Читать книгу The Riddle of Malnutrition - Jennifer Tappan - Страница 12

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DIAGNOSTIC UNCERTAINTY AND ITS CONSEQUENCES

The early history of severe acute malnutrition is a history embroiled in controversy. Disputes over diagnosis plagued the condition from the very outset, and in Uganda these diagnostic debates stretch back to the turn of the century. In fact, consensus that the condition was a form of malnutrition did not emerge within the scientific community until the middle of the twentieth century. This lengthy period of diagnostic uncertainty was not without repercussions. As long as the etiology remained elusive, treatment was haphazard and largely unsuccessful. Ongoing efforts to determine the cause of the condition in order to devise an effective cure translated into years of experimentation on severely malnourished children, the vast majority of whom ultimately died. Insufficient caution or concern for how this period of diagnostic uncertainty might impact local views of biomedical research and care converged with mounting economic and political grievances, such that colonial authorities and biomedical personnel were finally forced to pay attention. The brief interruption in nutritional research that followed reveals “a nervous state,” a colonial government responding to rumors and what they saw as superstitions in order to avoid further violence and unrest.¹ The resulting shift in research protocols furnish an opportunity to gauge how local engagement with biomedical research and care engendered changes that might otherwise remain obscure. Despite the advent of a more cautious approach and more effective forms of therapy, the consequences of this lengthy period of diagnostic uncertainty did not immediately dissipate, and local views of the nutritional work carried out in Uganda shaped therapeutic decisions with significant consequences for years to come.

“Groping Very Much in the Dark”

Diagnostic uncertainty surrounding severe acute malnutrition dates back to the early history of British colonial rule in Uganda and the early history of medical provision and training in the region. In the early 1900s, the preeminent medical missionary Albert Cook observed high rates of infant mortality and attributed the problem to congenital syphilis. Children suffering from syphilis, acquired during pregnancy and birth, exhibit a set of symptoms very similar to those with severe acute malnutrition, making a differential diagnosis difficult.² Both medical experts and historians have acknowledged that an inability to readily distinguish between different forms of syphilis and yaws contributed to the highly inflated and alarming prevalence rates cited in the early years of British colonial rule.³ Few have noted that an unknown, but potentially significant, number of severely malnourished children were misdiagnosed as syphilitic in this period. Nor was this the only diagnostic dispute to stymie early efforts to diagnose and treat severe acute malnutrition.

Cook’s view that venereal infections accounted for low birth rates in the protectorate was shared by his colleagues in government service. An investigation confirmed the exaggerated fears that venereal infections threatened demographic collapse in a region of increasing economic value to the British Empire, compelling the government to take immediate action.⁴ The few treatment centers that were then built in and around Kampala aggravated an already existing shortage of medically trained personnel in the protectorate. The antisyphilis campaign thus gave rise to a modest training program, which became the foundation of the Makerere Medical School. Medical students at Makerere obtained their clinical experience in the wards of the central venereal disease clinic, turned general teaching hospital, on Mulago Hill. Before long the high standards of training achieved at Makerere made it the leading institution of higher learning in East Africa. It also attracted a new cadre of personnel, interested in both training and research.⁵ The establishment of the Mulago-Makerere medical complex as the central medical institution in Uganda was so tied to this early antisyphilis work that the tendency to overdiagnose syphilis, and especially congenital syphilis in young children, continued in Uganda for much longer than might otherwise have been the case.⁶

Cook may have had the greatest stake in defending this diagnosis, as the colonial government also tapped Cook and his wife to start a maternity training school and establish a network of rural clinics as part of a further effort to reduce infant mortality and halt population decline. By the early 1930s, the Church Missionary Society (CMS) had already trained over one hundred Ugandan midwives and built more than twenty-five rural maternity and child welfare clinics, including the principal maternity center constructed on royal land in the village of Luteete.⁷ Maternity training and the range of services Ugandan midwives provided for new and expectant mothers and their young children became central to the work and finances of the CMS medical mission station in Uganda. The fees charged at the maternity centers in 1931, for example, amounted to over 98 percent of the total annual expenditures, thereby subsidizing CMS work in Uganda beyond maternity training and provision.⁸ There were therefore many who did not take kindly to suggestions that the condition most threatening the health and welfare of Ugandan children was something other than congenital syphilis.

