Book Review
Book Review | Weighing the Future: Race, Science, and Pregnancy Trials in the Postgenomic Era by Natali Valdez (University of California Press, 2022)
University of Melbourne
jaya.keaney@unimelb.edu.au
“You are pregnant.
You are pregnant and, as your mom explains, ‘heavy set’; or as your cousin says, nalgona; or as the tags on your
jeans read, ‘curvy’; or as your doctor terms it ‘obese’; or as you say, fat.” (1)
So begins Natali Valdez’s vivid ethnography of prenatal trials with pregnant women in the postgenomic era. The book presents a deft multi-sited study of two such large-scale trials, one in the United States and the other in the United Kingdom. These trials stage lifestyle interventions with the aim of addressing maternal obesity and diabetes and improving fetal outcomes. The trials mobilize postgenomic paradigms, drawing selectively on research in epigenetics and the developmental origins of health and disease (DOHaD) to connect the behaviors and diets of pregnant people to the health of future children. With a skilled ethnographic eye, Valdez traces how pregnant participants are produced as sites of risk, speculative value, and canvasses for imagining racialized population futures, to the detriment of adequate healthcare and social policy responses in the present. These outcomes are characteristic features of what the book terms “postgenomic reproductive politics.”
Weighing the Future is motivated by a stark reality that haunted me as I traversed its chapters: to date, despite hundreds of pregnancy trials across diverse contexts, there is no conclusive evidence that lifestyle interventions into diet and exercise reduce pregnancy complications or significantly improve health outcomes of birth parents and children. Indeed, this same outcome befalls the two trials at the heart of the book. How then, Valdez asks, do randomized controlled trials continue to be proposed, funded, and conducted, retaining their status as the gold standard for evidence-based medicine?
Part of the answer is a pernicious cultural discourse that defines good maternal subjects as thin, and as bearing ultimate responsibility for their children’s health, exercised through individualized behaviors and food choices. Valdez ably traces the conditions of possibility for this discourse. She finds a knotted web of racial surveillance capitalism and its bioprospecting tendrils, and the contraction of social welfare and basic healthcare symptomatic of late liberalism in both its US and UK incarnations. Postgenomic science has given new traction to an old and narrow discourse of maternal responsibility, Valdez argues, by centering the pregnant body as the site of epigenetic transmission for future health risk.
The book’s opening vignette, quoted above, crystallizes the creative flair and careful attention to positionality that is one of the strongest contributions of this text. Each chapter opens with a vignette crafted in the second person, interpellating the reader as a participant in a pregnancy trial. By centering the individuals through whom body size is materialized as the medical problem of “obesity,” Valdez highlights the disparities between normative scientific imaginings of lifestyle, food, home, and care, and their lived realities as they are contoured by racism, fat stigma, and unequal access to material resources.
As the first ethnography of postgenomic pregnancy trials, Weighing the Future makes a significant contribution to science and technology studies, gender studies, and medical anthropology. While the critique of maternal responsibility in reproductive healthcare and postgenomics is well established in these disciplines, Valdez makes a unique contribution through her careful attention to racism as a fundamental reproductive environment. Drawing on the entwined genealogies of Black feminism and reproductive justice, Valdez attends closely to how gender is always already racialized, with reproduction and the maternal body fundamental axes of racialization and attendant hierarchies of the human.
The book is organized into three parts, each comprising two chapters. Following an introduction that maps out the stakes and key terms of the book, Part I lays the groundwork for subsequent ethnographic chapters. Chapter 1 explores the “epistemic environments” of postgenomics and develops the concept of “epigenetic foreclosure,” the book’s keystone term. “Epigenetic foreclosure” powerfully describes the way that capacious epigenetic models of an expansive environment and indeterminate transmission are translated again and again into clinical interventions narrowly focused on maternal behavior. Such foreclosure not only hampers scientific creativity, but also fails to adequately grasp the realities of pregnant life.
