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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 sight of his goal to prevent malnutrition, but in the end his major contribution to applied nutritional science was the development of a highly effective and highly curative therapy. Moreover, given his mandate to develop a vegetable-based preventive mixture, as he had done in Germany, Dean’s high-protein therapy ironically ended up being a milk-based formula that mixtures of vegetable proteins could never rival.

Faced with the startling mortality rates of malnourished children at Mulago Hospital, Dean could not afford to squander time developing a plant-based therapeutic mixture. Once mortality rates fell, he would turn his attention to local sources of vegetable proteins that could become the basis of effective prevention. In the meantime, Dean sought to treat malnourished children with milk simply because dried skimmed milk was the most inexpensive and accessible source of protein in Uganda at the time. As a waste product in the manufacture of butter in Europe and the United States, ample supplies of dried skimmed milk were easily acquired in the postwar period.³ But skim milk was not without its shortcomings. Although it was not known at the time, many severely malnourished children in Uganda were lactose intolerant and developed diarrhea in response to the skim milk–based formula. Diarrhea is a very common symptom of lactose intolerance, but is extremely dangerous in already acutely malnourished children. One twelve-month-old child undergoing treatment in this early period of therapeutic experimentation developed such loose stools that her weight loss forced Dean to stop her treatment altogether. Fortunately, she did eventually make a full recovery, but her experience and similar reactions among other severely malnourished children indicated that, on its own, skim milk was not a satisfactory form of treatment. Dean dealt with this dilemma by reducing the amount of skim milk and supplementing the mixture with Casilin, a commercially produced preparation of calcium caseinate containing an 80 percent concentration of milk protein. Despite the added cost, this high-protein therapeutic formula was a resounding success. Even before cottonseed oil was added to the formula in order to compensate for the diminished caloric content, Dean and his team in Uganda were able to celebrate the development of the first effective therapy for severe childhood malnutrition (see fig 2.1).⁴

But the development of Dean’s high-protein formula was only part of the story. Given that the severely malnourished children brought to the hospital were already in such an acute state upon arrival and had considerably diminished capacities to digest and absorb even essential nutrients, Dean insisted on the institution of what he called “dietary discipline.” Coining the term “dietary discipline” emphasized that the provision of dietary therapy in severely malnourished patients was comparable to the provision of drug therapy to treat infection.⁵ In the regimented system of infant feeding that Dean developed, a precise amount of protein and calories, determined by the child’s weight, was prescribed and administered at specific intervals throughout the day and night. The high-protein therapy was prepared in a glass bottle that in order to avoid spoilage had to be replaced on six-hour rotations.⁶ In fact, under Dean’s direction all aspects of treatment then became standardized. Secondary infections were so prevalent that, in the initial week of treatment, routine therapeutic measures included daily injections of penicillin, whether or not an infection was evident. Children also automatically received treatment for malaria, anemia, dehydration, and potassium loss.⁷ In responding to the severe condition of the malnourished children brought to the hospital, dietary discipline transformed the treatment of severe acute malnutrition into a highly curative, hospital-centered experience involving tubes, formulas, syringes, IVs, and injections (see fig 2.2).

FIGURE 2.1. Child treated for kwashiorkor at the MRC Infantile Malnutrition Unit, Mulago Hill. Source: Annual Report of the Medical Department, for the year ended December 31st 1955, Ministry of Health, by permission of the Ugandan National Archives.

Only two years after arriving in Uganda, Dean could report in the Lancet that the concentrated milk-protein formula had already succeeded in reducing the mortality rate to between 10 and 20 percent, a significant achievement given the 75 to 90 percent mortality reported in the 1930s and 1940s by Trowell and others.⁸ Biochemical measures of recovery and rehabilitation provided equally compelling evidence of the formula’s therapeutic efficacy. Total levels of protein found in the blood, for instance, doubled within one week and reached expected levels for healthy children around the third week of treatment.⁹ For a child to achieve a full recovery required the resumption of weight gain and growth at rates that would facilitate the catch-up needed for a stunted child to reach the weight and height considered standard or normal for her age. Only in exceptional cases was it possible to keep a child in the hospital long enough to observe this final phase of rehabilitation.¹⁰ The few children who were treated for extended periods with high-protein therapies gained weight at accelerated rates, which over time could eventually reverse their underweight and stunted stature. One child, Bandiho, weighed five kilograms below the American standard when she began her therapy, but grew three and a half times more quickly than normal and began to reach the typical weight for her age after a year of hospital treatment.¹¹

