning … allows you to bond with them and is good for emotional wellbeing’ [37], informed by evidence that ‘books serve as inputs to influence an infant’s visual, social and linguistic development’ [32]. Here, the act of reading books together is framed as a scientifically recommended extra activity caregivers can carry out for the infant, independent of their day-to-day ‘adult activities’, which serves as a developmentally appropriate stimulus to encourage ‘good development’.

However, not all cultures share the view that childhood is foundationally a time of growth, conflicting with the dominant notions of ‘early life’ in contemporary public health, lifecourse, and development literature [38]. For example, Helen Kavapalu [39] describes how concepts of childhood in Tonga stemmed from how ‘children are perceived as inherently vale (foolish, ignorant, “crazy”)’ where socially undesirable characteristics such as laziness, aggression, and disobedience were viewed as ‘natural’. Punishment, including corporal, was commonly used by caregivers to remove such traits and instil socially desirable traits – a form of caregiving practice viewed as harmful, outdated, and often outlawed in high-income nations. In Tonga, however, ‘good development’ is dependent on removing traits, contrasting with the idea that development is necessarily a process of cumulative growth, with caregiver punishment being an effective tool to guide children away from socially undesirable characteristics.

Broadly, the belief that development requires removal of traits is not necessarily an incorrect one, from what might be seen as a traditional science perspective. Removal of traits occurs throughout childhood, with processes such as synaptic pruning (a process of development in the nervous system that eliminates synapses) being a core aspect of brain development and possibly later health [40]. Humans also possess a range of ontogenetic adaptations that are traits with specific functions for specific timepoints in development, to address the challenges associated with childhood and adolescence [41]. These traits may disappear before adulthood and are not immature versions of adult traits. A simple example is the newborn rooting reflex, where neonates turn their heads with an open mouth when touched around their cheek or mouth; a trait that disappears during infancy. High self-efficacy in early childhood, where young children aged 3–4 years tend to overestimate their abilities, has also been argued to be an ontogenetic adaptation to facilitate exploration and engagement with the external environment [42]. If focusing on these characteristics of development, children could be conceptualised as ‘full beings’ who are perfectly adapted to their socio-ecological niche of childhood.

The view that children are ‘full beings’ has been documented across cultural contexts outside of the Western world, reported by many anthropologists including Margaret Mead who described Samoans as viewing ‘children as little adults’ [12]. Reframing children as ‘full beings’ somewhat conflicts with the Western focus on early life as an immature period of growth – with potential implications for what might be considered as an optimal developmental environment. In contrast to the child-centred approach frequently championed in the West, Samoan children were not provided with tailored age-specific, developmentally appropriate environments: when describing their play, Mead states, ‘For dolls they have real babies; at six they are expected to sweep up the real house and pick all the scraps off the floor’ [12]. In Samoa, therefore, ‘children being children’ did not require children to be removed from the adult world; they were assumed to be competent in carrying out specific tasks, and play was incorporated into everyday life. Full societal participation was seen as key for children to develop the skills and knowledge they required for the future, meaning the child-centred approach promoted in the West may be seen as a poor caregiving practice.

Overall, the concept of early life as a period of growth, dominant in Western contexts, influences how we construct optimal childrearing practices and environments. The focus on growth frames children as immature and sensitive, reflected in the promotion of child-centred sensitive parenting practices. However, in cultural contexts where early life is not strongly equated to be a period of growth and immaturity, there may be fundamental schematic conflicts, particularly around removing children from the adult world. While evidence shows sensitive parenting leads to ‘good development’ in the West [33], it does not come without cost: assuming children are immature and vulnerable can encourage containment of children within developmentally appropriate and safe environments, which may limit their freedoms, agency, and social participation, which in itself impacts their learning and development [34, 35]. The presumed significance of caregiver input for ‘good development’ may lead to excessive and intrusive caregiving, or helicopter parenting, which has been associated with poorer mental and physical health outcomes for adolescents and young adults [42]. It may also overburden common caregivers such as mothers, with the emergence of intensive mothering cultures that have implications for their health and well-being [36].

20.4 How Concepts of Early Life Impact Research

We have seen above how concepts of childhood and development impact how caregivers interact with and construct environments around children and how in turn these conceptual framings themselves impact practices of child development. We suggest that concepts of early life also inform research and subsequently the understanding of the DOHaD. Here, we examine this hypothesis by using longitudinal birth cohort studies as a paradigmatic broad terrain of research on early childhood and the lifecourse. Analysis of how early life research is framed and situated theoretically and methodologically in birth cohort studies further illuminates how cultural framings of early development shape research practices. We suggest that critical reflection on how this terrain of research on early life is culturally constituted within birth cohort studies may also help to inform future directions for biosocial research.

Longitudinal birth cohort studies that follow the social and biological aspects of people’s lives have been an important methodological tool for different research communities, mainly epidemiological, for over 60 years [43]. These studies have been particularly useful for understanding developmental patterns and causal pathways [44], contributing to the DOHaD knowledge/evidence base. In this sense, birth cohort studies serve as a resource for and are also a ‘technology of’ biosocial research [45]. Recently, there has been an explosion of interest in birth cohort studies, with renewed efforts to maintain existing cohorts and new birth cohorts being established in many national contexts [46]). Detailed historical records that track the social context of intergenerational lives, while not always necessarily formulated as birth cohort studies as such, have been equally important. With public health and child development often underpinned by DOHaD frameworks, birth cohorts and other longitudinal studies have fuelled and facilitated an intense research focus on the ‘early life stage’ of pregnancy, infancy, and childhood and now also encompass the preconception period [47]. In turn, a range of ‘life stages’ have become ‘critical windows’ for public and global health interventions, with early interventions championed for their preventative approach and effectiveness [32, 48]. As Lappé and Landecker [49] point out, specific environments have become foregrounded in postgenomic and biosocial research, with consequences for how different stages of the lifecourse, including childhood and parenting, are temporally situated as being relevant to health. In this way, birth cohort research contributes not only to new temporal framings of the lifecourse but also to its explicit periodisation, suggesting discrete and definable life stages.

While there is today an intensive contemporary research focus on early life, its environment, and its consequences, this is arguably far from comprehensive. Birth cohort studies do allow researchers to better understand the biological and social determinants of development, including in childhood development and also across the lifecourse of participants [44]. Nevertheless, these studies have traditionally focused on limited aspects of the childrearing environment, almost exclusively focusing on the ‘microsystem’ within the ecological system (i.e. the immediate environment experienced by the child) [50], and in particular relying on the concept of the nuclear family household. For example, the Avon Longitudinal Study of Parents and Children [51] reveals an impressively detailed account of parenting and the household environment, including the pets that were owned by the families of birth cohort participants, how much toothpaste was put on the toothbrush, and when children first ate a raw carrot. However, there is surprisingly little information from beyond the household, such as who children see outside of this social context and what activities they do with them. This household focus persists in recent British birth cohorts such as the Millennium Cohort Study [52], which continue to hold limited information on how families and children interact with potentially important caregivers such as grandparents and even siblings of cohort participants, who are not always included in such studies.

The prioritisation of the microsystem and the household arguably stems from biases in what is valued as important aspects of the childrearing environment, including by the DOHaD and birth cohort research community, with research focus (and funding) directed towards these topics. To date, researching ‘early life’ has been heavily influenced by norms such as intensive mothering and the perception that two-parent nuclear families are the ‘default’ family structure [36, 53]. However, it has long been established that the environments beyond the household matter [52], including non-parental caregivers who are essential in the human childrearing system [2, 53]. Disciplinary silos, with their own traditions and theories, not only limit the understanding of DOHaD but may also introduce monocultural biases [53] and perpetuate an ongoing tendency for dyadic thinking in foregrounding parent (mostly mother) and child relations [54]. We suggest therefore that biosocial collaborations require critical reflection on how early life and childhood environments are culturally framed and examined in research contexts such as longitudinal birth cohorts, including how this may vary depending on histories and genealogies that shape systems of public health, concepts of the biosocial, and the emergence and evolution of birth cohorts in diverse national contexts. Understanding how norms and assumptions are built into research on early life is the first step in both challenging these normative parameters and evolving new approaches that can more fully address both diversity and variability in childhood development.

20.5 Conclusion

The examples above evidence how societal views of childhood and development have implications for childrearing practices, and in turn, understanding children’s developmental outcomes in DOHaD research, outlining how biology and society may interact to shape the DOHaD. Further, our cross-disciplinary and cross-cultural examinations show how our understanding of DOHaD is influenced by the meaning of childhood and development. This also has consequences for the staging and framing of the current intense focus on early life and childhood in birth cohort studies, raising many questions about what ‘good’ development in childhood looks like and challenging the idea of this process as necessarily linear and additive.

Cross-disciplinary research initiatives such as the Biosocial Birth Cohort Research (BBCR) network (https://bbcrnetwork.com) provide an important infrastructure for widening the frame of research in DOHaD on child development. They also help create contexts for collaboration, such as that between our own sub-disciplinary expertise of biological and medical anthropology. Such collaborations while nascent and in dynamic formation also lead to new research questions and challenges. This includes other dimensions of a biosocial approach that we have not been able to fully address in this chapter and that also need further elaboration through more detailed, reflexive, and engaged cross-disciplinary dialogue. Exactly how the cultural politics of childhood are variously invoked and contested in the intense focus on this stage of the lifecourse in birth cohort studies and in the way that DOHaD is implemented in public and global health are just some of the areas for future investigation. Similarly how the figure of the child and childhood continues to symbolically represent future promise in these contexts is, as yet, relatively underexamined. Integrating analysis of the wider institutional contexts of research cultures (including funding priorities) that are manifest in and help sustain the infrastructure for DOHaD-focused and birth cohort studies would also further expand the scope of critical reflexive engagement. DOHaD research has much to gain from viewing developmental processes that shape childhood and health outcomes in highly context-specific ways; an understanding that is both underlined and strengthened through cross-disciplinary dialogues, such as those with biosocial anthropology outlined here.

Chapter 21 Building Biosocial Collaboration in the HeLTI–South Africa Trial

Michelle Pentecost , Catherine E. Draper , Khuthala Mabetha , Larske M. Soepnel , and Shane A. Norris

21.1 Introduction

While the Developmental Origins of Health and Disease (DOHaD) as a field has been built on extensive physiological and epidemiological observational studies, there is recognition that the evidence base requires a shift to human intervention trials if it is to have any policy traction [1]. As intervention studies become more commonplace in the field of DOHaD, it is also essential to integrate a multidisciplinary perspective and social science approaches. Indeed, DOHaD is proving to be a productive and creative ground for biosocial collaboration between scientists and social scientists (including psychologists, anthropologists, sociologists, and science studies scholars), with recognition that integrating social science in interventions ensures that there is ongoing attention to assumptions embedded in research frameworks; maintenance of complexity in the face of the temptation to reach for the silver bullet; a retained sensitivity to socio-political and historical context; and active brokerage of new experimental forms of engagement with the communities of actors involved [2–4]. Such contributions are especially important given that DOHaD intervention studies will most frequently use complex public health interventions, where traditional methods are unable to capture the complexity of how context impacts intervention (and vice versa). New methods are required for understanding non-linear relationships and explaining results [5].

