Health: Reading our future in the bones of children past

Christian Harkensee (CH): I’ve always been fascinated by archaeology – I even volunteered to do small excavations with my district archaeologist when I was younger. A few years ago, I joined the British Association of Biological Anthropology and Osteoarchaeology, where Becky and I quickly discovered that we were both interested in the impact of living conditions on child health.

Rebecca Gowland (RG): Yes, one of our earlier discussions was about growth delay in children. I’d been doing research on Victorian children, which showed that some were very small for their age; Chris told me about his work with children in refugee camps, who were also showing delayed growth. These interactions allowed us to think about child health and adversity from different perspectives.

CH: I’ve travelled a lot, even before I became a doctor. I saw first-hand many of the health inequalities and social injustice that children around the world experience, and I felt compelled to do something about it. Later, I found the same issues closer to home. Gateshead, where I work, has very high levels of inequality and deprivation, and it is home to the highest proportion of refugees and asylum seekers in England.

RG: The growing body has always fascinated me: it is such a little miracle to see how various bones gradually come into being! Children are also very sensitive to environmental or social adversity – in bioarchaeology, we refer to them as the ‘canaries in the coal mine’. Their remains can tell us a lot about past societies and living conditions.

CH: In my acute paediatric practice, my focus is on managing the immediate problem in front of me, with little consideration for the wider context. Becky’s research has allowed me to take a step back, to look at how societal, economic and political factors impact living conditions and therefore the health of my patients. It has also provided me with an intergenerational perspective on child health, which is often missing from my day-to-day practice. In addition, our collaboration has made me realise how much recent policies have been threatening the progress we’ve made in clinical medicine and public health since the Victorian era.

RG: Bioarchaeologists often deal with a range of ‘unknowns’: we need clinical evidence and studies on living individuals to interpret the skeletal record, to attribute the pathological changes we witness in remains to a specific illness or environment. As a clinician, Chris sees first-hand how diseases and nutritional deficiencies manifest in his patients, and how this intersects with various social determinants of health. What’s more, listening to him brings to life the stories I see written in the bones of the children on my laboratory table – stories of hardship, hunger and hopelessness. At times, it is the resilience of these children that is most astonishing. Yet we know now that children don’t ‘bounce back’ from adversity, as people often think they do. Poorly children often become poorly adults, which in turn can affect the next generation.

RG: We need to lengthen our timeframes when we talk about health, and especially childhood health. For instance, recent research shows how food crises which took place decades before the Black Death created different levels of vulnerability to the bubonic plague in the population. Maternal health has also been important in the way I consider health stressors and their impacts in the past. The Dutch famine during World War II is an excellent example for this: a five-month period of severely restricted food intake had effects lasting across generations, with metabolic and mental health disorders being present at higher rates in the children and grandchildren of women who were pregnant at the time. Further research has built on these results to highlight the cumulative effects of adversity, for example forging the concept of ‘maternal capital’. Poverty and lack of social mobility can, generation after generation, deplete the biological, behavioural and community resources that mothers have at their disposal to invest in their children, creating inter-generational cycles of biological disadvantage. All this evidence shows us that our lives and fortunes are intertwined over lifetimes: if hardship experienced by my grandmother can influence my health today, then when does my biography begin, and when does hers end?

CH: As paediatricians, we know now that adverse childhood experiences such as neglect or abuse are linked to increased risk of heart conditions and other non-communicable diseases in adulthood. Poverty intersects several of these adverse childhood experiences, and we are starting to see evidence that these effects may be transferred through generations – potentially through epigenetic mechanisms. Looking at recent events, we can see that variations in COVID-19 mortality are clearly contingent upon socially determined and historical vulnerabilities. African American communities, for example, have experienced COVID-19 mortality rates which are disproportionately high, which has led public health researchers to consider the impacts of structural inequalities that originated centuries ago, during slavery.

RG: The Chief Medical Officer for England, Chris Whitty, observed that a map of COVID-19 mortality would look very similar to a map of child mortality in the 19th century, for which poverty was a key driver. Clearly the forces at work then still exist today. Syndemic theory is also gaining traction within our discipline, with implications for clinical medicine. This approach focuses on how health and societal problems reinforce each other to amplify detrimental outcomes for certain groups. Discussing these ideas with Chris, we can see why the pandemic fits this framework, with poverty or structural racism driving COVID-19 to cluster and interact with existing conditions such as cardiovascular illnesses, in a way that exacerbates the effects of each.

RG: People who say that health is a matter of personal responsibility usually speak from a position of privilege or ignorance. If you have power and social capital, if you haven’t experienced constraints in your life, it’s easy to believe that everybody has the same freedom of choice. But those at the lower end of the social ladder simply don’t have access to the same opportunities and resources. We see this in the 19th century, with children and women undertaking work that they knew would ultimately kill them; and we saw it during the pandemic, when workers in low-paid, zero-hours service jobs had to expose themselves to risk. What choice did people have? When you live hand-to-mouth, immediate survival becomes the focus, not future consequences. Individualising risk is a convenient way for governments to absolve their responsibility in the massive health inequalities that we see today, and to further demonise those experiencing poverty.