FIGURE 2.2. “Kwashiorkor in a 17 month old Ganda boy, showing syringe feeding . . . through a fine polythene tube.” Source: D. B. Jelliffe and R. F. A. Dean, “Protein-Calorie Malnutrition in Early Childhood (Practical Notes),” Journal of Tropical Pediatrics, December 1959, 96–106, by permission of Oxford University Press.

Despite the lengthy period required to reach healthy measures of growth, the initial phase of recovery involved a highly visible and striking set of transformations in a child’s condition, all of which occurred at a phenomenal pace. Even in the very severe cases that were brought to the hospital, nearly all of the most prominent symptoms began to improve within ten days and in some cases by the end of the first week. The anorexia that frequently made intragastric tube feeding necessary subsided so rapidly that children rarely had to be tube-fed the high-protein formula for more than two days.¹² The edema also promptly diminished, as did the rash or dermatosis and the fatty buildup beneath the skin. After only one week of Dean’s treatment, children who had been listless and apathetic began to clearly take an interest in their surroundings, and this improvement in their demeanor was interpreted as a clear sign that they were on the road to recovery.¹³ The formula’s capacity to rapidly and visibly resuscitate children who had been very near death did eventually contribute to shifts in local perceptions of hospital treatment even if the ongoing blood work at Dean’s MRC Unit on Mulago Hill meant that such shifts took longer than might otherwise have been the case.

In time local concerns over experimental procedures and reports of parents refusing treatment and absconding from the hospital gave way to signs of increasing acceptance of hospital therapy. By the early 1960s, if not before, growing local confidence became outright demand. Thus the development of the highly effective and highly curative emergency measures capable of saving the lives of severely malnourished children ushered in a distinct turning point in local views of and engagement with biomedical treatment of severe malnutrition. One of the physicians working in Uganda in this period, Mike Church, wrote for example that “the dramatic intravenous and intragastric therapies, which were often lifesaving, were expected by mothers. In fact, the fame of the hospital resulted in some mothers traveling hundreds of miles” in order to obtain treatment for their severely malnourished children.¹⁴ What had been an illness of olumbe, a condition for which there was no hope, became something else. What had been an illness prompting physicians and scientists to perform a myriad of highly extractive and experimental procedures on children who nonetheless died became a condition for which routine emergency measures could all but guarantee recovery and survival. No longer did physicians write of patients absconding from the hospital. Instead, the medicalization of malnutrition, the effective response to the severe condition in which children arrived, led to a growing local demand for life-saving hospital procedures.

The development of a novel therapy also signaled a new disease entity in both biomedical and Ganda diagnostic registers. For the biomedical community, the success of Dean’s high-protein therapy appeared to prove that the condition was a form of severe protein deficiency and, recognizing Williams’s earlier insight, the Ghanaian term kwashiorkor became the internationally recognized name for the condition. The condition for which Ugandan parents traveled great distances to obtain hospital treatment was known, for a brief period, as olbuwadde bw’eccupa or “bottle disease.” Like its Swahili counterpart, eccupa (pronounced “chupa”) is the Luganda term for “bottle” and the notion of eccupa disease reflects the bottles and tubes that were so central to the treatment of severely malnourished children. As Church later remembered,

We actually discovered that they had created a new mythology, they had a new word for kwashiorkor . . . they called it eccupa disease. Eccupa being the bottle and of course the bottle was the intravenous and intragastric feeding. So when they went into the pediatric wards they would immediately be put on drips, which would be intragastric feeding and intravenous fluids, and the mothers watched this with great wonder because of course, in the wards, that was what transformed them.¹⁵

