Introduction
The linkage between health and development is demonstrated by the evidence that investing in health is beneficial to socio-economic development 1 and, conversely, that socio-economic development results in better health and human capital. The United Nations (UN) Sustainable Development Goals (SDGs) were announced in a document entitled: ‘Transforming our world: the 2030 Agenda for Sustainable Development’. They incorporate 17 overarching global goals that supersede the Millennium Development Goals. They aim to comprehensively address four dimensions as part of a global vision for sustainable development: Inclusive Social Development, Environmental Sustainability, Inclusive Economic Development as well as Peace and Security. 2 , Reference Sachs 3 The 17 goals and 169 targets represent a call to action in terms of developing people and the planet, thereby creating prosperity, fostering peace and creating a lasting partnership with international stakeholders. 2 (Table 1).
Sustainable Development Goals (SDGs) 2
a United Nations SDGs directly relatable to Developmental Origins of Health and Disease.
Many of the interlinked SDG goals relate, directly or indirectly, to human growth, survival and thriving, which are also the concerns of the DOHaD agenda. The DOHaD concept was originally developed from epidemiological studies of mortality across infant and adult groups.Reference Gluckman and Hanson 4 The accumulating evidence from DOHaD studies convincingly shows how early-life exposures during conception, pregnancy, infancy and childhood can have a significant impact on health and disease risk in later life. 5
The 2015, the Cape Town DOHaD Manifesto 5 summarized the major early-life exposures that might impact later health. These include environmental factors (e.g. maternal, fetal and infant malnutrition), external toxins (e.g. from cigarette smoke, alcohol), age of pregnancy (teenage or advanced maternal age) and psychological and physiological stress. Scientific evidence shows the impact that these stressors may have in terms of increasing the risk for both short- and long-term illness and mortality, from both infectious diseases and chronic non-communicable diseases such as cardiovascular disease, type II diabetes, certain cancers, chronic lung diseases and mental illness. In particular, non-communicable conditions are on the increase in Africa.Reference Streatfield, Khan and Bhuiya 6
Along with our colleagues who are interested in DOHaD-related work, we have recently begun a 4-year initiative at the Stellenbosch Institute for Advanced Study (STIAS) entitled DOHaD and SDGs: Moving Towards Early Implementation in Africa.Reference Daar, Balasubramanian and Byass 7 , Reference Norris, Balasubramanian and Byass 8 Part of the impetus for this work came from a DOHaD summit held in Cape Town in 2015, captured in the Cape Town DOHaD Manifesto. 5 Our collaborative thinking during several meetings at STIAS in South Africa during the spring of 2016 convinced us that we must approach implementation of SDGs and DOHaD simultaneously. We argue that future investments in both will more effectively lead to greater positive societal impact, as will the dialogue and the advocacy efforts that will be needed to inform the public and compel governments to develop policies that link health to broader socio-economic development. We believe it will be easier to mobilize financial and human resources when SDGs and the DOHaD agenda are presented together. Further, it should be possible to jointly monitor and evaluate implementation. It has been argued by ChatoraReference Chatora 9 that, for the health agenda, an SDG-linked approach can help by providing clarity of goals and targets by 2030; by providing a ‘comprehensive and holistic approach’ to the entire environment of, for example, a child; and by optimizing the linkages of the SDGs in dealing with structural issues.Reference Chatora 9 It will also be easier to design interventions that serve both SDGs and DOHaD. In terms of SDGs there is strong potential for DOHAD to support countries in prioritizing areas of concern, including closure of the policy-implementation gap, setting interim targets to enhance political accountability, transforming interim targets into specific 3–5 year action plans, strengthening monitoring frameworks that reflect the interconnectedness of SDGs in an integrated manner and costing of action plans to inform national budgets.Reference Chatora 9
The examples illustrated in Table 2 reflect just a few of the many that link DOHaD and the SDGs. It displays how these developmental insights can be made to support each other. In applying these principles, the expected enhancement of human capital may lead to lasting positive change for people and the planet.