The man who became the central figure in this diagnostic dispute was Hugh Trowell. Trowell first encountered children suffering from severe malnutrition in the early 1930s while stationed in the neighboring British colony of Kenya. Trowell was so inspired by the idealism of the interwar period and the creation of the League of Nations that he joined the colonial medical service immediately after completing his medical degree in the late 1920s. In Kenya, Trowell very quickly ran afoul of the settler politics limiting the provision of medical care, and he was transferred from his rural outpost to Nairobi where, in the context of the Great Depression, he expected to be dismissed from colonial service and sent home. A senior official who shared Trowell’s interest in public health instead put Trowell in charge of a newly created African medical training program. Training African medical personnel beyond the level of hospital assistant did not have the support in Kenya that it did in Uganda. Reluctance to allow Trowell’s medical students into the wards of the African hospital in order to obtain the necessary clinical experience forced Trowell to demand that he be given his own ward. When he first went to visit the pediatric department to which he’d been assigned, he found “about two children in each bed, and one underneath. Quite a number had brown hair. Some had swollen legs . . . and some were crying [and] moaning.” Trowell later looked back on this moment as the first time that he came face to face with children exhibiting the classic symptoms of severe acute malnutrition.⁹

The consensus in Kenya was that these children were suffering from parasitic infections, especially hookworm. The problem with this diagnosis was that deworming medications did little to improve their chances of survival. Treatment failure was not only the linchpin in efforts to nail down the condition’s etiology, but it also did little to encourage parents to bring their severely malnourished children to the hospital. Nor did it persuade parents to allow their children to be subjected to experimental procedures of limited apparent therapeutic value. In one of his earliest publications on the condition, Trowell reported that mothers were, as he put it, among “the greatest obstacles in the treatment. It proved necessary in these cases to separate completely the mother and child and to forbid suckling.”¹⁰ Only ten of the twenty-six children Trowell attempted to treat in this early study achieved a full recovery, and these were children brought to the hospital at an early stage of their illness. None of those who arrived severely malnourished survived. According to Trowell, five children “were discharged by impatient parents in an improved condition” but with an uncertain long-term prognosis, as “it usually proved impossible to detain them or secure their re-attendance.”¹¹ Any resistance or reluctance on the part of parents is hardly surprising, given that Trowell later estimated he lost as many as three-quarters of his severely malnourished patients at this time. The largely futile attempts to treat the children in his care led Trowell to begin to suspect that he was dealing with a new disease.¹² Postmortem examinations conducted with the limited resources at his disposal revealed only that the children had an enlarged liver that was infiltrated with fat.¹³

A colonial medical officer stationed across the continent also became convinced that she was dealing with a new illness. Cicely Williams observed that the severely malnourished children at a children’s hospital in present-day Ghana had been fed a diet deficient in protein and she was the first to propose that the condition was a form of severe malnutrition. Her seminal article on the condition documented how the provision of a milk-based, varied diet appeared to reverse many of the symptoms. In the end all but one of the children later died, but the visible improvement of their health in response to a high-protein diet led Williams to conclude that protein deficiency was to blame. Her hypothesis challenged the accepted diagnosis of experts in the burgeoning field of nutritional science. Hugh Stannus, who identified the condition as the vitamin B deficiency, pellagra, while working in present-day Malawi over a decade before, promptly published a review refuting Williams’s evidence.¹⁴ Williams responded with a second article in the preeminent British medical journal, the Lancet, delineating the significant distinctions between pellagra and the condition, which she then referred to as kwashiorkor, the local name for the condition in Ghana.¹⁵

The debate between Williams and Stannus reflected both the inconclusive therapeutic outcome of dietary treatments and the heightened interest in micronutrients following the wave of vitamin and mineral discoveries in the initial decades of the twentieth century.¹⁶ Yet there was also a political dimension, as the proposition that children living within a British colony suffered from a diet deficient in one of the major food groups, rather than a newly discovered vitamin or mineral, was, in the words of a leading figure in British nutritional science, “politically objectionable.”¹⁷ Whereas previously unknown vitamin and mineral deficiencies provided further opportunities for science to improve the lives of colonial subjects, protein malnutrition pointed to the poverty of colonial populations. Williams was not easily deterred and despite her transfer to Malaysia (and interment during World War II), she remained an ardent advocate of the protein hypothesis throughout her life.¹⁸

