The Riddle of Malnutrition. Jennifer Tappan

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.