Section 2 - The Social Life of DOHaD

Chapter 4 A Biosocial Return to Race? Racial Differences in DOHaD and Environmental Epigenetics

Maurizio Meloni , Christopher Kuzawa , Ayuba Issaka , and Tessa Moll

4.1 Introduction

The growth of research within the Development Origins of Health and Disease (DOHaD) and related environmental epigenetics fields has catalysed a shift in the understanding of how genes and environments shape phenotypes. The attention to embryonic and fetal development as critical periods with important long-term health effects has led to a focus on the gestational environment and maternal experiences like nutrition and stress, as intergenerational determinants of health [1–3]. This emerging science has inspired claims that social exposures, including race-related inequalities, can drive physiological, developmental, and epigenetic processes operating in utero and during early postnatal life, becoming ‘embodied’ as relatively durable, albeit in principle modifiable, biological differences [4–6].

By eschewing fixed genetic differences, ‘biosocial’ perspectives on race have brought with them a renewed hope for a focus on the social, historical, and political bases of contemporary health disparities [7]. This emerging understanding of the role of environment-driven phenotypic and epigenetic plasticity is often viewed as aligning with progressive policy goals because it demonstrates newly appreciated pathways by which major health differentials might be reversed by timely intervention. This is reflected, for instance, in the emphasis on the ‘first 1000 days’ in global health initiatives [8, 9] and a vibrant area of economics that harnesses DOHaD frameworks to promote investments in maternal and child health [10, 11].

However, despite the promise of DOHaD and environmental epigenetics to set out modifiable and plastic models of biological inheritance, social scientists have illustrated how enduring forms of ‘environmental determinism’ [12] may become intertwined with local conceptions of racial difference. As one example, one thread of research has argued that environmental exposure to poverty (which is highly racialised in many contexts) could impair early brain development and determine children’s lifelong potential [13]. Indeed, a growing number of scholars, in studies from microbiomics to brain development, have raised critiques of what could be characterised as a postgenomic reinstantiation of race [14–18].¹ As sociologist Dorothy Roberts has warned, ‘When scientists write that epigenetic effects of racial discrimination are durable across generations, it sounds perilously close to biological theories of race’ [18, p. 143].

As epigenetic and DOHaD analyses of racial/ethnic health disparities expand significantly in scope and impact, we echo others in urging caution in the collection and interpretation of these new data. We recognise that much of this growing work has gravitated to biosocial understandings of health disparities in part because these understandings both avoid reductionist genetic explanations and offer new explanations that can hopefully be harnessed to foster positive social change, such as making links between current health differentials and past injustices [20–22].

Our cautionary view stems from two arguments that we will lay out in the following: in the first, we seek to undermine the assumption that environmentally driven effects are always inherently progressive. Not unlike gene-centric models of race, environmentally driven models are similarly capable of being abused and used to promote racial hierarchies, as evidenced by work on race in Latin America [23]. Here, we explore a lengthy history of proto-racism that traces presumed inherent group differences to environments, not genes. In the second, we explore the results of a review of current literature on racial health disparities in DOHaD and environmental epigenetics. This review demonstrates the enduring problems of reductionism and typological thinking in contemporary research. We believe that ongoing interdisciplinary work between social and biological scientists is key to correcting these creeping trends and strengthening this research in service of the goals of social justice. Towards these ends, we suggest various tools, such as community participation in all stages of research and moderation in reporting results, that can help avoid a potential reification of racial typologies in DOHaD research.

4.2 On the Long History of Biological Determinism and Racialisation

4.2.1 Genetic Determinism and Its Counterparts

For many contemporary researchers who grapple with debates about biological race, the modern concept that humans can be arranged into hierarchical typologies is often a starting point for discussion [24, 25]. In the eighteenth century, the Linnaean system of classifying living things, including humans [26], became the template for later anthropological work that assumed that humans could be ordered into distinct, indelible types that varied in level of sophistication as a matter of inborn potential. Modern racial science, grounded in assumptions of permanent psychophysical differences, experienced new legitimation in simplified understandings of Mendelism and early twentieth-century anthropology and eugenics. The crux of the argument was that genetic differences, assumed to determine phenotypes in a direct fashion, rendered environmental exposures or habits insignificant when considering racial characteristics: human types, now conceptualised as clustering of genes within geographically bounded groups, were viewed as fundamentally unchangeable at least within certain geographic clusters [27].

Genetic determinism – ‘the idea that genes alone have the power to shape both bodies and behaviors’ – enjoyed a remarkable albeit controversial success during the twentieth century [28]. The assumption that diverse groups of people can be characterised and essentialised based on presumed, immutable genetic characteristics has been evoked to naturalise the social, political, and historical underpinnings of inequality. As obvious examples of these dangers, during the twentieth century, research on human genetics and hard hereditarianism helped justify scourges like forced sterilisations in the USA and the Holocaust in Nazi Germany. More recently, widely discussed and controversial books have argued for a genetic basis to intelligence and a need to temper public investments in education [29], joining a long tradition of hard hereditarians that considered public welfare a wasted or misguided form of sentimentalism – a classical eugenic trope since the time of Galton (1822–1911).

As a response to the twentieth-century abuses of genetic determinism, the idea that human differences are tied to environmental influences and nurture has maintained an allure of progressivism [30], especially in the social sciences and humanities [31]. This is particularly obvious in Northern Europe and North America where most of the eugenics movement drew from theories and practices of genetic determinism. This means that the historical prominence of environments as determinants of racial typologies remains hidden. Focusing on a longer history, spanning two millennia rather than three centuries, demonstrates the potential for hierarchy and discrimination to be grounded in, and justified by, patterns of human difference tracing to shared environments and experiences (food, climate, and habits) rather than genetic or innate factors.

This ancient proto-racism reflected a persistent tendency at least since Graeco-Roman antiquity (where the most ancient evidence can be found) to refer to a range of sciences, prominently including humoralist medicine and geography, to express prejudices and a hierarchy of values among different populations, often in the context of imperial or military arguments [32]. We argue that a re-emergence of conceptualisations of body and race as open and malleable rather than fixed could lead to the subtle but gradual replication of biological race in contemporary postgenomic and biosocial developments, at a time when biology is moving away from the presumed centrality of DNA sequences as masters of phenotypic development. In what follows, we provide a concise summary of a lengthy history of pre-modern essentialism, in which intrinsic group-level human differences were viewed as an output of environmental mechanisms.

4.2.2 The Power of the Environment Before the Gene

Although this was not the only way to construct racial hierarchies in pre-modern times, the tendency to view people as deeply shaped by the places where they lived or the food they ate was a powerful intellectual device to assert the superiority of certain human groups [32, 33]. Often combined with a strong moralistic flavour, arguments about racial differences acquired through the embodiment of different environments were used to condemn whole human groups to inferiority because of the unfavourable places where they were born or, more subtly, by claiming that their placement in particularly unfavourable settings was a sign of their subordinate nature [34]. Nations were viewed as fit or unfit to rule not because of innate deficiencies but because of the power of the outside, such as the persisting effects of climate or habits on their bodies and minds. This framework has shaped pre-modern ideas of racial inferiority for centuries, connecting, with different nuances, Greek and Roman views of the East, to Columbus’ interpretation of the tropics as inhabited by people unfit to ‘exercise power’ [35].

In Classical Antiquity, grouping physical and moral traits of different populations and relating them to various environments – the geography of the places they lived, the climate in those areas, or the food they ate – was a common tool in developing the tropes and hierarchies of differing populations [32, 33, 37]. This is clearly seen in Hippocrates’ Airs, Waters and Places (fifth century BCE), a medical treatise written as a guide for travelling doctors, in which Asians are described as ‘more gentle and affectionate’ than Greeks as they live in a land where the weather is uniform and everything grows ‘more beautifully’. Airs, Waters and Places, while often overlooked in histories of proto-racism, was a widely influential text and translated for centuries through Pagan Antiquity, Latin and Oriental Christendom, and the Muslim world. It is considered a foundational text for theories of health, ecology, and geography of disease, and further one of the first scientific texts to establish ‘the greatest and most marked differences’ between Europeans and Asians.

A generation after Hippocrates, Aristotle built on these ideas to justify political differences within a wider imperial framework. People of Asia were now described as ‘intelligent and skilled but cowardly. Thus, they are in a perpetual state of subjection and enslavement’ (350 BCE: Politics, 7.5.6.1327b our emphasis; translation in [37, p. 44]. Filled with references to eugenic topics, the seventh book of the Politics (available in the West since 1260) went on to decisively influence early modern debates in the Spanish, French, and British colonies. There, the Greek/Asian dichotomy was replaced by one between temperate and tropical weather, leading to a climatological distinction between master races and naturally born slaves sealed by the authority of Aristotelian natural philosophy [38].

The Roman world continued and expanded the climatological tradition. Roman military treatises developed similar theories to maintain, for instance, that Orientals were naturally prone to slavery (from the ancient Roman historian Livy 36.17), to distinguish between the environment and hence ‘innate’ characters of different troops to favour a more rational process of recruiting militias (late-Roman writer Vegetius), or to avoid the risk of dangerous environmental influences in foreign areas [32]. We also see the appearance of a certain asymmetry in how negative and positive environmental effects are perceived as impacting populations, which foreshadow later doctrines of racial purity: with Roman historians like Tacitus or Livy, men transplanted from Rome into ‘inferior’ locales ‘acquire the degenerate characteristics of the alien environment’ but the reverse is only rarely mentioned [33, 37, p. 33].

While the Middle Ages are often overlooked in histories of racialisation based on environments, this period’s influence on the mental cartography of early modern European colonialism and political theory was immense [39, 40]. From the twelfth century onwards, the Middle Ages saw an increasing tendency to essentialise biological differences in humoral composition based on emerging ideas of human nature, heredity, or religious affiliation. Not only were people seen as a mirror of where they lived, but human groups who differed by ‘blood’ were often thought to inherit the same traits if living ‘under the same sky’. However, factors that could potentially alter the innate but changeable complexion of human groups were incorporated into medical and geographical treatises of the time. Hippocratic-Galenic ideas of environmental effects on humours led to concerns about the ‘transplantation’ of human groups into new soils and under new stars that ‘would affect not only themselves but their descendants’ [41], deeply shaping anxieties surrounding the first colonial expansions and lasting well into the European Renaissance and Elizabethan England [42]. Hence, colonies became places where the coloniser could be ‘re-raced’ [42, p. 19], spurring anxieties around the potential degeneration of a nobler European ‘stock’ under new environmental conditions [14].

As colonial expansion continued, and migration became increasingly common, racial science began to intermingle fixed and malleable characteristics strategically. For instance, this included the growing colonial anxiety that white settlers could degenerate in hot climates. Some historians have argued that it was precisely this fear of changeability under new environmental conditions, and the tendency of these ideas to potentially hinder colonial projects, that incentivised their replacement by notions of race as innate and immune to such environmental effects [43]. Lamarckian thinking, melded with rising social stratification and inequality, fuelled concerns about decay and degeneration in the European metropoles [44]. At the very foundation of the Enlightenment in the eighteenth century, we find a strong presence of environmental and climatological explanations of race differences. It would therefore be somewhat artificial to view the history of racism as the sole brainchild of the Enlightenment, overlooking the reality that Enlightenment intellectuals themselves wittingly inherited their ideas from Greek and Roman sources.

4.2.3 Historical Lessons for Current Work in DOHaD and Epigenetics

Our historical review highlights that the emphasis on immutable characteristics as essential to differentiating and hierarchising populations is a relatively recent phenomenon, and one influenced by the much lengthier prior history of differentiating groups based on shared environments. Without flattening different historical contexts into a simplified continuity or denying the distinct implications of environmental determinism with regard to contemporary political, legal, and economic formations, we suggest that it is possible to highlight a number of recurring characteristics in models of environmentally patterned human difference. Firstly, there is a predominance of typological models based on the causal power of the environment where common biological essences are viewed as being directly established by environmental effects and ignoring within-group variability. Secondly, binary thinking manifests in several ways. Environments were divided into categories of normal (that of the observer) and abnormal/pathological (that of the colonial subject or ‘other’), and ‘exposures’ were similarly viewed as having effects that were either present or absent, ignoring the possibility of a spectrum of phenotypic outcomes. Thirdly, there was a tendency to establish an asymmetry between negative and positive environmental effects, with the former more common and used to characterise the developmental trajectory of non-Western or subordinated groups. Fourthly, this work often assumed that environmental and social disturbances were transferred directly to individual bodies, which are portrayed as passive recipients of external forces: damaged environments (or non-European ones) were viewed as becoming ipso facto damaged bodies, thus eliding a wider focus on underlying causes. Finally, it was common to argue that environmental factors can cause loops that are difficult to break, with whole groups being stuck in social or cultural inertia because of acquired environmental insults.

Of course, even when based on environmental models, contemporary expressions of environmentally or socially patterned race and biology do not extrapolate seamlessly from these recurring patterns and historical examples. Our point is simply that environments are neither an innocent nor an inherently more progressive factor in explaining racial health disparities. Clearly, current postgenomic work around race and embodiment has overwhelmingly good intentions – of clarifying pathways, reducing societal impacts, and addressing the unequal distribution of ill health. However, some of the conventions of biomedical research may create openings to unwittingly recapitulate typological and essentialised thinking [18, 45]. We thus set out to investigate the literature and findings in DOHaD and environmental epigenetics that address the role of race/ethnicity in human health.

4.3 Current Work in DOHaD, Environmental Epigenetics, and Race

How common are essentialised and typological notions of environment-driven race and human difference in the DOHaD and environmental epigenetics literature? While an important catalyst for studies of developmental plasticity, DOHaD remains a niche in a wider trend exploring relationships between epigenetic changes, particularly DNA methylation (DNAm), and racial/ethnic differences. Within this broader field, do we see an emphasis on environmental determinism, a focus on negative environments understood as leading to permanent scarring, or perspectives that foster binary interpretations of exposures and outcomes?

Before we look specifically at research that addresses race and ethnic health disparities, there are some common practices within research design in the field generally that are worth noting for their potential to contribute to a reductionist portrait. For one, some DOHaD or epigenetic studies use observational and population-based case-control designs; these have a high potential for confounding because key influences on health, such as environmental stressors, diet, or activity levels, tend to cluster as a result of influences like socio-economic status, ethnicity, class, or gender [46]. Other studies have harnessed natural or quasi-experimental designs, using ‘exogenous’ stressors such as a war-imposed famine, terrorist attack, global pandemic, or earthquake (for instance, [47]) to evaluate the impacts of maternal exposure during pregnancy. Because this work approximates a randomised exposure, it achieves a stronger basis for causal inference; however, it does so at the expense of studying severe shocks and stressors, which are not effective targets for intervention. (See Pentecost et al. in this volume on the move in DOHaD to preconception intervention trials.) Such ‘shock’ focused research is not capable of assessing more subtle exposures that reflect typical lived experience, let alone potentially beneficial or favourable exposures. On a similar note, experimental animal model research, which represents the ‘gold standard’ of causal evidence in this field, often imposes extreme prenatal nutritional stress on species with far less maternal capacity for fetal nutritional buffering than humans [3, 5]. In addition to using models of severe stress, relatively little DOHaD work to date has been explicitly designed to clarify the potential reversibility of early life effects (see Lloyd et al. in this volume). This creates a default assumption that any effects induced by these (again, severe) exposures are also permanent. This simplified picture of permanent scarring may be further reinforced by the common convention in biomedical research of reporting relationships in a binary fashion, as being present or absent, depending on whether a threshold for statistical significance has been reached [48] (see also Sigurdadottir and Ayis in this volume).

As many of these observations apply to population-based health research more generally, we sought to offer a specific analysis of the use of the race concept in DOHaD and environmental epigenetics. We conducted a scoping review of studies within the fields of DOHaD and environmental epigenetics that address racial health inequities. We limited our review to empirical human studies that focused on race and ethnicity in health and related to epigenetics within a DOHaD framework. We reviewed 49 studies in total as they met all inclusion and exclusion criteria (see [49] for a full description of our methodology).

Given the largely biomedical nature of the reviewed literature, an emphasis on pathology is predominant, and exposures are generally understood exclusively in the negative, that is, as a source of risk for chronic disease and mortality and dysfunction of biological processes. Populations emerging from often self-reported categories are reframed as aligning through differences in methylation level, for instance, from our sample: ‘African American adults’, ‘African American children’, ‘black women’, ‘black ethnicity’, ‘Hispanic ethnicity’, and ‘Native Hawaiians’. All these groups are defined as at-risk populations mostly via reference to abnormal methylation levels, even in instances when the data do not fit with this account (e.g. higher global methylation levels, suggesting reduced cancer risk in African American children). Intra-group variability in biological responses to environmental exposures is rarely given credence, and often differences – such as immigration status or the wide array of meanings, countries, and backgrounds coalescing under ‘Hispanic’ in the USA – are flattened into typological race categories.

Many social scientists have urged researchers to reframe their discussions and suggestions for policy towards structural factors – namely enduring systems of racism, widespread income inequality, and the historical legacies of colonialism (see Kenney and Müller, Keaney et al., and Karpin in this volume). In our review, we found that only three articles (6 per cent) mention or recognise the importance of wider socio-structural factors as ‘drivers of racial health differences’ [50]. Similarly, reversibility is explicitly mentioned by 14 articles (28 per cent), but most discussions of this are brief and often limited to the conclusion.

Only a limited number of studies are self-reflective about the uncritical usage of racial categories (e.g., [50]). A few go in the opposite direction and suggest that methylation markers differ significantly by race [51], and one claims that it is possible to separate distinct populations (Caucasian American, African American, and Han Chinese American) by using differences in methylation [52]. One study is explicit about the importance of having one basal methylome map for each population and the potential value of epigenetic marks as distinct criteria for racial classification beyond and sometimes in contrast to genetic findings ([53], see [49] for further details).

A final significant finding in our sample is the application of epigenetic clock studies, which use methylation to gauge the pace of biological ageing, to explain racial or ethnic differences in health outcomes. In a highly cited article in our sample, the authors remain cautious about the mechanisms by which ‘race/ethnicity and sex affect molecular markers of aging’ [53]. At the same time, the study uses several conventions that reify typological thinking around human population variation. As one example, the authors describe differences across these groups in largely typological terms, without devoting space to intra-population heterogeneities (e.g. ‘African Americans have been shown to have longer telomere lengths than Caucasians’; ‘Hispanics have a consistently lower IEAA (i.e. intrinsic epigenetic age acceleration) compared to Caucasians’; ‘Tsimane have a lower intrinsic aging rate than Caucasians’) [53, p. 170].