The small medical library in Nairobi where Trowell lived and worked at the time did not carry a subscription to the Archives of Disease in Childhood that published Williams’s first article advancing the protein hypothesis, and thus Trowell only learned of the debate through the refutation written by Stannus. Trowell then assembled a collection of photographs and tissue specimens and consulted with Stannus while on home leave in 1935. According to Trowell, Stannus only glanced over the photographs and then confidently reiterated that the condition was a form of pellagra. When pressed about the fat deposits in the liver, Stannus apparently refused to examine the liver specimens and sent Trowell away with an article on pellagra among African Americans.¹⁹ For a time, Trowell nonetheless followed Stannus, referring to the condition as a form of “infantile pellagra” in his first two publications on the condition.²⁰

In fact, Trowell did not begin to suspect that the condition was not a form of pellagra until relocating to the neighboring colonial territory of Uganda. He first traveled to Uganda in order to assess and report on medical training at Makerere. His enthusiastic endorsement of the high level of African medical training in Uganda was not well received in Kenya. Antipathy to advanced medical training for African colonial subjects was so great among the white settlers that Trowell’s endorsement was met with a punitive relocation to a remote outpost in Kenya’s Northern Frontier District. Only through an invitation to join the teaching staff at the Makerere Medical School was Trowell able to avoid being demoted and separated from his wife and young children. Once in Uganda, Trowell was again placed in charge of pediatrics where he again found children suffering from severe acute malnutrition. His further efforts to determine the cause and devise a cure placed him at odds with many within the medical establishment in Uganda. The pathologist at Mulago Hospital, for instance, refused to thoroughly examine Trowell’s patients at autopsy.²¹ Albert Cook, who undoubtedly felt beleaguered by new legal restrictions on the services midwives could provide, which threatened CMS finances, was especially reticent to entertain the idea that the condition was not congenital syphilis.²² In fact, Cook never conceded that children previously diagnosed with congenital syphilis may have been severely malnourished, and severely malnourished children continued to be treated as cases of syphilis in the main CMS hospital until the mid-twentieth century.²³

Isolated, but undeterred, Trowell created his own small laboratory and trained a Ugandan assistant, John Kyobe, to examine liver extracts and blood slides. When a cable arrived from the United States announcing the synthesis of a new B vitamin and its arrival on the next plane, Trowell dropped everything to get to the airport, retrieve the bottle of niacin, and begin treating the children suffering from severe malnutrition in his ward.²⁴ Tragically, it was not known then that vitamin B therapies were harmful and dangerous to severely malnourished children, and eight of the ten children given the niacin died as a result.²⁵ Trowell resumed his efforts to treat the children with other B vitamins before eventually abandoning vitamin B deficiency as the cause of the condition, turning his attention 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 suggesting that the number of people involved in this particular set of studies may have been considerable.

During the Second World War, Trowell also sent liver specimens to Professor Harold Himsworth at the University College in London. Himsworth became interested in Trowell’s work when, in the context of wartime rationing, he was asked to determine the dietary protein requirements of young children. As very little was then known about the repercussions of protein deficiency, Himsworth began conducting experiments with rats and found that, like Trowell’s patients, when deprived of protein they developed a fatty liver, discolored hair, and even slight edema.⁴⁸ Himsworth then became a key advocate of Trowell’s work. Trowell preserved the liver specimens from his severely malnourished patients in his home refrigerator until they could be transported to England: “I would keep the bit refrigerated until I could take it to the plane, in the hope that it hadn’t ‘gone bad’, as you might say, by the time it got to London. I’d put some of it in pickle sometimes.”⁴⁹ He would, of course, as he later explained, warn his wife by letting her know “look, you mustn’t let the boys cook this.”⁵⁰ What the “boys” who cooked for Trowell and his family thought of the pickled liver specimens that were kept in the home refrigerator will probably never be known. It is, nonetheless, likely that such practices spurred scandalous rumors about the colonial medical officer conducting research on severely malnourished children.