This chapter summarises lessons from the established literature on biosocial collaboration in trial contexts and considers their application in DOHaD intervention trials. Using the case study of the Healthy Life Trajectories Initiative (HeLTI), we illustrate the dynamics of a biosocial approach in action and discuss the benefits of building research infrastructures in DOHaD such that diverse disciplinary perspectives are given equal standing.

21.2 From Observation to Intervention: Time for Pragmatism?

As discussed in the introduction to this volume, DOHaD was formalised as a field with the consolidation of both physiological and observational studies of developmental programming that showed consistent associations between early life factors and adult health and disease outcomes, for example the relationship between birth size (lower birth weights) and adult non-communicable disease outcomes [6]. At the time the DOHaD Society celebrated its 10th World Congress in 2019, the field had expanded significantly to study a much wider range of associations, including the effects of early-life factors on mental health outcomes. However, both past and present DOHaD Society presidents highlight that DOHaD’s translation to policy has been hindered by the kinds of evidence that DOHaD science has produced, citing the ‘much needed transition from observational to interventional studies’ [1, p. 265] alongside developing knowledge of the pathways to policymaking.

While interventions during pregnancy were an obvious first step, outcomes of behavioural interventions demonstrated limited evidence of efficacy in what is a very narrow time period. The LIMIT trial demonstrated that antenatal lifestyle interventions did not decrease the risk of infants born large for gestational age or impact maternal outcomes, but did reduce the risk of birthweight exceeding 4kg [7]. The UPBEAT trial similarly showed that antenatal lifestyle interventions for obesity in pregnancy are insufficient to affect rates of large-for gestational-age births and gestational diabetes [8]. A narrative systematic review of 27 studies of the effects of weight management via dietary counselling and dietary interventions in overweight or obese pregnant women showed little effect of these on childhood obesity outcomes [9].

There is thus a significant swing to assess interventions before conception to shape intergenerational health. Preconception care is an explicit focus of the World Health Organization’s (WHO) 2017 report of the Commission on Ending Childhood Obesity and the subject of a 2018 Lancet Series [10]. A systematic review and meta-analysis of the association between pre-pregnancy body mass index and child obesity confirmed the significantly increased odds of child obesity with increased maternal BMI, to the order of 264 per cent [11], with those authors recommending preconception interventions as a logical course of action in the light of these findings.

Testing the preconception intervention hypothesis requires large-scale trials of complex public health interventions that commence before pregnancy and track individuals and their potential offspring for long periods to assess intergenerational health impacts. In partnership with WHO, HeLTI is the first consortium of randomised controlled trials of this kind in China, Canada, India, and South Africa. HeLTI aims to evaluate the efficacy of interventions initiated prior to conception and for those that become pregnant, continued during pregnancy, infancy, and early childhood to address offspring obesity and development. As the test case for starting interventions in the preconception period, HeLTI is thus of huge significance to DOHaD science. Building on long-standing efforts towards interdisciplinary collaboration in trial contexts, HeLTI is also an important test case for what this volume terms ‘biosocial collaboration’. Biosocial collaboration here refers both to methodologically innovative ways of working and conceptual collaborations between disciplines (see Béhague et al., 2008 [12]), which should work in tandem to produce new models of understanding health and disease.

Lifecourse approaches encounter significant challenges around the best research practices and techniques in studies that include both long-term observational and interventional components [13]. Public health research thus increasingly works to understand not only whether a particular intervention will improve health or not but also how that intervention works to do so [14]. To achieve this, trial design, especially for behavioural and other complex public health interventions, increasingly employs ‘complex’, ‘pragmatic’, or ‘realist’ frameworks. As aims have shifted to encompass not only ‘what’ works (or not) but also ‘how’ it works (or not), trial design and process evaluation have incorporated interdisciplinary collaboration between epidemiologists, implementation scientists, evaluation specialists, and qualitative health researchers [15]. There is an expanding literature on the integration of qualitative methods into randomised controlled trials, especially of complex public health interventions [5]. Historically there have been epistemological limitations placed on the kinds of qualitative methods deemed applicable in the biomedical framework of trials, which has constrained the use of approaches from disciplines such as anthropology, sociology, or psychology [16]. However, the ‘turn to the complex’ in public health research acknowledges a broader set of social factors that influence health [14] and obliges pragmatic and adaptive trial designs that encompass more innovative and iterative qualitative methods.

21.3 Bukhali: The HeLTI–SA Trial

For HeLTI–South Africa, the Bukhali individual randomised controlled two-arm trial has recruited between 6000 and 7000 women aged 18–28 in Soweto for a complex public health intervention, which statistically should lead to a pregnancy and birth cohort of about 1530 mother–child pairs. All women aged 18–28 years are eligible except for those with a prior diagnosis of type 1 diabetes mellitus or epilepsy and those who are unable to provide informed consent. The primary trial outcome is to assess the effect of a four-phase intervention (preconception, pregnancy, infancy, and early childhood) on the index child’s adiposity at five years of age (fat mass index [fat mass/height]2 derived from dual-energy X-ray absorptiometry). The trial also assesses a range of secondary child outcomes (anthropometric, metabolic, developmental, and behavioural); secondary maternal outcomes (anthropometric, nutritional, physical health, mental health, and behavioural); and phase-specific outcomes in the 4-phase trial [17]. The intervention is community healthcare worker-driven and comprises a programme of nutritional and health screening and support interventions, including micronutrient supplements, health information booklets, and monthly informational interventions in-person or by telephone that use healthy conversation skills, a motivational interviewing technique that focuses on empowering participants to explore opportunities for and obstacles to behaviour change [18]. These sessions cover themes, including diet, exercise, sleep, contraception, safe sex, and emotional well-being, as well as health checks and measurements at in-person visits. The control group receives ‘standard of care plus’, comprising access to standard community primary healthcare provisions, as well as additional services provided by the control team at the trial site, including free HIV and pregnancy tests, and general non-health-related advice, for example finances, insurance, and accessing child support. Women in the intervention arm who become pregnant receive additional interventions including an ultrasound scan and health promotion materials on diet and physical activity in pregnancy, child developmental milestones, and accessing state child support. In the postnatal period, interventions will focus on current messaging about breastfeeding, nutrition, care, and developmental stimulation outlined in the South African ‘Road to Health’ booklet received by each birthing parent at the child’s birth, and women will be encouraged to return to preconception healthy behaviours. For the full trial protocol, see Norris et al. 2022 [17].

21.4 A Pragmatic DOHaD Trial

HeLTI–SA exemplifies the ‘pragmatic’ trial model. There is an explicit framework of trial as a process, where ongoing learning and adaptation to new knowledge as it arises are expected and desirable, such that the trial becomes a dynamic platform that does not just test the primary hypothesis – that preconception interventions might improve childhood metabolic and developmental outcomes – but also undertakes process evaluation analyses, as well as generating new hypotheses as situations arise, that can then also be tested in the course of the trial.

From the outset, the HeLTI team have needed to adapt the framework to a complex context of urban poverty. Pilot trial implementation of Bukhali led to significant changes to both the trial design and implementation approaches [19]. While the trial was initially conceptualised as a cluster randomised trial with 30 random geographical units in Soweto, the pilot demonstrated significant cluster contamination due to participants’ movement between households and parts of Soweto as part of a strategy of resource-sharing between different households [19]. This accords with the ‘domestic fluidity’ that anthropologists have noted as common for southern African households [20, 21]. HeLTI–SA was consequently converted to an individual randomised model. Pilot qualitative work was also able to capture the key priorities and key challenges for women in Soweto. Women are focused on obtaining further education and securing employment, while navigating difficult socio-economic circumstances [19]. As a result of the pilot, other key changes to Bukhali design and implementation included modifications to the intervention delivery, from group to individual sessions and to mostly telephonic rather than in-person delivery (a requirement further amplified by the onset of the COVID-19 pandemic and lockdowns in South Africa); the inclusion of additional incentives that respond to some of the priorities women discussed (such as making provision for the printing of their CVs at the research unit); and the implementation of a system for the delivery of supplements to participants’ homes.

The focused approach to adapt to the contextual complexities of the trial goes beyond the pilot. The pragmatic trial model means that the research team is highly responsive to new challenges or concerns as they arise [18]. The pilot findings that women preferred telephonic engagements meant a switch to delivering interventions telephonically. South Africa ranks third in Africa with regard to mobile phone penetration and therefore provides a robust platform for mHealth prospects [22]. The widespread availability of mobile phones has enhanced healthcare communication [23] as they are cost-effective and facilitate health professionals in clinical trials to stay in contact with participants and, where possible, deliver intervention components telephonically [23, 24]. Crucially, this adaptation preceded the COVID-19 pandemic and meant that the trial continued even during periods of lockdown in South Africa.

However, for the duration of the trial thus far, this has also meant a reliance on mobile coverage and continuity of mobile phone numbers for participants, raising concerns over participant accessibility in clinical trials that have been previously recognised within telemedicine and medical informatics [25]. Although a large proportion of individuals who are enrolled in the HeLTI trial own mobile phones, lower retention rates were observed among some participants who were hard to reach by mobile phone. The lack of accessibility and reachability of these participants was largely attributed to changes in their mobile phone numbers. Losing contact with some participants prompted further qualitative work to assess the reasons behind frequent changing of mobile numbers by trial participants and to identify other factors contributing to the challenges of contacting participants. Although a mixed-methods approach was employed to understand this outcome, the quantitative data produced contradictory results that did not confirm the qualitative findings as the majority of the participants had not changed their mobile phone numbers, contrary to what was observed in the qualitative data. Twenty in-depth interviews were conducted with the HeLTI cohort who were hard to reach by mobile phone. Their narrative accounts revealed that the participants predominantly changed their numbers due to mobile phone technical issues, such as poor battery life, faulty charging systems and mobile phones, and application crashes. Other challenges with contacting participants included network coverage issues, not personally owning a mobile phone, and phone (and thus sim card) theft. Participants also often left their phones at home to mitigate against theft. The significance of the daily risk of crime becomes a key data point for understanding participants’ ‘unreachability’ and why proposed interventions may or may not work in this context.

