to continue research on severe acute malnutrition. At the Infantile Malnutrition Research Unit that he established and directed, Dean implemented a policy requiring that all researchers and physicians working at the unit abide by the maxim “No Survey without Service.”85 For the parents of severely malnourished children brought to the unit, “No Survey without Service” meant an assurance that when their children took part in research, they received cutting-edge treatment and care. This practice was also followed at the unit’s rural Child Welfare Clinic where children living in the surrounding region were offered the medical care needed for healthy growth and development as part of their inclusion in studies of nutritional health and wellbeing.86 Crucially, Dean’s implementation of “No Survey without Service” was possible in the early 1950s in a way that it had not been prior to the insurrection. Immediately after he arrived in Uganda and observed the appalling mortality rates associated with severe malnutrition, Dean set to work devising an effective treatment. By the early 1950s, he had succeeded in reducing the mortality rates of the condition from between 40 and 60 percent down to between 10 and 20 percent.87 In cutting the mortality rates associated with severe malnutrition in half, Dean transformed a condition of almost certain death into one that could be reversed with hospital treatment.88
With an effective treatment in place, nutritional research in Uganda entered a new phase. More ethical research protocols and treatment that could save the lives of severely malnourished children meant that there was much to distinguish this work from the research conducted prior to the insurrection. There was, however, one component that continued unabated: blood extraction. Examining blood samples remained a fundamental and routine component of nutritional research in Uganda because it served a critical function as a tool of diagnosis. Due to the edema, or accumulation of fluid in the tissues, and the buildup of fat in the liver and under the skin, weight was an inaccurate indicator of the condition’s severity.89 Assessing the severity of the condition was essential to evaluations of whether or not a therapy was working, and significant research was devoted to the development of accurate diagnostic tools. In Uganda, these efforts focused on possible blood tests and, in the interim, serum protein examinations served as the most accurate measure of protein deficiency in young children. Thus blood extraction continued to be the most routine component of nutritional research on Mulago Hill.
In fact, part of what separated blood extraction in the period following the insurrection from the earlier blood work was that it became so routine. Whereas, prior to the 1950s, blood was withdrawn from a heterogeneous mix of patients by a diverse group of doctors and scientists who had multiple motivations for their many investigations, under Dean this research was largely coordinated and confined to the MRC unit. The research conducted in Uganda during the period of diagnostic uncertainty was far more haphazard and exploratory—unexpected findings prompted additional studies and definitive results concluded one line of investigation only to be replaced by another. However, from the 1950s onward, blood tests became the routine procedure performed on all severely malnourished patients admitted for treatment and investigation. As all of the reports and publications confirm, “it [was] usual to bleed each child on the day of admission. . . . The bleedings were repeated every 7 days, but some children were bled twice in the first week. The blood was taken from the internal jugular vein.”90
These routine blood tests were serial examinations, meaning that they were repeatedly performed on the same child throughout the course of treatment, a period usually spanning at least three weeks and often significantly longer. Serial examinations served to monitor progress toward full recovery, and to fulfil the need for control groups. As Dean and his first biochemist explained: “Blood samples were obtained from a neck vein . . . on admission and at approximately weekly intervals afterwards. The times between taking the samples were sometimes varied to coincide with planned changes of diet. . . . The greatest importance was attached to serial examinations on the same child, who thus acted as his own ‘control’.”91 Serial diagnostic serum protein examinations, in the absence of viable controls, made blood extraction the central procedure performed on severely malnourished patients at the MRC for more than two decades.
These routine serum protein estimations were not the primary focus of an investigation, but served as a means of monitoring the condition’s severity. Again, nitrogen balance studies provided the best example, as they involved routine and extensive blood extraction. The very young children brought to Mulago for treatment were usually in such a severe state of health that collecting specimens at all, let alone for extended periods, proved nearly impossible.92 In fact, nitrogen balance studies were not successfully incorporated into the MRC’s work until the mid-1950s, when the introduction of a “balance bed” originally devised at the MRC unit in the Gambia suddenly made such studies feasible (see fig. 1.1). In two studies that used the balance bed, the primary investigation concerned urine excretion, and yet, as the researchers explained, “the blood of both boys and girls was studied. The boys were placed on balance beds when they were admitted, and received no food . . . until they were bled, at 8 a.m. the next morning. . . . Blood was taken from the internal jugular vein of all the boys and girls at the end of initial fasting, and subsequently at various times during treatment.”93 Nitrogen balance studies were also used to determine the most therapeutically effective combination of ingredients in Dean’s effort to develop a therapeutic groundnut (peanut) biscuit, and the discussion of their methodology provides the most detailed description of balance beds in this period:
The balance beds which have been in use in the [MRC] Unit for several years, allow for the separate collection of urine and feces. . . . A harness around the trunk and legs limits movement but does not entirely prevent it. . . . The accuracy of all balance methods depends to some extent on the regular voiding of feces, which could not, of course, be assured in our children. Extending the length of the periods reduces the importance of inaccuracies, but two four-day periods necessitated a total of fourteen days continuously on the balance bed, and we believed that to be long enough for the children and the staff.
Moreover, as Dean and his colleague noted, “The wards of the Unit have large glass windows, and the children were under continuous observation. . . . Each child was weighed, and bled from the internal jugular vein before and after each period.”94 This continuous extraction of blood as a central feature of nutrition research before and after the insurrection was not without consequences. The advent of a more cautious approach and the development of treatment were crucial if nutritional research on young children was to continue in Uganda, but they could not immediately erase the impact of the questionable experimentation that had been performed on dying children during the period of heightened diagnostic uncertainty in the region.
FIGURE 1.1. “Bed for metabolic studies,” c. 1952. Source: Colonial Office, Malnutrition in African Mothers, Infants, and Young Children: Report of the Second Inter-African Conference on Nutrition, Fajara, Gambia, 19–27 November, 1952, 377 (plate 2) (London: H. M. Stationery Office, 1954), by permission of The National Archives.
An Illness of Olumbe
Even with the advent of effective therapy and a more cautious approach, parents of severely malnourished children remained wary of hospital treatment. The damage had been done and local apprehensions did not diminish overnight. People continued to turn to existing remedies and healers first, resorting to hospital treatment often in their final hour of need. This tendency to seek treatment from local healers before consulting a European doctor or biomedically trained physician had been widely observed in this and other parts of Africa since the beginning of colonial rule.95 Legal sanctions drove local healers underground, but failed to entirely convince people to avoid their services and seek hospital care instead. One physician, who took a special interest in local healing practices, found that even on the eve of political independence, local therapies could be obtained in markets, urban centers, thoroughfares, and near major hospitals and small dispensaries in amounts suggesting extensive and ongoing faith in their efficacy.96
This coexistence of local and biomedical forms of healing