The breakthrough in the search for the etiology of the condition finally came at the end of the Second World War when a new pathologist, Jack Davies, joined the staff at Mulago. Davies was already aware of Trowell’s nutritional research before he arrived in Uganda, and, unlike his predecessor, was eager to assist in future nutritional studies. He immediately agreed to conduct thorough postmortem examinations, and in the first child he examined, Davies found the long-awaited pathological link between the highly fatal condition and protein deficiency. The child’s pancreas was atrophied and the degenerate condition of the pancreatic cells indicated that the child’s pancreas had not been secreting digestive enzymes. This crucial discovery appeared to substantiate Williams’s protein hypothesis, as enzyme synthesis is dependent on adequate supplies of dietary protein. It was then that, in order to honor Williams and her foresight, Trowell began to refer to the condition as kwashiorkor. Pancreatic atrophy also explained why severely malnourished children were not easily treated. Even protein-rich foods like milk were of limited therapeutic value without sufficient protein to produce the digestive enzymes needed to breakdown and absorb essential nutrients. It was a vicious cycle: children suffering from severe acute malnutrition simply could no longer fully digest and absorb the food they consumed.⁵¹

To verify that the pancreatic atrophy occurred prior to death and not as part of a process of rapid decomposition, it was necessary to perform further autopsies within twenty minutes of the child’s death. This was not possible during the day when both Trowell and his colleagues were needed in the hospital wards. “It was possible at night if,” as Davies explained, he and Trowell “coordinated well.” Trowell would inform Davies that “he had a dying child expected to die in the night . . . [and Davies] would wait ready in the morgue . . . till a scuffle outside indicated Hugh’s arrival with the body of the sad victim he had pronounced dead only a few minutes before.”⁵² So little time had passed between when the children were pronounced dead and their delivery to the morgue that according to Davies, “usually the muscle twitched as [he] rapidly did a postmortem getting the essential organs into fixative as the time dictated.”⁵³ Trowell and his colleagues were aware of the sensitivity that such work required and did take precautions. They would only remain in the morgue long enough to get the specimens into the fixative, and would wait until the next morning when they were delivered to the laboratory to analyze them. “For,” as Davies explained, “never were Europeans allowed by the staff to carry anything other than papers from the morgue. This was in deference to local feelings. . . . Autopsies performed by Europeans in Mulago Hospital were closely watched, as were the pathologists. It would have been a very upsetting thing if a new pathologist, lithe and slender had become stout for the darkest suspicions would be aroused.”⁵⁴ In the end, as we will see, such precautions proved to be insufficient and did little to assuage a growing set of local concerns.

This important development in the long search for the etiology of kwashiorkor came at a significant moment in the rise of international medicine. In October 1949, an Expert Committee on Nutrition formed jointly by the United Nations Food and Agricultural Organization (FAO) and the World Health Organization (WHO) held its first meeting in Geneva. Kwashiorkor, described as “one of the most widespread nutritional disorders in tropical and sub-tropical areas,” was high on the agenda, and Trowell was asked to prepare a memorandum on the condition for the committee’s consideration.⁵⁵ The committee resolved to conduct an investigation of kwashiorkor in sub-Saharan Africa beginning with a visit to Mulago Hospital in order to first consult Trowell and his colleagues in Uganda. The subsequent WHO report, Kwashiorkor in Africa, was based in large part on evidence from Mulago and became the seminal study in the growing international focus on protein malnutrition.⁵⁶ A second meeting of the Joint FAO/WHO Expert Committee on Nutrition centered largely on discussions of this seminal report, concluding with a resolution to conduct further surveys.⁵⁷ Delegations later sent to Central America and Brazil confirmed that kwashiorkor was a worldwide problem requiring immediate action.⁵⁸