CH: Plenty of research shows that governmental interventions are required to effectively tackle important public health issues – anti-smoking legislation and the UK ‘sugar tax’ are good examples of how these measures can help to improve health. As healthcare professionals, we need to not only treat these conditions, but to also advocate at a policy level. Health, social and economic inequalities are currently worsening in this country; they are the result of deliberate policy decisions, taken by a government which is committed to policies that will only widen the gulf between rich and poor. As Michael Marmot – the head of the Institute of Health Equality at UCL – wrote in 2010, health is political, it is a matter of social justice and of fair distribution of resources.

CH: Things are much worse now. When we wrote the article, Marmot had just expressed severe concerns about escalating health inequalities in the country. Since then, we have been battered by the fallout of Brexit, the COVID-19 pandemic and a cost-of-living crisis which is exacerbated by the war in Ukraine, rising inflation and recent disastrous economic policies. This will hit the most vulnerable the hardest, with levels of poverty and inequality perhaps not seen since the Second World War or longer. Schools are reporting children coming in hungry, and food banks are running out of supplies. In his most recent report, Marmot warned that nearly two-thirds of the UK population could face fuel poverty this winter, potentially leading to cold, damp and mouldy homes: in fact, the case of a young child dying from mould in a damp flat hit the headlines just recently. We are likely to see rates of preventable child malnutrition and illness that would be unworthy and frankly shameful for the world’s fifth-largest economy. And we know that poor diet and damp living conditions in Victorian England led to malnutrition and respiratory diseases which contributed to high mortality rates in children, but also carried long-term health consequences. This winter worries me.

RG: I see many parallels in the way that those experiencing poverty have been demonised during the Victorian era and today. In fact, the language is often almost identical. In the 19th century, “the poor” were classed as “deserving” or “undeserving’” and poverty carried a moral charge: contemporary commentators argued that it was caused by laziness, fecklessness and “want of thrift” rather than long-standing structural inequality. This is a rhetoric that has been reintroduced more recently in the UK, especially in the years preceding the shift to universal credit [a heavily criticised social security reform in the United Kingdom]. Some newspapers, in particular, have led a sustained vendetta against welfare recipients, who have been similarly characterised as lazy “scroungers”. There was no wider public outcry at the demeaning and hazardous working conditions common in Victorian factories, partly because those in poverty were systematically othered and almost regarded as subhuman. Lord Shaftesbury, who attempted to reform working conditions in the 19th century, described factory children as “a set of sad, dejected, cadaverous creatures…the sight was most piteous, the deformities incredible”. Yet this “crooked” physical appearance was linked to working class people having innate biological deficiencies, rather than being victims of the social structures that subjugated them. In the early 1830s, this demonisation contributed to poor laws becoming much more punitive – a shift we have also witnessed in recent welfare reforms in the UK.

RG: We are increasingly aware that certain social components create structural inequities which impact the body. As originally discussed by Black feminists such as Kimberlé Crenshaw, these social factors include the intersection between aspects of identity such as race and gender. Race is a social construct, but the way it shapes access to power and resources in this country has biological repercussions. As bioarchaeologists, we are now integrating more closely social identity, intersectionality, and body/society interactions in the way we explore and interpret evidence.

CH: In paediatric work as well, there is now a clear trend towards considering the wider social factors that impact health. My work with refugee children and asylum seekers is often about unrecognised and unmet health and social needs, about barriers to healthcare that widen inequalities. Now this approach is being strongly supported by initiatives such as the Child Health and Wellbeing Network. Overall, I am hoping for a future where we can closely integrate curative care with preventative approaches, and clinical medicine with public health; where the goal is to promote and improve health, rather than ‘fix’ diseases. I believe that this is where we have the greatest potential for real change. But the NHS is so on its knees at the moment that many clinicians, myself included, struggle to even see beyond just providing safe care on a day-to-day basis.

RG: Researchers in different disciplines may be exploring the same problem from an entirely different angle. Escaping the silo of your own discipline will reinvigorate your approach and offer new ways of thinking and doing.

CH: Keep an open mind, and extend your curiosity to other research fields, even if they seem disconnected from what you do. Be humble about your own expertise… there is so much that you don’t know. And finally, be courageous: leave behind your well-trodden beliefs and thinking paths, and jump into the adventure!

Rebecca Gowland is a bioarchaeology professor at Durham University. Her work examines the long-term and intergenerational consequences of childhood poverty in the past, and the intersection between health and social identity. She works alongside public health researchers to assess the longer-term impacts of social change and catastrophic events on population health.

Christian Harkensee is a consultant in paediatric infectious diseases and immunology at the Gateshead Health NHS Foundation Trust, and an associate clinical lecturer at Newcastle University Medical School. He has worked extensively with refugee children in the United Kingdom and abroad, and is a health inequality adviser to the NHS North East and Cumbria Integrated Care Board.

Rebecca Gowland and Christian Harkensee were interviewed by Elsa Loissel, Associate Features Editor, eLife.