to the role of anemia. In 1938, he used his time on home leave to return to England via Cairo in order to collaborate with an Egyptian doctor who had been publishing on anemia, and to take a three-month postgraduate course on anemia and other “blood diseases.”26 Once back in Uganda, Trowell enlisted Eria Muwazi, a recent graduate of the Makerere Medical School, and together Muwazi and Trowell conducted a number of studies in an effort to identify the cause of the condition and to assess its prevalence in the region.27
Muwazi’s contribution to this research was significant. Muwazi, as a Muganda, could obtain detailed histories, dietary information, and more accurate appraisals of symptoms to compare with clinical examinations, biopsies, and blood tests.28 Muwazi’s involvement in the investigation of congenital syphilis and its true prevalence was pivotal, as he collected most of the data and ensured the success of the entire investigation, which found that only a very small percentage of children, perhaps as few as 1 percent, suffered from congenital syphilis. In fact, Trowell, Muwazi, and another researcher involved in the investigation concluded that congenital syphilis was uncommon in Buganda, particularly when compared to what they claimed was the “almost universal” prevalence of severe acute childhood malnutrition.29
It is not clear how they collected blood specimens in these preliminary studies, but the published findings indicate that in the early 1940s, they did not yet have the means to estimate blood protein levels in Uganda. Serum protein evaluations were therefore conducted on only a small fraction of the blood samples drawn for these early investigations and, as Trowell explained, “they used to take blood . . . and put it on a plane, and send it to Nairobi.”30 Over 180 severely malnourished children did, however, have blood drawn for a variety of other tests, including red blood cell counts and tests for anemia and congenital syphilis.31 A subsequent study involving more than 120 Ganda children provides the first glimpse of what appears to be a new method of acquiring blood samples from young patients in Uganda—withdrawing it from a vein in the neck. This became a standard practice and remained the preferred method of obtaining blood specimens from young children for several decades. According to Muwazi and Trowell, the method was both efficient and effective: “In all children blood for serological examination was removed from the jugular vein in the out-patient department. This was done without much difficulty and it was found to be the method of choice as it required no special preparation. It was found that with a little practice 3–5 c.cs. of blood could easily be obtained.”32 This marked not only the inauguration of a new procedure, but an overall expansion in blood extraction on Mulago Hill. As Trowell later explained to his daughter, “At this time, I was working very much with the blood side of it. . . . But I was still feeling myself groping very much in the dark.”33
In this early period of nutritional research in Uganda, severe acute malnutrition was not narrowly defined as a condition of early childhood and adult patients figured in a number of nutritional studies.34 Adult subjects were important, as it was found that repeated blood extraction was dangerous in very young children.35 The inclusion of adults also meant greater awareness of this work within the surrounding communities. Large numbers of immigrants from Rwanda and Burundi who came to work on Ganda farms through most of the colonial period arrived in Uganda so severely malnourished that they became the subject of numerous nutritional studies.36 One study, for example, entailed extracting blood from 144 adult immigrants from Rwanda and Burundi.37 Adults from the south-central Kingdom of Buganda were also included in investigations of childhood malnutrition as, for instance, in the 1947 investigation of 128 Ganda children that entailed extracting blood from their mothers for the very same blood tests.38 Another study involved extracting blood from either an umbilical cord or a newborn’s skull in order to compare it with venous blood taken from the newborn’s mother.39
The establishment of a physiology and biochemistry laboratory on Mulago Hill in 1946 meant a further expansion of blood work in Uganda. The new laboratory equipment made more complex examinations of blood samples possible, thereby eliminating the need to send them to Nairobi. One researcher, Dr. Ferdie Lehmann, explicitly came to investigate anemia, and reports and publications reveal that blood was the central focus of the research conducted at the lab for a number of years.40 Researchers working at the lab were able to conduct sizeable studies; thus, one investigation involved taking blood from 260 men chosen from among patients who sought treatment at Mulago’s outpatient department.41 Studies of blood protein levels involving such large cohorts of adults and children suggest that knowledge of this blood work could have spread in the area around Kampala, if not farther afield. The fact that Muwazi and Trowell did not confine their investigations to patients brought to the hospital must have increased this likelihood. In the post–World War II period, Muwazi and Trowell conducted a study at the Budo and Gayaza high schools—the two most prominent and well-known schools in Uganda. The students were divided into groups and each group was given a different meal before Muwazi and Trowell measured their blood pressure, weight, and height and took blood from each of the students.42
In the 1940s a growing number of scientists and physicians working at hospitals and clinics around the world also began to investigate and publish findings on the condition. Earlier publications and reports came from such far-flung regions and gave the condition such a wide variety of names that there was little awareness of their mutual interest or the global prevalence of the syndrome. With the “pellagra controversy,” as it came to be known, the debate over the etiology became the subject of an international exchange in the journals of pediatric and tropical medicine. This allowed Trowell to compare his findings with research conducted in South America, the West Indies, Asia, and especially other regions of Africa. As the tide turned against pellagra, the predominant focus of this research was the only pathological anomaly routinely found at death—the fatty infiltration of the liver.
Trowell and his colleagues used biopsies or specimens taken from live patients as part of their efforts to understand these unusual fat deposits in the liver. As Trowell later described the procedure, it is clear that liver biopsies were dangerous and in at least one instance resulted in a patient’s death: “We would put . . . [the patients] under an anaesthetic, and would put in a large bore needle, with which I could suck a small thread out. . . . I wasn’t doing it with as good needles as they have now. We hadn’t lost any children. We . . . had lost one adult over this . . . because I hadn’t realized how deep you could go in on a thin patient. It had made him bleed, I am afraid fatally.”43 Biopsies causing even one patient to die could alone generate local concerns, yet when it came to biopsies performed on young children, witnesses may have also had reasons to conflate biopsies with blood work. Trowell began conducting liver biopsies on young children after acquiring a special bore needle from Joseph and Theodore Gilman during a visit to South Africa in 1947.44 When Trowell demonstrated the procedure at a conference, he reported that in the fifty to sixty biopsies he had performed on severely malnourished children, “almost invariably he had found that the liver was being pushed forward and that blood collected in the syringe.”45 Thus, in this period, biopsies and blood extraction and the relative dangers of each procedure were, for all intents and purposes, largely indistinguishable.
Biopsies were also routinely performed alongside blood tests, further blurring the distinction. This was particularly true of the nitrogen balance studies carried out at the physiology and biochemistry lab. As nitrogen is a primary component of all proteins and a by-product of protein metabolism, measuring the amount of nitrogen consumed and then excreted was the most effective way of quantifying the amount of protein used by the body. Highlighting the extent of the extraction involved in these investigations, one nitrogen balance study entailed closely measuring the nitrogen consumed and excreted in addition to collecting liver biopsies, blood for red blood cell counts, and serum protein estimations, repeatedly throughout the duration of the study. In order to obtain the most accurate results, the nitrogen balance studies were extended until, as one researcher noted, “the patient had to be granted discharge, or in default of that, absconded, from hospital.” This meant that in some cases the investigation lasted for an astonishing 170 days.46 Exact figures for the number of participants were not provided, but one report indicated that “the limit indeed, was not the supply of cases, but the working capacity of the laboratory,”47