Mapping the Sustainable Development Goals (SDGs) that directly relate to the Developmental Origins of Health and Disease (DOHaD) concept
An example in which DOHaD evidence intersects with SDGs is the use of a community-based model for the delivery of Kangaroo Mother Care for improving child survival and brain development in low-birth-weight new-borns. The evidence in resource-poor settings is that this method reduces infant mortality and increases maternal–neonatal bonding.Reference Conde-Agudelo, Belizán and Diaz-Rossello 14 This in turn increases human potential including in parameters such as performance at school and long-term employment income. 12
Walker et al.Reference Walker, Wachs and Gardner 13 estimated that ~200 million children residing in developing countries fail to realize their inherent developmental potential. Further, a meta-analysis published in 2016 concluded that: ‘Breastfeeding is potentially one of the top interventions for reducing under-5 mortality’.Reference Dua, Tomlinson and Tablante 21 Yet, much still needs to be done to encourage exclusive breast-feeding programmes, and to educate mothers of the benefits of breast milk for their infant.Reference Dua, Tomlinson and Tablante 21 , Reference Bhutta, Das and Rizvi 22
The SDG targets for 2030 are undoubtedly ambitious, 2 and it will take vision, political commitment and well-planned and well-articulated measures to address these challengesReference Norris, Balasubramanian and Byass 8 , Reference Chatora 9 ; however, although the challenges are great, some optimism can be generated by adopting an SDG–DOHaD-linked strategy that lends itself to joint problem identification and problem solving. In this effort, advancing ideas that tackle root causes and result in high-impact positive changes will be essential.Reference Gluckman and Hanson 4 , Reference Norris, Balasubramanian and Byass 8 , Reference Chatora 9
Examples of strategies to advance a joint SDG and DOHaD agenda
Joint action to advance the DOHaD message of health promotion and the challenge of meeting specific SDGs requires the engagement of multiple agencies and groups in society to address core issues of both DOHaD and the SDGs and assess where interests overlap. Similarly, parallel dialogue can explore strategies required to advance the agendas, and identify the processes for effective engagement of all contributing agencies – many of which may well not have worked together previously.
Governments and their ministries
Governments often respond best when presented with compelling economic arguments. The costs and the benefits of prevention via DOHaD-informed early-life intervention v. the reality of spiralling costs of care for managing the same preventable diseases in later life is one such compelling argument. Such arguments can be strengthened further by referring to benefits of scale and reduction of duplication that can be obtained by combining the DOHaD and SDG agendas.
Ministries tend to work in silos in many situations, often asking for budgets without considering potential cost-savings achievable through the development of national level cross-cutting programmes. An example of such a national level cross-cutting programme could easily be based on the use of a joint SDG-DOHaD strategy. Doing this proactively would result in a bigger ‘bang for the buck’ for national ministries of planning, health and education. City and human settlement planning could then also draw upon joint SDG and DOHaD considerations so that cities may be safer and healthier (see Table 2).
Agencies and NGOs
Bilateral and multilateral aid and development partners, agencies and philanthropic foundations active in Africa all have roles to play in advancing the joint SDG/DOHaD agenda; however, DOHaD experts need to explain the issues and the benefits of a joint approach, whereas NGOs should consider rethinking their priorities. It is not easy to change the dominant paradigms of the kind of help these actors provide in poor resource settings. NGOs need to engage more and engage early with those they seek to benefit, and to learn to listen more.
In the end it will be evidence of the effectiveness of the joint DOHaD–SDG approach that will matter most in changing the minds of NGOs and other development partners; hence, this evidence must be sought early by DOHaD experts and it must be presented early. Another early-advocacy approach may be to point to ‘Calls for Action’ that make the argument for the DOHaD approach based on a number of different types of evidence.Reference Norris, Balasubramanian and Byass 8
Academies of science and universities
An attempt should be made to include SDG/DOHaD concepts in the curricula of a broad range of disciplines so the leaders of tomorrow can have an opportunity to discuss the issues; however, there is still a need for more research, including on the most promising methods of communication and advocacy, especially in the African context. With this in mind, the STIASReference Daar, Balasubramanian and Byass 7 , Reference Chatora 9 and the African Academy of Sciences are jointly helping to build a network of young research scholars to advance DOHaD science in Africa.
Scientists
Continued research is required, especially on DOHaD issues focussed on Africa. In doing this, it is important to appreciate the enormous variation in physical, economic and health realities among different African countries and the impact these may have on DOHaD–SDG research and implementation.