4.4 Fostering a Balanced Approach in Postgenomic Treatments of Race

Echoing a growing number of scholars [12–18], we believe it is important to interrogate practices within DOHaD and environmental epigenetics that run the risk of reinstantiating new forms of biological race. For one, we believe it important to remain vigilant against ‘damage-centred research’, a term coined by Indigenous academic Eve Tuck [54] to describe research that catalogues harms endured in a marginalised community with the intention of producing change, yet in practice rarely alters the social, material, or political causes of those harms and leaves populations labelled as ‘damaged’. Yet, we do not want to convey only criticism: these fields are stimulating crucial new understandings of the social and historical pathways underlying health inequalities, and many communities are leveraging this research to advance agendas of social justice and community resilience ([22, 55]; Keaney et al. in this volume). In the spirit of moving beyond critique, we end with recommendations for ways that researchers can help ensure that their work benefits communities while avoiding any unintended stigma or repetition of the simplifications and pitfalls of the past.

As noted in many of our above points, there are practices across biomedical research that may contribute to reductionist, simplified, and potentially stigmatising portraits of marginalised communities. The predominant focus in DOHaD research on documenting exposure–disease relationships that are characterised in such a de facto binary fashion (present or absent) can reinforce the idea that populations faced with early life adversity and stress necessarily carry negative biological baggage because of those experiences. These binary assessments can often also fail to find evidence of an effect simply due to a small sample size or, conversely, can find evidence that biologically trivial effects are significant if sample sizes are large enough [48]. Publication bias, as Non [56] points out, also contributes to foregrounding research that shows dramatic methylation differences, but that may not translate into phenotypic differences.

This convention in reporting and discussing findings leads to a form of binary thinking in which effects are either present or not, and the magnitude of effect, or biological importance in a typical human population, often receives comparably little attention. Thus, we support the efforts in fields like statistics and epidemiology to do away with this focus on binary or ‘bright line’ assessments of the significance of findings [57]. Furthermore, we identify practices that could prevent stigmatising groups: (1) moving away from interpretations of data that reinforce simplified cause-effect models, (2) avoiding characterisation of outcomes as present or absent, and (3) avoiding the generalisation of pathologies to entire groups without considering the magnitude, heterogeneity, or reversibility of these effects.

Non’s [56] recent review also points to other conventional practices in biomedical research that may contribute, for instance, to sampling biases favouring white populations (which perhaps feeds into the use of white populations as the norm from which other groups are seen as differing as we have detailed in our sample, see above). This type of practice, which we have documented in our sample (see for wider materials [49]), runs the risk of ascribing abnormality to marginalised communities ([45]; see also [58]). Researchers should consider the implication of their samples and the implicit racial ‘narratives’ (see Kenney and Müller’s chapter on narrative choreographies) that may emerge as a result.

Finally, we both echo the calls of communities involved in DOHaD research to study resilience and amelioration from early life adversity and reiterate alongside other chapters within this volume (Tu’akoi et al., Bourke, and Lovett) that future research needs greater collaboration with communities on DOHaD research. In the first, our review demonstrated an overwhelming, though not surprisingly, focus on pathology and ill heath arising from early life events. But DOHaD research cannot be limited to this. Future work should also explore the development of resilience from early adversity and the capacity for reversibility or amelioration of early life effects in response to later favourable experiences or other interventions. When reversibility is not explored, the default of permanence may often be assumed, thus increasing the potential for stigmatisation.

In the second, our point regarding reversibility has in fact been made by many communities that are the subject of DOHaD research, demonstrating the emergence of ‘bottom-up’ demand for research into practices that build resilience [55]. This demand points to the need for researchers to conduct future work in ways that are aligned with the interests of affected communities, including requests for reparation. This will require meaningful engagement with participants across the research cycle. (See Tu’akoi et al. and Saulnier et al. in this volume.)

Collaborative and interdisciplinary endeavours will continue to prove essential to any future efforts to improve the production, interpretation, and consumption of epigenetic and DOHaD knowledge. This volume is a testament to the growing embrace, challenges, and value of interdisciplinary work in DOHaD. If we can apply the metaphors from this field to its development, early exposure to cross-disciplinary collaboration – from inception, funding, and through the research cycle – should also foster introspection and a stronger mature science.

Chapter 5 The Promise and Treachery of Nutrition in DOHaD Science, Biopolitics, and Gender

Vivienne Moore and Megan Warin

5.1 Introduction

In this chapter, we explore how and why the application of Developmental Origins of Adult Health and Disease (DOHaD) theory has not led to social change and improved reproductive justice. We draw upon the framework of reproductive justice, paying homage to the work of feminist scholars of colour who argued that concepts of reproductive rights were too narrow in their focus on autonomy, choice, and abortion [1, 2]. In combining ‘reproductive rights’ with ‘social justice’, the concept of reproductive justice encompasses much broader aspects of social life that intersect with reproduction, including family relations, conditions of work, housing, and welfare arrangements. Reproductive justice invites us to envisage DOHaD in a broader political field that takes account of how these social and structural inequalities profoundly shape the reproductive experiences of women.

In previous work, we have examined how DOHaD ideas can lead to blaming of mothers when health is seen as an individual responsibility, rather than socially determined. In this present piece, we try to understand more about the unfulfilled promise of addressing health inequities relating to food, gender, and reproductive justice. We suggest it is not just the tenacity of neoliberal ideas that gained prominence in the 1980s, foregrounding individual choice and responsibility while curtailing public services and welfare provisions (see [3]). We argue that older entangled histories of nutrition and militarism as well as neoliberal politics have enabled a particular understanding, positioning, and uptake of nutrition within DOHaD.

We build on the arguments of others that the field of nutrition and health has long been dominated by a narrow mode of thinking that has been termed ‘hegemonic nutrition’ [4]; this is characterised by standardisation and reductionism, in which food is reduced to its constituents and bodies are decontextualised [4, 5]. In the United Kingdom (UK), as we will explain, this ideology resonates with a celebrated history of nutritional research from the early twentieth century that identified the causes of common, intractable diseases and enabled improvements to be achieved by simple means. The approach was only slightly modified when dietary imbalance and energy excess came to the fore as the nutritional problems of the second half of the twentieth century, with dietary advice now the remedy.

Drawing on Foucault’s concept of biopolitics and approaches used in the field of feminist science and technology studies (STS), we critically explore the deeply embedded logic of hegemonic nutrition, pointing to an assemblage of taken-for-granted politics and practices that work towards efficiency, bodies fit for purpose, and ‘proper’ moral conduct (long before the present neoliberal era). We trace this history and argue that this mode of thinking pervades the research that was undertaken to advance DOHaD ideas and the dominant interventions that were then devised. This stance continues to reproduce universal views of food and women’s bodies that render invisible the complex realities of daily lives.

5.2 A Feminist Science and Technology Studies Approach

We come to the field of DOHaD from our respective disciplines of social epidemiology and social anthropology, with central interests in health inequalities, gender, and feminist STS. Science and technology studies sees science and society as inextricably intertwined. The analytic approach entails tracing the histories that are written into scientific practice, of how ‘particular knowers, were embedded in, and influenced by, their religious, political, or gendered convictions, about how they could know depended on the people around them, the time and place, their class, and their own identities and interests’ [6, p. 161]. While there are many different approaches within STS, a feminist STS approach draws attention to gender and its intersections with other relations of power and how these are smuggled into a science that is often presented as value free.

As feminist STS scholars, we actively interrogate disciplinary knowledge (including our own), their boundaries, and unequal power relations, reflecting on the taken-for-granted assumptions that underpin common-sense understandings of women’s biosocial lives in DOHaD. We attend to matters of power within DOHaD and where it is vested – manifest in the conference arrangements, the keynote speakers, the websites, the reviews, and special issues. We notice who and what gets funded; how calls for new grants are framed and specified. We notice what sort of research receives accolades. We notice what is marginalised or left out. We think about how this is the result of much larger historical and political agendas and the continued dominance of biomedicine [7].

We are attuned to the boundary work that defines the fields of nutrition and DOHaD, and how nutrition has been discursively constructed to align with the ‘epistemic authority of science’ [8, p. 12], that is, the biomedical model. Such ‘legitimation of knowledge claims [are] intimately tied to networks of domination and exclusion’ [9, p. 1], which are themselves tied to structural systems of inequality.

We know that many DOHaD researchers will not be familiar with the above ideas. More simply, but with much loss of nuance, we think about which disciplines are seen as authorities on women’s health and the implications of this view. When social conditions lead to health problems, surely this would invite social research and responses. Instead, what occurs is biomedical research and responses, and we seek to understand and critique this.

5.3 Social Inequalities in Health and the Promise of DOHaD

In 1980, the UK Working Group on Inequalities in Health reported that inequalities in health had widened since the National Health Service was established in 1948; this was attributed to various aspects of daily life and work, with implications for social policy [10]. Shunned by the Thatcher government, the ‘Black report’ (named after the chair of the Working Group) nevertheless received international attention and renewed research and advocacy around the social determinants of health.

Against this backdrop, within a decade, the theory that growth and development before birth influenced a person’s health over the life course was proposed by David Barker and his colleagues. It suggested a new mechanism for the link between social position and health [11], expanding the reach and relevance of ideas about the social determinants of health. With the accumulation of evidence and growing acceptance of DOHaD ideas, action to address social determinants seemed imminent with the 1998 Independent Inquiry into Inequalities in Health [12].

Yet social inequalities have continued to widen, in the UK and elsewhere, accompanied by an increase in economic insecurity [13, 14]. In Western countries, DOHaD ideas have not led to improvements in the social determinants of health of women and infants. Instead, a narrow view of nutrition and its role in the first 1,000 days has taken hold [15].

5.4 Developmental Origins of Adult Disease and Maternal Nutrition

The cohort studies undertaken by Barker and his colleagues in the UK in the late 1980s showed that an individual’s weight at birth was associated with the risk of death from cardiovascular disease many decades later. Extended work pointed to problems with nutritional supply in fetal life. This understanding was consolidated in discussions with specialists in fetal physiology and placental development in the UK, Australia, and New Zealand [16].

Barker had been thinking about intergenerational nutrition for many years. In 1966, he published three papers from his PhD on prenatal factors and ‘subnormal intelligence’. He noted an excess of children with an intelligence quotient between 65 and 74 in the two lowest social classes and suggested this might be explained by poor maternal diet or physique (with short stature reflecting stunting). In subsequent research, he considered a wide range of explanations for geographic variations in disease (such as gout and gallstones) within Britain, including occupational exposures and trace elements in drinking water [17]. However, he is said to have been most interested in adult diseases as possible consequences of nutritional conditions or infections in early life, evident in the studies that commenced when he became director of the Medical Research Council (MRC) Environmental Epidemiology Unit at Southampton University in 1984.

Research on disease aetiology, as upheld in biomedicine, is inevitably reductionist through the emphasis on identifying mechanisms and insisting that causation is only convincingly demonstrated by the experimental manipulation of specific factors [18]. Thus, despite the appreciation by Barker and his colleagues of the relevance of social circumstances and structural factors [19], wider environments were erased in the laboratory experiments and clinical studies required to provide the proof that maternal nutrition has effects on fetal growth and development. Not only has this logic directed vast attention to the physiology (and later, epigenetics) of the fetus and placenta, but it has also heavily influenced ideas about how to respond to nutrition as a cause of poor health.

Research motivated by the DOHaD theory concerning women’s diets, pregnancy, and fetal growth indicated that the problem did not lie in specific nutrient deficiencies or in a specific condition such as anaemia. Historical and contemporary cohort studies of pregnant women suggested dietary imbalance or quality might be relevant, but also body composition (see [20]). Women’s diets in pregnancy are usually a continuation of their established dietary patterns, and older work had already suggested that cumulative nutritional status before pregnancy influenced fetal growth more than dietary intake during pregnancy [21].

By the early 2000s, the focus had shifted to body size and women classified as obese, partly in response to concerns about gestational diabetes and obesity in children [22]. DOHaD researchers and practitioners might have emphasised the connections between obesity and stress and hardship [23]. Instead, they largely succumbed to what Scrinis [24] has called ‘nutritionism’, where individuals are provided with advice and detailed information on the constituents of food and induced to think in microbiological terms. This is an approach to problems involving nutrition that harks back to early-twentieth-century ways to address nutritional deficiencies. Excess body weight does not arise from a nutritional deficiency, but it is cast as a deficiency of information and willpower that is squarely located within ‘non-normative’ bodies [25].

5.5 The Treachery of Nutrition

We suggest that identifying nutrition as a cause of poor health invokes modes of research and institutional responses that do not involve social or structural change. As we will explore, nutritional causes of poor health are widely seen to require detailed biomedical analysis, translated into ‘lifestyle’ advice for individuals. This template does not attend to eco-social causes [26]; thus class and racial/racist inequalities are unacknowledged and undisturbed. We refer to this as the treachery of nutrition. This epistemic privileging of biomedical sciences renders other disciplines (such as social sciences) marginal to DOHaD knowledge and acceptance and constrains possibilities: for multiple knowledge (including lay knowledge); for inclusive funding for different research questions, methods, and interventions; and for new policy agendas.

At the core of the treachery of nutrition are its historical roots in biochemistry and physiology and the biomedical model. This disciplinary alliance and approach were remarkably successful in addressing deficiency diseases (such as rickets) in the early twentieth century, as will be outlined. However, the nature of the pressing problems changed to dietary imbalances and over-consumption. The old emphasis on micronutrients and the need to instruct people to consume unpalatable substances (such as cod liver oil) was carried forward. The approach was renovated as profiling of nutrients in foods and diets and providing people with instructions around this, despite the fact that lack of knowledge was hardly the problem it had been. Others have criticised the reductionist approach that dominates thinking about nutrition and health, in general, and the narrow responses this offers [4, 24, 27]. Here we take this up specifically in relation to DOHaD, which has become a site for the reproduction of hegemonic nutrition and a means for its proliferation in healthcare and popular media.

The expectations of nutrition as a means to improve public health rest on portable, insertable solutions: a spoonful of cod liver oil, a dose of lime juice, a dab of Marmite. These do not improve the living and working conditions of people but rather make them fit for work (historically, as sailors or labourers) or bearing arms (notably in World War I). This has been carried forward: an ounce of education, a brief piece of advice, a mobile phone app. The legacy of this tradition is clear within DOHaD. Also clear is that certain views of bodies and food pervade the field: making women fit for childbearing and food as substrate for fetal growth.

What this approach neglects is the gendered, sociocultural, economic, and political contexts of food and food systems, and the everyday lives of women and their emotional wellbeing, that shape the many practices of how eating, care, and nourishment are done. We acknowledge that some DOHaD efforts have been directed to these broader contexts [28, 29], and we would encourage much more of this. We know it remains important to address micronutrient deficiencies in pregnant women in many parts of the world [30], and folic acid supplementation is important to prevent neural tube defects [31]. However, different approaches are needed for obesity.

5.6 The Overweening Shadow of Historical Nutritional Research

The history of nutrition research and its emergence as a science, as represented in imperial and colonial accounts, emphasises advances made in the UK and the USA from the 1900s [32]. These advances prioritised the discovery of nutrients, descriptions of nutritional deficiencies, and factors affecting nutrient availability. In the UK, this history is marked by concerted government efforts to research specific public health problems and then mobilise a response on a large scale. Unparalleled elsewhere, this reflects the much greater involvement of the UK than the USA in the two world wars. Nutrition was an ‘instrument of state’ [33, p. 702], as outlined below, pressed into service to ensure the food security of troops as well as that of the home population, with the UK vulnerable to blockade and experiencing a shortage of agricultural labour (see [33, 34]).

As recounted by Acheson (who preceded Barker as the director of the MRC Environmental Epidemiology Unit and then became Chief Medical Officer 1983–1991), ‘The story of the Government’s triumphantly successful food policy in World War II has often been told …’ [35, p. 210]. To ensure the food supply, there was rationing underpinned by nutrition science. Thus, staples of bread and potatoes were not restricted, while meat, fat, and sugar were; vitamins were distributed; expectant and nursing mothers had an extra allowance of milk. The physical health of the population, notably children, measurably improved [35].

Less well known is an older history of endeavours, for example, to avoid scurvy in troops in World War I. An appeal by the War Office led to Harriette Chick at the Lister Institute recommending the consumption of beans and lentils that had been germinated or sprouted [34]. The political situation (war) made the study of vitamins (then known as accessory food factors) an imperative, and the functional properties of certain foods were used to solve the problem of maintaining the health of troops within the constraints of army food supplies; pulses for germination were much easier to store and distribute than fresh fruits and vegetables.

Also noteworthy is the history of rickets [32], which manifests in children as bowed legs and other skeletal deformities. Rickets was perplexing in research, long the subject of apparently contradictory findings and debate. In retrospect, we know that this confusion was because rickets is due to a deficiency of vitamin D (needed to absorb calcium), which can be sourced from sunlight or from diet (while some cereals can reduce absorption of calcium). In 1914, the (then) Medical Research Committee funded Edward Mellanby to undertake research that included his famous experiments with dogs; he fed puppies different diets to see which resulted in rickets, systematically identifying a deficiency of a fat-soluble accessory food factor that must be responsible and testing ‘anti-rachitic’ diets. Mellanby concluded that rickets was a deficiency disease that could be cured by providing animal fats or cod liver oil. After World War I, clinical trials with children in Vienna (led by Harriette Chick) demonstrated that rickets could be treated and prevented by these means (or sunlight) [36].

Mellanby went on to have a long career providing advice to the Ministry of Health and to the War Cabinet in World War II. His early work set a pattern for the interaction of clinical and experimental work that he advocated in a book with that title and as Secretary for the MRC from 1933 to 1949. Mellanby was hugely influential through the positions he held, and biomedical and nutrition science was shaped by his historically resonant presence. (See, for example, the celebration of this research tradition in the ‘Timeline of MRC research and discoveries’ on the website of UK Research and Innovation.) This pattern of clinical and experimental work was carried forward by McCance and Widdowson in their work on fetal and infant growth after World War II [37] and was advocated and upheld in the DOHaD field as the biomedical model par excellence.