During the implementation of HeLTI–SA, questions also arose over terminations of pregnancy among HeLTI participants, observed to occur in about 5.2 per cent of pregnancies enrolled prior to 20 weeks gestational age. This has led to a qualitative inquiry into participants’ reasons for terminating their pregnancy. Using 10 in-depth interviews, the team used a socio-ecological model [26, 27] to explore how contextual and social complexities at micro- and macro-levels, including the COVID-19 pandemic, impacted participants’ decision to terminate their pregnancy [28, 29]. The main reasons for termination included intra-personal factors, such as financial instability and dependency; not being emotionally prepared for pregnancy; and the impact of pregnancy on future employment and education opportunities. Reported interpersonal reasons included a lack of partner support and stability and the threat of an adverse impact on family dynamics, including abusive behaviour. In addition, participants’ experiences reflected the impact of family and community beliefs around termination, accessibility, and attitudes of termination services, and the participants’ sense of agency in choosing to terminate. Interestingly, the COVID-19 pandemic seemed to play a secondary and indirect role in participants’ choice to terminate their pregnancy, mainly as a potential contributor to socio-economic insecurity. Exploring these factors across socio-ecological domains provides an understanding of unintended pregnancies in this setting and can help align termination services more effectively with women’s needs. By extension, it also sheds light on the social and contextual elements impacting (1) the practical implementation of HeLTI in terms of pregnancy loss and (the team’s understanding of) the number of participants retained in the trial through pregnancy and (2) participant experiences of (unintended) pregnancy, which can contribute to an informed interpretation of participant engagement with the intervention in its various phases. In the preconception phase, for example, a deeper understanding of participants’ circumstances and priorities can help explain the degree to which intervention components resonate with young women without (current) pregnancy intent. In the pregnancy phase, insight into the experiences and challenges faced in the context of unintended pregnancy can, for instance, highlight the need for additional support among participants.

Utilising a dynamic approach means that emerging obstacles also present opportunities to address novel research questions. Attending to new questions through qualitative work with trial participants not only allows for practical adjustments to trial protocols to ensure participant retention but also illuminates social factors that might later account for or help trialists to make sense of trial outcomes. Equal investment in the gathering of biological samples and qualitative data means that integrated biosocial analyses are possible. In a nutshell then, intervention trials that adopt biosocial models are not only more likely to ensure that the trial reaches completion, but they are also more likely to offer meaningful conclusions that contextualise findings in ways that matter for learning and policy recommendation.

21.5 Discussion

The novelty of DOHaD intervention studies raises important theoretical and methodological questions that cannot be parsed without a biosocial lens. This is especially crucial for DOHaD research that employs complex public health interventions, given that these present their own unique methodological and epistemological issues [14, 30, 31]. The manner in which social context is understood and accounted for in trials has the potential to amplify or diminish attention to the social drivers of health inequities. Collaborations that encompass anthropological and science studies perspectives are more likely to account for the structural and processual factors that might offer ‘real-world’ explanations of trial outcomes [16]. Pragmatic and adaptive designs in DOHaD intervention trials allow for both the robust methodology and contextual relevance that are required when testing complex public health interventions [14]. Ensuring that this balance is struck is essential given that it will have a direct bearing on how recommendations are framed at the end of the trial. In sum then, a biosocial collaboration that affords ‘the social’ equal weight as an aspect of the trial to be studied, incorporated, and analysed means that trial outcomes are better explained and that recommendations are more suitable to local context [32].

As Béhague and colleagues described some time ago, focusing on methodological innovation without an equally rigorous approach to conceptual collaboration risks reinventing old dichotomies (deductive or inductive; specific or generalisable) that do not hold in reality, where ill-designed qualitative methods can be equally reductionist [12]. A commitment to the development of shared conceptual models that are theoretically innovative and critically informed alongside appropriate methods is thus a better hallmark of meaningful biosocial collaboration. Examples include the development of the syndemics framework (see Chapter 15 in this volume); bioethnography (Chapter 15 in this volume); and foundational work that has developed novel methods to integrate ethnography and statistics [33].

On ‘doing’ biosocial collaboration in practice, it is useful to borrow Anthony Stavrianakis’s concept of collaboration: ‘a worthwhile collaboration is one in which two kinds of participants, in their engagement, are able to name a problem or do a practice that in their position as participants (prior to engagement) they would not have been able to do … Collaborative participation presupposes an endeavour of transformation’ [34]. This is very rarely straightforward, given the necessary work required to delineate the boundaries of collaboration and to navigate pre-existing organisational and disciplinary hierarchies and the range of ethical and social demands that collaboration as a practice may introduce ([34], see also Niewöhner in this volume). However, it is critical for both the constitution of evidence in DOHaD research and the framing and communication of the DOHaD message. As outlined in the introduction, DOHaD requires an expansion of its evidence base, and in a fashion that is likely to have a policy impact. As DOHaD scientists themselves begin to take on the language of seeking evidence for ‘politically palatable’ solutions, it is crucial that social scientists seize the opportunity at hand – the openness of DOHaD to transdisciplinary evidence synthesis as a more productive way to find scalable solutions to the question of fostering intergenerational health. This transdisciplinary approach in HeLTI will in itself serve as a case study and will be documented so we may further learn how to better integrate these ideas in future DOHaD-inspired RCT research.

Chapter 22 Doing Environments in DOHaD and Epigenetics

Sophia Rossmann and Georgia Samaras

22.1 Introduction: Environment as an Elusive Concept

Every organism lives in an environment. We are able to sense, measure, experience, and even change environments. Simultaneously, environments influence and shape us. For scholars in the Developmental Origins of Health and Disease (DOHaD) field, researching environmental effects on health is a key concern: the interdisciplinary field has a long history of drawing attention to the environment and its potential influence on health trajectories by traditionally relying on observational studies in human populations [1].

As scholars from the field of science and technology studies (STS), we are especially interested in understanding what the environment ‘is’ that emerges in biomedical research and its interactions with our bodies. Such questions prove particularly important in the current postgenomic era, where new scientific research challenges the previous emphasis on the gene as a core explanatory concept for human development by reinvigorating the role of the environment [2].

In recent years, environmental epigenetics has emerged as a key approach towards better understanding disease aetiologies in DOHaD research, which offers scientists a molecular mechanism to trace how environments biologically inscribe themselves into bodies and change health trajectories. Epigenetic research explores how socio-material environments, such as toxicants, stress, nutrition, or poverty, induce biochemical and structural changes on the DNA that impact gene expression, without changing the genetic code itself. In contrast to permanent changes in the DNA (e.g. gene mutations), epigenetic changes are not fixed but allow us to understand bodies as dynamically shaped by the environments in which they live [3].

Although the environment is gaining renewed attention in biomedical research, it still lacks an overarching theoritisation: even in life science publications dedicated to explore the nexus between epigenetics and the environment, scientists barely offer a detailed description of how to theorise the environment that organisms live in. Broad definitions of the environment as multiple factors, for example ‘[c]hemical pollutants, dietary components, temperature changes and other external stresses’ [4, p. 97], reveal that the environment is often conceived of as everything that surrounds cells and organisms. It is a loose definition that foremost understands the environment as distinct from anything genetic [5, 6].

In this chapter, we first discuss how DOHaD research tends to operationalise and measure environments to produce knowledge on how environmental experiences relate to health outcomes. We then show why it is important for researchers to consider how they conceive of and address the environment. We argue that what ‘is’ the environment is not self-evident but something that needs careful consideration. By scrutinising how environments come to matter in epigenetic DOHaD research, we aim to lay the ground for interdisciplinary critical reflections about the social and political dimensions of DOHaD.

22.2 Environments, DOHaD Research, and Environmental Epigenetics

In the twenty-first century, DOHaD has moved towards researching the health effects of a variety of environmental factors. Looking at how complex socio-material environments enter DOHaD research reveals how environments as research objects are not just ‘out there’; instead, researchers have to actively do environments in the laboratory. For example, in population-based research, DOHaD scientists use measurements such as body mass index or birthweight as indicators for the food environment of cohort participants [7], while in experimental rodent models, food becomes operationalised as a nutrient component [8]. We therefore suggest that how DOHaD researchers are doing environments needs careful consideration to understand the consequences that these doings might have and for whom.

Social sciences’ and humanities’ conceptualisations of the notion of environment offer theoretical avenues for how to conceive of the relationship between organisms and the environment in which they live [9]. Understanding this relationship as dynamic and mutually influencing renders stressors not as stressors per se but as phenomena that become stressors in relation to an organism. In theory, DOHaD has the potential to provide evidence on how diverse biological and socio-material environments spanning across different scales (intrauterine environment to neighbourhoods to social and economic structures) interact with organisms in a non-linear fashion and impact developing organisms and populations across different temporal horizons (preconception, prenatal periods, infancy, childhood, adolescence, adulthood, and generations). However, operationalising and measuring these dynamic, perhaps ‘unfinalizable relations’ [10, p. 708] between environments, bodies, spaces, and times is proving to be a challenging task for DOHaD researchers [11].

Social scientists appreciate the potential of epigenetic research to unpack what counts as environments and to reconsider questions of individual and collective responsibility towards these environments, potentially furthering political quests for health equity and social and environmental justice [12, 13]. At the same time, they frequently criticise that concepts of environments in the life sciences tend to be too simplistic [14] or lack consensus over what is meant by ‘environment’ [15]. There are three central social science critiques on how epigenetic DOHaD research operationalises the environment.

First, social science scholars have pointed out that epigenetic research tends to reduce complex environments to how environmental factors have an effect on the molecular level. For example, Landecker [16] demonstrates how research in nutritional epigenetics reconfigures the complexity of food to a molecular exposure capable of changing epigenetic mechanisms and the metabolism: what we eat has come to be framed as an epigenetic environment, that is an external exposure that conditions the (prenatal) body for later-life health outcomes such as diabetes or heart diseases.

This ‘molecularization of biography and milieu’ [3] that is rendering complex environments, relationships, and histories in terms of their molecular effects on bodies has been cautioned against also by DOHaD researchers in interdisciplinary collaboration. Social and life scientists together have argued how such an understanding might obscure how these exposures are socially patterned and unequally distributed across the social worlds we live in [17, 18].

Second, social science scholarship has discussed the potential of DOHaD research to individualise environments. As Chiapperino et al. extensively discuss in this handbook, epigenetic DOHaD research tends to focus on individual behaviours and traits as primary sites to make environmental exposure visible. This focus can be problematic as neglecting how structural factors impact health beyond individual decisions can lead to rendering exposure situations as products of lifestyle decisions, thereby favouring behavioural over structural health interventions. Thus, individuals might be responsiblised for managing their health risks and diseases [17].

Interestingly, as Warin et al. [19] outline, DOHaD research originally had a focus on how gendered socio-economic effects of maternal undernutrition impact the disease susceptibilities encountered in adulthood. However, with an increasing focus on overnutrition, maternal obesity, and diabetes, DOHaD’s notions of the environment have become narrower over time, ‘telescoping’ on the uterus as ‘“the environment” of scrutiny; … the social environment [became] an independent and secondary context’. [19, p. 456]. Such tendencies to become more concerned with individual-level factors and choices also speak to a gendered stereotype of female caregiving that is especially prevalent in the Global North and perpetuates culturally situated concepts of the environment as singular and bounded [12].

