The Riddle of Malnutrition. Jennifer Tappan

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СКАЧАТЬ 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 diminishing resources of overcrowded Native Reserves or as squatters and tenants on white-owned farms. The agreement, together with the completion of the Uganda Railway in 1901, set the stage for the rapid development of a flourishing export-oriented cash-crop economy, based initially on the small-scale peasant production of cotton and later on the far more lucrative cultivation of coffee. For average Ganda, most other avenues of upward mobility were effectively blocked by the Indian and expatriate monopoly on the processing and marketing sectors of the Ugandan economy.³²

      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.

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      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 СКАЧАТЬ