Thus, after the initial findings from observational epidemiological studies, animal experiments that are the hallmarks of ‘proper’ scientific nutritional research were soon undertaken. This was vital to prove the principle that dietary manipulations in pregnant animals can alter long-term metabolic function in offspring. Most of the research was undertaken in rats, with consequences for offspring of maternal low-protein diets, in particular, described in detail: altered fetal growth; reduced size of truncal organs (but brain sparing); hypertension; abnormal glucose and insulin responses; impaired inflammatory responses; and shortened lifespan (e.g. [38]).

But these experiments should not be interpreted as demonstrations of what should happen in humans, in the way the older experiments on deficiencies provided direct guidance on what to insert into the diet. Even research with laboratory animals induced to have large amounts of body fat (e.g. [39]) only proves that this condition can affect the morphology and physiology of offspring; it does not indicate when or how obesity in women forming families should be addressed. Kelly and Russo [40] have identified this mistake in reasoning: the mechanisms of aetiology for non-communicable diseases are not the mechanisms of prevention. Thus, identifying obesity as a cause of poor health is not enough; it is not a pathogen or isolated behaviour to be eliminated; it has complex social origins that need to be understood for prevention to be possible.

We do not question a role of basic nutrition science, but we question it being viewed as almost all that is necessary, as providing a guide for clinical trials and related actions. The reductionism apparent in nutrition and in biomedicine more broadly was as strong as ever in DOHaD research, perhaps firmly embraced in the effort to gain legitimacy. The early findings from cohort studies had received the standard criticisms of observational epidemiology (see [41]): findings might reflect bias or confounding, correlation is not causation, and what was the mechanism? So the response was to undertake experiments in which nutrition was manipulated and to pursue biological mechanisms (eventually epigenetics). But more than this type of knowledge is required, and Penkler [15] notes that DOHaD researchers are beginning to recognise this.

Biomedicine and the basic sciences have profoundly shaped the field of nutrition and health, leading to well-trodden patterns of organisation across the scientific community. Thus, nourishment is seen in reductionist terms, food and the food–body relationship are standardised, and expert knowledge is seen as the corrective. This hegemonic nutrition is decontextualised: it does not attend to the exigencies of everyday lives; the roles of place, racism, gender and gender relations; or the politics of food systems. It dominates at the expense of other ways of thinking about food and health and possibilities for intervention. Valdez refers to this pervasive logic as an ‘epistemic environment’ [42, p. 9], as it highlights how scientific knowledge production is shaped and ‘how science imagines, manages and apprehends future health’ [42, pp. 9, 10]. This boundary work involves selective foreclosures [43], and in the case of DOHaD, this foreclosure consistently locates the ‘problem’ in maternal diets and in women’s reproductive bodies, not in the broader conditions of daily lives.

5.7 Biopolitical Deployment of Nutrition Interventions

The DOHaD field clearly reflects a genealogy of hegemonic nutrition that can be further understood through Foucault’s concept of biopolitics. Foucault argued that a new form of power emerged in the nineteenth century, with governments seeking to control and manage populations from a distance through expectations of collective conduct. Through shaping expectations about appropriate ways to live and behave, and having citizens monitor themselves and others, governments did not have to exert overt power (e.g. through threats of physical punishment or imprisonment). This form of power is known as biopolitics. Citizens learned about these expectations and how to conform through institutions such as schools and clinics (that had become widely accessible), as well as laws and regulations. Although the strategies and technologies of biopower (the ways expectations are created and maintained) have changed over time, one enduring focus has been reproduction and the role of mothers in serving the health of their children and in maintaining the population needed for labour and war [44, 45]. The biopolitics of reproduction is now extended to the health of their children before birth [46].

Biopower works subtly as it operates horizontally in everyday worlds rather than appearing to be imposed directives. People are asked to take responsibility for their health through self-care and to work on their own bodies according to normalised standards (see [47]). Autonomy is emphasised, and this resonates with a liberalism ideology. (But as the example of obesity makes clear, individuals are not free to reject expectations to do this work.) Expectations for collective conduct are set in conjunction with a range of networked agencies and professional organisations that authorise and legitimise norms. The medical profession and the basic sciences have long been sources of authority drawn upon in biopolitics (sometimes notoriously, as in the eugenics movement) [48, 49]. Biopower can be useful in organising communities and improving health, but it can also entail harm when problems are purely individualised.

There is a history of research in which pregnancy, childbirth, and caring for children are considered through the lenses of medicalisation and biopolitics [44, 50]. Mothers-to-be and mothers are subject to expert advice, medical monitoring, and public scrutiny, with discourses on appropriate self-care proliferating in popular media. Conforming is a personal responsibility and a moral imperative, regardless of a woman’s life circumstances or constraints. In general, biopolitics identifies certain groups as needing more scrutiny and guidance to comply with bodily self-regulation. The ‘problem’ groups are those that fall outside the normalised parameters of health or civility, such as the poor, the unemployed, migrants, or people of colour. Such groups are often represented as ignorant and uneducated, requiring heightened surveillance and education. In relation to pregnancy, women whose body size is classified as obese are now seen as a ‘problem’ group. Here lies the potential to re-inscribe discrimination.

Antenatal lifestyle interventions for pregnant women, particularly those with large body size [51], are an exemplar of gendered biopolitics. Women are typically counselled by dieticians and provided individual advice. There are now apps to track nutritional intake and physical activity and to receive behaviour modification messages. Other educational supports in the service of improving lifestyles include any number of pamphlets, social media sites, and food marketing. While the use of digital technologies gives this a veneer of twenty-first-century self-help, these lifestyle interventions have not significantly changed since the 1950s [42].

Conceptually, biopolitics helps us see how medicine, nutrition science, and health promotion – now integrated in DOHaD – direct women to put more effort into managing their pregnant bodies and securing the future health of their children. For some women, this may be useful and provide a sense of control, but for others it is a source of unfair pressure. The individualisation of responsibility means that women are blamed, or feel blamed, when they do not act appropriately [52, 53], and the difficulties faced by women in disadvantaged circumstances and/or ethnic minorities are not taken into account. Furthermore, meaningful support and social change do not occur.

We are not trying to deny that improvements in antenatal care have reduced maternal and perinatal mortality and morbidity, notably over the first half of the twentieth century. We are not suggesting that women are not agents in biopolitical processes (especially middle-class, white women). However, we do criticise lifestyle interventions in antenatal care as the dominant response to DOHaD in Western countries. From within this paradigm, there have been questions about the efficacy of the approach because it probably occurs too late to benefit fetal development [54], so a shift in focus to pre-conception care has been proposed [55]. That would simply shift the problem of foreclosure we identify to an earlier point in women’s lives.

Biopolitics constructs health as an individual responsibility. But as Wells has argued, society has created ‘metabolic ghettos’ in which people are susceptible to obesity, and there are many steps that governments could take to address the commercial and corporate determinants of obesity and to support people to have healthier lives [56]. These are social justice initiatives – not the portable, insertable solutions exemplified by cod liver oil.

5.7 Interdisciplinary Approaches Are Needed

The challenges of broadening and transforming disciplinary boundaries are multiple, even for those working from within. Tensions in the field of nutrition concerning its disciplinary emphasis have long been recognised (e.g. [57]). In 2005, Cannon and colleagues [27] set out the basis for a ‘new nutrition science’ that was social and environmental as well as biological. Within the American Society for Nutrition, the case for ‘mode 2’ research (another term for applied research) has been made [58]. Several European nutrition entities have jointly proposed embracing broader research domains and disciplines, including anthropology, sociology, and cultural studies [59].

But where are the funds to be found? For decades, nutrition science has received enormous funding from industries involved with agricultural production and food manufacturing. We note that the food industry has a vested interest in human nutrition being framed as food composition, with consumers needing better education, as this deflects attention from the corporate determinants of health (via multinational corporations making huge profits from processed food that is high in salt, fat, and sugar [60]). It is unclear how to fund the volume of research needed to provide depth and variety in the eco-social knowledge of nutrition, especially when health and medical research councils continue to see nutrition in biomedical terms. DOHaD could become a strong advocate for such research diversity.

It is not just through biomedicine and nutrition science that a repressive approach to diet and nutrition proliferates. This is reproduced across health and educational institutions as well as popular culture. DOHaD ideas have generated a great deal of wider interest [61], so there is an opportunity to engage with institutions and communities to ask questions about the traditional framing of nutritional problems and their solutions and to showcase alternatives [4, 43].

5.8 Conclusion

In conclusion, we would first like to acknowledge some limitations of this piece. There is also entangled colonialism and racism that we have not explored, nor have we been able to do justice to the biopolitics of the foundations of antenatal care (to avert population decline) (see [62]). We have focused on hegemonic nutrition as seen in the UK and Australia (which ignores Aboriginal and Torres Strait Islander knowledge). We had to be selective with the references provided, and we acknowledge there are many other scholars whose work is relevant.

The UK, Australia, and similar countries have favoured individualised responses to obesity prevention, despite being urged to take a societal or systems approach [63]. So far, this is also the dominant response within DOHaD, and DOHaD ideas have not changed social or structural factors that shape the health of women and their children. Indeed, the ideas might have found acceptance in an era that emphasises individual responsibility precisely because they follow a well-trodden path and are not disruptive. From our interdisciplinary standpoint, we recommend looking beyond biomedicine and nutrition science for answers to problems that encompass socio-economic-political-material-bio systems. Broadening attention to social environments includes appreciating and attending to the power relations of multiple knowledges, to differing disciplinary knowledges, and to the situated knowledges of the people and communities that are the focus of DOHaD. Without such interdisciplinary and co-constituted attention, DOHaD will not be able to address health inequalities.

Chapter 6 Gender, Racism, and DOHaD

Natali Valdez and Martine Lappé

6.1 Introduction

Contemporary scholars, many of whom are included in this edited volume, have highlighted the gendered dimensions of DOHaD research, noting its social and historical contours and consequences, particularly for women and mothers [1–4]. This chapter furthers these important discussions by highlighting how a gendered analysis of DOHaD must focus not only on how women’s bodies and lives are taken up and affected by science but also on DOHaD’s relationship to racism. By examining DOHaD through a feminist and critical race lens, we address how both gender and racism operate as relations of power in and through this science. Our analysis critically examines how gender has traditionally been studied as distinct from race and racism in DOHaD research, and the need to do otherwise.

This approach reflects our interest in transformational feminist interventions in the life sciences, and the need to centre reproductive justice and anti-racism in these efforts. Rather than seeing categories like gender, race, and class as discrete variables that merely need to be included or compared to one another in DOHaD and other areas of research, here we draw on Black feminist scholarship to highlight gender and racism as mutually constructed and reinforcing power relations that inform the history and contemporary contours of DOHaD and its ongoing effects. By analysing these dimensions of the science, this chapter reflects how gender and racism unequally survey and manage the living conditions and behaviours of Black, Brown, and Indigenous bodies, highlights the unequal impacts of DOHaD research, and reflects the need for a critical gender analysis of DOHaD and other postgenomic sciences [5]. Our analysis therefore focuses on how gender is always already bound up with racism and other forms of oppression, and how this shapes the practices and possible futures of DOHaD in critical ways.¹

6.2 Gender, Reproduction, and Biopolitics

We begin this chapter with a review of feminist and critical race analyses of reproduction and an emphasis on biopolitics and processes of medicalisation that are central to the focus on pregnancy and early development in DOHaD research. Biopolitics refers to how the population emerged as a political problem to be managed by the state, and medicalisation focuses on how domains of social life become defined as medical problems [6, 7]. We discuss these concepts and their contributions to our analysis in relation to the ‘politics of reproduction’, which Ginsburg and Rapp [8] developed to explore the vital role that reproduction plays in social and institutional organisations [9]. Engaging these approaches and their intersections is important, as DOHaD has increasingly become central to reproductive science, medicine, and conceptualisations of health and illness more broadly [10, 11]. Further, Lappé, Jeffries Hein, and Landecker have framed DOHaD and its sibling science environmental epigenetics as part of an ‘environmental politics of reproduction’ to address the intersections of the environment and reproduction in late capitalism [12].² This approach and others explicitly highlight the racialised politics of reproduction in contemporary DOHaD and environmental epigenetics research and how broader relations of power shape these sciences and their effects [13–15]. Drawing on this rich set of literature, this section positions gender and DOHaD as part of a larger feminist discussion on the biopolitics of reproduction and in relation to race/racism, a term that Valdez uses to intervene on references to race as if it were not always already embedded in racist logics [16]. While our own work is situated in the United States, Canada, and the United Kingdom, here we draw on scholarship across various locations to illustrate why a critical gender analysis is necessary anywhere DOHaD research is conducted and circulates.

Reproduction was and often still is conceived of only as a ‘woman’s issue’ with the science and medicalisation of reproduction centred largely on cis-gendered women’s bodies. Numerous scholars have analysed how DOHaD’s focus on pregnancy reinforces this emphasis and positions cis-gender women as central objects of study and primary targets of intervention [17]. DOHaD researchers claim to study this period of the lifecourse because of the unique plasticity and programming of biological systems during ‘critical windows’ of fetal development. However, historians of maternal–fetal relations argue that this emphasis on pregnancy shapes and is shaped by gendered forms of social control and surveillance that have been central throughout the history of the reproductive sciences [1, 18].

Scholars of the contemporary also illustrate how a focus on the individual behaviours and exposures of pregnant people in DOHaD research overwhelmingly positions mothers as primarily responsible for the health of future generations. For example, Pentecost and Ross, Sharp and Richardson, Warin, Moore and Davies, Kenney and Müller, and others discuss how DOHaD emphasises pregnancy as an ideal time for research and intervention, despite the recognition that social environments shape health throughout the lifecourse [2, 4, 19, 20]. These authors and others show how the focus on early life and pregnant bodies within DOHaD studies relies on and reinforces self-surveillance and anticipatory care work for people with the capacity for pregnancy [11]. In their chapter in this volume, Chiapperino and colleagues also detail how DOHaD influences gendered responsibilities for health in ways that reinforce the gender binary and unequally impact women’s bodies and lives. This occurs around food and nutrition, as Moore and Warin discuss in this volume, and in relation to pollutants, pesticides [21], and stress [22], in ways that disproportionately affect Black, Brown, and Indigenous lives [13, 23], as we discuss below.

Of course, as numerous scholars of gender, women’s, and queer studies reflect, reproduction is not only the domain of cis-gender women. Recently, feminist science studies scholars in particular have brought attention to the missing science of men’s reproductive contributions and paternal effects [24], providing a necessary intervention into discussions of gender and DOHaD [1]. Feminist science studies is a transdisciplinary area of scholarship that addresses how gender and other social categorisations shape and are shaped by science and technology. While these specific interventions are important to consider, our review of biopolitics, medicalisation, and the politics and environmental politics of reproduction in this section reflects that merely expanding scientific and medical surveillance to men deemed capable of reproduction will do little to address how power relations influence DOHaD science and its unequal impacts. Rather, we argue that a critical gender analysis must focus on the racial and gender politics of DOHaD and question the premise that individuals are the appropriate target for intervention at all. Doing so relies on well-established literature that actively positions reproduction as a topic crucial to social theory [25]. As we detail below, a continued focus on individual bodies as sites of intervention, rather than on broad social structures and power relations, reflects the convergence of biopolitics and reproductive politics within DOHaD and underscores the need to address the central logics that influence this science [6, 9].

Biopolitics and the politics of reproduction illuminate how social institutions like medical and population health programmes, as well as the military–industrial complex, provide the infrastructure that makes it possible to systematically collect health data and the unequal impacts of these efforts. This is important for our analysis because foundational observational studies that inform DOHaD’s focus on the long-term health consequences of experiences and exposures during early development were originally based on the systematic collection of state and military health records [26]. The concept of biopolitics therefore allows us to address how power relations and social institutions have shaped DOHaD and its relationships to race/racism from its very beginnings and their ongoing effects today.

In his elaboration of the concept of biopolitics, Foucault argued that because of a fundamental shift in European nation-states during the seventeenth century, individual bodies became a key target for the maintenance of the nation. In that context, he argued that individual and aggregate bodies became important for protecting and defining the state, nation, or population, and keeping bodies healthy became crucial to produce labour and maintain the military. While Foucault focused on the management of ‘families’ as the fundamental units of the population [6], feminist scholars highlight that the ‘family unit’ Foucault imagined was primarily the bodies and behaviours of women [27]. Feminist scholars of colour have arbitrated further by emphasising that Black, Brown, and Indigenous reproduction is seen by the nation-state as a threat to the white supremacist imagination across multiple locations and time periods [23, 27].

The connection between individual bodies and the body of the nation has therefore justified the control and intervention of people’s reproductive capacities in numerous ways. Public health campaigns from the nineteenth and twentieth centuries targeted poor women to reduce their fertility rates and prescribed a ‘domestic science’ of house cleaning for germ prevention [28]. Later approaches focused on behaviours related to alcohol and tobacco consumption [29] and breastfeeding [30]. In more contemporary examples, forced sterilisation of immigrant populations, family separation at the United States and other borders, expansive juvenile detention, and the overturning of Roe v. Wade in the United States provide just a few of the state-endorsed reproductive and family policies that emerge from racist, nationalist, and xenophobic laws and policies [31–33].

The medicalisation of reproduction was also founded on the biopolitical aim of controlling and managing people’s reproductive capacities and frames pregnancy as an illness that requires medical intervention and surveillance [34]. Riessman argues that the medicalisation of reproduction is a ‘contradictory reality for women’ [35, p. 16] as it provides certain women a way to gain some control and autonomy over aspects of reproduction while strengthening the control of biomedicine to define and survey reproductive experiences. We draw on this approach to emphasise that not all women and non-binary people experience ‘reproductive freedoms’. Rather, as Black feminists argue, current notions of reproductive ‘freedom’ that focus on bodily autonomy and choice are based on systemic forms of control, exploitation, and oppression forced upon formerly enslaved people over the course of hundreds of years and continue to affect Black, Brown, and Indigenous lives today [27].