The pathological evidence that appeared to connect the condition to protein deficiency did not immediately gain widespread acceptance, however, especially in Uganda. The pancreatic atrophy explained why it was so difficult to treat severely malnourished children, but it did not provide a clear way to address this problem. Experiments with pounded steak and desiccated hog stomach were disappointing and, in Uganda, as Davies later explained, they simply “had no special high protein material to feed the children.”⁵⁹ Ongoing therapeutic failure fueled doubts that were compounded when the pancreatic atrophy found at autopsy could not be independently verified. At the time it was not known that the changes to the pancreas were only visible in children who died prior to receiving any treatment. The rapid recovery of the pancreas in children given sufficient milk reversed the signs of pancreatic atrophy found by Davies and Trowell.⁶⁰ The next step was to examine the secretion of pancreatic enzymes, and the British Medical Research Council (MRC), now headed by Himsworth, sent an expert who had been working on a new procedure to extract the contents of the small intestine from a tube inserted through the stomach with the guidance of an x-ray. The procedure furnished further evidence that the production of digestive enzymes was severely suppressed in children suffering from severe malnutrition. But before they had a chance to complete the analysis of their findings and publish the results, nutritional research in Uganda was swept up in a political insurrection with far-reaching consequences for future medical research in the region. As it turns out, this further extraction of fluids and tissues from severely malnourished children, who had very slim chances of survival, may have actually done more harm than good.

Muwazi and the Insurrection of 1949

On April 25, 1949, thousands of Ugandans gathered at the central palace of the kabaka, the king of Buganda. By 10:00 a.m., an estimated four thousand people were reportedly pressing against the palace gates. Leaders of the political organizations representing the protesters were allowed to enter the palace and present the kabaka with a set of demands, but tensions remained high, and more than a thousand people reassembled at the kabaka’s palace early the next morning. Attempts to disperse them with baton charges erupted in violence. Arson and looting spread rapidly throughout the Ugandan capital and into the outlying districts of the south-central Kingdom of Buganda and continued for several days.⁶¹ The violence explicitly targeted the property of specific individuals, including members of the Ganda chiefly class, elite Ganda officials, the Indian community, and a Ugandan doctor, Eria Muwazi.⁶² Muwazi was at the central Ugandan hospital on Mulago Hill when news broke that his property and home had been destroyed. Muwazi feared that he and his family were in imminent danger and unsuccessfully sought police protection.⁶³ He believed he was “a marked man” because, as another medical officer reported, “Muwazi is said to kill children by taking blood.”⁶⁴

Mounting dissatisfaction with the ongoing experimentation on severely malnourished children who continued to die converged, in the late 1940s, with political unrest, contributing to what was already an explosive situation. Attention to this moment in the history of nutrition research in Uganda sheds light on how parents and guardians of severely malnourished children and their communities viewed these initial efforts to determine the cause of the condition. Pickling liver specimens and keeping them in the refrigerator until they could be flown to Europe would spur rumor and raise suspicion in any context. When combined with the risky and often experimental procedures performed in this period, such practices were sufficient to raise local concerns. But what made these practices especially alarming was the fact that, prior to the early 1950s, little if any progress had been made in the treatment of severe acute malnutrition. As Trowell later acknowledged, they were “not getting much information out of it.”⁶⁵ This meant that the biopsies, autopsies, nitrogen balance studies, and extensive blood taking had not yet translated into clear benefits for dying children. In the period leading up to the 1949 insurrection, mortality rates associated with the condition remained very high, with rates at Mulago still in the order of 40 to 60 percent and WHO citing mortality rates in Africa as high as 90 percent.⁶⁶ Against this background, accusations that Muwazi “kill[ed] children by taking blood” became emblematic of an escalating set of economic and political grievances in late colonial Uganda.⁶⁷

Across the continent, the 1940s were a period of heightened political dissent and labor activism. In Uganda, workers calling for higher wages and crop prices organized a general labor strike in 1945, and in both the labor strike and the political insurrection that followed, political activists sent a clear message that the increasing economic constraints of the postwar period represented a failure of political leadership.⁶⁸ Despite distinct visions of how best to achieve a more just and equitable society, activists shared a strong objection to the unethical abuse of power for personal gain in colonial Uganda. The landed oligarchy of Ganda chiefs and Indian middlemen became obvious targets of unrest, as postwar inflation created great hardship for ordinary Ganda and intensified longstanding accusations of profiteering on the part of the Indian middlemen.⁶⁹ The worsening economic situation exposed the practice of indirect rule in Buganda as an inherently autocratic and oppressive system. The inaction of Ganda chiefs and officials in the face of economic and political threats to general welfare and wellbeing indicated that their alliances were with the British rather than with the people, making them targets of the insurrection.⁷⁰ When the delegates met with the kabaka in 1949, they sought to critique this enduring alliance between the British and the landed chiefly class, and they notably couched their grievances in references to hunger and starvation.⁷¹ One representative told the kabaka, “people are undernourished, they eat bad food because they have no money.” Another claimed that “the people outside there are in agony. . . . The growers are dying from hunger.”⁷²

