OPINION

Unequal by birth: time to break the vicious cycle

“The impact of impaired intrauterine nutrition is not only on a girl child in the womb but also on that growing baby’s own oocytes (forming eggs) in her ovaries. So, the epigenetic changes in the yet-to-be-born baby may also affect the future of her future children.” Picture shows a malnourished child at the Apanalay centre in Mumbai.— Photo: AP

“The impact of impaired intrauterine nutrition is not only on a girl child in the womb but also on that growing baby’s own oocytes (forming eggs) in her ovaries. So, the epigenetic changes in the yet-to-be-born baby may also affect the future of her future children.” Picture shows a malnourished child at the Apanalay centre in Mumbai.— Photo: AP  

As long as the problems of the poor are not radically resolved by rejecting the absolute autonomy of the markets and financial speculation, and by attacking the structural causes of inequality, no solution can be found for the world’s problems. Inequality is the root of social ills. — Pope Francis

It is not just the worldwide acclaim for Thomas Piketty’s troubling tome ‘Capital in the Twenty-First Century’ that calls for examination of the effects of inequality on human development. A recent Oxfam report which states that the 62 richest billionaires of the world own as much wealth as half the world’s population is evidence that we are not moving in the right direction, despite public pronouncements of concern by political leaders and economists.

Since global leaders have now committed themselves to adopt and achieve the Sustainable Development Goals by 2030, it is imperative that the many social, economic and biological ill-effects of inequality are recognised as being inimical to those goals. Low levels of literacy and education, impeded opportunities for gainful employment, low income, malnutrition, inadequate housing, unhygienic environments, and poor physical and mental health heap a load of injustices upon the poor and cumulatively weigh down upon their efforts to escape from poverty. Lack of access to information technology in an increasingly digital world and persistent social discrimination of various kinds are additional barriers to their emancipation.

Many of these have been viewed as disadvantages that affect one or, at the most, two generations. It is assumed that opportunities provided during the lifetime of an individual would overcome these disadvantages and that subsequent generations would carry no trace of the deprivation that parents or grandparents suffered. ‘Equality of opportunity’ is the liberal response to inequality. As the early twentieth century British economist R.H. Tawney remarked, equality of opportunity is tantamount to “decorous drapery” when individuals who carry a huge disadvantage of multiple deprivations are expected to compete on equal terms with those who have had a more privileged upbringing. As Tawney points out, it is “not just an open road but also an equal start” that is needed.

Inequality over generations

The intergenerational carry-over of the biological disadvantages created by social and economic inequality adds particular piquancy to this debate. It is not just the shared social environment of poverty that tethers the child to the same low rung of development as the parent. Biological shackles too tie the child’s future to adverse early developmental influences. While it was believed that these biological links run from parent to child, recent evidence suggests that they may extend further to even more generations.

The two-generation link is now well explored in research. Undernutrition of the mother, preceding and during pregnancy, affects the growing foetus in the womb. If that semi-starved foetus is to escape still birth, it has to programme itself to survive on limited nutrition. The growing brain and nervous system are prioritised for nutrition, because they are the key to survival. Muscles grow insulin-resistant to spare glucose for the brain. The child is born malnourished, metabolically compromised, and suffering some loss of cognitive potential. The mismatch between early programming for extreme frugality and later availability of more nutrients, as the child grows, leads to accumulation of body fat in preference to lean muscle mass. This is associated with metabolic abnormalities that lead to early onset of diabetes and a higher risk of heart disease.

This link between early life malnutrition and chronic diseases in adulthood, described as the Barker hypothesis, is now known to be due to epigenetic changes in gene ‘expression’. While the basic genetic structure of the child’s genome remains unaltered, the functional effects of some genes may vary because their expression is modified by chemical changes induced by an adverse environment. Such epigenetic changes can also occur due to other adverse intrauterine or early childhood influences. Even some paternal influences are now known to induce epigenetic changes in the foetus. A high degree of epigenetic plasticity is evident in genes that regulate development of the body, especially the brain. Adversity faced by the growing foetus and child, resulting from parental poverty, can have deleterious epigenetic effects.

The impact of impaired intrauterine nutrition is not only on a girl child in the womb but also on that growing baby’s own oocytes (forming eggs) in her ovaries. So, the epigenetic changes in the yet-to-be-born baby may also affect the future of her future children! At the highest stage of mammalian evolution, the placenta forms a vital link between the mother and the growing baby. It enables three generations of genomes — of the mother, foetus and foetal ovaries — to interact. This provides a mechanism by which the developing foetal brain can receive adaptive information, related to potential future environmental conditions, from the mother. The hypothalamic area of the foetal brain is co-adaptively linked with the hypothalamus of the maternal brain, helping it to engineer an optimal transfer of energy resources for its development. In turn, when that child grows to adulthood, her hypothalamus is programmed to efficiently transfer energy resources to her own child. Programmed adaptation to anticipated future environment is built in to these relationships.

Adverse influences during the lifetime of the mother can thus impact three generations. Placental size is compromised in the small pelvis of a woman who grew up as an undernourished girl child in pecuniary or prejudicial circumstances. When she has a nutritionally deprived pregnancy, it affects her unborn daughter as well as her yet-to-be conceived grandchildren.

Long shadow of inequality

Inequality thus casts a long shadow of biological ill-effects, not only across the life course of an unfortunate individual but also across the generations that will draw life from that life. Brain growth and adaptability (plasticity) that are vital for future development and can be marred by the impact of inequality on biological development. Those who are now alarmed by the apprehension of the Zika virus causing microcephaly in some babies in India should be even more concerned about the tremendous loss of brain power and poor physical health that inequality is imposing on several generations of children. We cannot permit gross inequality-linked deprivation to leave its malign signature on the lives of those who are yet to come.

(K. Srinath Reddy is president, Public Health Foundation of India. He formerly headed the department of Cardiology at the All India Institute of Medical Sciences.)



We cannot permit gross inequality-linked deprivation to leave its malign signature on the lives of those who are yet to come



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