Lastly, social scientists have argued how specific experimental set-ups in epigenetic DOHaD research give more attention to some environments than others [20]. Studying clinical trials in the UK and USA, Valdez [14] demonstrates how with selecting some experimental set-ups (e.g. animal models and randomised clinical trials), researchers choose certain environmental factors as significant over others, ultimately influencing what public health professionals regard as central for designing and implementing interventions. These choices often stem from the epistemological traditions of scientific fields. For example, in social epidemiology, diet might be access to different types of food shaped by socio-economic structures [20]. In comparison, nutritional epigenetics operationalises diet as environmental exposures in the form of nutrients [16], whereas in the mundane experiences of family meals diet, even if considered unhealthy, might be interpreted as expressing love to one’s family members [21].

22.3 Caring for More Complex Environments in DOHaD Research

With environments playing a central role in DOHaD research, we believe it is important to consider how scientists measure and operationalise environments. As findings are increasingly taken up in healthcare and global policy guidelines [22], they have social and political consequences for wider society. They shape how society understands diseases, (re-)assigns responsibilities towards tackling them, and what health strategies and interventions are imagined possible. If framings of the environment are mostly done on the individual level and as simplistic factors, they steer interventions in the direction of educational public health messaging and lifestyle changes rather than examining the structures that undergird certain choices (cf. Chapter 16).

However, this does not mean that DOHaD researchers do not engage in reflections on the complexity of human lives. Penkler [11] shows how the simplistic environments emerging in DOHaD study designs are sometimes ‘at odds with the researchers’ own normative commitments and aspirations’ and their aim to position themselves against the ‘reductionist science’ (p. 2) of gene centrism in the 1990s and 2000s.

Looking at very recent developments in DOHaD fields provides interesting cases of researchers’ attempts to conceptualise environments in more complex ways and to shift attention to environments that might have a positive effect on health trajectories. Informed by our own ethnographic fieldwork in environmental epidemiology (Rossmann) and neurobiology (Samaras), we briefly discuss two examples: green spaces and stress as a complex experience. Both examples exhibit a fundamental question that receives renewed attention with environmental epigenetics: how can DOHaD research account for the entangled relationship between organisms and environments?

22.3.1 Green Spaces

Green spaces (e.g. parks) have been associated with a plethora of beneficial health outcomes such as improved physical and mental health and a lowered risk of cardiovascular and respiratory diseases. Treated as an exposure variable, green spaces tend to be operationalised using established variables available and harmonised across different cohort studies. These variables currently include (1) surrounding greenness using satellite-derived indices to quantify the intensity of greenness; (2) access to a green space within 300 metres of residence; (3) straight line distance to the nearest green space; and (4) area of the closest green space.

Yet, what green spaces ‘are’ at the specific institute for epidemiology and public health at which Rossmann conducted her fieldwork is not fixed from the start but instead the outcome of a series of negotiations among the researchers. Rossmann could observe how green spaces are done in practice: in scientific articles, international guidelines, through infrastructures and their available data sets, and in scientific meetings. Researchers actively assemble the variable ‘green spaces’ using different types of aggregated data, including satellite images, topographical maps, questionnaires, measurements, and experiences through particular modes of calculation. They reflect upon its temporal dimension measured as the greenest moment of the year and time spent in green spaces; spatial dimension measured quantitatively as distance, access, and size and qualitatively emphasising the importance of local environments; and social dimension considering how people might experience and use these spaces differently, where green spaces can create both restorative effects and stressful experiences when perceived as dangerous.

At the end of these negotiation processes, the group Rossmann followed will have decided to focus on two variables to analyse for one of their first publications on epigenetic changes in relation to exposure to green spaces: greenness and access. These two variables will appear as clear-cut definitions of green spaces in their publication, momentarily stabilising a specific version of green spaces reintegrated into the classical terminology of exposure variables while excluding the process that went into deciding upon them.

22.3.2 Stress as a Complex Experience

The experience of stress has long been a subject in neurobiological research. This branch of research describes stress as having a potential pathogenic effect, leading to depression or anxiety, especially when considered severe or occurring over a long period of time. Rendered as an environmental exposure, neurobiologists tend to operationalise stress by eliciting a systemic response, for example by placing mice into a narrow tube to measure the traces stress leaves behind as changes in DNA methylation or histone modifications. In these re-enactments, stress is reduced to (a series of) singular measurable events that challenge organisms, obscuring how stress is omnipresent in a lab rat’s life, for example through differences in their handling or housing.

The work of the research group with which Samaras conducted her ethnographic fieldwork contrasts with this reductionist approach. The group attempts to invite a more complex notion of environment into the mouse model by including what they term ‘social’ factors: they create a completely new experimental arena for the mice to live in to construct a ‘semi-natural’ or ‘enriched’ environment that allows the researchers to test the mice in groups. This highly sophisticated experimental arena, termed ‘complex behaviour’, consists of various interconnected cages in which the mice are offered toys, food, and water at all times. By extending the experiment over several days during which the mice experience exposure to stress, undisturbed phases, and even positive environments (toys), researchers attempt to emphasise the temporal dimension of the environment and to account for the dynamics of experiencing stress. Stress emerges as a processual experience that spans across life instead of singular events that are disconnected from most parts of an organism’s life. The ‘complex behaviour’ set-up therefore allows researchers to understand stress as an environmental phenomenon proceeding in action, where the mouse is triggered and then equilibrated, triggered again, and so forth.

Both examples demonstrate that it matters to care for constructing more complex exposure variables and research arrangements. First, these examples illustrate current developments in DOHaD to move away from a historically strong emphasis on ‘damaged-centred’ [23] research towards environments with buffering and restorative effects. Green spaces, for example, are assembled as elements of the urban environment that can have buffering effects, counterbalancing adverse health trajectories. Similarly, the ‘complex behaviour’ experiment offering ‘enriched environments’ encourages conversations on how positive social interventions, especially early in life, might have therapeutic effects [cf. 24]. Taking seriously the dynamic and processual character of environments across time increasingly means for DOHaD researchers to also consider ‘positive’ environments.

Second, these more complex renderings of environments shift attention away from dominant interventions on the individual level towards understanding organisms embedded in the ecologies in which they live. Evidence on green spaces is directed at policymakers to raise questions on how to design the cities where we want to live. ‘Complex behaviour’ experiments shift attention to how certain variables of interacting life circumstances shape health outcomes.

22.4 Obstacles to Put Complex Environments into Practice

As outlined in the previous section, DOHaD researchers discursively care about acknowledging the dynamicting character of environments, with some moving towards incorporating more complexity into the study designs. Simultaneously, most DOHaD researchers grapple with this complexity: being embedded in institutional contexts and established infrastructures hampers scientists to put their complex understanding of environments into practice [11]. We see three obstacles arising from the current disciplinary and research policy structures from putting main drivers of this challenge.

First, while constructing environments as phenomena taking place over time carries more ecological validity, this poses new challenges as to how to turn these considerations into research set-ups that capture the dynamic relations. Ackerman et al. [25] identify a ‘moral economy of quantification’, which arises from the dominant and collectively negotiated virtues in science that ‘shape … how knowledge about complex causality can be produced.’ (p. 213). This moral economy favours operationalisations of environments that can be turned into ‘precise measurements’ and data to be harmonised and traded across laboratories. Such aspirations to produce universal data incentivise researchers to focus on environments that are easier to manage in the laboratory, making it unrewarding to operationalise environments as experiences arising from structural circumstances.

Second, these epistemological reasons are intertwined with the power of current research infrastructures and framework conditions in the life sciences [26]. As Pinel [27] points out, the biological environment to trace how exposures and experiences produce epigenetic changes is embedded within a social environment of the entrepreneurial university where research is conducted. This environment is structured and influenced by multiple overlapping scales of funding bodies, audit cultures, peer-reviewed journals, and scientific communities and their established practices. Thus, decisions on how to operationalise environments are not only guided by the research questions but also depend on institutional settings, economic aspects (e.g. time and material resources), and technical infrastructures (e.g. computing power available for statistical analyses) [27].

Third and relatedly, the current and rather rigid logic of publishing may not allow to include how researchers negotiate which environments to re-enact and how. Life science publication culture is mostly geared towards representing research as linear and producing unambiguous results. We know from STS that research practices are tedious processes in which scientists have to negotiate what materials and methods they in-/exclude, how, and why [28]. To account for these local and situated experimental conditions that bring about the final research results, as discussed above with green spaces and stress, would require a new publication ethos that allows research to be portrayed as a dynamic and social process, for instance, in the form of an extended Materials & Methods section [29].

22.5 Conclusions: Avenues for Interdisciplinary Conversations

The environment represents an elusive concept to capture for biomedical research. With findings from DOHaD research becoming increasingly relevant for policy and healthcare [22], it matters how scientists conceive of and address the environment. In order to conceptualise environments that allow for more complexity in research designs, we discuss the merits of interdisciplinary collaboration in which social and life scientists together engage in critical reflections about the social and political dimensions of DOHaD.

On the epistemological level, including certain environments in research designs is necessarily selective to become workable: most research has to be reductionist to a certain degree to be feasible. Engaging in these kinds of ‘pragmatic reductionisms’ [30] demands reflections on the strategic choices and trade-offs made and their potential political consequences outside the scientific arena. To take this task seriously, we consider it important for both, DOHaD researchers and social scientists, to critically and responsibly question their own practices: being aware of which reductionisms they want to engage in, that is which reductionisms they potentially reproduce with their research and still comply with.

On the practical level, interdisciplinary collaborations could help provide more complex accounts of the biosocial environments that shape health trajectories across the lifespan and generations. Examples of the forms that these collaborations can take can be found in this handbook (Chapters 15 and 29). Roberts et al., for example, propose the method of bioethnography, which combines ethnographic observation and biochemical sampling and encourages both social and life scientists to engage in an open-ended and iterative process of doing research.

Niewöhner advances the term ‘co-laboration’ to think about interdisciplinary collaborations, as he argues elsewhere, in terms of ‘temporary, non-teleological, joint epistemic work aimed at producing disciplinary reflexivities not interdisciplinary shared outcomes’ [31, p. 2]. In other words, interdisciplinary work is not about giving up on one’s own disciplinary positioning but encouraging spaces to think differently about one’s own knowledge practices. Such spaces to engage in processes of mutual learning emerge from encounters in ‘reading groups, joint empirical work, visiting conferences together, writing together, designing and conducting experiments together’ [31, p. 18].

