The Riddle of Malnutrition. Jennifer Tappan

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