/ 8 October 2014

Critical questions of future growth

Critical Questions Of Future Growth

What is human potential? Can it be measured? If so, how? And what might these mea­surements miss, overlook or ignore?

What used to be philosophical questions, pondered by pedantic greybeards or perhaps students in pubs, are now critical questions of future development.

One site in which they are receiving considerable scholarly and policy attention is in relation to “the first 1 000 days of life”, a framing that is rapidly emerging as a field of know-ledge bringing together diverse ­disciplines across the biological and social sciences.

Recent findings in epigenetic and neuroscience research have demonstrated that the earliest periods of life, from conception to two years, are critical “windows” in development. Interventions in this period may have lasting effects for the individual and, significantly, some of these have epigenetic and thus partially heritable effects. These findings open new questions about potential and how to actualise it.

Through a series of “provocations”, the stream called “potential” at the Medical Humanities in Africa conference hosted a sustained conversation about emergent discourses of “the first 1 000 days of life”.

In his book, The Normal and the Pathological, Georges Canguilhem noted the increasingly pointillist nature of the knowledge of life, arguing that specialisation simultaneously deepens and narrows know-ledge at the expense of a broader sense of how they are embedded in life and social experience. Critical conversations become more limited and audiences smaller.

Productive conversation
The aim of the conference’s “potential” panel was to develop a ­productive mode of conversation across a wide range of disciplines, opening spaces to challenge, enlarge or perhaps even foreclose concepts and practices. We posed questions such as: What might the life-sciences such as (epi)genetics, neuroscience, nutrition and psychology offer to and receive from other disciplines? Using what bodies of theory and what concepts? What is the social purchase of terms such as “attachment”, “foetal life” and “exclusive breast-feeding”?

What kinds of challenges do our differing uses and engagements with these and other terms offer to the making of expert knowledge of life? How does scientific knowledge embed itself in social relations and with what consequences? What kinds of “common sense” ideas and practices inform interventions in South African society? How do these impact on everyday life?

Part of the conversation centred on key terms such as attachment, risk, potential, intervention. Many of these terms are associated with specific disciplines or arguments and have long genealogies.

Take attachment, for example. Early psychological research on infant bonding gave rise to a body of theory about infant security and resilience. Psychologists now measure a baby’s attachment to its mother with a sliding scale and make prognostications on its basis.

The most recent version of this knowledge explores the developing brain, showing the ways that hormonal responses interact with and shape neural pathways. Environmental stressors produce responses that become ingrained. When stressors are not acute and are well managed by an attentive caregiver, babies learn to “self-regulate”, a key process in developing resilience.

Several of the presenters in our panel drew from these bodies of work, noting the importance of sustained and attentive caregiving and pointing to interventions (such as skin-to-skin contact immediately post-birth, or kangaroo care and breastfeeding) that can facilitate infants’ abilities to self-regulate. Others drew attention to more diverse possibilities of belonging, such as the ways that people seek to attach children to families, genealogies, ethnic identities, religions and nationalities.

Broader possibilities
Core to our project was to expand the terms of discourse, framing resilience not solely in terms of the mother and child but in terms of broader social possibilities. And still others pointed to the harm done when experts offer advice that, for a variety of reasons, people cannot live up to.

In their social operations, these models may lend themselves to blaming responses that individualise, and all too often pathologise, women. What then are the risks and gains of scholarly knowledge when it enters and becomes naturalised in everyday practice?

Indeed, what does it mean to intervene in the first 1 000 days of life? As evidence-based findings on which policy can be made emerge, there is an imperative to intervene. A host of state and civil society initiatives have taken up the idea with courage, sometimes zealotry. The positive potential of policy and intervention is cast as the possibility of the health of nations. Its counter is the risk of smuggling in Eurocentric models.

Questions of risk quickly animated our discussions. For example, there has long been a robust social science critique of medicalisation, especially of childbirth, but it is state policy to ensure women’s access to biomedical services as a democratic right and as a way to secure life and wellbeing.

As medical practice, social demand and capital’s hold over medical institutions connect, questions of risk are increasingly framed in managerial terms as well as in the older injunction to assess proximity to harm and death.

How then should practitioners and patients make decisions about the riskiness or otherwise of interventions? When does medicalisation become a necessity – the difference between life and death – and when is it an intrusion on freedoms? Can these relations be ascertained in advance?

Social anxieties
These are critical questions in a context in which the state is committed to medically attended birthing, to reducing an unacceptably high C-section rate and to exclusive breastfeeding for six months. And we are reminded that risk itself is informed by a larger network of social anxieties, political discussions and economic processes, embedding our very bodies and their assessment in a far broader set of discussions about human potentiality in this strangely unsettled world.

The South African state has committed to a range of interventions, particularly in relation to the mother-child dyad and early childhood. Pregnant women and children receive free healthcare. Women are encouraged to book early for antenatal treatment – yet, as a growing literature shows, there are many reasons they do not, ranging from ideas that pregnancies which seem normal do not need intervention to difficulties in accessing resources, uncertainties about procedures and fear of what they might learn in addition to the wellbeing or otherwise of the foetus.

The Western Cape government’s Catch and Match programme (currently in the early stages of development) seeks to use community health workers to identify households and individuals at risk, and catch and match them to appropriate state resources. This would be a large-scale population-based intervention. What are the implications of this modality of governance for the health of populations?

Fiona C Ross is professor in anthropology at the University of Cape Town, where she holds an AW Mellon Research Chair focusing on the anthropology of the first 1 000 days of life