Many of the grievances that fueled unrest in this period coalesced in the figure of the elite Ganda doctor and aspiring politician, Eria Muwazi. After graduating from Makerere in 1934 with the prestigious Owen Medal, Muwazi became the senior African medical officer and “medical tutor” or “African Registrar” at Mulago, making him an especially prominent member of the medical profession in Uganda. “By the later 1940s,” the historian John Iliffe notes, “medical graduates had become the elite of the elite. . . . They were professional men . . . with growing families and many social contacts. They were invited to tea at Government House [and] became the first African members of official boards.”⁷³ For Muwazi this was especially true. As the central figure in the formation of the Makerere Medical Graduates Association, Muwazi led the struggle for official recognition of their professional status. He was the first East African to publish in a scientific journal, later became a high-ranking politician closely connected to the kabaka, and was named the third most important figure in the parish in a 1955 survey of a Kampala suburb.⁷⁴ Moreover, Muwazi remained a prominent member of the ruling elite and became involved in the controversies that sparked political crisis in the postcolonial period.⁷⁵

Muwazi’s particularly prominent position within the social and political hierarchy of Buganda alone might account for the destruction of his house in 1949. Yet the fact that mortality rates associated with severe acute malnutrition remained extremely high in this period meant that Muwazi’s work with Trowell involved extracting blood from severely malnourished children who had very slim chances of recovery. Muwazi’s professional knowledge and skill, therefore, entailed working closely with British Protectorate officials in a capacity that increased his personal wealth and prestige, without any clear benefits for the children brought to the hospital for treatment and care. Far from suggesting an “unsophisticated” misunderstanding of biomedical procedures, as some argued, connecting blood-taking accusations leveled at Muwazi to his nutritional research reveals a local dissatisfaction with and distrust of the biomedical work that was being carried out on Mulago Hill.⁷⁶ Those who targeted Muwazi and destroyed his house sought to critique a depraved form of political leadership in Buganda and the lengths to which some Ganda were willing to go in order to achieve and maintain an elite status. They sought to critique ongoing experimentation on severely malnourished and dying children. Understanding the attack on Muwazi’s property as a local indictment of his nutritional work makes it possible to then examine the resulting consequences for the future of nutritional research, treatment, and prevention in Uganda.

“No Survey without Service”

Expatriate physicians and colonial officials routinely disregarded African objections to biomedical practices as ignorance and suspicion rather than valid critique and concern. Yet in the aftermath of the insurrection, they exhibited a far more heightened awareness of the explosive potential of blood work. Clear steps were then taken to reduce local resistance to blood taking procedures and to ensure that future nutritional research proceeded with a much greater degree of caution. Even without fully appreciating the connection between the accusations against Muwazi and the insurrection, the colonial administration and physicians working on Mulago Hill responded to this local engagement with medical work by implementing more ethical research protocols.

Immediately after the insurrection, nutritional research entered what one physician generously referred to as a “rather intensely speculative phase.”⁷⁷ Officials temporarily suspended further nutritional research, and due to concerns that he “experimented on children,” Trowell was passed over for promotion.⁷⁸ His junior colleague was appointed the new Professor and Chair of Medicine at Makerere, the pediatric department was moved to a different building, and Trowell was transferred to different ward.⁷⁹ In an interview with his daughter many years later, Trowell regretfully acknowledged that his research prior to the insurrection involved questionable experiments:

At first I didn’t realize how dangerous they were—taking blood, and doing other things to the liver, liver biopsies, and so on. In the end I thought, we’ve certainly lost one case, we may have lost two cases, by this investigation. We didn’t realize this when I started. So I cooled off, and said, we can’t go any further with this. We’re not getting much information out of it, and really all this taking of blood, and the rest of it, is upsetting them too much.⁸⁰