We propose that such interdisciplinary collaborations, even when situated in divergent research ecologies, prove fruitful to further discussions on doing environments. We suggest five (non-exhaustive) reflections for these discussions to account for the different epistemological and socio-political dimensions environments are made up of in DOHaD research:

1. 1. to discuss doing environments as an active achievement, that is as a product of the decisions made and methods used to know and measure environments (performative dimension);

2. 2. to take seriously the temporal dimensions of environments beyond their re-enactments as singular damage in the laboratory (processual dimension);

3. 3. to carefully consider how environments as research objects are embedded in the (research) contexts in which they occur, that is to acknowledge accounts of environments as historically, socio-politically, and economically influenced (situational dimension);

4. 4. to understand doing environments as political, bearing potential consequences for which environments become relevant outside the scientific arena (political dimension);

5. 5. and to allow for interdisciplinary reflexivity to identify blind spots in defining environments across disciplines (reciprocal dimension).

We hope that these reflections further encourage interdisciplinary conversations about the importance of carefully attending to how environments are done in DOHaD research. We consider it necessary to acknowledge doing environments as a concrete research practice and as a repertoire in scientific discourse, instead of leaving this central scientific task undiscussed. In doing so, DOHaD researchers could, for example, take into account environments beneficial to organisms and invest in studying the effects of ‘enriched’ environments [24]. This could open up discussions about the restorative effects of social interventions and help address structural problems in public health policy [cf. 13]. Here, we see a great opportunity to go beyond individualised and damage-centred narratives in DOHaD research in order to tell scientific stories that account for the complexity of biosocial worlds.

Chapter 23 Narrative Choreographies DOHaD, Social Justice, and Health Equity

Martha Kenney and Ruth Müller

Communicating research findings is a storytelling practice. The stories we tell as researchers are important to how publics understand research findings and how research circulates in society. This is especially true for fields that have important social, political, or policy implications, such as the Developmental Origins of Health and Disease (DOHaD). In its emphasis on gestation and early childhood, DOHaD research often focuses on the behaviours of parents (especially mothers) as crucial to the development and health of their children. Depending on how the story is told, this can lead to blaming mothers for future diseases [1]; however, this is not the only possibility. If we zoom out and focus the narrative not on the individual, but on the larger social, economic, and political environment, it is also possible to use DOHaD research to problematise the structural conditions that shape health across generations [2, 3]. In this case, the upstream social determinants of health such as wealth inequality, economic exploitation, sexism, and systemic racism become targets for public health intervention. The stories we tell about the research matter to how research questions are framed, how studies are conducted, how findings are interpreted, and what kinds of interventions are proposed. Thus, it is important to understand storytelling as crucial to the practice of doing responsible research at the science–society interface.

We use the term ‘narrative choreographies’ [4] to capture the way researchers, clinicians, science journalists, and other actors conceptualize and embed DOHaD knowledge claims as part of larger scientific, social, and political narratives. Sometimes narrative choreographies are strategic, where we deliberately choose language to encourage certain interpretations of research findings and discourage others; however, more often than not we employ narrative choreographies unconsciously, using scientific and cultural narratives that are available to us in our wider social environment – which can have unintended consequences. For example, DOHaD narratives are often focused on the effects of maternal obesity¹ and gestational diabetes on fetal development. Feminist science studies scholar Sarah Richardson argues that this narrative focus can lead to self-rapprochement in mothers who have a BMI classified as ‘obese’ and a lower standard of care in clinical encounters. Furthermore, framing obesity in children as a negative outcome of maternal obesity runs the risk of ‘replicating harmful stereotypes and misconceptions that contribute to stigma about fat children, which in itself can harm their mental and physical health and imperil their safety’ [6, p. 215]. These narratives could be productively rescripted to focus on access to tasty, culturally appropriate, nutritious, and affordable food for parents and children rather than pathologising the size of their bodies. When we rely on narrative conventions we inherit from our field, we can miss the opportunity to ask critical questions about how to tell responsible stories about our research. While we don’t always have control over how our research is interpreted in other arenas, carefully constructing narrative choreographies increases the likelihood that our research will have the social impact we desire.

Our years of working with DOHaD researchers have taught us that many researchers in this field do research explicitly with the intention of affecting positive changes in the world: they want to increase the health and well-being of people, especially those who have historically been disadvantaged, marginalised, and underserved. However, current narratives emerging from DOHaD often unintentionally serve to further stigmatise these groups rather than support their health and well-being [7, Chiapperino et al. in this volume].

In this chapter, we advocate for deliberately choreographing DOHaD narratives to address structural inequality and support struggles for social justice and health equity. In order to do this, we suggest moving away from focusing on individual responsibility, and instead, emphasising the social determinants of health. A narrow focus on individual responsibility can unduly blame people for their health status and the health status of their children, without addressing the causes of inequality, which are structural and socially determined. We further recommend crafting narrative choreographies that avoid pathologising people who have experienced early life adversity, and instead focus on possibilities for healing, growth, and health throughout the lifecourse.

In your own research area, you will likely have a sense of some of the harmful narratives that circulate among researchers, in policy, and in the wider media; these may be different than those we present here. We encourage you to reflect on how to choreograph your DOHaD narratives to avoid harmful social and political implications and to suggest policy interventions that better support parents, children, and communities. We offer three examples from our own research to demonstrate how to recognise narrative choreographies at work in DOHaD and neighbouring fields with an eye towards avoiding potential pitfalls and connecting research with the real-life challenges that communities face due to inequality and discrimination. We conclude by offering recommendations for DOHaD researchers who are interested in workshopping their own narrative choreographies.

23.1 Example #1: Epigenetics of Maternal Care

Our first example comes from a research area that has emerged from a series of experiments on the epigenetic effects of maternal care in rats conducted at McGill University. These experiments have not only been influential within the field of environmental epigenetics but also in fields like DOHaD that have significant policy implications. The McGill group found that when a mother rat licks and grooms her pups regularly, it leads to the stronger expression of a glucocorticoid receptor gene in the pups’ brains, which makes them calmer and easier to handle as adults [8]. When there is less licking and grooming behaviour, they found that the rat pups become more anxious and aggressive, a change in behaviour that is considered to be epigenetic in origin and is thought to last throughout the lifecourse. When this research is translated into claims about human behaviour and health, it is often embedded in narrative choreographies that blame mothers for undesirable epigenetic changes that affect the health and well-being of their offspring [1, 9, 10]. Despite the fact that rats do not practise bi-parental care, the model organism findings are used to argue that human mothers are responsible for the future health and disease of their children, without paying attention to the role of fathers, extended family, paid caregivers, and the environment beyond the home [11]. This too-quick translation between model organisms and humans leads to narratives that focus on mothers’ parenting behaviours without considering the larger social and economic environment in which parenting occurs [10].

For example, in the article, ‘Maternal warmth buffers the effects of low early-life socioeconomic status on pro-inflammatory signaling in adulthood’ [12], Chen et al. use the McGill experiments to frame their research on ‘maternal warmth’ in humans.² They find that in low socio-economic status (SES) households, high levels of maternal warmth protect children against the negative health effects of poverty, which they measure via biomarkers of immune activation and systemic inflammation. At the end of the article, they discuss the policy implications of this research:

Working to alleviate poverty, as lofty and important a goal as this is, has remained an intractable problem in our society. Complementing this effort, encouraging and teaching parenting behaviors that facilitate warm emotional climates, even in the face of adversity, might prove to be a supporting, effective target of intervention (as suggested by cross-fostering and environmental manipulation studies in previous animal research).

[12, p. 735]

By framing poverty as ‘intractable’, these researchers advocate instead for interventions on the individual level, such as parenting classes for low-SES women. This narrative choreography precludes interventions that target the upstream social determinants of health, and instead places the burden of social transformation on low-SES mothers to protect their children from a world that is stacked against them from the start. Furthermore, they do not discuss the structural reasons for low-SES status such as racism, discrimination against people with disabilities, and xenophobia.

Individual interventions are popular in a neoliberal policy climate that seeks the most cost-effective solutions to public health problems. However, these interventions do not target the root cause of health inequity and put the burden for change on the most vulnerable. In the US context, where systemic racism limits life chances for Black Americans, prominent political activist and scholar Angela Davis and her sister, Fania Davis – a leader in the restorative justice movement – write:

While the difficulties besetting the family should by no means be dismissed, any strategies intended to alleviate the prevailing problems among poor Black people that methodologically target the family for change and leave the socioeconomic conditions perpetuating Black unemployment and poverty intact are doomed to failure at the outset.

[13, p. 81].

Following Davis and Davis, public health interventions that focus on poor and racialised mothers³ fail to support efforts for anti-racism and economic equality [see Valdez and Lappé in this volume]. Rather than parenting classes and other forms of public health surveillance, Chen et al. could advocate for more parenting resources, such as paid parental leave, free daycare, and affordable food and housing. Local activists and organisations as well as researchers in sociology and social work who support low-SES parents might be able to offer specific policy recommendations that would be relevant to their goals. Seeking out the necessary experts and expertise for crafting responsible narratives and policy recommendations is essential for DOHaD research to have a positive impact on the life worlds of the people they study. We include specific recommendations for interdisciplinary inquiry and collaboration at the end of our chapter.

23.2 Example #2: NEAR Science Trainings

In our work on the McGill experiments on the epigenetics of maternal care in rats [10], we became concerned by narrative choreographies that focused almost exclusively on the damage caused by early-life adversity. We felt that a focus on damage without a concomitant discussion of healing and reversibility could run the risk of pathologising those who have experienced childhood adversity and increase stigmatisation and discrimination [14; see also Meloni et al. in this volume]. However, in our later fieldwork in the US Pacific Northwest, we were surprised to find that this research had been taken up by actors outside of DOHaD and public health and placed into a different narrative choreography that emphasised how widespread early-life adversity is and that focused on possibilities for healing, health, and well-being throughout the lifecourse.⁴

At our field site, actors reported a crisis in schools, which was characterised differently depending on who we spoke to. This is how the crisis was framed by a community leader at a local nonprofit:

We have a very high teen suicide rate here. The school district, the reason that they became motivated for trauma-informed practices [was that] they had two high school students the same year [die by] suicide. It’s a small school, right? The then-superintendent was just devastated. And she goes to her school board and says, ‘We had two kids kill themselves. We’ve got to do things differently.’ They didn’t know what to do differently, but she and her district became kind of like this learning community.

(NEAR-org 2)

One of the novel approaches they adopted to address this crisis was NEAR Science trainings. These trainings are based on the findings of the CDC-Kaiser Adverse Childhood Experience (ACE) Study, which shows that the more ACEs a person has experienced out of an ACE score of 10,⁵ the more likely a person is to develop negative physical and mental health outcomes across the lifecourse. In the trainings, trainers combine the ACE Study with more recent research findings in epigenetics and neuroscience to explain how ACEs can lead to negative health and behavioural outcomes. The NEAR acronym brings these different research strands together; it stands for Neuroscience, Epigenetics, ACEs, and Resilience.

