As the commercial and administrative center of the British Protectorate, Buganda was also the hub of both government and missionary education and medical provision. Albert Cook of the Church Missionary Society (CMS) established the largest and most successful medical mission station in East Africa on a hill not far from the capital or kibuga of Buganda. As in other regions of the continent, education and medical services for African populations were initially the sole purview of the missionaries.33 Particularly in the wake of a devastating sleeping sickness epidemic and concerns over demographic decline linked to venereal infections, the colonial government did eventually begin providing medical services and training medical auxiliaries.34 The very high standards of medical training achieved at Mulago transformed the associated vocational school into a major research university. By the late colonial period, the Mulago medical complex was a center of research and training, drawing the best students from Uganda, Kenya, present-day Tanzania, and other regions of the continent.35 It was this strong foundation of medical training that made Uganda a site of cutting-edge biomedical research—research initially focused on understanding and treating severe acute malnutrition.
MAP I.1. Uganda. Map by Shawna Miller.
The Riddle of Malnutrition traces longstanding efforts to understand, treat, and prevent severe acute malnutrition. These efforts initially served to medicalize the condition in the eyes of both biomedical personnel and the Ugandans who brought their severely malnourished children to the hospital for treatment and care. Medicalization meant that the condition came to be seen as a disease and a medical emergency.36 My analysis explores how this understanding of the condition undermined prevention with unintended consequences, further imperiling the health and welfare of young children in Uganda. Biomedical personnel responded to the failure of prevention by launching Africa’s first nutrition rehabilitation program. The program they designed aimed to demedicalize malnutrition, to learn from past mistakes, and it is one of the arguments of this book that the apparent efficacy and remarkable longevity of the nutrition rehabilitation program was the result of this critical reflection on the inadequacies of prior initiatives. Examining the perspective that was thereby gained reveals the immense value of historical epidemiology. It also shows how the advent of a novel public health approach to severe acute malnutrition built on Uganda’s strong foundation of biomedical training and expertise and local engagements with biomedical treatment and care. As the program evolved it became a truly local initiative with a lasting legacy in at least one part of Uganda and with, at one time, aspirations to become a national program promoting nutritional health among all Ugandan children. How such a program could be largely forgotten outside Uganda is also a part of this history, and the potential implications of this unwitting amnesia are considered in a final examination of how recent innovations may return us to an earlier era when a medicalized approach compromised nutritional health in Uganda. This study is written in part to try to break this cycle of neglecting past public health initiatives as a new generation works to devise and advocate for policies, technologies, and programs that promise a healthier and more secure future for people around the world.
1
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