Trowell was not alone in his efforts to “move more cautiously,” as he put it.⁸¹ The insurrection prompted a deliberate shift in the practices of nutritional research in Uganda. When the MRC began making arrangements to establish an Infant Malnutrition Research Unit on Mulago Hill in 1951, for example, authorities in Uganda insisted the MRC secretary promise the unit would not conduct “school or institutional trials . . . in such a way as to upset susceptibilities.”⁸² The MRC researcher who had been sent to Uganda prior to the insurrection to extract pancreatic enzymes even considered relocating due to the “difficulties created by the political situation and local feeling about blood sampling.” She chose instead to spend several months testing a less invasive method of taking blood, which, she explained, “was an essential preliminary in this country as procedures involving repeated venepuncture would be doomed before they began.”⁸³ Another physician made a clear reference to Trowell’s nutritional research, warning that “extreme caution is necessary, as even finger-pricks are the subject of much suspicion and rumor. It is popularly supposed that Europeans take away African blood and sell it. A rumor of this kind can undo the results of years of hard work.”⁸⁴

This shift in research protocols was especially evident when Dr. Rex Dean, an established expert in nutritional science, arrived in Uganda in 1951 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 even led to new categories of illness in Buganda. The word used to designate sickness and disease, obulwadde, could be qualified in order to specify whether they were illnesses requiring consultation with local healers (basawo) and were thus endwadde ez’ekiganda, Ganda diseases, or illnesses that could be treated by a European doctor, known as endwadde ez’ekizungu (“European diseases”).⁹⁷ Not all forms of sickness and disease required treatment, as in the case of the common cold, and not all illnesses could be treated. Forms of debility and disease for which little or nothing could be done were known in Buganda as olumbe.⁹⁸ The emergence of a category of illness that required biomedical treatment rather than consultation with a healer points to a general willingness to seek hospital therapy when it was proven to work. This was especially evident across East and other regions of Africa with the introduction of highly effective yaws and syphilis treatments. As soon as people saw that a single shot rapidly reversed all visible symptoms, demand for injections skyrocketed. In Kenya such demands exceeded the capacity of existing facilities and treatment camps had to be erected.⁹⁹ The popularity of injections for syphilis at the rural maternal and child welfare clinics in Uganda, was, as already noted, substantial enough to generate revenue supporting the work of the CMS-run Mengo Hospital, the largest medical mission station in East Africa.

But not all ailments could be effectively treated in the hospital. As one African medical worker at Mengo was quoted as saying, “My father has worked in the hospital for thirty-five years and he knows how many diseases Europeans cannot cope with.”¹⁰⁰ Until mid-century, severely malnourished children were either diagnosed as syphilitic and, according to a physician at Mengo, were given “bismuth injections until they would end up in a toxic state with a blue line around the lips,” or they were treated with deworming medications or the newly discovered B vitamins, among a range of other largely ineffective forms of treatment and care.¹⁰¹ Only a small fraction of the severely malnourished children brought to the hospital in the period of diagnostic uncertainty survived. Parents and guardians of malnourished children who turned first to their local remedies were not acting according to an irrational or traditional mind set. Until effective therapies were developed in the early 1950s, they had little reason to have faith in hospital therapy. In fact, prior to the adoption of more ethical and cautious methods, parents and guardians had much to fear. The ongoing centrality of blood work even after the advent of effective therapies and a more cautious approach meant that anxieties surrounding the hospital treatment of severely malnourished children subsided more slowly than might have otherwise been the case.¹⁰²

References to patients “absconding from hospital,” “running away,” or refusing specific procedures remained frequent through the early 1950s. Often such flight or noncompliance reflected uncertain outcomes, as Dean and others experimented with different therapies. One trial, for example, involved feeding children a variety of locally available foods, and in a number cases the child’s condition deteriorated or failed to improve. Parents reportedly and not surprisingly responded by removing their children from hospital care.¹⁰³ Another trial, which achieved the highest degree of therapeutic success up to that point, saw over thirteen percent of the children removed from the hospital before making a full recovery.¹⁰⁴ The trepidation with which many parents and guardians approached hospital treatment of severely malnourished children led, at times, to tragic consequences. One child, Mukandekeze, was just two years old when her parents brought her to Mulago Hospital suffering from severe acute malnutrition. Clearly uncertain about the range of procedures performed on malnourished children at Mulago, Mukandekeze’s parents refused to allow hospital staff to tube-feed her for very long. After three weeks and with little improvement in her condition, they removed Mukandekeze from the hospital. They continued to take their daughter to a child welfare clinic not far away, but Mukandekeze remained seriously ill and six months later she died.¹⁰⁵