Although the findings of the CDC-Kaiser ACE Study can be discouraging for those with ACEs, the trainers frame the NEAR Sciences as ‘sciences of hope’. They employ narrative choreographies that deliberately avoid biological determinism (i.e. ACEs always lead to negative health outcomes) and pathologisation (i.e. stigmatising people with ACEs). For example, after saying that toxic stress can rewire the brain to expect danger everywhere, the trainers make clear that this is not necessarily negative or a disease state; they explain that people with ACEs have ‘protector brains’ and are well suited for high-stress careers such as ‘first responder’. Trainers emphasise that ACEs are common and that having ACEs does not necessarily mean future ill health. They tell the story of a doctor who was highly successful and respected in her community. When she attended a NEAR Science training, she raised her hand during the discussion and said, ‘I have all ten ACEs; why did I turn out so well?’; she went on to talk about the support she received in her life that led to her success. This story is used to illustrate how resilience – which is often defined as interpersonal – can protect people against the potential negative health effects of ACEs. One adage that trainers repeat frequently is that a positive relationship with ‘one caring adult’ can support resilience. Although this at first may appear similar to the notion that maternal warmth can ‘buffer’ against early childhood adversity, the NEAR Science trainings move the locus of responsibility out of the home and into the community and the institutions that support children (e.g. schools). They emphasise that this “one caring adult” does not have to be a mother or parent to be effective. Thus, in the NEAR Science trainings, the biology of early life adversity is framed as actionable with community support, rather than dooming people to a life of poor mental and physical health.

When ACEs are framed as deterministic, prevention becomes the only solution to the problem of ACEs. And while prevention is important, it does not help those who have already experienced early-life adversity live healthy and fulfilling lives. The narrative choreographies of the NEAR Science trainings emphasise that ACEs are common and assert that it is possible to intentionally build resilience in individuals and communities. For example, inspired by the NEAR Science trainings, schools are making changes to how they address difficult behaviours. In the NEAR Science framing, these behaviours are understood to be as a result of ACEs rather than wilful disobedience. Therefore, schools are intentionally reducing punitive disciplinary measures, such as suspension and expulsion, and introducing practices from restorative justice and trauma-informed care [4].⁶ Restorative justice is an established alternative to punitive justice that focuses on building and maintaining relationships and repairing harm. This approach allows children to engage in social-emotional learning and mend relationships rather than be excluded from the community when they harm others. This rejection of received forms of punitive discipline and this new focus on maintaining strong interpersonal relationships creates novel possibilities for children with ACEs – and indeed all children – to flourish in the school environment. The narrative choreography of the NEAR Science trainings, with its emphasis on growth, learning, and healing throughout the lifecourse, makes these kinds of novel interventions possible.

23.3 Example #3: An Obesity Epidemic in the Global South?

The last example we will discuss concerns the effects of maternal nutrition on children’s health. While maternal nutrition is a broad topic of concern within DOHaD [15], here we specifically focus on discourses within DOHaD that engage with the rise in average BMI in the Global South [16]. Researchers in DOHaD have been warning that obesity is on the rise in nations such as India where eating habits are changing, and more people are adopting a so-called ‘Western diet’. This shift is thought to increase the risk of non-communicable diseases (NCDs) in the population. In the popular science book, Mismatch: Why Our World No Longer Fits Our Bodies, Gluckman and Hanson have argued that this dietary transition constitutes a ticking ‘lifestyle disease timebomb’ [17], while others have called India the new ‘diabetes capital’ of the world [18]. The DOHaD explanation for India’s rise in average BMI and NCDs is that there is a mismatch between the current nutritional environment and the nutritional environment of the previous generation. In utero, the current generation was exposed to their mothers’ diet, which is assumed to be variously ‘less processed’, ‘traditional’, or contributing to ‘undernourishment’. Experiencing their mother’s diet as a fetus would have programmed the bodies of the current generation to anticipate low-caloric foods through their lifecourses. Thus, their bodies would exhibit a ‘thrifty’ metabolic phenotype that gains body weight easily when transitioning to a calorically dense ‘Western diet’, putting them at an elevated risk of NCDs.

Narratives in the DOHaD literature about why eating patterns change in post-colonial contexts such as India are often focused on individual choices: adopting a Western diet is thought to be a sign of wealth and cosmopolitanism, particularly in the growing Indian middle class (see, e.g. [19]). Indians in this context are often framed as eager to catch up with the West and unaware of the possible health consequences of their new diet. At the same time, phrases like ‘lifestyle disease timebomb’ construct Indian bodies as a threat to themselves as well as to global health. By adopting these paternalistic and alarmist narrative choreographies to discuss emerging health challenges in India, DOHaD inadvertently perpetuates colonial tropes that serve to obfuscate histories of colonial violence and persistent post-colonial power differentials. It also upholds the notion that it is the role of Western science to educate and manage non-white bodies in the Global South – an ongoing legacy of colonial science.

There are different narrative possibilities, however. When discussing a rise in median BMI in India, DOHaD researchers could draw attention to how Western food corporations have come to colonise food markets in the Global South and increasingly control the foods that are available to the local population, as well as large-scale industrial agriculture that encourages monoculture. They could also discuss the shift in priority setting in local agriculture towards crops for export rather than traditional foods for local consumption. In this context, researchers could partner with local social movements and activists who work to achieve food sovereignty and access to healthy, affordable foods and follow their lead in how to define problems, solutions, and interventions.

23.4 Recommendations for Narrative Choreographies

Drawing on the three examples listed above, we have compiled two sets of recommendations for DOHaD researchers who are interested in connecting their research to social justice and health equity goals. The first is a set of suggestions for developing an active practice of choreographing DOHaD narratives. The second is a list of pitfalls we have observed in commonly circulating DOHaD narratives. These lists are not exhaustive, and we fully expect pitfalls to change over time as the research field grows and narratives change. The important part is to recognise that storytelling is a consequential scientific practice and to reflect on the social and political effects of the stories we tell about our research.

23.5 How to Make and Revise Your Narrative Choreography

• Reflect on the narratives you are currently using when communicating your research. Consider why you are using these narratives and how they could be reimagined to better support positive change. Ask yourself: who is included in the narrative, and who is excluded? Who is held responsible for healthy/unhealthy development, and do they have the resources and support needed to effect change? Does this narrative reinforce or challenge existing inequalities? Are there any implicit stereotypes about gender, race, sexuality, disability, fatness, or other categories of difference that should be addressed? Which policy positions does this narrative support or undermine? Does this narrative explicitly advocate for social justice and health equity goals?

• Partner with stakeholders, communities, and organisations that represent and support vulnerable people. Learn about the real-life problems that parents, children, and communities face and what kinds of interventions and resources would most benefit them. If possible, connect your research findings with these goals.

• Reach out to colleagues in other fields such as science and technology studies, education, social work, history, women and gender studies, and ethnic and area studies as potential research partners to benefit from their expertise and to learn viable alternatives to dominant narratives.

• Deliberately plan your narrative choreographies. Decide which framings and interventions you want to promote and which might be harmful and should be avoided. Consider whether the language you are using supports this plan or surreptitiously works against your goals. Practise your narrative in front of different audiences to learn how it is received and make changes accordingly.

• Revise your narratives. Storytelling is situated. What might work well in one context may not work in another [20]. Re-choreograph narratives for different audiences and as political language and awareness changes. For example: what does it look like to talk about racism and health in the wake of the Black Lives Matter movement? Or childhood sexual abuse after the #MeToo movement?

23.6 Pitfalls to Avoid

• Avoid policy recommendations that identify marginalised individuals and families as the singular target of intervention. Employ narrative choreographies that emphasise structural issues such as racism, wealth inequity, and the upstream social determinants of health. Connect DOHaD findings to key issues in social justice and health equity. Advocate for resources that support parents and children’s healthy development.

• Avoid narratives that pathologise those with ACEs or perinatal exposures. Instead, use non-deterministic frameworks that acknowledge opportunities for health and resilience across the lifecourse. Recognize that early-life adversity is common; when early-life adversity is framed as rare and pathogenic, it can alienate and shame people with these experiences. Partner with educators and others who work with children to create institutions and programmes that support social-emotional growth.

• When doing research that involves a different national or social context, pay attention to power differentials and to how global histories shape the available narratives. No matter what our social position and national context, it is important to avoid imposing our own problem/solution framework on the lives of others. Often people themselves are the best experts on their own lives and can readily identify which problems are important/unimportant and which interventions are helpful/harmful [21]. Avoid using alarmist language and terms like ‘obesity epidemic’ or ‘disease timebomb’ to speak about entire populations, and thereby, implicitly framing them as a danger to themselves and to global health writ large.

• Avoid pathologising obesity in pregnant women/people and in children in both research and clinical encounters. Making people feel shame about their bodies is an ‘affective determinant of health’ [22] that can negatively impact pregnancy and health outcomes [23]. DOHaD narratives should support people’s health goals regardless of their body weight, disabilities, mental health status, etc. Health can act as a moral category [24] that is used to shame people who ‘deviate from an imagined ideal norm of health, youth, fitness and … attractiveness’ [22]. It is important to avoid shaming and blaming those who fall outside of a perceived norm. Question your own assumptions about health and listen to those who have had negative experiences with the healthcare system.

• Reflect on your own research area and add any additional pitfalls you haven’t seen to this list.

We believe that many researchers in DOHaD are committed to strengthening social justice and health equity worldwide. We offer these recommendations in a spirit of collaboration and hope that they open more opportunities for partnership across disciplines and sectors as we attempt to address the significant public health implications of DOHaD. Deliberate narrative choreographies, narrative choreographies that link NCDs back to structural violence and avoid individual blame, constitute one important practice in the co-creation of responsible biomedical research and clinical practice.

Chapter 24 Interdependence Reworking Ontogeny through Tendrel Fishbones and Dirty Chickens

Shivani Kaul and Emily Yates-Doerr

24.1 Introduction

In 2008 and 2013, The Lancet published a series on maternal and child undernutrition that laid the groundwork for public health policymakers to approach nutrition as a foundational component of global development. In the series introduction, Robert Black and his co-authors emphasise a hierarchy of medical and monetary factors that cause malnutrition and serve as sites for intervention. Using a framework developed by UNICEF, they list eight color-coded risk factors, all stacked vertically [1]. ‘Basic’ causes of malnutrition like ‘social and economic conditions’ and ‘lack of capital’ sit at the bottom of the stack (see Figure 24.1). Then come monetised ‘underlying’ conditions like ‘income poverty’, which is listed prior to and distinct from conditions like ‘unhealthy household environment’. At the top of the stack, closest to undernutrition, are ‘immediate’ causes such as ‘inadequate dietary intake’ and ‘disease’. In the first article of the series, Geneva and US-based authors emphasised the period from conception to the second birthday – a period of roughly 1000 days – as a ‘crucial window of opportunity’ to address undernutrition [2, p. 510]. The series’ second article emphasises the health and ‘human capital’ consequences of malnutrition. Here, the multidisciplinary authors draw on the Developmental Origins of Health and Disease (DOHaD) hypothesis to argue that poor fetal nutrition in early life leads to ‘irreversible damage’ to future adult health, school achievement, and adult income for up to three generations [3, p. 340].