To study these dynamics of reproduction, feminist scholars have developed a varied repertoire of tools and frameworks important to a critical gender analysis of DOHaD. Central to these, and part of the politics of reproduction introduced at the beginning of this section, is Ginsberg and Rapp’s notion of ‘stratified reproduction’. This concept describes how political, economic, and social forces create the conditions under which people carry out reproductive labour [36]. Stratified reproduction emphasises the need to explore reproductive experiences based on social, racial, and gendered locations and reflects how the treatment of people’s reproduction is not equally valued: certain people’s reproduction is cherished, while the reproduction of others is denied and denigrated [13, 26, 35–37]. This is a critical lens through which to understand how gender has always been tied to race and racism within the sciences associated with reproduction, including DOHaD.

Another key concept for understanding the politics of reproduction, especially in a postgenomic era, is the Reproductive Justice (RJ) framework developed by the SisterSong collective [23, 38–40]. It focuses on how racism shapes reproductive experiences and prioritises the stories of women of colour as the foundation for new knowledge. Reproductive Justice also emphasises how social justice issues like mass incarceration, premature death, disinvestment in public services, and environmental justice are all reproductive issues. This approach highlights how the management of population health through the control of reproduction was operationalised at the level of the individual through ideas of responsibility that were always deeply connected to racist ideologies. Thus, the RJ framework aims to move beyond the individualistic and neoliberal discourse of ‘choice’ to recognise that not everyone lives in an environment that provides them with the same options from which to choose [41].

Applying these feminist and critical race concepts allows us to explore how DOHaD theories deepen the stratification of reproduction. For example, in her book Weighing the Future, Valdez highlights how contemporary pregnancy trials that draw on DOHaD and epigenetic theories to study how maternal diet during pregnancy impacts children’s health outcomes are akin to nineteenth- and twentieth-century biopolitical strategies that focus on controlling, managing, or surveying women’s bodies and behaviours. Her analysis shows how, historically and presently, the surveillance and control of reproduction are unevenly distributed across populations based on race and class. Through her ethnographic study, Valdez illustrates how this occurs through what she calls the ‘politics of postgenomic reproduction’, a framework that examines how new science and technology emergent in a postgenomic era, including the fields of epigenetics and DOHaD, create conditions that both enliven twentieth-century reproductive politics and stimulate novel iterations of surveillance, risk, and control in the twenty-first century [16].

This feminist lens critically attends to issues of race and gender in two main ways: its application is based on the premise that processes of racism are enacted in and through reproduction and that queering reproduction requires a reframing of the maternal environment that is not biologically and genetically essentialised or individualised to cis-gendered bodies deemed capable of reproduction. Queering reproduction reflects the need to rethink reproduction beyond heteronormative, cisgender, white supremacist, and biocentric ways of thinking and aligns with the ethic of recent feminist scholarship on the environmental politics of reproduction as well. Building on the politics of reproduction and the intellectual and advocacy movements of RJ and Environmental Reproductive Justice (ERJ), Lappé, Jeffries Hein, and Landecker’s analysis of the environmental politics of reproduction critically addresses the intersections of lived experiences of oppression, environments of late capitalism, and postgenomic sciences to illustrate how human reproduction is increasingly bound up with environmental issues in ways that are always already connected to gender and racism [12]. Both the politics of postgenomic reproduction and environmental politics of reproduction therefore highlight how racism, white supremacy, and neocolonialism shape the unequal distribution of resources, lived experiences of reproduction, and the practices and ethics of emergent sciences [12, 41]. Alongside the concepts detailed above, this scholarship provides a critical entry point for addressing the intersections of gender and racism in DOHaD science today.

6.3 Don’t Blame the Poor Black, Brown, and Indigenous Pregnant Person

Two examples from our own scholarship illustrate how the emphasis on the bodies and behaviours of cis-gendered pregnant women and a lack of attention to racism and stratification influence the practices and consequences of contemporary DOHaD science. Our findings and the work of others reflect that even when measures of race and socio-economic status (SES) are incorporated into DOHaD studies, merely including these variables does little to address how racism shapes lived experiences or to dismantle the gendered and racial logics that inform many DOHaD studies [16, 45]. These examples show that inconsistent and superficial measures of race and class often stand in for the deeply embedded power relations that influence health outcomes of central interest in the studies we follow. Thus, both examples introduced in this section reinforce the need for critical gender analyses of DOHaD and other postgenomic sciences that attend to the ways that gender and race/racism shape research practices, knowledge claims, and the impacts they have on experiences of reproduction and the broader environments that influence health across the lifecourse.

The first example comes from Valdez’s ethnographic study of contemporary postgenomic pregnancy trials in the United States and United Kingdom. Introduced briefly above, her influential project draws on critical race theory and Black feminist theory to address how race/racism is foregrounded at the recruitment phase of trials focused on maternal diet during pregnancy and children’s future health and then disappears during the collection and analysis of the trials, only to return as significant in the comparison of outcomes in the publication of results [16, 42]. Her findings reflect how race is imbued with meaning, yet remains mercurial and mobilised in ways that distance it from the contexts and relations of power that shape the lives of trial participants.

Valdez’s findings illuminate the need to shift the focus away from diversity and inclusion efforts in postgenomic research and instead theorise how racist environments impact maternal health outcomes across the lifecourse [16]. Her work shows that individual-level interventions, which are central to these trials, need to be read as symptomatic of systemic racism, rather than as a solution to multidimensional illnesses like diabetes and obesity that disproportionately impact communities of colour. This is because the ‘underlying logics of individual lifestyle interventions are cut from the same ideological cloth that assumes poor, fat, and ethnically diverse individuals have risky bodies and are responsible for changing their bodies and behaviors’ [16, p. 10].

While such individual lifestyle interventions are framed as if all bodies live in similar environments and have equal access to ‘healthy’ opportunities, choices, and material conditions, Valdez shows that the pregnant people classified as ‘high risk’ for diabetes and obesity that are targeted for these interventions live in racist and poorly resourced environments that make it nearly impossible for them to comply with the intervention during the trial or sustain the intervention changes after the trial is completed. These findings reflect a key aspect of our argument here, which is that gender analysis without a critical understanding of race/racism is not a comprehensive framework for understanding DOHaD science and its consequences. This is particularly so when numerous studies show that focusing solely on individual interventions in maternal nutrition or early care is ineffective in addressing health and disease inequities [43].

In our second example, Lappé’s multi-sited ethnographic study of epigenetic research related to children’s behavioural health finds a similar emphasis on cis-gender women and their individual care practices during pregnancy and early parenthood, rather than on the structural conditions that shape their lives. Lappé’s project focuses on the production and circulation of epigenetic and DOHaD knowledge related to children’s behavioural health across laboratories, clinics, and communities in the United States and Canada. By studying the material practices and epistemic cultures that inform this science and its translation, she shows how many studies and initiatives focus on early-life adversity (ELA) as central in their broader questions about children’s behavioural health. She finds that scientists and others often use ELA to capture how myriad early-life experiences, including neglect, abuse, and poverty, shape health trajectories across the lifecourse [12, 44, 45].

Through her observations of behavioural epigenetic studies and their translation, Lappé describes how past and present DOHaD theories and findings critically inform the practices and impacts of these efforts [44, 45]. For example, even when epigenetic scientists, clinicians, and community members emphasised the health impacts of racism as primary motivations for their work, she finds that standardised measures of race and disadvantage used in many studies provide poor proxies for how racism and gender mutually shape lived experiences of pregnancy, parenting, and children’s health. Often limited to self-reported race, maternal education, and SES, Lappé reflects how scientists themselves noted the limitations of these measures, which nevertheless became built into large-scale epigenetic studies of children’s health. Her analysis shows how these measures and the primary focus on cis-gender women’s behaviours do little to address how systemic oppression influences the outcomes of interest in the studies she follows [45].

Lappé also finds that epigenetic and DOHaD studies of early life often build on previous results from animal models to focus primarily on the effect that women’s behaviours and experiences during pregnancy and early parenthood have on their children’s future health. As a result, concerns about the health effects of racism become channelled through measures and analyses that emphasise the maternal–child dyad and women’s care practices, rather than on how racist and sexist environments influence their lives. Even when studies aimed to improve children’s health through supporting families, the focus on women’s behaviours and experiences during pregnancy and postpartum had the effect of individualising responsibilities for children’s health, rather than addressing the need for broader social and structural change [46].

The analyses provided in these two empirical examples reflect how narrow and persistently individualistic models in DOHaD and epigenetic research focus on binary notions of gender and do little to address how systemic racism shapes experiences of reproduction and health across the lifecourse. The absence of racism as a central factor in prominent DOHaD studies therefore helps perpetuate understandings of health and inequity that overemphasise comparisons across racial and ethnic groups while ignoring the role of systemic racism in shaping health inequities. Such understandings reflect how race and ethnicity continue to be used in DOHaD and postgenomics research despite the knowledge that it is racism that fundamentally shapes health inequities across all gradients of income [5, 47, 48].³ Further, the focus on behaviours during pregnancy and early life in these and many other studies reinforces the individualised focus on cisgender pregnant women and mothers, rather than emphasising the unequal social environments that shape their lives.

These findings matter as new epigenetic and biopolitical strategies in the postgenomic era emphasise how present exposures and experiences may shape both intergenerational and transgenerational health. This extension of individualised responsibilities can further white supremacist and neoliberal notions of health by ignoring the connections between gender, racism, and reproduction. A feminist and critical race lens draws attention to these dimensions of DOHaD science and their unequal consequences, particularly when studies are overly dependent on individual-level interventions. The persistent focus on cisgender bodies and race, rather than racism, in DOHaD research also reflects how systemic racism and late liberalism shape science. The findings described in this section therefore reinforce the importance of addressing how gender and racism operate as mutually constituted power relations that shape DOHaD research and its effects in the world.

6.4 Conclusion

Over the past several decades, scholars have drawn more awareness to how systemic racism and other forms of oppression impact health, pointing to structural and institutional power relations, rather than individual actions, as critical sites for intervention. This work builds on a history of activism by Black, Brown, and Indigenous communities to address how racism, violence, and environmental injustice shape health inequities and lived experiences of reproduction [49, 50]. As we have illustrated above, these agendas and those in critical gender studies offer opportunities for DOHaD researchers to examine their research, its history, and its current mobilisations to address how gender and racism shape this science.

Through the frameworks and empirical research introduced above, we have shown that merely including gender, race, ethnicity, and class as variables of interest in DOHaD research does little to address how the mutually constituted power relations of gender and racism shape science and its unequal impacts on people’s lives. Addressing this is of utmost importance as Black, Brown, and Indigenous people have been and continue to be exploited through scientifically legitimised narratives that allow the state to remove their autonomy, force reproduction and sterilisation, and deny their reproductive rights [27, 51]. As reflected in rates of premature birth and maternal mortality among Black women in the United States regardless of SES, the relationships between gender and racism shape health inequities in clear and ongoing ways [48, 52]. These forms of ‘obstetric racism’ and the analysis we provide above reveal how gender is always already bound up with racism and other forms of oppression [34].

To address gender and racism in DOHaD, interdisciplinary engagements with this science must explicitly name how power relations shape research and its effects. In this chapter, we have highlighted how a feminist and critical race approach to gender and racism in DOHaD is necessary to accomplish this goal. In doing so, we advocate for critical gender analyses that push social and biological scientists alike to examine how systems of oppression inform research and its unequal impacts in the world. We end by highlighting the need to move beyond description and critique to create real change in the structures that affect people’s lives. This requires not only rethinking how we analyse DOHaD science but also actively reshaping the racist environments that impact health [53, 54].

Chapter 7 DOHaD in Economics Orthodox and Egalitarian Approaches

Jennifer Cohen

7.1 Introduction

The Developmental Origins of Health and Disease (DOHaD) is now an established area of inquiry in the economics discipline, cutting across subfields like health and demographic economics. Orthodox economists increasingly use econometric methods to make the case that individual-level epigenetic changes have measurable impacts on labour market outcomes. While some literature seeks to document disparities in health outcomes, most economic research considers the effects of health or economic shocks on educational attainment, employment, and wages. This focus on ‘nonhealth endpoints’ is guided by assumptions and definitions in orthodox economic thought that direct attention to concerns typically – or ultimately – related to market outcomes.

A wide range of unorthodox, egalitarian approaches within economics could contribute to DOHaD by integrating social forces, social structures, and social inequities. These approaches consider the origins and impacts of hierarchical power relations between groups. Compared to orthodox economists, egalitarian economists typically have a broader understanding of what an economy is and what an economy is for. Some view economics as the study of provisioning life or as the reproduction of society itself [1–3].

Differences between orthodox and egalitarian approaches are especially pronounced in analyses of the reproductive economy, an area of thought and policy relevant to DOHaD research. In orthodox economics, DOHaD research signals renewed interest in reproduction, but reproduction never fully disappeared from orthodox economic thought. Optimising economic outcomes through intervening in reproduction underlies eugenic research in economics, population control and ‘family planning’ in economic development, and DOHaD [4, 5]. The work and function of the reproductive economy, although essential for DOHaD, continue to attract little attention.

Some egalitarian economists highlight the critical roles of both. Reproductive labour includes the care work, housework, and other tasks associated with reproducing human life on a daily and intergenerational basis. Much of the work is unpaid. Functionally, production fundamentally depends on this unpaid labour, which reproduces the labour supply [2]. Despite its obvious economic importance, in the twentieth century, unpaid reproductive labour was defined outside of the boundaries of the mainstream economics discipline [6, 7]. This historical erasure of women and their economic contributions devalues women and the work they do, with material ramifications among other costs. Like the labour itself, economic research about it remains undervalued and marginalised in the discipline [6].

Hence, a resurgence of interest in reproduction by orthodox economists could be heartening. Yet when orthodox economists have been interested in reproduction historically, women have been instrumentalised in efforts to optimise economic outcomes such as gross domestic product (GDP) growth or income per capita by controlling reproduction. While women’s ‘maternal capital’ [8] is sometimes recognised as playing a role in the creation of future value (e.g., offspring’s wages), women themselves tend to be reduced to fetal environments, characterised as instruments of reproduction rather than as fully human people with valued lives.

Following a review of the literature, I demonstrate how egalitarian economic thought could usefully be brought to bear in DOHaD research, first by identifying weaknesses in the orthodox approach; second, by integrating social and historical context; and third, by suggesting areas for novel, socially grounded, collaborative DOHaD research. The egalitarian analysis indicates that richer understandings of social determinants of health could be a key contribution of DOHaD research. Egalitarians’ sophisticated understanding of social structures and constructed categories can situate DOHaD in a real-world context. I conclude that egalitarian approaches can address a critique of DOHaD research both inside and outside economics: the failure to adequately integrate social structures. The analysis reveals the real-world risks of this failure for women and girls, linking DOHaD literature to political debates about ‘fetal personhood’, women’s autonomy, and gender inequity.

7.2 DOHaD in Economic Research

To date, DOHaD-related empirical studies in economics take two main forms. One set attempt to document the effects of exposure to shocks, such as new access to medical technologies like antibiotics or adverse events like famines, epidemics, or recessions [9–12]. Many studies link women’s bodies (as in utero environments) to offspring’s childhood health or later-life outcomes. For studies in which health outcomes are dependent variables, health is a thing produced (an output) as a function of health investments (inputs) at different developmental stages of ‘childhood’ [13]. For example, some studies examine health outcomes such as adult height, a proxy for nutrition [14]. The second set of studies consider the efficacy of interventions to mitigate the detrimental effects of adverse events or social determinants of health, from public policy to micro-level service delivery [15]. This brief review of the literature focuses on the former studies as these are common in economics and can be foundational to the latter.

A distinguishing characteristic of economic research in DOHaD is the use of outcome variables aligned with most economic research: educational attainment, paid employment, and wages. According to Almond and Currie’s original review of the DOHaD literature, the addition of ‘nonhealth’ endpoints is one of four major contributions from economics [16]. The other three contributions are (a) novel identification strategies for working around data availability issues, (b) the variety of exposures modelled, including infectious disease, pollution, and recessions, and (c) the argument that studies that focus on survivors are likely to find weaker relationships than they would if data accounted for those who did not survive. Conti et al. identify contributions from economics as ‘rang[ing] from developing theoretical frameworks, to establishing causality, understanding mechanisms, and also computing costs and benefits of early interventions’ [16].

The theoretical basis of nonhealth-endpoint studies is human capital theory [17]. Human capital is typically understood by orthodox economists to mean education. The definition in the literature is more expansive. Conti et al. describe human capital as ‘…the intangible stock of knowledge, skills, personality, and other attributes – including health – that produce economic value in the life of an individual’ [15]. The economic model is an equation called a production function in which the thing produced, the output, is human capital. There are two periods of investment in the model discussed by Almond et al.: the in utero period of ‘childhood’ and the ‘second period’ of childhood [18]. In orthodox economic thought, human capital is the theoretical link between exposure to adverse events/shocks and wages: exposure impacts human capital that determines productivity, which in turn determines wages. Hence, for most economists, human capital is a key explanatory factor for labour market outcomes like wages – and wage inequality.

Empirically, the relationship between human capital and wages holds in general, but it does not hold for all people in all occupations. Where the relationship is present, its strength varies by demographic group because social inequities by race, gender, and disability status intervene. Racism, sexism, and ablism are oppressive systems of social relations that construct glass ceilings, glass elevators, and other impediments that constrain (or enable) advancement and mobility. For example, returns to human capital investment (education) have historically been lower for Black¹ people in the United States due to racial segregation [9]. Almond et al. note that long-run benefits of investment in human capital vary for Black men exposed to different degrees of segregation, ‘…suggesting that despite a strong economic climate (better early life conditions), institutional environment affects the rewards to investments in human capital’ [18]. The institutional environment encompasses systems of social relations like racism, sexism, and ableism. Those systems can translate into inequitable ‘returns to investment.’ Institutional economics and related egalitarian approaches have much to offer such analyses.

Orthodox and egalitarian thoughts about labour markets and wages differ considerably. In orthodox economics, occupational segregation, or the concentration of certain demographics in certain occupations, is the result of individual investments in human capital. In other words, occupational segregation is interpreted as the result of freely made individual decisions. The orthodox explanation for occupational segregation by gender and women’s lower earnings is that women choose to invest less in education or skills valued by employers and seek out jobs where experience plays little role in pay because they expect employment to be intermittent, due to their reproductive responsibilities [19, 20].

