Enduring Engagements
One of the most important facets of nutritional research and programming in Uganda is that it represents a largely uninterrupted effort to understand and contend with a single condition for the better part of a century. This is remarkable because many, if not most, biomedical interventions in Africa from the colonial period onward have been time-limited. Public health projects and programs with end dates seek to make a lasting impact through temporary measures, and these measures are seen to either succeed or fail. Historians of colonial medicine and global health have, especially in recent years, drawn attention to the many insights that emerge from an examination of these targeted endeavors. A key observation is that Africans on the receiving end of health-related work are not merely passive recipients or biomedical subjects. Instead, they interpret and make meaning of health provision in ways that are tied to a complex set of local, and very often historical and thus dynamic, perceptions and experiences.18 It has been shown that interpretations of both research and programming shape how people engage with biomedical projects and programs, how they are incorporated and thereby altered, or rejected and avoided.19 The result has very often been a number of unintended consequences that typically impede stated objectives. Among scientists and public health experts, failure signals the need to return to the drawing board in order to devise better tools and methods, and in the global health context this typically involves packing up and returning to North Atlantic centers of research and policy development. Prior public health programming, especially when unsuccessful, is frequently then forgotten, leaving the lessons of past mistakes sadly out of reach for those launching at times nearly identical initiatives at a later date.20 Yet, when these interventions come to the end of their time frame, they leave a trail of data and reports for later analysis and what historian Melissa Graboyes has recently referred to as “accumulated reflections.” Interpretations and perceptions of medical endeavors accumulate among populations in Africa and elsewhere, and the residue of these past experiences continues to influence their view of and response to future efforts for perhaps decades if not generations to come.21
Recognizing that health-related work leaves a residue of past interactions and encounters and that even time-limited projects have a social afterlife illustrates one of the fundamental shortcomings of neglecting historical epidemiology.22 Assuming that recipient populations are like blank slates in their perceptions of biomedical work overlooks how past experiences and programs influence future initiatives. While communities in Africa may at times be “biological blank slates,” and thus represent unparalleled opportunities for testing new vaccines and drugs, their interpretation of and engagement with such work filters through the residue of past medical projects and programs.23 The long history of nutrition research and programming in Uganda is an opportunity to examine how perceptions of biomedical research and treatment shaped the outcome of such endeavors. My analysis explores how the residue of past medical work fundamentally influenced how people engaged with biomedicine and public health. It asks how the residue of past experiences thereby influenced health-related research and programming. In tracing this influence it also reveals the dynamism inherent in local interpretations and interactions. Even “accumulated reflections” are open to change and, as nutritional work in Uganda shows, were highly responsive to the shifting research protocols and evolving programs of treatment and prevention that they themselves engendered.24
The nutritional work conducted in Uganda for the better part of a century challenges common definitions of global health. According to a recent volume titled Global Health in Africa, global health has its origins in colonial times, but emerged in the post–World War II period and can be defined “broadly to refer to the health initiatives launched within Africa by actors based outside of the continent.”25 Yet, in addition to the ways that local interactions influenced nutritional work in Uganda throughout the period under consideration, it is also true that Ugandans were pivotal to the nutrition research and especially the later programming that are at the center of this study. In fact, both biomedical training and infrastructure in Uganda proved crucial to the evolution and longevity of a public health program that continues to be of great significance to many Ugandans. The public health approach that emerged in Uganda was far more of a local endeavor than it was a global health initiative.26 When initial efforts failed, biomedical personnel returned to the drawing board, but it was a drawing board in Uganda. The research protocols and initiatives that were then devised explicitly harnessed local engagement with biomedicine—they put enduring engagements in the service of public health. In fact, the period of failure that preceded the advent of this novel public health approach was one marked by Uganda’s emergence as an international center of nutrition science and the post–World War II rise of global health.27 In launching Africa’s first nutrition rehabilitation program, the expatriate architects of the initiative saw the errors of existing global health models and devised a new one.
Mulago and the Kingdom of Buganda
The Mulago medical complex has long been the locus of biomedical research and provision in Uganda, and Mulago together with the region surrounding one rural health center constitute the two principal sites of fieldwork for this study. Mulago is one of the many hills that define the landscape of Uganda’s contemporary capital city, Kampala. This urban center has also long been the political capital of Buganda, one of the numerous interlacustrine kingdoms that dominated this region of East-Central Africa prior to colonial imposition.28 Stretching like a fertile crescent across the northwestern shores of Africa’s largest lake, Buganda spans from the Nile River in the east to the Kagera River in the southwest. The kingdom’s controversial northern boundary was extended under British suzerainty to the Kafu River, finalizing a centuries-long process of territorial expansion and regional ascension (see map I.1).29 European explorers and missionaries had been present in Buganda, alongside coastal merchants, since the mid-nineteenth century, but the British did not become actively involved in Buganda’s political affairs until the late 1880s. Through amicable relations and a strategic alliance formalized with the British in 1894, Buganda and the port town of Entebbe became the political and economic headquarters of the British protectorate. Ganda participation in the pacification and administration of other areas within present-day Uganda placed Ganda in an advantageous position and created a divisive context with significant consequences following independence.30
The British were impressed by what they saw as an exceptional example of a progressive and sophisticated state in the heart of tropical Africa, and sought to govern indirectly through Buganda’s highly centralized and bureaucratic structure of chiefs and royal officials. An agreement signed in 1900 established, for the kabaka (king) and the reigning Ganda chiefs, a degree of political autonomy and, notably, freehold rights to virtually all of the productive land in Buganda. Parceled out in estates so vast that they were measured in miles (and became known as mailo), land in Buganda was transformed into the private property of what then became an oligarchy of Ganda chiefs.31 Even as it increased the power of chiefs vis-à-vis ordinary Ganda, this agreement kept Uganda from becoming a settler colony. Ugandans were able to thereby avoid the fate of those in neighboring Kenya and Southern Africa, where, by contrast, land alienation left Africans to subsist on the