of blood work. Clear steps were then taken to reduce local resistance to blood taking procedures and to ensure that future nutritional research proceeded with a much greater degree of caution. Even without fully appreciating the connection between the accusations against Muwazi and the insurrection, the colonial administration and physicians working on Mulago Hill responded to this local engagement with medical work by implementing more ethical research protocols.
Immediately after the insurrection, nutritional research entered what one physician generously referred to as a “rather intensely speculative phase.”77 Officials temporarily suspended further nutritional research, and due to concerns that he “experimented on children,” Trowell was passed over for promotion.78 His junior colleague was appointed the new Professor and Chair of Medicine at Makerere, the pediatric department was moved to a different building, and Trowell was transferred to different ward.79 In an interview with his daughter many years later, Trowell regretfully acknowledged that his research prior to the insurrection involved questionable experiments:
At first I didn’t realize how dangerous they were—taking blood, and doing other things to the liver, liver biopsies, and so on. In the end I thought, we’ve certainly lost one case, we may have lost two cases, by this investigation. We didn’t realize this when I started. So I cooled off, and said, we can’t go any further with this. We’re not getting much information out of it, and really all this taking of blood, and the rest of it, is upsetting them too much.80
Trowell was not alone in his efforts to “move more cautiously,” as he put it.81 The insurrection prompted a deliberate shift in the practices of nutritional research in Uganda. When the MRC began making arrangements to establish an Infant Malnutrition Research Unit on Mulago Hill in 1951, for example, authorities in Uganda insisted the MRC secretary promise the unit would not conduct “school or institutional trials . . . in such a way as to upset susceptibilities.”82 The MRC researcher who had been sent to Uganda prior to the insurrection to extract pancreatic enzymes even considered relocating due to the “difficulties created by the political situation and local feeling about blood sampling.” She chose instead to spend several months testing a less invasive method of taking blood, which, she explained, “was an essential preliminary in this country as procedures involving repeated venepuncture would be doomed before they began.”83 Another physician made a clear reference to Trowell’s nutritional research, warning that “extreme caution is necessary, as even finger-pricks are the subject of much suspicion and rumor. It is popularly supposed that Europeans take away African blood and sell it. A rumor of this kind can undo the results of years of hard work.”84
This shift in research protocols was especially evident when Dr. Rex Dean, an established expert in nutritional science, arrived in Uganda in 1951 to continue research on severe acute malnutrition. At the Infantile Malnutrition Research Unit that he established and directed, Dean implemented a policy requiring that all researchers and physicians working at the unit abide by the maxim “No Survey without Service.”85 For the parents of severely malnourished children brought to the unit, “No Survey without Service” meant an assurance that when their children took part in research, they received cutting-edge treatment and care. This practice was also followed at the unit’s rural Child Welfare Clinic where children living in the surrounding region were offered the medical care needed for healthy growth and development as part of their inclusion in studies of nutritional health and wellbeing.86 Crucially, Dean’s implementation of “No Survey without Service” was possible in the early 1950s in a way that it had not been prior to the insurrection. Immediately after he arrived in Uganda and observed the appalling mortality rates associated with severe malnutrition, Dean set to work devising an effective treatment. By the early 1950s, he had succeeded in reducing the mortality rates of the condition from between 40 and 60 percent down to between 10 and 20 percent.87 In cutting the mortality rates associated with severe malnutrition in half, Dean transformed a condition of almost certain death into one that could be reversed with hospital treatment.88
With an effective treatment in place, nutritional research in Uganda entered a new phase. More ethical research protocols and treatment that could save the lives of severely malnourished children meant that there was much to distinguish this work from the research conducted prior to the insurrection. There was, however, one component that continued unabated: blood extraction. Examining blood samples remained a fundamental and routine component of nutritional research in Uganda because it served a critical function as a tool of diagnosis. Due to the edema, or accumulation of fluid in the tissues, and the buildup of fat in the liver and under the skin, weight was an inaccurate indicator of the condition’s severity.89 Assessing the severity of the condition was essential to evaluations of whether or not a therapy was working, and significant research was devoted to the development of accurate diagnostic tools. In Uganda, these efforts focused on possible blood tests and, in the interim, serum protein examinations served as the most accurate measure of protein deficiency in young children. Thus blood extraction continued to be the most routine component of nutritional research on Mulago Hill.
In fact, part of what separated blood extraction in the period following the insurrection from the earlier blood work was that it became so routine. Whereas, prior to the 1950s, blood was withdrawn from a heterogeneous mix of patients by a diverse group of doctors and scientists who had multiple motivations for their many investigations, under Dean this research was largely coordinated and confined to the MRC unit. The research conducted in Uganda during the period of diagnostic uncertainty was far more haphazard and exploratory—unexpected findings prompted additional studies and definitive results concluded one line of investigation only to be replaced by another. However, from the 1950s onward, blood tests became the routine procedure performed on all severely malnourished patients admitted for treatment and investigation. As all of the reports and publications confirm, “it [was] usual to bleed each child on the day of admission. . . . The bleedings were repeated every 7 days, but some children were bled twice in the first week. The blood was taken from the internal jugular vein.”90
These routine blood tests were serial examinations, meaning that they were repeatedly performed on the same child throughout the course of treatment, a period usually spanning at least three weeks and often significantly longer. Serial examinations served to monitor progress toward full recovery, and to fulfil the need for control groups. As Dean and his first biochemist explained: “Blood samples were obtained from a neck vein . . . on admission and at approximately weekly intervals afterwards. The times between taking the samples were sometimes varied to coincide with planned changes of diet. . . . The greatest importance was attached to serial examinations on the same child, who thus acted as his own ‘control’.”91 Serial diagnostic serum protein examinations, in the absence of viable controls, made blood extraction the central procedure performed on severely malnourished patients at the MRC for more than two decades.
These routine serum protein estimations were not the primary focus of an investigation, but served as a means of monitoring the condition’s severity. Again, nitrogen balance studies provided the best example, as they involved routine and extensive blood extraction. The very young children brought to Mulago for treatment were usually in such a severe state of health that collecting specimens at all, let alone for extended periods, proved nearly impossible.92 In fact, nitrogen balance studies were not successfully incorporated into the MRC’s work until the mid-1950s, when the introduction of a “balance bed” originally devised at the MRC unit in the Gambia suddenly made such studies feasible (see fig. 1.1). In two studies that used the balance bed, the primary investigation concerned urine excretion, and yet, as the researchers explained, “the blood of both boys and girls was studied. The boys were placed on balance beds when they were admitted, and received no food . . . until they were bled, at 8 a.m. the next morning. . . . Blood was taken from the internal jugular vein of all the boys and girls at the end of initial fasting, and subsequently at various times during treatment.”93 Nitrogen balance studies were also used to determine the most therapeutically