In some egalitarian approaches, gendered value systems and gender roles condition individual preferences, and gender discrimination crowds women into a subset of feminised occupations [21, 22]. Discrimination limits economic opportunities for the majority of the population – underrepresented men and women of all races – while restricting competition in occupations available to the minority [23]. Benefits for men include reduced competition for well-paid jobs and skilled employment in sectors that have historically been closed to women, such as economics and STEM fields [6, 24]. Directly related disadvantages for women include economic insecurity and a relatively weak ability to pursue divorce or to save for retirement.

Another explanation is that occupations become feminised because the people doing the work are themselves of low status [25]. Feminisation is a demographic process in which the proportion of women in an occupation rises, but it is also a process of devaluing those occupations as women enter them [6]. Evidence suggests that feminisation has a causal relationship with low pay and low status; hence, men have historically resisted women’s entrance into higher education and male-dominated occupations [26]. Conti et al.’s definition of human capital as knowledge, skills, personality, health, and other attributes ‘that produce economic value in the life of an individual’ offers some insight into the relationship between feminisation and value, economic and otherwise (emphasis added) [15]. In societies with gendered value systems in which women and men are valued inequitably, skills stereotypically associated with femininity and masculinity also tend to be valued inequitably [6]. Thus, some skills contribute far more than others to the economic value one’s life may hold. Finally, the same skill may be valued in male workers and penalised in women workers.

In summary, orthodox economists brought later-life labour market outcomes into DOHaD research, which they connect to health through human capital theory: investments in human capital should have positive returns in the form of higher wages. However, as egalitarian economists point out, systems of social relations like racism and sexism generate inequitable ‘returns to investment’.

This brief consideration of human capital theory reveals why social context matters in DOHaD literature. First, it is necessary for understanding existing economic analyses in which outcomes may be misinterpreted as the result of freely made individual-level choices. Egalitarian schools of thought, such as social economics, feminist economics, stratification economics, critical political economy, and institutional economics, draw insight from rich theoretical and practical understandings of the social context in which individuals make decisions. Egalitarian research offers historically grounded analyses of the origins and reinforcement of social structures. For example, feminist economists demonstrate how structural inequalities create gendered outcomes and explore how gender shapes understandings of economic activity [6, 7, 21, 22]. Some, especially women of colour, use intersectionality to describe how hierarchical social relations combine [27]. Institutional economists focus on evolving systems of power in which institutions coordinate economic behaviour, while social economists consider the ethical consequences of complex social interactions [28]. Stratification economics provides analyses of group-based inequality and is the product of research by Black economists [29].

Second, social context is also requisite for designing public policy to address the causes of inequitable outcomes. Egalitarianism contains justice-oriented guidance for policy and interventions because integrating power relations into analyses widens the scope for seeking social solutions to social challenges. Lastly, placing analyses in a social context may prevent the misinterpretation or misuse of DOHaD research for racist or sexist purposes.

In the remainder of the chapter, I demonstrate the usefulness of egalitarian thought in DOHaD. In Section 7.3, I make visible how the marginalisation of women’s labour and, historically, of women’s economic research contributes to the dehumanising instrumentalisation of women in orthodox economic research in DOHaD. The following section suggests that DOHaD could contribute to research on determinants of health, but its current contribution is limited by a narrow focus on molecular factors and uncritical use of demographic variables. I bring these points together in a short exploration of some real-world risks of dehumanising instrumentalisation for women and girls, linking DOHaD literature to political debates about ‘fetal personhood’, women’s autonomy, and gender inequity.

7.3 Economic Orthodoxy and Reproduction

Most economists exhibit little concern about the unpaid reproductive labour typically done by women, like cleaning, cooking, and raising children, among other tasks [2, 22, 30]. Still, it is women’s perceived responsibility for reproductive labour that links gender roles/norms to economic outcomes. The social expectation that women are responsible for the unpaid reproduction of life has economic consequences for women and men:

[W]omen are less likely to [do paid] work, they earn less than men for similar [paid] work, and are more likely to be in poverty even when they work [for pay]. Women spend almost twice as much time on housework, almost five times as much time on childcare, and about half as much time on [paid] market work as men do [30].

Women’s unpaid work has been defined out of the economics discipline theoretically, professionally, and empirically through decisions made by powerful actors in the field. In economic theory, disciplinary boundaries are established and enforced through gendered interpretations of value that treat unpaid work as a ‘non-economic’ activity [6]. Activities that are monetised are included on one side of this ‘arbitrary line’, while those ‘services gratuitously rendered by women’ are not [31]. Professionally, a process of ‘defeminization’ of the discipline took place in the early twentieth century, excising the study of the household by women economists [32]. Empirically, official state-based recordkeeping, such as the United States Census, excludes unpaid labour [7, 33]. The decision to exclude unpaid work from GDP was made by Richard Stone in pursuit of a ‘universal method’ against the advice of Phyllis Deane, a woman economist Stone hired to study the method’s accuracy in colonial territories [33]. Despite critiques by Deane and the only two women on international committees on national income statistics at the time, Hildegarde Kneeland (League of Nations, 1947) and Margaret Mód (United Nations, 1968), the method was promoted globally and widely adopted [33]. GDP is among the most commonly used pieces of economic information about a given country; ‘economic growth’ refers to a positive change in GDP.

The gendered method of calculating GDP and the gendered definition of value reinforce a hierarchical gender division of labour: monetised, valued labour associated with masculinity and the ‘public sphere’ termed ‘production’ is at the top, and non-monetised, devalued labour associated with femininity and the ‘private sphere’ is at the bottom. The division is informed by productivism, a bias that privileges monetised economic contributions, one aspect of reproducing life, over others. The gender division of labour and associated value judgements are so naturalised that they inflect the definition of what ‘The Economy’ is; what activities it includes, both popularly and according to most economists; and the ends of economic activities. It is deeply embedded in economic thought, with implications far beyond the discipline because of the influence economics and economists have on policy [6].

Women’s unpaid labour is the foundation of the reproduction of society on a day-to-day basis and intergenerationally. The term ‘labour’, as in ‘going into labour’, connects biological/physiological reproduction and the uncompensated work of social reproduction. There can be no production without the reproduction of life itself, including that of those in the paid labour force. If production is understood to constitute ‘The Economy’, then there is no ‘The Economy’ without women’s reproductive labour. Given this history and its negative effects on women materially and in terms of social status, orthodox economists’ newfound interest in reproduction could be welcome: it presents an opportunity to take the value of women’s reproductive labour seriously.

Historically, however, economic research on reproduction has embraced optimisation strategies that instrumentalise women. Eugenic projects sought to improve ‘the race’ with policy interventions like forced sterilisation that primarily targeted women, especially women of colour, in developed and underdeveloped countries from the United States to Sweden to Bangladesh as recently as 2020 [34, 35]. Forced sterilisation was thought to ‘improve the race’ in part by controlling population growth and therefore raising economic output (measured as GDP per capita). In this dehumanising project, women are reduced to instruments for economic growth.

DOHaD research in economics has often in similar ways emphasised the optimisation of economic growth, mainly by proposing forms of intervention in women’s lives. Critically, optimisation is framed in economistic terms with effects on knowledge production beyond the discipline: scholars point to the ‘“growing adoption of economics” “cognitive infrastructures” or “epistemic infrastructures” in global health governance’ [8]. DOHaD studies often employ economic language, framing economic benefits as ‘resource savings’ in the form of reduced child deaths, reduced morbidity, and the savings from potential adult chronic disease [8, 36]. Authors also find returns on investment in the forms of increased worker productivity, school attendance and achievement, and better employment in the future [36]. The economic logic driving some epigenetic research finds its rationale in human capital and the future earnings of fetuses.

Economistic thought, in which economic ends dominate other possible commitments, such as equity and justice, is enormously consequential. Some DOHaD research constructs women as vessels that [should] act in the interest of potential future progeny, a normative position that violates basic premises of orthodox thought. In some studies, the ‘future value’ of fetuses appears to take precedence over the value of actually - existing women, whose preferences are unaddressed. Women’s autonomy – especially that of women of colour – may carry relatively little weight in studies that prioritise economic growth over justice (see Section 7.4.2.1). As Chiapperino and colleagues discuss in this volume, this introduces a set of moral paradoxes for DOHaD.

7.4 Egalitarianism in Economics and DOHaD

The critiques of (a) the devalorisation of women’s reproductive labour and (b) of the dehumanisation and instrumentalisation of women in Section 7.3, and the implications that I explore below, exhibit the kind of historically grounded, socially informed insight that egalitarian economists can bring to DOHaD research. The analysis here makes two main points: first, it demonstrates how DOHaD research could contribute to more complete understandings of social determinants of health. Egalitarians integrate social context and can steer DOHaD analyses away from biological and/or cultural essentialism. Second, it shows how reducing women and girls to instruments of reproduction reinforces gender inequities.

7.4.1 DOHaD and Social Determinants of Health

A key contribution of DOHaD research could be in providing better explanations of existing social inequities and informing policies to address their causes. In contrast to imagining ‘utopian visions of where life can be remade and further harnessed for economic gains’ through technological innovations, this information could help make unjust social forces the primary targets for policy [36]. However, a common critique is that DOHaD literature, and a great deal of published research in economics, fails to integrate social forces, social structures, and social inequities [37]. Additionally, and related, some scholars criticise DOHaD research for endorsing biological and/or cultural essentialism [38]. Socially oriented economic research helps address these critiques through the theoretical and practical recognition that social variables reflect systems of social relations, not individual characteristics.

Racism and sexism are critically important determinants of health, including maternal, infant, and child health [39–41]. Notably, it is racism, not race, and sexism, not gender, that are social and structural determinants of health (SDH). The SDH are the systems of social relations that reinforce hierarchies of constructed categories to the detriment of people at the bottom of those hierarchies – women, people of colour, LGBTQI people, and those with disabilities – and benefit those at the top.² Variations across groups, such as disparities in health and other domains, largely reflect social dynamics and relations of power. DOHaD research may find disparities in outcomes, but the origins of those disparities are social.

One review of how empirical epigenetic studies integrate SDH began with 337 studies of social exposures ranging from low socio-economic status (child and/or adult), early-life adversity, to workplace or neighbourhood exposures, and adult DNA methylation [37]. Of those, over 115 studies included race or gender as variables without an explanation of the social exposures the variables represented. In other words, one-third of the studies misrepresented social categories as biological traits. To contribute to research on SDH, researchers must recognise that demographic variables serve as proxies for hierarchical power relations. Some scholars argue that researchers must try to measure the social structures and processes that result in the inequitable group-level distribution of resources [37].

Social determinants of health are widely acknowledged as primary determinants of health that encompass inequities resulting from social structures [39]. By collaboratively theorising and documenting the impacts of SDH, DOHaD research has the potential to shed light on the persistence and costs of inequities. Inequity is conceptually distinct from inequality; inequities are recognised as ‘unfair or stemming from some form of injustice’ [43]. Economistic logic that prioritises economic growth may preclude alternative logics like the pursuit of equity and justice. Orthodox scholarship in economics does not typically centre these pursuits due to the economism that guides research. Theory, methodology, and foci can be path dependent, meaning that existing literature defines the future trajectory of research because scholars use it as a foundation, making it easier to publish related work and build the literature. These are nonetheless decisions made by researchers who could opt for alternative, egalitarian approaches.

There are substantial risks to the limited exploration of social structures. First, scholars may overemphasise findings that add little explanatory power beyond that of existing social systems. For example, based on animal models, Almond et al. conclude that ‘it is highly likely that changes in the foetus or young child could be passed on to the next generation. This type of mechanism could offer an additional reason for the intergenerational persistence of poverty, and for the existence of poverty traps…’ (emphasis added) [18]. The authors do not identify the other reasons for the persistence of poverty, but presumably they include the myriad social factors that reproduce poverty. In comparative terms, the impact of an additional, potentially epigenetic effect in an explanation of the intergenerational persistence of poverty is probably marginal. As articulated in Almond et al. and elsewhere in published DOHaD research, this type of conjecture overstates the likely impact. Such emphases can give the misguided impression that there may be individual-level solutions to social inequities.

Second, a small impact may still be worth investigating, but scholars often combine potential epigenetic mechanisms with social variables like race and gender. Without acknowledging that those variables are proxies for racism and sexism, analyses are open to misinterpretation – scholarly and popular – as identifying biological or cultural ‘deficiencies’ in certain gendered and/or racialised groups.

Instead of contributing better explanations of existing social inequities, a narrow focus on molecular factors combined with an uncritical use of social variables risks making inequity-generating social structures and their unjust consequences less visible. The gender division of labour is a core element of the social structure that reinforces gender inequities. The next part of Section 7.4 explores some real-world risks of the failure to integrate social structures into analyses. More specifically, it describes how reducing women and girls to instruments of reproduction reinforces gender inequities.

7.4.2 Instrumentalisation of Women and Girls: Gender Inequities

Egalitarian approaches reveal the ways that policies, interventions, and language can reinforce inequities. Egalitarian economists offer socially aware insight and may identify alternatives. In this analysis, by locating policies/interventions/language in a real-world social context, feminist political economy elucidates some stakes of DOHaD research for women and girls. I describe two ways that the dehumanisation and instrumentalisation of women and girls contribute to gender inequity: (a) limitations on women’s autonomy and (b) the high costs of emphasising women-as-mothers vis-à-vis the low value of reproductive labour covered in Section 7.3.

7.4.2.1 Restrictions on Women’s Autonomy

Women’s dehumanisation is not an abstract danger. Some DOHaD literature is consistent with rhetorical and legislative strategies of pro-life political groups, which have ‘transformed their framing of the abortion issue, from one that pits foetal rights against maternal rights to one that emphasises the unique and intimate bond between the woman and the “child”’ [44]. In human capital models in the DOHaD literature, a zygote, embryo, and fetus – stages of in utero development – are described as part of ‘childhood’ (e.g., [18]). Thus the DOHaD literature overlaps with political debates about ‘fetal personhood’ and women’s autonomy.

For example, personhood laws in the United States have sought to establish fertilised eggs, embryos, and fetuses as entities with rights independent of those of a pregnant person [45]. The 1973 Supreme Court decision in Roe v. Wade ‘explicitly rejected the claim that foetuses, even after attaining viability, are separate legal persons with rights independent of the pregnant women who carry, nurture, and sustain them’ [45].

Hundreds, perhaps thousands, of women have nonetheless been arrested and prosecuted for ‘crimes’ against fetuses in the period between 1973 and 2022. Between 1973 and 2005, there were 413 such cases in which women were deprived of freedom through arrests or forced medical interventions [45]. Almost three-quarters of those women were African American [45]. Judges, juries, prosecutors, healthcare practitioners, and social workers have all represented the purported interests of fetuses at the expense of women’s physical freedom. For orthodox economists, gender-specific constraints on women, and the treatment of women’s preferences more generally, present theoretical, methodological, and practical challenges. Of further concern for DOHaD scholars should be the fact that criminal charges were typically based on the risk of harm without evidence of harm. The 2022 Supreme Court judgement overturning the 1973 Roe v. Wade decision brings these issues to the fore.

7.4.2.2 Women-as-Mothers and the Low Perceived Value of Reproductive Labour

Feminists in economics have long been deeply concerned about economic research that simultaneously reduces women and girls to instruments for productivity and economic growth and assigns them responsibility for the same. For example, microcredit schemes target women as sources of social capital based on gender stereotypes (i.e., cooperation) [46]. Reducing women and girls to their reproductive capacities similarly instrumentalises them as containers of ‘maternal capital’. DOHaD research inside and outside economics adopts the language of ‘capital’: health capital, human capital, maternal capital, somatic capital, cognitive capital, resource capital, and offspring capital all appear in the literature [4, 8, 16, 47]. The language places responsibility on individual women for accruing and maintaining their ‘maternal capital’ during potential childbearing years. For most women, this accounts for half of their lifetimes, starting prior to adulthood, sometimes as early as six or seven years old [48]. As Currie recognises in an interview, this implies a shift in the logic of intervention:

It really means you should be targeting a whole different population than, say, 15 years ago, when we thought, Oh, we need to be targeting preschool kids instead of kids once they reach school age. Now we’re kind of pushing it back … Now the implication is that we’ve got to reach these mothers before they even get pregnant if we really want to improve conditions.

(emphasis added) [8]

Any such effort to reach ‘potential mothers’ would likely need to cover half of the general population over time. Yet most DOHaD literature does not target that half of the population as women or girls; it targets them as potential fetal environments. Imagining all women and girls as ‘mothers’ reduces them to their reproductive role, overvaluing the fetal environment and undervaluing the people embodying it.

The emphasis on women-as-mothers has ramifications in other domains. Gender roles in reproductive labour link framing women-as-mothers and material and social impacts. I argue elsewhere that constructing women-as-mothers contributes to gender disparities in pay [6]. That is, gender inequity contributes to gender pay gaps, including those related to occupational segregation. In turn, pay gaps contribute to women’s economic dependence on men and penalise single women by making it more difficult to save for a down payment for a home or to save adequately for retirement.

The reduction of women to instruments of reproduction is a disciplinary mechanism with material consequences. It imagines dependent children and responsibility even where none exists to a punitive effect in the labour market. Critically, DOHaD’s concern with maternity is not likely to do women any favours materially without a dramatic shift in the perceived value of reproductive labour.

7.5 Conclusion

Orthodox economists brought later-life labour market outcomes into DOHaD research, which they connect to health through human capital theory: investments in human capital, including health, should have positive returns in the form of higher wages. However, systems of social relations like racism and sexism are sources of inequitable ‘returns on investment’. Further, inequity-generating social structures and their unjust consequences are made less visible by research that uncritically uses social variables. The gender division of labour is part of the social structures that reinforce gender inequities.

Reproductive labour, and who is believed to be responsible for this low-status, poorly paid, and unpaid work, is key to understanding persistently gendered and racialised inequity. Social structures that devalue women and ‘women’s work’ are institutionalised in practices like gender-based discrimination in the labour market. Women are discriminated against in the labour market because of their perceived responsibility for reproductive labour (i.e. because of gender roles). Women are obviously more than instruments of reproduction but have been instrumentalised in the interest of optimising economic outcomes. DOHaD research continues this tradition, but it does not need to.

Many opportunities remain in the field for ‘exploring structural factors that capture intersectional and interlocking systems of oppression’ [37]. Egalitarian economists are well equipped theoretically and methodologically for analyses of social structures and oppressions. Many of the people conducting equity-oriented research in economics are members of underrepresented groups and have related experiences that inform their research. Those experiences can be sources of insight from which a diverse group of economists develop economic theories that better reflect power dynamics in the social world.