Figure 24.1 The Lancet model of causal interdependence

[1, p. 244]

The dominant logic woven through this publication series is that a narrow window of physiological development has profound implications for future health and economic productivity, which neoclassical economists value for its contribution to gross domestic product (GDP). Though the potential nutrition interventions discussed in these papers range from land reform to rest during pregnancy, most ‘proven’ nutrition interventions the authors recommend focus on what they call immediate causes. The third article illustrates the overarching message of the series: that policy actions on maternal and child undernutrition can include a wide range of interdependent interventions while excluding ‘important interventions that might have broad and long-term benefits’ because they are ‘outside the scope’ of review, or because they lack an appropriate evidence base appropriate evidence like randomised control trials [4, p. 418]. ‘We must be targeted in our approach’, one US-based politician has said about the need to address malnutrition during the early developmental stages (see also Jacob et al. in this volume).

In our chapter, we draw upon research on child development that inspires a reworking of The Lancet’s causal models and the policies that result. The DOHaD scientists in Bhutan and Guatemala whose work we describe are in conversation with The Lancet’s series on child development. But whereas The Lancet’s authors place ‘social, economic, and political’ factors at the edge of the conversation about child development, these scientists place cultures, economics, politics, and ecologies squarely at the heart of development, advancing a theory of ontogeny that insists on a complex and interdependent web of causation.

Ontogeny (from the Greek words onto/being and genesis/birth) is a term biologists use to describe physiological growth and development. It emphasises how an organism’s form emerges through a process of temporal maturation, with early-life inputs coming to shape later-life physiological structures. This chapter illustrates how different scientific models for ontogenic (biological) development shape the terrain of possibility for global (economic) development, which warrants attention since scientists’ vision of development impacts the interventions they design. In Bhutan, we highlight the example of ‘fishbone’ modelling that unfolds child development factors along multiple, horizontal, spatial, and temporal themes. That child development is the effect of collective well-being amplifies Buddhist relational logics of tendrel, or interdependent origination. In Guatemala, we highlight the example of the ‘dirty chicken hypothesis’, which directs attention to ecological relations. In the Guatemalan case, the normative question of how the organism should develop is one that requires also asking whether the environments that shape and surround this development are well supported.

While The Lancet’s models and the Bhutanese and Guatemalan models for malnutrition all emphasise interdependence between humans and their surroundings, they differ in how they organise this interdependence, and, as a result, where the work of intervention must fall. Whereas The Lancet’s models are linear and hierarchical, resulting in a policy focus on what and how mothers eat, the theories of interdependent ontogeny that we describe in Bhutan and Guatemala insist upon the value of an ecological approach to health policy, where any given intervention must be reformulated away from targeting individuals to instead amplify caring coalitions. ‘Target’, we learn from this theory of ontogenesis-as-interdependence, is frequently the wrong metaphor: human communities and landscapes must be cared for together.

24.2 Bhutan: The Fishbone Model

24.2.1 The Golden 1000 Days

Since 2008, the Geneva-based organisation Scaling Up Nutrition (SUN) has been rallying governments, multinational corporations, and non-profit organisations to fund 13 ‘high impact’ interventions selected from The Lancet series. The organisation has become ‘the most important symbol for the increased interest in nutrition’ in global development today [5, p. 552]. Leaders in food policy from 65 countries have joined SUN so far. But some governments have not been so quick to sign up for this targeted approach to intervention and financing. In 2016, the Royal Government of Bhutan sent three representatives to Bangkok to attend the SUN workshop on public finance for nutrition in Asia. Bhutanese representatives did not join SUN, instead citing the need to complete more research on broader actions that follow different pathways of maternal health.

Scientists and policymakers in Thimphu, the capital of Bhutan, have been mobilising over the last decade around a range of interventions related to the first 1000 days agenda, known locally as the ‘Golden 1000 Days’. This agenda has generated passionate public discourse within Bhutan – a country never directly colonised, in which an alternative philosophy of economic development circulates named Gross National Happiness (GNH). The agenda’s proposed interventions include standard actions like micronutrient powders, breastfeeding and nutritional counselling, and conditional cash transfers, but also broader socio-economic interventions such as six months of paid maternity leave for all civil servants. Additionally, the Golden 1000 Days builds on existing development policies to ensure GNH or collective well-being, including the constitutional protection of 60 per cent of the country’s forest coverage, free education, and fully state-funded biomedical and Sowa Rigpa (Tibetan) healthcare, with an emphasis on primary care [6].

24.2.2 Developing Differently

While The Lancet authors model the causes of malnutrition through hierarchical, monetary, and medicalised factors, Bhutanese scientists emphasise interdependence across causal domains – adopting a more horizontal and multidisciplinary approach to addressing undernutrition. Take, for example, the work of Deki Pem, Deputy Dean of Nursing & Midwifery at Khesar Gyalpo University of Medical Sciences in Bhutan. When conceptualising The Golden 1000 Days agenda in Bhutan in 2015, Deki published a ‘fishbone’ diagram for child development designed to model cause and effect [7]. The ‘fishbone’ is a conceptual tool that identifies multiple factors that could be contributing to unanticipated outcome variation developed by Japanese organisational theorist Kaoru Ishikawa in the 1970s. Deki used this modelling technique to fan out the potential risk factors for undernutrition to 14 factors (see Figure 24.2). She organised these factors horizontally, not vertically. Instead of separating and then ordering undernutrition’s causes into basic, underlying, and immediate causal classes, the ‘fishbone’ model brings concerns for the environment, society, and culture, parental care, and eating into the conversation of ontogeny. Collective norms of care appear along the sociocultural rib, and safe drinking water features in the environmental rib. What women themselves eat or feed their children becomes a small part of this causal map.

Figure 24.2 The ‘fishbone’ model of causal interdependence

[6, p. 2]

Multiplying the causal origins of child development opens up alternative strategies for nutrition intervention and research. Approaching the Golden 1000 Days through the ‘fishbone’ model, it becomes difficult to imagine designing effective interventions targeting what women eat – though economists and nutritionists working for the Ministry of Health and international organisations like the World Bank do promote micronutrient sachets and behaviour change interventions in Bhutan [8, 9]. As a nursing practitioner and medical university instructor, Deki has been concerned about customary alcohol use during pregnancy and first food practices that might disrupt exclusive breastfeeding, but her horizons were open. A wide range of remaining known unknowns compel her work – from intergenerational changes in the relationship to food and childcare due to rural-urban migration to the capital Thimphu, to potential sources of environmental lead exposures.

Over a shared plate of omurice, Deki explained to Shivani her recent collaborative research on elevated blood levels among children in Thimphu and Phuntsholing. The specific concern in this study on undernutrition was anaemia, ‘a critical public health problem in Bhutan’, with indicators that had not improved in over 18 years [7, p. 2]. The multiplication of causal factors involved in ontogenetic development also invites multidisciplinary collaboration. With a coalition including physicians, medical statisticians, nursing faculty and anthropologists, Deki has pivoted from studying feeding practices to studying environmental exposures.

Their recent research showed that about 44 per cent of a sample of children between two months and five years of age from the capital city Thimphu and the industrial border town of Phuntsholing had elevated blood lead levels [10]. Deki and her co-authors were surprised to find a significantly higher prevalence of elevated blood lead levels among the children living in otherwise ‘clean’ Thimphu, in spring, and those who regularly eat with their hands. Their findings indicate the need for more research on the role of ‘demolition and construction, weather differences, and possible water contamination’, in childhood malnutrition [10, p. 12]. Environmental exposures potentially have knock-on effects on iron deficiency, anaemia, and undernutrition, confirming the need to multiply the sites of research and to rethink the strategy for nutrition interventions during the Golden 1000 Days.

24.2.3 Tendrel Interventions

The Lancet’s diagram for ontogeny dismissed ‘social, economic, and political context’ factors for development as too difficult to operationalise in health interventions. Meanwhile, Deki Pem and other malnutrition researchers in Bhutan have highlighted the need to care about what and how different generations of people eat, what social supports they encounter, and the unevenly contaminated environments in which they live. Rather than causally write off ecology and history as ‘distant’, the scientific practice of Deki Pem and her colleagues enacts a vision for development where socioeconomics, culture, history, diet, safe living environments, water quality, and so on could all be understood as ‘immediate’ contributors to conditions of inequitable nutrition outcomes. One factor does not precede another in importance; likewise, quick or targeted interventions are not necessarily more effective than those with a slower temporal horizon.

The ‘fishbone’ diagram of child development amplifies the causal logic of tendrel or interdependent origination, which informs health practice in Bhutan. Physician historians Tandi Dorji and Bjorn Melgaard articulate how Buddhist theories of causality facilitate health interventions that open a multiplicity of interdependent factors:

The concept of interdependence of all phenomena, that nothing exists as a separate entity but as a part of the whole, is one of the fundamental beliefs in Buddhism. When considering health and disease, this concept implies that the person with the illness must be viewed in relation to the whole, i.e. all internal and external factors that the person is dependent upon, such as physical, mental, social, moral, environmental, familial, work, diet, etc. [11, p. 25].

While this may sound romantic, tendrel, in its evocation of being dissimilar but related, emphasises the need to cooperate across difference – across scales and sites. Tendrel emphasises the co-arising of beings as an impermanent and indeterminate process of relationship, according to the cultural historian Karma Phuntsho [12]. From this causal logic of interdependence, it is important to discern which relations are generative and which relations are harmful. As much as connecting or adding relations, identifying and refusing toxic attachments becomes key for development and collective well-being. Human interdependence with landscapes is a distinguishing causal feature of Sowa Rigpa and healing practices in Bhutan [13] and has also influenced how complex global health problems like pandemics have been addressed through coalitions and careful refusal of global market relations [14].

Incorporating tendrel into child development policy shifts how DOHaD-informed nutrition interventions might be designed. In contrast to short-term interventions to address immediate causes, policymakers must identify and act upon the multiple conditions that contribute to a given goal. From the interdependent causal logic of tendrel, effectively intervening in the ontogenesis of undernourished bodies requires working in multidisciplinary coalitions to address a wide range of cultural, political, and ecological conditions. This attention to the ‘gradual unfolding’ of child development is what Deki Pem’s fishbone diagram and scientific practice opens up [7, p. 1], reminding policymakers why the Golden 1000 Days in Bhutan would not be possible without development actions as expansive as tending to natural resources like forests, providing free biomedical and Tibetan healthcare, and free public education.