Chapter 2 further contextualizes the postgenomic turn by tracing historical developments since the 1950s in scientific understandings and guidelines regarding nutrition during pregnancy. Valdez highlights that while scientific paradigms may have shifted in significant ways from the 1950s, the mechanism for intervention has remained squarely focused on individualized lifestyle solutions targeting pregnant women, tilling the ground for contemporary epigenetic foreclosure.
Part II delves into the ethnographic material gathered through intensive study of two trials, in which Valdez attended staff meetings, shadowed health workers, interviewed primary investigators and other staff, and witnessed interventions with participants, including delivering them herself as a staff member in the US trial. The ethnographic detail here is rich, and Valdez captures palpable scenes that resonate long after reading: stilted staff meetings to brainstorm challenges with recruitment; a table that groaned with Subway sandwiches at a “lunch and learn” event for a community health clinic; the thick and off-putting hospital smell flooding her nostrils as she entered the premises of the UK trial; and emotional exchanges with trial participants as they shared everyday experiences that were technically outside the remit of the nutritional intervention she was tasked with delivering.
Chapter 3, the first chapter in Part II, focuses on participant recruitment as the stage when “people are transitioned into research subjects and data points for science” (83). As Valdez highlights, risk is salient in all randomized controlled trials, but in prenatal trials, its operation is distinct: pregnant people are framed as risky before they enter a trial, due to persistent fat stigma, racism, and a postgenomic discourse of maternal responsibility. While race is obscured in many aspects of postgenomic research, it is materialized explicitly in the recruitment stage, as studies depend on racially and ethnically diverse cohorts. As participants’ self-identities are translated into legible and categorizable data points, Valdez shows how racism is a mercurial process of “improvisation” that most often appears in technoscience in the language of diversity and inclusion (112).
Chapter 4 turns to the narratives of pregnant participants. By tracing their understandings of food and pregnancy, and their motivations for participating in research, Valdez gives depth to the people whose bodies and behaviors are transformed into data. Control and responsibility emerge here as two powerful themes that structure research design and the experiences of participants, who survey their own weight and food choices with reference to deeply classed and racialized discourses of health. In many instances, conforming to the nutritional interventions of the trials required participants to abandon culturally specific methods of eating and sharing food. A narrow reliance on Western food cultures, such as the valorized “Mediterranean diet,” thus presents one salient way that pregnancy trials participate in ongoing processes of racism and colonization.
Part III of the book takes up the consequences—racist, gendered, methodological —of how “environments” are defined in pregnancy trials. In Chapter 5, Valdez tracks the processes by which the notion of environment is persistently reduced to the intrauterine environment of the maternal body. Producing this narrow iteration requires many aspects of life to be black-boxed. While food is treated as a paramount exposure, other less controllable or readily individualized environmental factors, such as structural racism, housing stability, stress, and toxic exposure, are sidelined.
Although the narrow focus on the intrauterine may not adequately explain pregnant experience, it does produce valuable resources for scientific research: the pregnant “biobits” that are the focus of Chapter 6. Blood and urine samples, placental tissue, and cord blood are extracted from participants and made valuable through a temporal formation that Valdez terms “speculative time” (187). In yet another foreclosure, present-day health needs are sidelined in the service of preventing future disease, optimizing future value within a racial capitalist imaginary.
Weighing the Future concludes by turning to the “afterbirth of foreclosure.” The foreclosures that weave their way through this book are shown to constrain scientific creativity, forestall innovation, and stand in the way of health justice. And yet, as Valdez maintains, foreclosure is not inevitable. Calling into question the method of the randomized controlled trial itself, Valdez urges us to imagine environments in ways that are not individualized, and to center racism, not depoliticized racial identities, in our theories of reproduction.
Ultimately, this meticulously researched and beautifully crafted book models the health justice framework for which it agitates. Driven by a deep commitment to understanding the lives of pregnant participants, Valdez demonstrates how feminist and anti-racist critique is a route to better science and health policy, and to a more accurate portrait of how we all collectively create the reproductive environment.
Author Bio
Jaya Keaney is a Lecturer in Gender Studies in the School of Social and Political Sciences at the University of Melbourne.