Chapter 8 The ‘Moral Paradox’ of DOHaD

Luca Chiapperino , Cindy Gerber , Francesco Panese , and Umberto Simeoni

8.1 Introduction

Knowledge of the molecular and physiological mechanisms of the Developmental Origins of Health and Disease (DOHaD) is no longer confined to the lab and/or to research. Rather, the idiom of DOHaD is part and parcel of a scattered landscape of policy initiatives; that is, endeavours directed at translating DOHaD’s central tenets into political discourses, programmatic statements, as well as implemented public health measures. Policy initiatives around DOHaD both inspire new policy approaches in public health [1, 2] and cast a new outlook on several policy domains in our societies – crafting, in some cases, previously overlooked links between existing policies and novel opportunities for intergenerational health promotion [3].

Yet, the central policy messages of DOHaD research are not devoid of criticism, especially on the side of the social sciences and/or ethical, legal, and social aspects (ELSA) analyses. The reason is that translating DOHaD messages into policy means walking a difficult tightrope. On the one hand, the field has the political potential to illuminate the temporal extension and far-reaching implications of the social determinants of health [4]. What happens during the developmental period has ramifications that extend to the lifecourse of parents (not just the pregnant mother-to-be), much like to the relational, social, and material environment of gestating bodies, or the structural patterning of health inequalities in our societies. If anything, DOHaD is – to this reading – only a demonstration that social inequalities hit harder in developmental times. As such, DOHaD policies would be expected to lean towards a syndemic approach to health; that is, to affirm a holistic conception of health, which considers risks as biosocial complexes emerging at the intersection of biological predispositions as well as social and environmental modulators of disease [5]. On the other hand, scientific literature and circulating evidence often provide a rather different take-home message from DOHaD research. This message affirms the importance of maternal–offspring dynamics for the programming of adult health and only recently has expanded into a broader focus on periconceptional and family-related dynamics, including effects following the paternal line [6]. Key to the enactment of DOHaD findings is – to this alternative reading – behaviour change, parental (and especially maternal) lifestyles, and more generally responsible actions based on literacy of developmental effects. In a nutshell, the key policy objectives of DOHaD research are highly idiosyncratic and taken in a tension. What could be called the ‘moral paradox’ of DOHaD is the idea that, while the scope, foundations, and practical implications of DOHaD research call for structural interventions addressing social determinants of health over the lifecourse, DOHaD messages can at times boil down to simplistic claims of individual responsibility [7, 8].

In what follows, we attempt an explanation of these paradoxical implications of DOHaD research. We do so by offering a comprehensive analysis of claims towards individual responsibilities in the DOHaD literature. The chapter draws from a systematic literature review documenting the whole spectrum of policy and normative discourses in DOHaD research. Within this diverse set of policy interventions, the chapter unpacks the often-underlying normative claims pointing to the responsibilities of individuals (e.g. parents, parents-to-be, etc.). Complementing previous publications from our group [9–11], the literature review highlights the complexities of scientists’ engagements with the moral and societal aspects of DOHaD research. Systematically analysing scientific publications allows us to unpack the intricate processes that bring about an economy of individual-oriented norms, responsibilities, and obligations [12] to the detriment of other ethical orientations of the field. DOHaD scientists, we argue, hardly make any straightforward argument in favour of individual responsibilities for health. The ‘moral paradox’ of DOHaD rather arises from an ambiguous stance on the possibilities of health promotion strategies inspired by DOHaD. This stance mixes up the current practical possibilities of the field with its policy framing, opportunities, and political ambitions.

By clarifying the normative scope and limitations of policy debates around individual responsibility in DOHaD research, we hope to prompt a deeper appreciation of the political ramifications of DOHaD knowledge and concepts. A higher awareness of the normative ambiguities and moral idiosyncrasies that raise critique of DOHaD research may help redefine the boundaries, priorities, objects, and representations of this research. In the discussion, we elaborate on how knowing the modalities and emergence of the ‘moral paradox’ of DOHaD calls into question the policy advocacies currently animating the field and points to the need for finally embracing the social justice framing of the field David Barker had hypothesised [2].

8.2 The Hyper-responsibilisation Critique of DOHaD Research

Several critiques have addressed normative and policy discourses in DOHaD research or the way its concepts and evidence circulate in the wider society. Anthropologist Megan Warin and colleagues have followed the genealogy of obesity discourses in Australia and highlighted the gender inequalities ‘squeezed out’ of Barker’s hypothesis. How did his research programme – inaugurated with the discovery of a gendered socio-economic patterning of undernutrition and its effects on adult health – end up paradoxically reinforcing the social acceptability of a gendered stigma for obesity [13]? Along the same lines are those critiques that underline the reduction of the maternal body in DOHaD research to a ‘vector’ [14], or a ‘capital’ holder [15] for the healthy development of the child. According to these scholars, there is a risk that DOHaD research inspires a hyper-responsibilisation of women in contemporary societies [16]. Not only does DOHaD evidence replicate narratives of responsibilisation for women [17], but it also adds an ethics of stewardship and responsibility for future generations, which virtually extends over multiple generations [8, 18] (see also the chapters by Valdez and Lappé as well as Warin and Moore).

Others have shifted the focus of normative critique of DOHaD to studies of the epigenetic mechanisms of inheritance via the gametes – hence potentially both from the paternal and the maternal lines [10]. This line of research reaches beyond the intrauterine environment to include epigenetic predispositions via both parental gametes. While the increasing role assigned to paternal influences partly counterbalances ‘the tendency to pin poor outcomes on maternal behaviour’ [19], these attempts are not devoid of criticism. Besides raising questions as to their stereotypical treatment of paternal roles and responsibilities,¹ studies of parental effects still tend to support over-simplistic attributions of individual responsibilities. In fact, they only mark a switch to an extended version of gendered claims of individual responsibilities for health, which includes the environments, behaviours, life trajectories, and actions of the father (and fathers-to-be). In other words, the ‘moral paradox’ of DOHaD holds even without an exclusive gendered emphasis on women’s bodies. We could in fact reformulate it as follows, by including also the injunction to protect one’s gametes that virtually applies to all individuals of reproductive age: how did a research field founded on the socio-economic patterning of parental influences over development end up promoting discourses of individual behaviour change, parental responsibilities, and health literacy to promote the health of future generations? Let us turn to a tentative answer drawn from scientists’ treatment of these normative matters in the DOHaD literature.

8.3 Methods and Materials

The literature review draws from peer-reviewed publications indexed on Web of Knowledge and follows the PRISMA guidelines for systematic literature reviews and meta-analyses [20]. Data collection took place between October 2020 and January 2021; source consultation and analysis were led by Luca Chiapperino (LC) and Cindy Gerber (CG) between March 2021 and December 2021. Francesco Panese (FP) and Umberto Simeoni (US) intervened later in data analysis. We searched Web of Knowledge for papers including the phrases ‘1000 days’, ‘developmental origin*’, ‘DOHaD’, and ‘fetal origin*’, each accompanied by the specific search term ‘polic*’. The star at the end of search terms allowed us to include papers using any derivative of these terms (e.g. in plural and singular forms). This database query returned different kinds of articles: reviews, editorial papers, perspective articles, commentaries, and theoretical discussions, much like empirical studies (n = 287). The substantive number of duplicate records across the different combinations of search terms (n = 93) hints at the evidence that ‘1000 days’, ‘DOHaD’, or ‘fetal origins’ are often used interchangeably within the literature. After these duplicate items were removed from the database, CG and LC proceeded independently with the screening of records through abstract reading. This excluded a set of articles as out-of-topic items (n = 33). Either these articles did not inscribe themselves within DOHaD literature (e.g. they mentioned DOHaD for comparison, or in opposition to their subject matter) or they mentioned policy/policies in ways unrelated to translations of DOHaD in society (e.g. the manuscript mentioned policies on animal research or, more broadly, ethics policies governing research). The remaining records retrieved (n = 161) were grouped and imported into Nvivo for coding and analysis.

A preliminary screening of sample records (n = 20) conducted by LC and CG revealed that some papers included a mention of policies that was rather abstract or rhetorical. With this, we mean papers that offered only a generic appeal to the ‘need to bring DOHaD evidence closer to policy-making’ without really expanding on the reasons, motives, nor the strategies and objectives to be achieved through these translations. We excluded these papers (n = 50) due to their poor informational value for the present analysis. This iterative screening, selection, and analysis retained a total of 111 articles, which were coded through Nvivo. Within this set of papers, 50 offered at least one reference for coding to potential policies and interventions addressed at individuals (e.g. behaviour change, lifestyle change, ensuring breastfeeding, and health responsibilities) or made an explicit mention of ‘mothers, fathers and families’ as ‘critical agents for change in setting up healthier trajectories for their children’ (e.g. [21]).

8.4 The ‘Paradox’ Explained: Ambiguities and Difficulties of Translating DOHaD into Policy

All papers included in the analysis argue – through different formulations and to different degrees – for ‘a process of broad societal engagement’ ensuring that individuals adopt ‘DOHaD-informed practices as feasible, positive and lifelong options’ [21]. Of note, even the articles offering a substantively individual-centred rhetoric (e.g. putting a strong emphasis on the need to inform/educate mothers-to-be about healthy lifestyles) still acknowledge that choices and lifestyles of individuals are tied to broader ‘political or financial incentives’ that could motivate people to ‘change modifiable risk factors for adverse health outcomes’ [22]. In simpler terms, the main result of our review is that DOHaD researchers do not make straightforward arguments in favour of individual responsibilities for health. We did not find a paper treating individual obligations to adopt a healthy lifestyle in the periconceptional period in isolation from the need to target institutional or collective factors. Rather, individual and collective, public and private actors eminently mix and overlap as those responsible for a societal implementation of DOHaD research. Some, for instance, plead for the ‘establishment of properly functioning economic and financial structures which supports children from underprivileged households’ [23]. Others argue for the reduction of exposures to environmental chemicals found in the air, water, and soil [24]. Researchers from the Global South argue that ‘nutrition-sensitive agricultural investments’ are required to achieve ‘income generation and nutrition outcomes’ [25]. Finally, even marketing regulation is a widely recommended measure by DOHaD researchers [22, 26].

Thus, the ‘moral paradox’ of DOHaD is partly explained at least by the ambiguities and challenges scientists face in elaborating these normative claims. DOHaD authors do recognise that the developmental patterning of health inequalities largely depends on structural configurations of our societies. However, when turning these considerations into values, norms, and expectations, they still reproduce figurations, claims, and expectations that situate action at the individual level. None of the articles we analysed dwells in fact on a simplistic injunction towards behaviour or lifestyle change to be promoted with policies that, for instance, ‘simply [recommend] a “good diet” to optimizing nutrient delivery for the developing child’ [27]. Rather, scientists’ policy thinking often acknowledges the need to consider ‘direct education, social marketing, and policy, systems, and environmental changes’ that could accompany the promotion of ‘healthy diets for mothers, infants, and young children in the first 1000 days’ [27]. What seems to be missing from these different policy articulations of DOHaD is a recognition one could easily draw from the fairly developed body of social sciences and/or ELSA scholarship on these matters [8, 9, 28]. Healthy eating, lifestyle changes, and healthy behaviours during this crucial time – or, in normative terms, individual responsibilities to act on DOHaD knowledge – cannot really be separated from social, economic, and political structural conditions of agency – much like, it should be added, from other material determinants of programming such as genetic variation and stochasticity [11]. The responsibilities for epigenetic and developmental predispositions to disease can therefore hardly be handled individually, or ‘easily’ translated into practice through ‘modifiable behaviours that can be targeted during pregnancy’ such as ‘diet and exercise’ [29].

Of interest is how DOHaD authors guard their work against simplistic responsibility claims [1]. The publications we analysed often situate the objective of acting on the determinants of developmental programming, such as, for instance, maternal nutrition, within ‘multisectoral and broad double-duty actions by policymakers’ [26]. Yet, in most cases, these articles fail to advocate straightforwardly in favour of addressing these responsibilities as a collective matter. The ‘moral paradox’ of DOHaD thrives therefore in the following ambiguity: failing to underline and prioritise social and political interventions – instead of individual behaviour change – as critical instruments of health promotion policies. This is the reason, we argue, policy translations of DOHaD research lend themselves to critiques alleging them to reinforce the idea we are morally accountable for these predispositions as individuals. In what follows, we draw from our literature review to offer several illustrations of this ambiguous stance as it touches upon a) reflections on the actors in charge of enacting DOHaD knowledge; b) the concrete policy proposals DOHaD should inspire; and c) the kind of health promotion interventions derived from DOHaD knowledge.

8.4.1 Mothers, Fathers, Families, and Society: Who Are the Actors of Change?

A first striking ambiguity in DOHaD researchers’ writing on public health policy and intervention relates to the actors they designate for social change and for producing the public health benefits of this knowledge. Reflections on the scale and distribution of agency inspired by DOHaD research are fundamentally blurred, and the discourses of scientists often waver on who should be the bearer of responsible action over evidence of developmental programming of health.

For instance, a recent review by clinical scientists Birgit Arabin and Ahmet Alexander Baschat [30] draws insights from research on the ‘Barker hypothesis’ and ‘reverse Barker hypothesis’ into reflections on intervention and public health policy. The former is the typical knowledge claim of DOHaD research: that is, the recognition that poor maternal health conditions accelerate the risks and susceptibility to chronic diseases in the offspring. The latter is instead the idea that evidence of health issues in pregnancy predicts also the mother’s future health or even the grandparents’ risk for chronic diseases. This knowledge base, the authors argue, positions pregnancy as a unique window of opportunity to protect the future health of the mother and the child, revealing that the ‘disease risks’ of ‘today and tomorrow’ are fundamentally linked [30].

If anything, one could read the evidence Arabin and Baschat mobilise as a demonstration that the origins of intergenerational health inequalities largely extend beyond pregnancy. These rather stem from the multi-generational reproduction of patterns of inequality that affect family units – see [31] for an example of DOHaD researchers developing this perspective. And, in fact, Arabin and Baschat do recognise that DOHaD and epigenetic ‘findings relate to questions of social and environmental justice and not only to individual responsibility’ [30]. However, at the same time, their article forecloses this normative and political reflexivity by putting forward suggestions for primary prevention that can be resumed into ‘personalized care paths for mothers and infants’ (p. 13). The social and historical processes patterning health inequalities through the developmental period get here evacuated to give way to an implementation of DOHaD as ‘sentinel risk profiles’, ‘lifestyle interventions’, and maternal health ‘passports’ – if they do not consist in explicitly leveraging the ‘fact that pregnant women are more sensitive for healthcare advices’ as ‘a chance to intervene’ during pregnancy (p. 13).

Reducing practical options for implementing DOHaD evidence to the actions and behaviours of pregnant women has consequences for the political potential of the field. We do not mean to suggest that we expect clinical scientists to formulate a coherent community-based or intergenerational social policy strategy for primary prevention of developmental susceptibilities to diseases. Nor are we focusing on Arabin and Baschat’s paper because we consider it particularly problematic compared to others (see [6, 32]). Our point is a different one. As DOHaD gains relevance in policy settings, it becomes crucial that scientists adequately consider the complexity of the contextual and social dimensions of DOHaD effects. While we agree that pregnancy is an underestimated window of opportunity, we also warn DOHaD researchers against the conceptual slippage of mixing up those who are mostly affected (mothers and children) with those who should act upon the social, individual, and biological determinants of developmental programming. The risk is not simply of making advice inert and unspecific; that is, turning the complex temporal and socio-environmental ramifications of health into banal advice towards balanced lifestyles in preconception and pregnancy. Rather, this unwarranted conceptual move risks tanking the political implications of DOHaD for health promotion. Can the multi-generational effects of the social determinants of health be simply translated into an injunction towards responsible behaviours of parents-to-be? How are matters of families, communities, and the wider society, which have often also longer histories than the people affected, to be solved just through individual action?

8.4.2 Education, Education, and Education: How Effective Is It?

Education is the most frequent individual-level intervention discussed by DOHaD researchers. Although educational policies take many different forms, they often invite the translation of DOHaD-inspired health ‘recommendations into simple messages provided through an attractive graphical format’ [33]. This effective communication is the pivot of this kind of DOHaD translation, targeting ‘specific consumer [and] groups’ and inspiring behaviour change [33]. As a corollary, this also raises the question as to who should oversee this communication most effectively. For instance, nurses are at the centre of these debates, as arguments abound that claim that they are in a unique position ‘to disseminate information and promote maternal and infant mental health at every level of policy advocacy, public education, primary prevention, screening and intervention’ [34].

Health literacy and effective communication are also an issue DOHaD researchers problematise as part of scientific practices (e.g. making sure one’s research reaches out to critical actors for change; [21]), or as crucial activities of scientific societies. This is, for instance, the case of the ‘DOHaD Society of Australia and New Zealand’ (DOHaD ANZ), which has established several working groups (WGs) – including one on ‘Translation, Policy and Communication’ – to promote the ‘collective identity’ of the field and advance its agenda in science and society. Educating at-risk individuals is one of the core strategies the society has given itself ‘to decrease the incidence and severity of noncommunicable diseases in Australia and New Zealand’ (p. 438). The WG ‘Translation, Policy and Communication’ reports on its activities in ‘three broad areas: knowledge synthesis, communicating this knowledge and translating this knowledge’ (p. 438). The point for its policy uptake, translation, and communication is just to keep the DOHaD message simple and present it consistently by taking into account ‘the mindset of each user group’ [35].

It could be questioned whether mass communications directed at individuals are an effective strategy of health promotion – and, incidentally, a good way to bring DOHaD closer to societal action, whether individual or collective. Although a body of work on ‘right messages’ in health communication is built on intuitive assumptions about the receptiveness of intended audiences, a whole social epidemiology literature exists on what some call ‘communication inequalities’ [36]. These inequalities result from social determinants (e.g. class, social networks, education access and quality, neighbourhood, and built environment) that act on health literacy – much like they do on the individual capacity to be an actor for change in one’s health. Health literacy and its translation into responsible health-related behaviours go therefore beyond the process of tailoring the right message to the right individual: rather, literacy demands the empowerment of the individuals concerned and entails an interactional process between them and their social environments [37–39].