Not all decisions to remove children from the hospital prior to an official discharge were the result of dissatisfaction with the therapy provided or even unease with specific procedures, although this was often the case. Many parents or guardians of severely malnourished children chose to leave the hospital at the earliest sign of positive therapeutic outcome and their actions may simply reflect satisfaction with treatment and a desire to return home. Parents frequently demanded early discharge as soon as their child’s edema dissipated and their appetite improved.¹⁰⁶ One child, Namadu, who had been brought to Mulago for treatment on a number of occasions, was admitted with severe acute malnutrition again in 1952. As soon as Namadu’s edema diminished and he showed clear signs of recovery, his parents removed him from the hospital, or in the typical biomedical shorthand of the time, they reportedly “ran away.”¹⁰⁷ The vast majority of those who removed their children prior to an official discharge, however, reveal a lingering set of misgivings over procedures performed on severely malnourished children in Uganda. In the examination of pancreatic enzymes discussed above, for example, 20 percent of the children died and as many “ran away” before physicians could extract digestive enzymes a second time.¹⁰⁸

The decision to bring a severely malnourished child to the hospital for treatment was not a decision parents and guardians took lightly. In addition to transportation expenses, time spent with a sick child in the hospital meant neglecting work and household duties, including the cultivation of food and cash crops, the care of other children, and the collection of water and firewood.¹⁰⁹ Given the burdens of lengthy periods of treatment, parents undoubtedly demanded discharge or simply removed their children from the hospital as soon as recovery appeared certain due to such practical considerations. Yet, a decade after the development of effective therapies, physicians and scientists working with severely malnourished children at Mulago no longer reported that parents refused specific procedures like tube-feeding or removed their children before they were officially discharged. This absence alone is telling. As we will see in the next chapter, those working to treat and prevent severe acute malnutrition in later decades faced a different set of concerns due to growing demands for hospital therapy. This contrast reveals that parents of severely malnourished children remained concerned about the questionable research practices for a number of years after they were replaced by a more cautious approach.

Physicians and scientists working in Uganda in this period were fully aware that people lacked confidence in the hospital treatment of severe malnutrition. In addition to their frequent references to patients “absconding from hospital” or running away, they openly acknowledged that malnourished children were rarely brought to them for treatment. According to Trowell and his colleagues, “it is only in exceptional circumstances . . . that children are brought to any hospital because they are suffering from kwashiorkor. . . . They are brought to hospital largely because they have acquired some well-recognized infection.” As a result, “expeditions into the villages were necessary to convince mothers that their children . . . had an illness which could be treated in hospital.”¹¹⁰ This reticence to seek hospital treatment for malnutrition meant that throughout this period, children were only brought to the hospital as a last resort and only after a range of local remedies had been tried.

Physicians treating severely malnourished children often found that parents first sought treatment for a number of locally recognized illnesses. The principal one was obwosi, a condition signaled not by a specific set of symptoms, but by signs of illness in a child whose mother had become pregnant.¹¹¹ The “heat” from the subsequent pregnancy was seen as the cause of illness and in order to prevent or alleviate obwosi, a newly pregnant mother ceased breastfeeding and physically distanced herself from her child by no longer sleeping in the same bed or carrying her child in a sling or ngozi.¹¹² Pregnancy and fears of obwosi were also a pretext for sending a young child to live with an aunt or grandmother.¹¹³ Conditions associated with specific symptoms of severe acute malnutrition included omusana, which attributed the lightening skin hue and loss of hair pigment to sun exposure; obusulo and empewo, which were linked to swelling; and ekigalanga, a condition characterized by fever, diarrhea, abdominal pain, appetite loss, and cold feet.¹¹⁴ Ekigalanga and empewo were both conditions connected to spiritual forces requiring spiritual remediation. Obusulo was an illness caused by seeds entering a child’s body and treatment focused on their removal. Children diagnosed in the hospital as severely malnourished often had many small incisions in their skin, at times with a paste containing ash from burnt plantains applied 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