The Riddle of Malnutrition. Jennifer Tappan

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СКАЧАТЬ to develop a therapeutic groundnut (peanut) biscuit, and the discussion of their methodology provides the most detailed description of balance beds in this period:

      The balance beds which have been in use in the [MRC] Unit for several years, allow for the separate collection of urine and feces. . . . A harness around the trunk and legs limits movement but does not entirely prevent it. . . . The accuracy of all balance methods depends to some extent on the regular voiding of feces, which could not, of course, be assured in our children. Extending the length of the periods reduces the importance of inaccuracies, but two four-day periods necessitated a total of fourteen days continuously on the balance bed, and we believed that to be long enough for the children and the staff.

      Moreover, as Dean and his colleague noted, “The wards of the Unit have large glass windows, and the children were under continuous observation. . . . Each child was weighed, and bled from the internal jugular vein before and after each period.”⁹⁴ This continuous extraction of blood as a central feature of nutrition research before and after the insurrection was not without consequences. The advent of a more cautious approach and the development of treatment were crucial if nutritional research on young children was to continue in Uganda, but they could not immediately erase the impact of the questionable experimentation that had been performed on dying children during the period of heightened diagnostic uncertainty in the region.

      FIGURE 1.1. “Bed for metabolic studies,” c. 1952. Source: Colonial Office, Malnutrition in African Mothers, Infants, and Young Children: Report of the Second Inter-African Conference on Nutrition, Fajara, Gambia, 19–27 November, 1952, 377 (plate 2) (London: H. M. Stationery Office, 1954), by permission of The National Archives.

       An Illness of Olumbe

      Even with the advent of effective therapy and a more cautious approach, parents of severely malnourished children remained wary of hospital treatment. The damage had been done and local apprehensions did not diminish overnight. People continued to turn to existing remedies and healers first, resorting to hospital treatment often in their final hour of need. This tendency to seek treatment from local healers before consulting a European doctor or biomedically trained physician had been widely observed in this and other parts of Africa since the beginning of colonial rule.⁹⁵ Legal sanctions drove local healers underground, but failed to entirely convince people to avoid their services and seek hospital care instead. One physician, who took a special interest in local healing practices, found that even on the eve of political independence, local therapies could be obtained in markets, urban centers, thoroughfares, and near major hospitals and small dispensaries in amounts suggesting extensive and ongoing faith in their efficacy.⁹⁶

      This coexistence of local and biomedical forms of healing even led to new categories of illness in Buganda. The word used to designate sickness and disease, obulwadde, could be qualified in order to specify whether they were illnesses requiring consultation with local healers (basawo) and were thus endwadde ez’ekiganda, Ganda diseases, or illnesses that could be treated by a European doctor, known as endwadde ez’ekizungu (“European diseases”).⁹⁷ Not all forms of sickness and disease required treatment, as in the case of the common cold, and not all illnesses could be treated. Forms of debility and disease for which little or nothing could be done were known in Buganda as olumbe.⁹⁸ The emergence of a category of illness that required biomedical treatment rather than consultation with a healer points to a general willingness to seek hospital therapy when it was proven to work. This was especially evident across East and other regions of Africa with the introduction of highly effective yaws and syphilis treatments. As soon as people saw that a single shot rapidly reversed all visible symptoms, demand for injections skyrocketed. In Kenya such demands exceeded the capacity of existing facilities and treatment camps had to be erected.⁹⁹ The popularity of injections for syphilis at the rural maternal and child welfare clinics in Uganda, was, as already noted, substantial enough to generate revenue supporting the work of the CMS-run Mengo Hospital, the largest medical mission station in East Africa.

      But not all ailments could be effectively treated in the hospital. As one African medical worker at Mengo was quoted as saying, “My father has worked in the hospital for thirty-five years and he knows how many diseases Europeans cannot cope with.”¹⁰⁰ Until mid-century, severely malnourished children were either diagnosed as syphilitic and, according to a physician at Mengo, were given “bismuth injections until they would end up in a toxic state with a blue line around the lips,” or they were treated with deworming medications or the newly discovered B vitamins, among a range of other largely ineffective forms of treatment and care.¹⁰¹ Only a small fraction of the severely malnourished children brought to the hospital in the period of diagnostic uncertainty survived. Parents and guardians of malnourished children who turned first to their local remedies were not acting according to an irrational or traditional mind set. Until effective therapies were developed in the early 1950s, they had little reason to have faith in hospital therapy. In fact, prior to the adoption of more ethical and cautious methods, parents and guardians had much to fear. The ongoing centrality of blood work even after the advent of effective therapies and a more cautious approach meant that anxieties surrounding the hospital treatment of severely malnourished children subsided more slowly than might have otherwise been the case.¹⁰²

      References to patients “absconding from hospital,” “running away,” or refusing specific procedures remained frequent through the early 1950s. Often such flight or noncompliance reflected uncertain outcomes, as Dean and others experimented with different therapies. One trial, for example, involved feeding children a variety of locally available foods, and in a number cases the child’s condition deteriorated or failed to improve. Parents reportedly and not surprisingly responded by removing their children from hospital care.¹⁰³ Another trial, which achieved the highest degree of therapeutic success up to that point, saw over thirteen percent of the children removed from the hospital before making a full recovery.¹⁰⁴ The trepidation with which many parents and guardians approached hospital treatment of severely malnourished children led, at times, to tragic consequences. One child, Mukandekeze, was just two years old when her parents brought her to Mulago Hospital suffering from severe acute malnutrition. Clearly uncertain about the range of procedures performed on malnourished children at Mulago, Mukandekeze’s parents refused to allow hospital staff to tube-feed her for very long. After three weeks and with little improvement in her condition, they removed Mukandekeze from the hospital. They continued to take their daughter to a child welfare clinic not far away, but Mukandekeze remained seriously ill and six months later she died.¹⁰⁵

      Not all decisions to remove children from the hospital prior to an official discharge were the result of dissatisfaction with the therapy provided or even unease with specific procedures, although this was often the case. Many parents or guardians of severely malnourished children chose to leave the hospital at the earliest sign of positive therapeutic outcome and their actions may simply reflect satisfaction with treatment and a desire to return home. Parents frequently demanded early discharge as soon as their child’s edema dissipated and their appetite improved.¹⁰⁶ One child, Namadu, who had been brought to Mulago for treatment on a number of occasions, was admitted with severe acute malnutrition again in 1952. As soon as Namadu’s edema diminished and he showed clear signs of recovery, his parents removed him from the hospital, or in the typical biomedical shorthand of the time, they reportedly “ran away.”¹⁰⁷ The vast majority of those who removed their children prior to an official discharge, however, reveal a lingering set of misgivings over procedures performed on severely malnourished children in Uganda. In the examination of pancreatic enzymes discussed above, for example, 20 percent of the children died and as many “ran away” before physicians could extract digestive enzymes a second time.¹⁰⁸

      The decision to bring a severely malnourished child to the hospital for treatment was not a decision parents and guardians СКАЧАТЬ