The issue of DOHaD-related education requires therefore that language, metaphors, and arguments adequately consider such multi-level and integrated views of literacy and behaviour change for health. A nuanced critique of the centrality of behaviour change for DOHaD-related policymaking can be found in a paper by DOHaD researchers Luseadra McKerracher and colleagues [40]. They show that DOHaD knowledge translation (KT) can be made compatible to different degrees with an emphasis towards social, community, and institutional change. First, they put forward the ‘pragmatic and moral reasons’ against DOHaD KT. Educational interventions, they argue, could be detrimental to mothers-to-be by placing ‘yet another layer of psychological responsibility (essentially blame) on the[ir] shoulders’ (p. 424). To prevent this outcome, DOHaD KT should take into consideration that individuals or communities ‘of lower socioeconomic status’ are often simply ‘unable to prevent nutritional shortfalls, to avoid environmental contaminants, or to avoid (or reduce) psychological and/or physiological stress in the environments’ (p. 424). It is thus ‘morally arbitrary’ to expect that improving the health literacy of parents-to-be suffices as a policy translation of this field.

Second, the authors plead for the centrality of DOHaD KT to individuals in the policy agenda of the field and consider it a duty ‘to actively disseminate crucial information regarding pregnancy nutrition’ (p. 424). There are, they maintain, a few ‘teachable moments’ (p. 423) at different life stages (e.g. adolescence and pregnancy) where the dissemination of health-related information may be effective. This is due to a combination of higher individual information-seeking and higher receptiveness and will to engage in behavioural change. The fact, the authors conclude, that ‘expecting mothers/couples, or people planning pregnancies are not being targeted’ represents ‘a surprising gap’ in current programmes. As problematic as DOHaD KT may be, the authors recommend to multiply and reinforce KT strategies in more receptive populations: access to information is a pillar of the policy translation of DOHaD [40].

McKerracher and colleagues attempt to formulate a balanced view concerning the importance of sustaining direct-to-public KT efforts. They underline the importance of KT all while ensuring ‘that public institutions hold the lion’s share of moral responsibility for ensuring environmental nutrition/health equity’ (p. 425). Their strategy starts from the recognition that DOHaD researchers, much like the concerned individuals, cannot change the structural factors that shape ‘developmental environments, developmental trajectories, disease risks over the lifecourse and long-term health outcomes’ (p. 425). It also puts at the centre the importance of KT initiatives: parents-to-be, especially prospective mothers, ought to be informed while also being reassured about the fact that their ‘capacity to improve their children’s developmental environments, their bodies and behaviours’ is just ‘a small piece of a large and complex environmental puzzle’ [40]. In the words of another DOHaD author critically addressing the field’s emphasis on literacy and education, this issue should be treated with a nuanced view of what actions are really available to a given person in a given context: ‘having information about healthier diets and some of the skills does not necessarily mean that choosing the healthier options is easy in today’s society’ [41].

8.4.3 Behaviour Change for the Sake of Pragmatism

Another conspicuous source of ambiguity in the policy discourses of DOHaD scientists stems from a mismatch between tools, ways of knowledge-making, and the scope of a clinical and/or public health science like DOHaD. While some pursue the line of research inaugurated by Barker’s hypothesis (focusing on the populational effects of geographical and socio-economic conditions), current epigenetic studies of developmental programming in, for instance, a mother–child cohort often cast a far narrower outlook on these issues. This understanding of aberrant developmental effects during pregnancy is located in women’s bodies, and the corresponding interventions are putatively supported by this evidence within the sphere of individual action and/or behaviour change. Thus, when presenting their results and their relevance for public health, DOHaD researchers often need to make multiple conceptual leaps: from the evidence produced at the individual level to a concept developed at the populational level; from the molecular mechanisms of developmental processes to the social and epidemiological factors that influence them; or even from the animal models providing mechanistic knowledge of developmental programming to the humans at the centre of clinical/primary prevention practice. Holding these multiple layers of evidence – and potential policy interventions – together is a difficult task. While awareness of the need to consider how all these factors interact is not lacking in the literature, a whole different task is to produce compelling evidence to intervene in these complex biosocial processes [42].

The challenge of holding together the individual and the collective, the clinical and the populational, the behavioural and the structural constitutes a third (and last) way DOHaD researchers end up legitimising – perhaps unwillingly – individual responsibilities for health. Take, for instance, a series of papers by influential DOHaD researchers – and contributors to this handbook – Mark Hanson, Peter Gluckman, and Lucilla Poston [1, 42, 43]. The complex social ramifications of DOHaD could not be stated in a clearer way in their work: ‘if the result is a culture of blame or shame, the resistance to change induced [by DOHaD] will make the battle against NCD[s] even harder’ [43]. And yet, these authors also affirm that there are ‘pragmatic’ reasons to support and promote lifestyle improvements in ‘women and young girls’, much like in ‘men’ and ‘adolescents’ [43].

With pragmatism, Hanson, Gluckman, and Poston have in mind an argument we partly encountered already above: there exist ‘teachable moments’ during anyone’s lifetime that are a promising opportunity for an investment into health literacy with long-term consequences. Educating adolescents could have a dramatic impact on individual ‘self-efficacy’ and capacity ‘to make decisions about lifestyle themselves’ [43]. Therefore, although ‘sensitivity’ and a ‘focus on empowerment’ are paramount [43], translations of DOHaD knowledge into policy cannot afford to give up on the promotion of behaviour change and healthy lifestyles in vulnerable populations. The challenge for DOHaD scientists is striking the right balance between the need to offer ‘evidence-informed strategies and where possible [also] pragmatic solutions’ [1]. More than formulating a theory of DOHaD-inspired health justice, the challenge of DOHaD researchers is what can be ‘back[ed] with impunity’ [1], or what ‘policy interventions may be most efficacious’ [44].

While tapping into the political potential of DOHaD would encompass ‘population-based complex interventions’, the efforts of DOHaD researchers are limited by available evidence and the affordances of the science they practice. Policy translations that support lifestyle changes for women and their partners are often simply ‘a more immediate message’ [1], which they can offer with assurance and factual support. This raises the question of what DOHaD scientists can do from where they stand. In the absence of a complex, systems-based approach to the multi-generational mechanisms of developmental programming and the social determinants of health, the promotion of individual responsibilities for health – although tempered by DOHaD scientists’ own critical reflexivities – appears to be a policy option with strong practical hold.

8.5 Discussion

Our systematic and critical review reveals that DOHaD scientists are no less concerned than public health advocates or ELSA scholars with the pathogenic environments and the social determinants of health that modulate developmental predispositions to adult disease. While they do not lack awareness of the relevance of these complex and multi-level processes for DOHaD thinking, they also know too well that reordering those socio-material circumstances is beyond their reach. As one gets closer to the ways DOHaD scientists write about individual agencies, parental behaviours, maternal/paternal lifestyles, and periconceptional health promotion, one cannot but notice their difficult position. On the one hand, they deplore the social, environmental, and multi-generational inequalities that pattern developmental exposures and reproduce health inequities in our societies. On the other hand, they lack the evidence (validated knowledge), tools, and influence to fully take issue with the complex biosocial origins of developmental programming and act upon the structural problems that interfere with periconceptional health behaviours, gestational lifestyles, or infant health. In the face of this situation, what remains open to these practitioners is the possibility to address DOHaD knowledge and advice to parents-to-be, pregnant women, prospective fathers, or couples in a reproductive project. Hence, the primary finding of our critical review is that the ‘moral paradox’ of DOHaD gets in part explained by the challenges scientists face when elaborating upon the policy options backed up by their research and practice. A thorough appreciation of their situatedness reveals that appeals towards individual responsibility in DOHaD are far from being (yet) another neoliberal disciplining strategy for health promotion. Quite the contrary, they are a suboptimal compromise. It is the necessity of tailoring the complex policy messages of DOHaD to the concrete opportunities for action and change available to most periconceptional health practitioners. To them, what is better, rather than worse, in the absence of an opportunity for structural change, is to encourage and educate prospective parents to become the actors for change and protect the health of their future children.

This does not mean that the hyper-responsibilisation critique we highlighted above is misplaced or unfounded. The truth is that, although grounded on pragmatic reasons, the public policy strategies of DOHaD researchers often boil down to providing mothers, fathers, and families with the ‘right’ information and to warning them about the long-term health consequences of their lifestyles and behaviours. In this respect, social scientists and ELSA scholars hit the right note when writing about (what we call) the ‘moral paradox’ of DOHaD. By foreclosing the reflexivity on the syndemic and multi-level implications of their knowledge, DOHaD scientists offer an ambiguous societal uptake of this evidence. This paradoxically ends up reinforcing problematic discourses of individual responsibility for health, especially in their uneven, gendered version that overburdens pregnant women and mothers-to-be. By targeting health behaviours as a main interventional strategy within their reach, DOHaD authors hamper the production of more elaborate policy imaginaries flowing out of their field. Thus, the hypothesis by David Barker that gestational socio-economic hardship translates into an unequal distribution of non-communicable adult disease turns into an admonishment to individuals on how to behave ‘best’, urging them to take the kind of control over their health that may simply be unaffordable to them from their own social and environmental positionality. Here lies our second conclusion: the ‘moral paradox’ of DOHaD represents an ambiguous normative stance that mixes up the pragmatic possibilities of clinical and public health sciences with the policy discourses, practical ambitions, and political potential of a scientific field.

So, what can scientists do to avoid this situation? Taking scientists’ situatedness seriously, no ready-made solution exists to complexify DOHaD knowledge and its policy translations. This notwithstanding, scientists could at least embark upon two kinds of concrete actions that might defuse the ‘moral paradox’ of DOHaD. First, they could make explicit the tensions highlighted above at the core of their research: between the individual intervention and the social aetiology of a condition, between the behavioural recommendation and the need for political/structural change, between the tools and knowledge of biomedical sciences and the possibilities of populational health research, or, finally, between mechanistic knowledge and the need to remove the so-called ‘causes of the causes’ of diseases [4]. When discussing their data, presenting their results, and, especially, when positioning their science’s implications for policy and society, they could explicitly acknowledge that what can be proven in the context of their research does not capture the complex biosocial dynamics that bring about these phenomena in the real world. DOHaD scientists could – as some of the authors we studied have already done – clearly state in their writing that the individual ‘capacity to improve … children’s developmental environments, their bodies and behaviours’ is just ‘a small piece of a large and complex environmental puzzle’ [40]. While the knowledge they produce is of immense value to shed light on bits and pieces of this puzzle, they can advocate caution in extrapolating general solutions from partial knowledge. If such a provision were systematically part of the discussion sections of DOHaD papers investigating any of the biological, behavioural, relational, social, structural, and environmental dimensions of early-life programming (studied in conjunction, as much as in isolation – as they often are), there would be little doubt about the policy framings of DOHaD research. The ‘moral paradox’ of DOHaD would simply be dispelled.

Second, another opportunity to counter the ‘paradox’ is to ensure that explanations, interventions, and policy discourses support or initiate social interventions in relevant developmental windows and biosocial pathways of disease. This is, of course, easier said than done, as detailed by sociologist Michael Penkler in the context of DOHaD studies of social-biological transitions [45] leading to diseases [46]. The challenge is not simply identifying early-life predictive (epigenetic) biomarkers of relevance to adult disease [47]. Rather, it resides also in the identification of the structural ‘windows of plasticity’ and intervention in body–environment interactions [48]. Resilience and reversibility of programming processes at different life stages are also largely unexplored corollaries of DOHaD evidence; a far more complex biopsychosocial approach to early life in research settings is in order for the proliferation of different DOHaD policy discourses.

The present work has tried to sketch a few points of normative ambiguity in scientific writing as potential paths of improvements for the social and political circulation of DOHaD research. In the wish to make social science critique instructive of novel avenues of biosocial research, these suggestions should be read as no more than an analytical contribution to finally dispel the ‘moral paradox’ of DOHaD. And, perhaps, also as a contribution to a collaborative push to unleash DOHaD’s full political potential for social reform, development, and change.

Chapter 9 Intra- and Intergenerational Justice, Law, and DOHaD

Isabel Karpin

9.1 What’s Law Got to Do with It?

9.1.1 Introduction

Developmental Origins of Health and Disease (DOHaD) research focuses on the environmental causes of disease in the preconception, prenatal, and early-life periods of human development. Epigenetics is a key mechanism that underlies this research and refers to non-genetic inheritable changes that impact gene expression. DOHaD and epigenetics research can provide a critical resource for legal thinkers determining the lines of responsibility for environmental harms (both physical and psychosocial) that affect a child’s growth and development. The epigenetic research that makes these claims is both contested and controversial; nevertheless, some DOHaD scholars argue it provides evidence of the origin of early-life health harms in events that occurred during pregnancy [1–3].¹ Additionally, some researchers argue that it is possible for disadvantageous epigenetic changes to occur in future children who were not even conceived at the time of the harm to their putative parents and thus were never directly exposed. Moreover, there is a body of scientific research that provides evidence that those suffering disadvantage throughout their lifecourse in conditions of systemic oppression, such as that arising from racism, sexism, or poverty, for example, may be disproportionately subject to epigenetic molecular changes creating harmed subgroups that are then intergenerationally reproduced as socially disadvantaged communities [4–10]. This chapter argues that, despite the tendency in Western common law systems to individualise responsibility, epigenetics may provide the key to an alternative approach that highlights interconnectedness within and across generations. In this way, whole communities and State systems may be held responsible rather than individuals.

Using examples from Australian, US, and Canadian legal systems, this chapter asks what legal obligations, if any, should or can be imposed on contemporary society to ensure not just the future ‘health’ of existing children (as they grow into adults) but also the generations of people yet to be born? It examines the possibility of legal protections and remedies for early-life and pre-life harms (ultimately manifesting as epigenetic changes), including from psychosocial adversity stemming from systemic mistreatment.

When identifying a ‘risk pathway’ for the attribution of responsibility in DOHaD research, there is a significant body of literature focusing on maternal causes for poor health outcomes in children. At the same time a growing body of literature in the interrelated field of epigenetics, highlights multiple and intersecting transmission pathways of harm stemming from marginalisation and disadvantage, including via the paternal line [11–13]. Epigenetic and DOHaD research show that social harms emanating from both psychosocial and physical environments can have long-term intergenerational effects. This poses a challenge to the standard reflexive response in law that identifies maternal responsibility and reinforces individualised models of blame. Epigenetics as an explanatory discourse makes a case, I argue, for a legal duty owed by the State for the harms caused by environments of systemic disadvantage. This would be a duty owed to parental actors rather than by them – an approach that would demand laws and public policy distribute responsibility across the community and demand State action.

9.1.2 Legal Persons and the Rights of Future Generations

The attribution of interests and rights (and thereby a capacity to be harmed) to an imagined future person whose development and birth are highly contingent challenges liberal legal and feminist views that rights should only accrue to legal persons. This is because what constitutes a legal person in law is not settled. The environmental and animal law fields have already had some success in attaching personhood status to natural entities such as rivers and non-human animals [14, 15]. However, there is ongoing concern that a flexible idea of personhood will be, if it has not already been, co-opted to control women’s reproductive autonomy through the attribution of personhood to fetuses. Feminist disability scholars such as Rosemarie Garland-Thomson have come up against this problem when trying to create a space for autonomous decision-making in the abortion context alongside a deeper understanding of people with disability [16]. The risk of harm to ‘future persons’, for example, is already a justification used for a range of policy and regulatory strategies in Australia and the UK in laws around assisted reproductive technology [17, 18].² In those laws, the welfare of the future child is paramount or must be considered carefully when making reproductive decisions. The attribution of welfare rights to future individuals imposes a duty on existing persons.³ An alternative and arguably more just approach, in keeping with feminist accounts of the self, involves articulating a collective duty (moral, political, and legal) to future generations. Edith Brown Weiss, for instance, argues that ‘each generation receives a natural and cultural legacy in trust from previous generations and holds it in trust for future generations’ [19, p. 2]. Given that it is a certainty that there will be a next generation, arguably, we can and must articulate legal and ethical duties in relation to those future communities. Claims about the intergenerational transmission of harms via epigenetic changes, however, demand a more complex articulation of the call for intergenerational justice, one that incorporates or understands the impact of intra-generational injustice – the unequal distribution of harms and resources within a generation. Eisen et al. argue, for instance, that the

[T]endency in the orthodox intergenerational justice literature to define the ‘interests’ of a given generation as an aggregate of all individual interests, is both misleading as description and perilous as prescription. It glosses over the significant disparities within generations, and thus cannot provide the analytical tools to think about how those disparities persist and transform over time. [20, p. 5]

Epigenetic effects manifest when the body responds at a molecular level to the external physical and psychosocial environment [21]. This may happen by activating biochemical changes to methyl groups that modify the histones that wind around DNA, for example. These epigenetic changes can alter the usual trajectory of a gene towards activation or deactivation. In such cases, the outcome may be a disease or deficit that would not have otherwise eventuated. The resulting harms can be significant and serious, including heart disease, cognitive impairment, diabetes, and neurological disorders among others [9, 22, 23]. DOHaD research evidences epigenetic changes that occur to an existing person or to a fetus during pregnancy. But, as foreshadowed above, there is also research showing that even before a person becomes pregnant, changes to their or their partner’s epigenetic system brought on by environmental harms may be passed on to the not-yet-conceived [1–3]. While this research is still nascent and contested, it is significant that epigenetic research is increasingly claiming to evidence the physical impact of systemic psychosocial harms such as racism, colonisation, slavery, child abuse, gendered violence, and socio-economic disadvantage [4–10, 24].

It is critically important to the development of a legal response to examine how DOHaD scholars and those working in the field of epigenetics articulate these harmful effects, because this will influence the way those harms are understood in the legal context. Epigenetic understandings may fundamentally challenge the reliance on ideas of individual responsibility in common law Western legal systems. I have argued elsewhere that if law incorporated an epigenetic understanding, the response to cases of systemic mistreatment would need to acknowledge the impact of a cultural milieu of hostility to certain groups [25]. As epidemiologist Nancy Krieger states, ‘We live embodied – and our bodies each and every day biologically integrate each and every type of unjust, and also beneficial, exposure encountered, at each and every level’ [26, p. 45].

