expenses, time spent with a sick child in the hospital meant neglecting work and household duties, including the cultivation of food and cash crops, the care of other children, and the collection of water and firewood.109 Given the burdens of lengthy periods of treatment, parents undoubtedly demanded discharge or simply removed their children from the hospital as soon as recovery appeared certain due to such practical considerations. Yet, a decade after the development of effective therapies, physicians and scientists working with severely malnourished children at Mulago no longer reported that parents refused specific procedures like tube-feeding or removed their children before they were officially discharged. This absence alone is telling. As we will see in the next chapter, those working to treat and prevent severe acute malnutrition in later decades faced a different set of concerns due to growing demands for hospital therapy. This contrast reveals that parents of severely malnourished children remained concerned about the questionable research practices for a number of years after they were replaced by a more cautious approach.
Physicians and scientists working in Uganda in this period were fully aware that people lacked confidence in the hospital treatment of severe malnutrition. In addition to their frequent references to patients “absconding from hospital” or running away, they openly acknowledged that malnourished children were rarely brought to them for treatment. According to Trowell and his colleagues, “it is only in exceptional circumstances . . . that children are brought to any hospital because they are suffering from kwashiorkor. . . . They are brought to hospital largely because they have acquired some well-recognized infection.” As a result, “expeditions into the villages were necessary to convince mothers that their children . . . had an illness which could be treated in hospital.”110 This reticence to seek hospital treatment for malnutrition meant that throughout this period, children were only brought to the hospital as a last resort and only after a range of local remedies had been tried.
Physicians treating severely malnourished children often found that parents first sought treatment for a number of locally recognized illnesses. The principal one was obwosi, a condition signaled not by a specific set of symptoms, but by signs of illness in a child whose mother had become pregnant.111 The “heat” from the subsequent pregnancy was seen as the cause of illness and in order to prevent or alleviate obwosi, a newly pregnant mother ceased breastfeeding and physically distanced herself from her child by no longer sleeping in the same bed or carrying her child in a sling or ngozi.112 Pregnancy and fears of obwosi were also a pretext for sending a young child to live with an aunt or grandmother.113 Conditions associated with specific symptoms of severe acute malnutrition included omusana, which attributed the lightening skin hue and loss of hair pigment to sun exposure; obusulo and empewo, which were linked to swelling; and ekigalanga, a condition characterized by fever, diarrhea, abdominal pain, appetite loss, and cold feet.114 Ekigalanga and empewo were both conditions connected to spiritual forces requiring spiritual remediation. Obusulo was an illness caused by seeds entering a child’s body and treatment focused on their removal. Children diagnosed in the hospital as severely malnourished often had many small incisions in their skin, at times with a paste containing ash from burnt plantains applied to the cuts or rubbed over their bodies.115 One such child was observed in the mid-1950s, “encrusted with a grey coating of ashes; her mother was desperate with anxiety for her and was simultaneously arranging to take her to the hospital.”116
In light of the reasonable fears surrounding hospital treatment of severely malnourished children in this period, many parents and guardians only brought their children to the hospital when it appeared that there was little or nothing that could be done, when it appeared that they suffered from an illness of olumbe. The problem was that by the time severely malnourished children were finally brought to the hospital, they were in such an acute and severe state that they required immediate emergency measures to save their lives. The years of diagnostic uncertainty had taken their toll. Parents were justifiably wary of the procedures performed on severely malnourished children and continued to try existing forms of treatment first. These children often arrived at the hospital desperately ill and so physicians devised the emergency measures needed to save their lives. The diagnostic uncertainty of the early years of nutritional work in Uganda influenced local interactions with hospital treatment in ways that then shaped the form that treatment took. Children were often not brought to the hospital until their condition was a medical emergency. Physicians and scientists responded, as we will see, by medicalizing malnutrition.
In 1949 nutritional research in Uganda was swept up in a political insurrection, and the attack on Eria Muwazi brought this research to an abrupt halt. The insurrection convinced colonial administrators that, in order to avoid further unrest, future nutritional work had to proceed with greater caution. The accusations that Muwazi “kill[ed] children by taking blood” successfully altered the course of nutritional research in Uganda, prompting researchers to devise more ethical procedures, even as they dismissed the rumors of blood taking as unsophisticated and ignorant fears of Western medicine. The fact that blood tests remained a central feature of the research that resumed in the postinsurrection period, without further incident, suggests that blood extraction was not the crucial issue prompting concern. Instead, the accusations leveled at Muwazi were about the ethics of performing dangerous procedures on children who faced almost certain death. Targeting Muwazi was a local indictment of biomedical work that failed to improve health and wellbeing, work that appeared to improve Muwazi’s status and prestige at the expense of the people in his care. When colonial officials insisted on more cautious research protocols, they were responding, albeit unwittingly and from a state of nervousness, to the demands of the Ugandan people and their engagement with biomedical work.
Connecting the so-called rumors of Muwazi’s blood taking to his medical work on Mulago Hill reveals that local concerns regarding the ethics of this work compelled future researchers to devise new policies, like “No Survey without Service.” Any other analysis risks attributing the adoption of these more ethical protocols solely to Rex Dean and his expatriate colleagues, a move that further obscures African agency in a narrative that leaves biomedical ethics an import of the West. It also illustrates how notions of “unsophisticated” fears and “native ignorance” of “Western” medicine miss important local appraisals and critiques of questionable ethical practices.117 These local appraisals also indicate that people in Uganda had very little faith in biomedicine when faced with severe acute malnutrition, and with good reason. The diagnostic uncertainty that characterized the early decades of nutritional work in Uganda meant that children brought to the hospital suffering from severe acute malnutrition were often subjected to a number of experimental and extractive procedures, even though little could be done to save their lives and the vast majority did not survive. Under these circumstances, parents in Uganda had little reason to bring their malnourished children to Mulago for treatment that did not yet exist and appear to have only done so as a last resort, when nearly all hope was lost. Severely malnourished children were, as a result, brought to the hospital when their illness had become acute, when it became an illness of olumbe. The highly extractive and dangerous procedures that characterized nutritional research in Uganda until the mid-twentieth century allow us to, therefore, see anxieties surrounding biomedicine in a new light. Parents who sought alternative treatments first were clearly not acting according to an irrational and traditional mind set, as has often been assumed. Instead their fears appear now, in retrospect, to be warranted. This early chapter in the history of nutrition and colonial medical research serves as a reminder to both historians and global health practitioners that local responses to medical interventions cannot be reduced to cultural frameworks alone; rather, they must be seen as complex and dynamic historical engagements or “accumulated reflections.”
Children brought to the hospital in such a severely malnourished state required emergency measures to save their lives. As will be explored in the next chapter, this local response to nutritional work thereby shaped the measures that the physicians and scientists at Mulago developed in response to the condition, with repercussions for years to come. Thus the diagnostic uncertainty of the early years of nutritional work in Uganda influenced when parents brought their children for hospital treatment, and this in turn shaped the development
