to the cuts or rubbed over their bodies.115 One such child was observed in the mid-1950s, “encrusted with a grey coating of ashes; her mother was desperate with anxiety for her and was simultaneously arranging to take her to the hospital.”116
In light of the reasonable fears surrounding hospital treatment of severely malnourished children in this period, many parents and guardians only brought their children to the hospital when it appeared that there was little or nothing that could be done, when it appeared that they suffered from an illness of olumbe. The problem was that by the time severely malnourished children were finally brought to the hospital, they were in such an acute and severe state that they required immediate emergency measures to save their lives. The years of diagnostic uncertainty had taken their toll. Parents were justifiably wary of the procedures performed on severely malnourished children and continued to try existing forms of treatment first. These children often arrived at the hospital desperately ill and so physicians devised the emergency measures needed to save their lives. The diagnostic uncertainty of the early years of nutritional work in Uganda influenced local interactions with hospital treatment in ways that then shaped the form that treatment took. Children were often not brought to the hospital until their condition was a medical emergency. Physicians and scientists responded, as we will see, by medicalizing malnutrition.
In 1949 nutritional research in Uganda was swept up in a political insurrection, and the attack on Eria Muwazi brought this research to an abrupt halt. The insurrection convinced colonial administrators that, in order to avoid further unrest, future nutritional work had to proceed with greater caution. The accusations that Muwazi “kill[ed] children by taking blood” successfully altered the course of nutritional research in Uganda, prompting researchers to devise more ethical procedures, even as they dismissed the rumors of blood taking as unsophisticated and ignorant fears of Western medicine. The fact that blood tests remained a central feature of the research that resumed in the postinsurrection period, without further incident, suggests that blood extraction was not the crucial issue prompting concern. Instead, the accusations leveled at Muwazi were about the ethics of performing dangerous procedures on children who faced almost certain death. Targeting Muwazi was a local indictment of biomedical work that failed to improve health and wellbeing, work that appeared to improve Muwazi’s status and prestige at the expense of the people in his care. When colonial officials insisted on more cautious research protocols, they were responding, albeit unwittingly and from a state of nervousness, to the demands of the Ugandan people and their engagement with biomedical work.
Connecting the so-called rumors of Muwazi’s blood taking to his medical work on Mulago Hill reveals that local concerns regarding the ethics of this work compelled future researchers to devise new policies, like “No Survey without Service.” Any other analysis risks attributing the adoption of these more ethical protocols solely to Rex Dean and his expatriate colleagues, a move that further obscures African agency in a narrative that leaves biomedical ethics an import of the West. It also illustrates how notions of “unsophisticated” fears and “native ignorance” of “Western” medicine miss important local appraisals and critiques of questionable ethical practices.117 These local appraisals also indicate that people in Uganda had very little faith in biomedicine when faced with severe acute malnutrition, and with good reason. The diagnostic uncertainty that characterized the early decades of nutritional work in Uganda meant that children brought to the hospital suffering from severe acute malnutrition were often subjected to a number of experimental and extractive procedures, even though little could be done to save their lives and the vast majority did not survive. Under these circumstances, parents in Uganda had little reason to bring their malnourished children to Mulago for treatment that did not yet exist and appear to have only done so as a last resort, when nearly all hope was lost. Severely malnourished children were, as a result, brought to the hospital when their illness had become acute, when it became an illness of olumbe. The highly extractive and dangerous procedures that characterized nutritional research in Uganda until the mid-twentieth century allow us to, therefore, see anxieties surrounding biomedicine in a new light. Parents who sought alternative treatments first were clearly not acting according to an irrational and traditional mind set, as has often been assumed. Instead their fears appear now, in retrospect, to be warranted. This early chapter in the history of nutrition and colonial medical research serves as a reminder to both historians and global health practitioners that local responses to medical interventions cannot be reduced to cultural frameworks alone; rather, they must be seen as complex and dynamic historical engagements or “accumulated reflections.”
Children brought to the hospital in such a severely malnourished state required emergency measures to save their lives. As will be explored in the next chapter, this local response to nutritional work thereby shaped the measures that the physicians and scientists at Mulago developed in response to the condition, with repercussions for years to come. Thus the diagnostic uncertainty of the early years of nutritional work in Uganda influenced when parents brought their children for hospital treatment, and this in turn shaped the development of that treatment. The history of colonial medicine in this part of Africa represented not a single encounter, but a set of interactions. The shifting local response to nutritional research suggests that people in colonial Africa were not averse to biomedical procedures and care, provided they in fact improved health and wellbeing. This insight is not only essential to an appreciation of the history of colonial medicine in Africa and other parts of the world, but is also important to contemporary health programming. It suggests that particularly when it comes to global health, it is crucial to recall that local engagement with biomedical work is shaped in large part by the residue of past experiences. People engage with health systems in ways that are shaped by long histories of medical research and provision. Evolving practices are influenced not only by the latest scientific developments, but also by the therapeutic decisions of patients and their communities, and their responses to the quality of the care they have received and continue to receive.118
2
MEDICALIZING MALNUTRITION
As the story goes, when Rex Dean, the nutritional scientist, arrived in Uganda he was astonished to find severely malnourished children dying at such alarming rates, and so he immediately set to work devising a life-saving treatment.1 Dean’s therapeutic regimen centered on the provision of a high-protein formula that, in light of the foregoing (and future) controversies over the protein hypothesis, garnered much of the attention. Yet the reason severely malnourished children suffered excessive rates of mortality was only partly due to the presumed absence of a high-protein formula to feed them. High case fatality was also tied to the severe state in which malnourished children were brought to the hospital. Local reticence to seek hospital care for severely malnourished children represented, as we have seen, the residue of a period of ongoing diagnostic uncertainty in Uganda—a period characterized by questionable experimentation on dying children. This period of diagnostic uncertainty meant that the children who were brought to the hospital required emergency medical measures just to save their lives. Dean’s efforts to do just that served to medicalize malnutrition. This medicalization of malnutrition precipitated an era of unwavering faith in the capacity to contend with the problem of severe acute malnutrition. But lifesaving curative measures did not prove to be an effective basis for prevention. Local engagement with and interpretation of hospital treatment, especially as it morphed into prevention, led to unintended consequences that further compromised the nutritional health of young children. This chapter explores these developments and how they were obscured and then forgotten. The unintended consequences of medicalizing malnutrition and the resulting scandal were swept under the rug, making the lessons that might be drawn from an analysis of this mid-twentieth-century effort to prevent severe acute malnutrition unavailable to those involved in future efforts to contend with the problem of severe acute malnutrition around the globe.
Medicalizing Malnutrition
The Medical Research Council sent Dean to Uganda as a result of his expertise in the prevention of malnutrition. His earlier success developing mixtures of plant proteins “rivaling milk in nutritive value” for malnourished orphans and schoolchildren in postwar Germany appeared directly applicable to the problem of severe childhood malnutrition in Uganda.2 Dean never lost