In Ganda diagnostics and etiology, this transformation confirmed the diagnosis: olbuwadde bw’eccupa was a condition that required hospital treatment and a veritable barrage of therapeutic measures centered around bottles containing prescribed amounts of Dean’s skim milk formula. A new and effective treatment indicated the presence of a new disease, one that for both biomedical practitioners and Ganda observers was seen to require extensive and immediate medical attention. Whether known as kwashiorkor or eccupa disease, this medicalization of malnutrition was to have far-reaching consequences for child health and welfare, especially as it shaped both international perceptions of the condition, the resulting programs of prevention, and local engagement with these preventive measures.

Defining the Gap

Even before Dean’s high-protein formula appeared to provide the final confirmation that severe acute malnutrition was caused by protein deficiency, the condition was seen as a worldwide scourge demanding intervention. The international attention on protein malnutrition during the 1950s was such that one expert claimed that “in human nutritional studies and in international public health this has been a protein decade.”¹⁶ This view was also echoed by the head of the nutrition department in Bombay, who wrote, “We have moved from the era of vitamin research to the era of protein research.”¹⁷ The international response reflected particular interpretations of the mounting evidence implicating protein, and much of that evidence emerged from Uganda. The medicalization of malnutrition on Mulago Hill not only launched the “protein decade,” but continued to have an influence for many years. When the Joint FAO/WHO Expert Committee on Nutrition held its second meeting in 1952, the proceedings were dedicated entirely to the condition and Trowell, Davies, and Dean presented the findings of their latest research.¹⁸ Suddenly thrust onto the world stage as an international center of nutrition research, Dean’s MRC Infantile Malnutrition Research Unit was in a position to shape how the condition was understood and what was to be done about it. Moreover, the fact that the protein decade coincided with the postwar development era was far from coincidental. Efforts to contend with the problem of protein malnutrition reflect the international faith that was placed in scientific solutions to the problems facing so-called developing world regions. The potential promise of Dean’s high-protein therapy, its simplicity and visibly transformative impact on child health, emboldened those persuaded by the proverbial magic-bullet, one-size-fits-all approach. It was in this way that a specific framing of the problem of protein malnutrition, temporarily at least, foreclosed alternative ways of promoting nutritional health.

The first move in the increasingly narrow and highly medicalized definition of the condition was to confine the problem of severe malnutrition solely to young children. Initially people of all ages were included in studies of severe malnutrition and the steady stream of immigrants who came from present-day Rwanda and Burundi and arrived in severely malnourished states were, as we have seen, an important part of early studies of nutritional health in Uganda. In fact, research on protein malnutrition in adults was so central to the work carried out in Uganda that an entire part of the seminal text that Trowell, Davies, and Dean published on kwashiorkor in 1954 was devoted to protein malnutrition in adults and the symptoms observed in adult cases were not regarded as entirely distinct from the infantile syndrome.¹⁹ With the advent of an increasingly medicalized vision of kwashiorkor as a medical emergency, the focus shifted to young children. It was the WHO’s seminal report, Kwashiorkor in Africa, that first narrowly defined the condition exclusively as a childhood illness. Even while acknowledging that “a syndrome very similar to kwashiorkor is undoubtedly encountered in other age-groups and even in adults,” the authors of the report argued that the condition known as kwashiorkor should be confined to children and especially to children in the weaning phase of life.²⁰ The rationale was that the protein requirements for growth and development were higher in children under five years of age than at any other point in the life cycle.²¹ Young children were thereby particularly susceptible to severe protein deficiency and the condition posed a much greater threat to their survival. This pronounced prevalence, severity, and mortality made young children an obvious and understandable focus of medical research and attention.²² With the publication of the 1952 WHO report, the medicalization of malnutrition, in which children were not brought to the hospital until their condition had become so severe that they required emergency measures to save their lives, came to therefore define the condition and circumscribe the resulting international response. Rather than a broad public health concern requiring comprehensive interventions, this narrow definition of the problem prompted a far more limited and targeted solution.