24.3 Guatemala: The Dirty Chicken Hypothesis

24.3.1 Nutrition as an Interdisciplinary Science

In the mid-1970s, Dr Nevin Scrimshaw, the founding director of the United Nations’ Institute of Nutrition of Central America and Panama (INCAP), recommended one of his former students, Noel Solomons, for a research position at the institute’s headquarters in Guatemala City. In operation since 1949, INCAP has become a key international centre for science and policy on child development. Guatemala, a country that was roughly half-Maya with a long history of resistance to colonial conquest, is also reported to have high rates of hunger and malnutrition. Americas. INCAP was founded with the goals of learning about the biology of nutrition and carrying out policy interventions to act upon this knowledge.

Both Solomons and Scrimshaw held medical degrees, with specialisation in clinical nutrition, but they were also both interdisciplinary and expansive thinkers. Scrimshaw was widely known for his knowledge of biochemistry, but after a decade at INCAP he took a sabbatical break at Harvard to complete a master’s degree in Public Health. His 1959 thesis examined the ‘Interactions of Nutrition and Infection’ to make the argument that malnutrition enhanced the susceptibility to infection, while the burden of infection impaired the acquisition and retention of nutrients. Solomons would later call this Scrimshaw’s ‘most transcendental conceptual synthesis’, [15] celebrating Scrimshaw’s talent for making crucial connections across vastly different domains of expertise.

Solomons, a Black man from Boston whose paternal grandparents were raised on the Dutch island colony of Aruba and who self-identifies in policy spaces as a feminist, was also accustomed to linking diet to broader social contexts, including those of imperialism, colonialism, and social oppression. In addition to holding a medical degree from Harvard, he was trained in internal medicine and infectious disease at the University of Pennsylvania and in gastroenterology and clinical medicine at the University of Chicago. His inclination towards systems thinking afforded him insight into the shortcomings of studying nutrients in isolation. He is fond of pointing out that an understanding of the human body requires a deep understanding of the surrounding environment. To the adage that people eat food, not nutrients, Solomons has added his insight that people don’t just eat food, but they ingest adverse influences from certain social and ecological environments.

24.3.2 Contaminated Ecologies

In 1985, Solomons split with INCAP to found his own nutrition research centre in Guatemala City, named the Center for Studies of Sensory Impairment, Aging, and Metabolism out of the recognition that nutrition was linked to the development of metabolic and sensory integration processes. Among the hundreds of scientific articles and briefs Solomons has published over the last half-century, he is especially fond of a 1993 paper titled ‘The Underprivileged, Developing Country Child: Environmental Contamination and Growth Failure Revisited’, which advances what he calls ‘the dirty chicken hypothesis’. This is an allusion to the phenomenon well known by poultry scientists that chickens would not grow or put on meat when reared in unsanitary surroundings despite an abundance of feed. A background concern animating the publication is that the public health nutrition community is overly focused on diet. In contrast, Solomons et al. write that ‘poor growth appears to be strongly influenced by environmental factors as well as nutrition’ [16, p. 327].

With an eye to veterinary science, Solomons observed that veterinarians had long known that animals raised in cleaner conditions – or, alternatively, animals who were fed a low-dose supply of antibiotics to ward off repeated inflections – grew bigger than those raised in contaminated growing conditions. Growth failure in humans, he and his co-authors argued in this 1993 paper, might similarly be more influenced by ‘recurrent, overt infections of the respiratory and gastrointestinal tracts’, than by whatever foods people are, or are not, eating. He explained that frequent microbial infections brought about by poor sanitation will ‘result in continual activation of the immune system and specific metabolic changes’ [16, p. 329]. These infections were often ‘inapparent’ – that is they were not visible to the naked eye or perceived by the person living in these conditions – but they nonetheless led to the condition of ‘immunologic stress’ and hampered growth. The paper proposed that monokines such as interleukin, tumour necrosis factor-α, or interleukin-6 become caught up in an immune response that alters metabolism. They write,

The metabolic changes represent a homeorrhetic response that alters the partitioning of dietary nutrients away from growth and skeletal muscle accretion in favour of metabolic processes that support the immune response and disease resistance. These changes form the basis for impaired growth and feed utilization, and for altered nutritional requirements in chicks [16, p. 329].

A human child is, of course, not a baby chicken, but the scientists saw that their observation about chicks might influence the science and policy of human development. In the background of the dirty chicken article is Solomons’ critique of the field of public health nutrition for taking a ‘monolithic’ approach to malnutrition, overly focused on dietary supplementation. One of Solomons’ scientific domains of expertise is the metabolism of anaemia, and he frequently points to the short-sighted impulse to treat anaemia with iron supplementation. This is not only a largely ineffective route to improving the amount and circulation of iron in the blood, he argues, but can affect the production and circulation of haemoglobin that can, in regions where malaria is common, exacerbate this blood-borne illness. Targeting deficient nutrients and not environmental toxicity will throw interdependencies between human biologies and ecological systems out of balance. The challenge, he writes, is to reduce recurrent harmful stimulation to the immune system by addressing environmental damages associated with living in communities that have been forcibly held in toxic poverty. In other words, the ‘developmental origins’ of malnutrition may be more tightly linked to growing up in toxic environments than to conventional approaches to food security focused on insufficient access to food.

Although Solomons does not write explicitly about racism and sexism in his paper, his conclusion poses challenges for these systems of oppression. When the origins of malnutrition lie in prenatal nutrition, it becomes women – and, especially, Indigenous women who experience Guatemala’s highest rates of chronic malnutrition – who are marked as deficient and targeted for supplementation. Similarly, when the problem of malnutrition lies in what people are eating, it is women’s expertise that is undermined, given that they primarily run their families’ kitchens. In contrast, when malnutrition becomes understood as originating in toxic water and sanitation systems, the burden of treatment might shift to governments, who have the responsibility to provide healthy infrastructures.

24.3.3 Care for the Context

In the years since the publication of the dirty chicken hypothesis, Solomons’ critique of nutrient-based development interventions has grown more pronounced [17, 18]. He wants his colleagues in nutrition and public health to see human growth as an adaptive and ecologically interdependent process of development. Human growth on its own is not an obvious or intrinsic good, he argues; environments must also be conducive to this growth. As he explains, in an article titled ‘Environmental Contamination and Chronic Inflammation Influence Human Growth Potential’,

[P]ushing dietary interventions to achieve faster growth in the absence of other measures to improve living conditions could prove to be futile (and expensive), counterproductive (and dangerous) or both, depending upon the specifics of ethnicity, climate, cultural practices and human ecology in a given underprivileged setting [18].

The resultant argument is that along with care for diet, the public health community must care about environmental antigens, including toxicities and contamination that impede growth, and cultural and political systems that shape urban planning and family planning alike.

Solomons critiqued a narrow understanding of development that pushed mothers and babies to grow larger while ignoring the environments in which they lived, including not only questions of hygiene but also questions of whether women birthed with midwives or in hospital settings, and whether there were resources to support obstructed labour. He was particularly concerned that the field of public health nutrition’s goal of producing large babies, and its reliance on prenatal supplemental nutrition as a means of achieving this goal, would set up conditions of obstetric violence, increasing rates of maternal and child mortality. The implication, building upon Scrimshaw’s long-standing interest in the interdependence of bioecological systems, was that the public health and development communities should direct more attention ‘to the material environment than to the infant/toddler diet’ [15]. As Solomons had earlier written, ‘Such a comprehensive public health approach should permit children to be bigger under environmental circumstances in which becoming bigger is truly better’ [18].

24.4 Conclusion

In this chapter, we have asked how the field of global development might change by adopting models for DOHaD that emphasise how human ontogeny is interdependent on social and ecological conditions. In our two cases, scientists in Bhutan and Guatemala concern themselves with how relational and systemic interactions shape child development. In the Bhutanese case, Deki Pem observes that maternal and child nutrition, substance abuse, intergenerational eldercare, and environmental toxicities might also be interdependently addressed in DOHaD interventions. Caring for one input of the ‘fishbone’ while neglecting others makes little sense, since they all contribute to the child’s development. In the Guatemala case, interdisciplinary interest in the immunological impact on metabolic processes leads scientists to advocate for the importance of addressing environmental contamination. While the cases differ in their historical and cultural specificities, the scientists in Bhutan and Guatemala both argue that equating nutrition primarily with nutrients misses out on the dynamic, systemic interdependencies that give shape to development.

To be sure, biological models of interdependent ontogeny pose their own challenges. Solomons found the science of ontogeny inspiring because it shifted attention away from how mothers cooked and what they ate and towards environmental contaminants, ranging from microbes to chemical pollutants. In practice, however, a focus on ontogeny can risk cementing the notion that mothers are responsible for the future development of their children [19, 20]. Natali Valdez illustrates how theories of the interdependency of development that might inspire policymakers to act capaciously become foreclosed by reductionist – and frequently racist and sexist – policy imperatives [21]. For example, in The Lancet’s hierarchical modelling, development may depend on a great many factors, but it’s the mother’s behaviours (what and how she eats) that matter most. This model risks reinstating the oppressive mother-focused interventions that some DOHaD scientists wielding models of interdependent growth endeavoured to overcome.

Although interdependence is not a virtue in its own right, we have shown how scientific analyses of interdependent ontogeny from Guatemala and Bhutan can offer a pathway for reworking development interventions. Amber Benezra, in her research on nutrition science, points to the need for policymakers to recognise how they are engaging with interdependent, intergenerational, interdisciplinary, interactive, and intersectional processes [22]. We have likewise described a pathway for conceptualising development through selectively unfolding relations. Rather than understand development as hierarchical, teleological, or following a pre-programmed trajectory, we might rather see the development of the child as part of an adaptive ecological system that coalitions of actors can work to shape. Politics, culture, and environments must all be cared for together.

Expanding the conceptual vocabulary surrounding development to think of ontogeny as an interdependent process helps to cultivate new possibilities for health intervention, inspiring what Hannah Landecker has described as ‘different biologies than otherwise would have existed’ [23, p. 149]. The Lancet’s hierarchical and linear models of development encourage health policymakers to focus primarily on malnutrition’s most proximate causes. Taking a page from the sciences of ontogeny in Bhutan and Guatemala, however, may help inspire policymakers to consider that which appears neither immediate nor urgent, but which nonetheless has a structuring influence on global development and human health alike. They might prioritise, for example, the virtue of a clean water system (see also Roberts in this volume). When water is clear, affordable, and contaminant-free, its flow can allow an entire community to flourish. When it comes to implementing health interventions, policymakers might ask if these interventions attenuate stress and build strong communities. Is the land people live in on safe, and do they have sovereignty over this land? Are people encouraged to engage in political and social advocacy and taught how to organise themselves to refuse sources of hunger and exploitation? A lesson from the tendrel fishbone model and the dirty chicken hypothesis is that DOHaD-informed child development policies must look far beyond the child, caring not just for the nutrients this child eats but for its relations. The questions are at once scientific and political: how do we strengthen those relations that are nourishing and detach from those that further toxicity?