Some early-life exposures are still more prominent in Africa than elsewhere and may be on the rise; these will require more thorough investigation. For example, with extensive prevention of malaria during pregnancy, and drug interventions to reduce mother-to-child transmission of human immunodeficiency virus, the role of in utero exposure to antimalarial drugs and antiretroviral therapy require investigation of their effects in offspring at different stages of development.
Healthcare professionals and the media
The current healthcare focus on lifestyle change, particularly in adult life, to address known chronic non-communicable disease risk factors such as diet, physical activity, tobacco smoking and abuse of alcohol is relatively unsuccessful; on the whole, conditions such as type II diabetes, cardiovascular disease, chronic lung diseases and certain cancers are on the rise in many parts of the world. It makes more sense to also focus on early-life exposures that seem to programme people from an early age to suffer from these conditions later in life; however, many medical practitioners have not yet heard of the evidence supporting the DOHaD paradigm. There is work to be done here, for this constituency could play a crucial role in implementing and disseminating the message through contact with their patients, by acting as champions linking DOHaD to SDGs and through their interactions with the media; indeed, they might play a crucial role in educating the media that reports on science and health.
Educators
SDGs No. 1–6 directly address factors that contribute to health, disease and well-being in children (e.g. poverty, malnutrition, health, education, empowering women and girls, and water). Educators should be made aware of their potential to impact the lives of children by providing knowledge relevant to these SDGs and their relationship to DOHaD. An innovative approach to doing this in Africa could be to use the World Health Organization’s Health Promoting School (HPS) model to effect change. 15 , Reference West, Sweeting and Leyland 16 We have early evidence that the HPS’s approach that we have used previously in other contexts can be used to engage youth in DOHaD-related issues.
Discussion
Of the 17 SDGs, at least eight (indicated with ‘a’ in Table 1) can be mapped directly to the DOHaD approach.
DOHaD mapping to the relevant SDGs (Table 2) demonstrates a potential unifying, reinforcing and synergistic approach to implementation. We would expect that employing this unified approach will have greater benefits than employing either approach alone.
We have recently argued for consideration of early DOHaD interventions in Africa.Reference Daar, Balasubramanian and Byass 7 – Reference Chatora 9 Numerous strategies to improve population outcomes have been, and are currently being, studied. Table 2 presents a targeted mapping of the applicable SDGs to the DOHaD framework, with illustrative examples.
It is time to focus on early-childhood development in Africa, energized by DOHaD thinking and implemented with the SDG goals in mind. Barros and EwerlingReference Barros and Ewerling 23 have urged policymakers, governance bodies and researchers to prioritize equitable early-childhood development. These researchers, and others, have highlighted the need to focus on implementation strategies of the SDGs to ensure that all children and adolescents have an equal opportunity ‘to thrive and not simply survive’.Reference Bhutta, Das and Rizvi 22 , Reference Barros and Ewerling 23 This has paved the way for the ‘first 1000 days of life’ focus, in which the period from conception to a child’s second birthday is prioritized in terms of nutrition, social development and environmental exposures. It is now being realized that the window of opportunity can be extended beyond the 1000 days.
Former Secretary-General of the UN, Ban Ki-moon implored policymakersReference Ki-moon 24 to consider that ‘sustainable development is the pathway to the future we want for all. It offers a framework to generate economic growth, achieve social justice, exercise environmental stewardship and strengthen governance’.
DOHaD convincingly offers such a pathway, by providing the upstream answers necessary to achieve the UN SDGs. As we embark on energizing our approach to realizing the SDGs, DOHaD holds great potential in mapping the way forward.
Acknowledgements
The authors acknowledge the contribution of Dr Rufaro R. Chatora, WHO representative to South Africa, who provided key insights into how a DOHaD-linked approach could benefit policymaking toward achieving SDG goals.
Financial Support
The conference at the STIAS was sponsored by the Wallenberg Foundation.
Authors’ Contributors
The conceptualization of this article resulted from the 21–23 September 2016 conference at the STIAS in South Africa, with a focus on DOHaD and the SDGs, and moving towards early implementation in Africa. The workshop was led by A.S.D. All authors contributed to the planning, drafting and editing of the article; all authors have read and approved the final version.
Conflicts of Interest
None.