The attribution of an obligation of care towards future persons is problematic because, historically, the State’s interest in promoting the well-being of future persons has been enacted on and through the presumptively recalcitrant bodies of reproductive women. This has occurred using disciplinary legislative, medical, and public health regimes that attribute culpability to individuals, and women in particular, for failure to avoid poor reproductive outcomes [27]. However, this individualised model of blame can only gain traction if we see the future child as having different and conflicting interests from the people who created them. In fact, as I will show, a better approach, which aligns with the trajectories of harm identified by epigenetic changes, is to argue that the well-being of future generations is impacted by social inequality (intra-generational inequality) as well as specific individual harms. This gives rise to a duty on the State to protect the well-being of future generations by assisting the existing person whose future progeny may be harmed by their unequal treatment. This would also unburden the pregnant person or potentially pregnant person from sole or even primary culpability and instead equip them with a claim themselves for legal remedies that demand State protection from the risk of harm to the health and well-being of their prospective children. In what follows, I draw on the research being undertaken in the fields of DOHaD and epigenetics to make a case for a legal duty that is owed to parental actors rather than by them for the harms caused by hostile, degrading, and discriminatory environments.

9.2 Law’s Reliance on Discourses of Epigenetics

9.2.1 Expert Evidence and Epigenetic Narratives in Law

The term epigenetics has been slow to enter the legal lexicon in Australia. A review of Australian legislation turns up almost no mention of epigenetics or epigenetic processes in bills, Acts, regulations, and subordinate legislation [28, 29].⁴ A quick search of Australian case law, however, identifies a small bundle of cases where the word epigenetics has crept in once or twice. These cases evidence the slow but definite infiltration into the law of a particular aspect of this scientific narrative that speaks to the intergenerational impact of trauma. While these were only single paragraphs or sentences in lengthy judgements that turned on many factors, their appearance is a sign that this relatively new and highly contentious scientific discourse seeking to explain the DOHaD is slowly finding its way into legal decision-making.

One example from Australian administrative law is a 2017 Coronial Inquest⁵ examining the deaths of 13 Aboriginal children and young persons in the Kimberley region⁶ of Western Australia. Epigenetics was referred to in that report to highlight the collective impact of intergenerational trauma. The inquest was initiated because ‘there were similar circumstances, life events, developmental experiences and behaviours that appear to have contributed to making [the 13 children] vulnerable to suicide’ [30, para 1]. It is further commented that

To focus only upon the individual events that occurred shortly before their deaths would not adequately address the circumstances attending the deaths. The tragic individual events were shaped by the crushing effects of intergenerational trauma and poverty upon entire communities. That community-wide trauma, generated multiple and prolonged exposures to individual traumatic events for these children and young persons. [30, para 3]

Dr Paul Simons, the Kimberley region’s child and adolescent psychiatrist draws on epigenetics to support his argument that the poor health and well-being of Indigenous young people in the Kimberly region is, in part, due to ongoing trauma resulting from colonisation and forced family separation. He states:

Before birth, some children are exposed to high levels of stress and trauma, to alcohol and drugs, and poor nutrition; high levels of stress hormones in utero can affect the expression of genes, and these epigenetic processes can affect brain development, such that babies can be born hardwired to preferentially employ ‘fight and flight’ coping strategies as they develop, at the cost of executive brain functioning, which facilitates emotional regulation. [30, para 195] (my emphasis)

Scholars Warin, Kowal, and Meloni have cautioned that the use of epigenetic discourses by Indigenous scholars and activists may result in a different kind of determinism tied to ‘milieu, history, and social and physical location (molecularly incorporated into the body)’ [31]. The danger here is that the focus will not be on the environment that creates the harm but on the individual who has been harmed, undermining possible remedies and declaring them redundant. While this is a concern, there is the possibility of a different response, and in the 2017 Coronial Inquest, the evidence led to a recommendation for training in intergenerational trauma for those working with Indigenous youth in the Kimberley region.

On the other hand, there are other areas of law where there is frustration that this evidence is not being more thoroughly incorporated and considered. I consider three areas briefly below.

9.2.2 Environmental Law

In the field of environmental law, there is a tendency to regulate to limit rather than prohibit polluting agents. Eisen et al., for example, suggest that Canada and the United States have a permissive approach to chemical regulation ‘in which the burden of proof falls on those trying to show that chemicals are harmful’ [20, p. 13]. This needs to change as evidence of long-term effects accumulates. Eisen et al. point out that there ‘is increasing scientific support for the theory that children, even grandchildren, of those exposed to brominated flame retardants (BFRs) and phthalates [ubiquitous chemicals in household furniture and products] may incur health consequences’ [20, pp. 10, 17].

Legal scholars are drawing on epigenetic claims to argue that environmental protection needs to be crafted around the potential intergenerational and early-life impact of toxic environments, understood as incorporating both physical and psychosocial harms. As Rothstein et al. point out, systemic disadvantage increases the potential for harm from polluted environments. They state that

It is well-known that disadvantaged populations with poor nutrition, substandard or nonexistent healthcare, stress from factors such as housing instability and fear of violence, and high-risk lifestyle factors increase susceptibility to environmental exposures. [33, p. 4]

In the case of chemical pollutants, for example, Scott et al. argue that ‘BFRs can be thought to create a fleshy material archive of one’s social location, practices, and movements. Not only are bodies embedded in social contexts and structures, but the social is also embedded, literally, in material bodies’ [34, p. 333]. Thus, the presence of BFRs does not just tell us about immediate harm but also about the likely location of that harm and the social circumstances that led to its magnitude. Intergenerational harm is thus integrally linked to intra-generational inequality. Epigenetics too suggests that people are integrated into harmed communities and are subject to multiple networks of harming effects that are passed on to existing children and future generations, distributing the responsibility for the harm across communities and the State. These realisations demand a conceptual change to law’s traditional approach of assigning responsibility by tracing an uninterrupted line of cause and effect.

9.2.3 Tort Law

US tort law offers another example where the traditional response to these kinds of harms fails to protect those who are harmed. In torts, remediable transgenerational epigenetic effects do not generally include those that manifest in the first unexposed generation because the line of causation is narrowly cast and cannot accommodate multiple forms of insult. The classic example is the case of diethylstilboestrol known as DES, the drug that was given to women from the 1940s up to the 1970s to prevent miscarriage. It was withdrawn from the market after it was found to cause vaginal cancer. The children who were in utero when the drug was given were also found to have a higher incidence of cancer and infertility as were the children of those children [35]. However, the US Courts limited claims to the mothers directly given the drug and their children who had been exposed in utero, disallowing claims beyond first-generation exposure because of what they called ‘victim attenuation’ – namely, the difficulty of connecting, causally and temporally, the tortious conduct, and the injured victim [29, 33, 35].

In other words, the greater the distance in time between the offence and the victim’s injury, the greater the possibility for potentially unknown causal acts to have been responsible or even partly responsible. However, as we have seen above, even when there is direct exposure there is also a network of other environmental influences and effects that may make one more susceptible to the harm. Individuals are exposed to thousands of different toxins from multiple sources throughout their lifecourse. The likely scenario where those who are most disadvantaged economically and socially are also those who will be most harmed, allows for the argument that the identification of a single responsible agent is untenable, leaving generations of victims with no recourse. On the other hand, scholars such as Doci et al. argue that ‘individuals who are affected by epigenetic side effects should have a right to obtain justice and to present an epigenetic case within a legal system which is suited to handle it’ [29, p. 274].

9.2.4 Regulating Reproductive Bodies

On the other side of the coin is the willingness of law to identify a cause and effect when it comes to the putative pregnant person. The proximity of a pregnant person to their fetus appears to create a sufficiently un-attenuated line of causation that justifies pre-emptive hyper-surveillance of their behaviour from policymakers, public health institutions, and sometimes legal actors. While the scientific literature is contested, it nevertheless offers an alternate narrative that can be used to insist on a more complex and contingent account of responsibility and harm. However, rather than cautiously drawing on the scientific claims emerging in the fields of epigenetics and DOHaD that trace a physical harm from psychosocial sources such as stress, trauma, violence, and abuse against the pregnant or potentially pregnant person, public health initiatives tend to focus instead on the aspect of DOHaD research that identifies the pregnant woman as the locus of harm. Pregnant women and those seen as of reproductive age are schooled to modify their behaviour to counter some of these societal and environmental effects.

One example of such schooling is the US Centre for Disease Control (CDC) guidelines on preconception care, for example, that were published in 2006 but are still referred to in the literature. These guidelines have as their first recommendation that there should be individual responsibility across the lifespan. They describe the ‘target population’ as women from ‘menarche to menopause who are capable of having children, even if they do not intend to conceive’ [36]. These women are told that they should be conscious of their genetic factors and cumulative risks and modify their diets accordingly. Among the lengthy list of things for women to avoid while pregnant is a caution to be aware of ‘fetal exposures to teratogens’. In the plain English version on their website, the CDC warns women to avoid harmful chemicals at work and at home. Perhaps unsurprisingly, there is thus considerable concern among feminist legal scholars that more research in the field of DOHaD and epigenetics will see women subjected to more scrutiny. Take, for example, studies such as that of Roberts et al. linking maternal exposure to child abuse with a higher rate of autism in their offspring, or Slykerman et al.’s study linking depression in early adolescence with stress during pregnancy [37, 38]. These are just two examples among many [39].

Outside the discipline of law, scholars such as Sarah Richardson and Megan Warin have cautioned against an approach that places women at the centre of this harm. Richardson asks, for instance, whether there is ‘potential for this research to heighten public health surveillance and restrictions on pregnant women and mothers through a molecular policing of their behaviour?’[40, p. 210] Warin et al. argue that ‘A new and powerful meta-discourse has emerged in which women are blamed for both their reproductive physiology and their social role as mothers, thus constructing women as potentially contaminating future generations by creating obesity lineages’ [41, p. 361]. This they say, ‘coupled with a neoliberal agenda that emphasises self-governance and individual responsibility’, individualises the responsibility for harm, and it does so in a gendered manner [41, p. 361]. In such a discourse, the responsibility for harm is shifted back to the individual who must, it seems, find a way to protect her offspring from the harms to which she herself has been subjected. A collection of cases where women have been prosecuted for neglect and abuse in raising obese children or not protecting their children from an abusive partner speak to the concern that epigenetics will be used to increase the scope of that responsibility, not delimit it [43, 44]. Contrary to such cases, feminist challenges suggest the need for an approach that recognises systemic injustices that create, as stated above, networks of harming effects.

Interestingly, scholars Loi, Del Savio, and Stupka optimistically suggest that we should look forward to ‘a society in which people can be informed by their family physician of the accumulation of risk due to specific environmental insults, including those arising prenatally and in early childhood for which people cannot be held responsible’ [45, p. 143]. Unfortunately, however, their assumption that women will not be held responsible is not borne out by recent history and is likely to be significantly amplified in the next few years with the recent development of so-called epigenetic tests. According to Dupras, Beauchamp, and Joly, these tests ‘may provide sensitive information about individuals, not only their increased risks of diseases but also about their exposures and lifestyles’ [46]. They list some of those exposures as comprising smoke, stress, alcohol, and other ‘toxic chemicals’ and describe the tests as potentially ‘uncovering new layers of sensitive information about individuals that were not made accessible by genetic tests’ [46]. Dupras et al. note the burgeoning industry specifically in the unregulated field of direct-to-consumer epigenetic tests with companies such as Chronomics, EpigenCare, Muhdo, MyDNAge and TruMe now offering them.

Arguably, women could be pressured to use direct-to-consumer epigenetic tests and, depending on the outcome, be held responsible for the ‘harms’ that follow. Dupras et al. indicate that one of the present uses of direct-to-consumer epigenetic testing is to reveal a person’s smoke exposure history. In the traditional legal framing of individual responsibility, this might be an area where a regulatory response is triggered. Typically, women are viewed as culpable for harm if they smoke while pregnant, and while they might not be morally condemned for unwittingly exposing themselves to secondhand or environmental smoke, should they undergo a test that identifies their level of exposure to such smoke, a new responsibility arises to respond to the information provided by that test, and with it, a choice to either terminate an affected pregnancy or not move forward with plans to become pregnant. This new burden of responsibility is further complicated by the context of anthropogenic climate change, as demonstrated by epigenetic studies on smoke exposure undertaken in the wake of the Australian bushfires of 2019, which tracked the increased risk of adverse pregnancy and fetal outcomes for pregnant women who were exposed to bushfire smoke [47]. Viewing exposure through the prism of the individual maternal body in such studies highlights how social responsibility for harm can be masked and neutralised by such testing regimes [47].

Developing an alternate approach entails recrafting laws and public policy to recognise the network of harming effects. Ideally such an approach would distribute responsibility across the community and demand State action and responsibility, as I will examine in more detail below.

9.3 How Can Law Respond?

Because epigenetics blurs the distinction between the physical and the psychological by revealing a physical register for psychological harm through changes to methylation and the epigenome, it is possible to show how social adversity has physical effects. This kind of evidentiary trail is particularly appealing to law.

9.3.1 Legal Orthodoxy and the Autonomous Individual

Legal systems found in most common law countries operate within an orthodoxy which, to differing degrees, centres on the self-determining, independent, and autonomous individual both in terms of who it is aimed to protect and to whom it attributes responsibility. At the same time and perhaps ironically, law is sometimes used to assign responsibility to the harmed individual by characterising it as a failure of self-care and self-regulation. This accords with a contemporary neoliberal ideology where, as Robertson puts it,

notions of individual autonomy, the free market and limited government are related, in a mutually producing and sustaining way, to the imperatives of ‘self-care’ – in the form of self-surveillance and self-regulation. [47]

It is clear then that we cannot understand or develop a response to epigenetic harms derived from psychosocial adversity and their intergenerational impact without revising these underlying ideological limitations.

Feminist legal scholar Jennifer Nedelsky argues for an alternative model for law that foregrounds our relational status. She states that ‘human beings are in a constant process of becoming in interaction with the many layers of relationship in which they are embedded’ [49, p. 38] and ‘a relational self requires relational conceptions of values, which then require appropriate forms of law and rights built around those conceptions’ [49, p. 5]. This relational model is one alternative. Another is Fineman’s model of universal vulnerability, a model that demands that laws are refashioned around people as ‘embodied creatures who are inexorably embedded in social relationships and institutions’ and ‘experience the world with differing levels of resilience’ [49, pp. 1–7]. ‘Resilience’ according to Fineman is not an inherent trait but rather a resource that is unequally distributed. This occurs, as I have said elsewhere, ‘when the “assaults” of inequality turn ordinary vulnerability (and dependency) into a politically amplified source of embodied and abiding psychosocial harm’ [11, p. 1121].

In this vein, epigenetics offers us both a scientific account of cause and effect and a model for a conceptual shift to the relational self as an animating architecture around which to construct laws (rights, duties, and responsibilities). While there is a risk that foregrounding epigenetics can lead to a new form of stigma – the epigenetically disadvantaged – I argue that epigenetic processes nevertheless offer a constructive metaphor for rethinking legal rights and responsibilities. This is because epigenetic discourses reveal the impossibility of the autonomous, self-sufficient individual of liberal legalism.

Laws and public policy that are reworked to recognise the network of harming effects, however, must also be conscious of assumptions around what constitutes a harm. Assertions of ‘harm’ are inevitably entangled in prescriptions about what is normal, and therefore to talk about harm risks further stigmatising diverse embodiment. As such, a disability studies critique must also be mapped over the top of any legal remedies that are proposed to ensure that we do not simultaneously and unthinkingly instantiate inherited difference as self-evidently a harm. (See also Azevedo et al. in this volume.) Rosemarie Garland-Thomson has argued, for example, that feminist disability studies ‘questions our assumptions that disability is a flaw, lack or excess’ [51, p. 1157]. Eisen et al. argue too that ‘critical disability studies scholarship calls on us to confront evocations of “anomalous bodies” as emblems of a tragic or dystopian future as constituting a distinct set of harms with their own distinct intertemporal dimensions’ [20, p. 40]. They go on to note, quoting Alison Kafer, that the critical disability studies literature frames disability as relational and ‘that individuals inhabit: the social institutions, laws, and policies within which they are embedded and that regulate their daily interactions and encounters; and the “social patterns that exclude or stigmatize particular kinds of bodies, minds and ways of being.”’ [20, p. 40]. Clearly, then, any invocation of relational accounts of harm and responsibility must not degrade anomalous embodiment and determine it as presumptively harmed.

9.3.2 Bioinequality and the Dismantling of the Individual in Law

Creating a new conceptual apparatus for legal action requires a linguistic device that names the previously unnamed. Karen O’Connell and I have developed the term bioinequalities, a concept that ties together biology and inequality to offer a language in which legislative life can be given to a harm previously unnamed in the law: the bodily effects of unequal treatment [25]. What is understood by unequal treatment is not simply different treatment but disadvantageous treatment in a system of oppression and subordination based on gender, race, socio-economic status, and ability among other traits. Bioinequalities suggest material harms tied to systemic injustices that inhere in bodies that occupy those systems both now and in the future. By taking account of the growing literature suggesting that trauma associated with unequal treatment affects us materially in our molecular biology and may be transmitted intergenerationally, it can be argued that a legal response that provides only an individual remedy to an individual incident of harm is insufficient. Instead, what is needed are positive legal obligations to protect communities (and in particular disadvantaged communities) from harmful bioinequalities that are shared among them both intra-generationally and intergenerationally.

Harmful environments in the workplace, in public spaces, in educational institutions, and in private corporations currently operate within a cultural milieu that upholds certain hierarchies of power and subordination that favour some individuals over others. Treating harms as environmental anomalies only, and not pervasive, entrenches bioinequalities by masking the way environments are reflections of cultural values and standards of oppression. It fails to identify the cultural framework of inequality that informs law and infiltrates legal processes and systems rendering the harms invisible to normative (dominant group) legal thinking.

Currently, where law provides redress, it tends to do so on the basis that the incident is resolved once the finding is made. The possibility that the harm continues materially and internally is not addressed I have argued throughout this chapter that DOHaD’s version of an interconnected and entangled human provides a unique counter to the reductive individualised notion of legal subjectivity that currently pervades common law systems. Legal thinkers must address the claim that the psychosocial harms of systemic oppression cause harmful epigenetic changes in individuals and their progeny (both gestating and not yet conceived), creating intergenerationally harmed communities. Only by doing so can we craft real protective legal action that acknowledges that people are not just harmed as individuals but are always situated inside an epigenetic logic of relational, vulnerable, and continuous entanglement with others.