of colonial medicine in this part of Africa represented not a single encounter, but a set of interactions. The shifting local response to nutritional research suggests that people in colonial Africa were not averse to biomedical procedures and care, provided they in fact improved health and wellbeing. This insight is not only essential to an appreciation of the history of colonial medicine in Africa and other parts of the world, but is also important to contemporary health programming. It suggests that particularly when it comes to global health, it is crucial to recall that local engagement with biomedical work is shaped in large part by the residue of past experiences. People engage with health systems in ways that are shaped by long histories of medical research and provision. Evolving practices are influenced not only by the latest scientific developments, but also by the therapeutic decisions of patients and their communities, and their responses to the quality of the care they have received and continue to receive.118
2
MEDICALIZING MALNUTRITION
As the story goes, when Rex Dean, the nutritional scientist, arrived in Uganda he was astonished to find severely malnourished children dying at such alarming rates, and so he immediately set to work devising a life-saving treatment.1 Dean’s therapeutic regimen centered on the provision of a high-protein formula that, in light of the foregoing (and future) controversies over the protein hypothesis, garnered much of the attention. Yet the reason severely malnourished children suffered excessive rates of mortality was only partly due to the presumed absence of a high-protein formula to feed them. High case fatality was also tied to the severe state in which malnourished children were brought to the hospital. Local reticence to seek hospital care for severely malnourished children represented, as we have seen, the residue of a period of ongoing diagnostic uncertainty in Uganda—a period characterized by questionable experimentation on dying children. This period of diagnostic uncertainty meant that the children who were brought to the hospital required emergency medical measures just to save their lives. Dean’s efforts to do just that served to medicalize malnutrition. This medicalization of malnutrition precipitated an era of unwavering faith in the capacity to contend with the problem of severe acute malnutrition. But lifesaving curative measures did not prove to be an effective basis for prevention. Local engagement with and interpretation of hospital treatment, especially as it morphed into prevention, led to unintended consequences that further compromised the nutritional health of young children. This chapter explores these developments and how they were obscured and then forgotten. The unintended consequences of medicalizing malnutrition and the resulting scandal were swept under the rug, making the lessons that might be drawn from an analysis of this mid-twentieth-century effort to prevent severe acute malnutrition unavailable to those involved in future efforts to contend with the problem of severe acute malnutrition around the globe.
Medicalizing Malnutrition
The Medical Research Council sent Dean to Uganda as a result of his expertise in the prevention of malnutrition. His earlier success developing mixtures of plant proteins “rivaling milk in nutritive value” for malnourished orphans and schoolchildren in postwar Germany appeared directly applicable to the problem of severe childhood malnutrition in Uganda.2 Dean never lost sight of his goal to prevent malnutrition, but in the end his major contribution to applied nutritional science was the development of a highly effective and highly curative therapy. Moreover, given his mandate to develop a vegetable-based preventive mixture, as he had done in Germany, Dean’s high-protein therapy ironically ended up being a milk-based formula that mixtures of vegetable proteins could never rival.
Faced with the startling mortality rates of malnourished children at Mulago Hospital, Dean could not afford to squander time developing a plant-based therapeutic mixture. Once mortality rates fell, he would turn his attention to local sources of vegetable proteins that could become the basis of effective prevention. In the meantime, Dean sought to treat malnourished children with milk simply because dried skimmed milk was the most inexpensive and accessible source of protein in Uganda at the time. As a waste product in the manufacture of butter in Europe and the United States, ample supplies of dried skimmed milk were easily acquired in the postwar period.3 But skim milk was not without its shortcomings. Although it was not known at the time, many severely malnourished children in Uganda were lactose intolerant and developed diarrhea in response to the skim milk–based formula. Diarrhea is a very common symptom of lactose intolerance, but is extremely dangerous in already acutely malnourished children. One twelve-month-old child undergoing treatment in this early period of therapeutic experimentation developed such loose stools that her weight loss forced Dean to stop her treatment altogether. Fortunately, she did eventually make a full recovery, but her experience and similar reactions among other severely malnourished children indicated that, on its own, skim milk was not a satisfactory form of treatment. Dean dealt with this dilemma by reducing the amount of skim milk and supplementing the mixture with Casilin, a commercially produced preparation of calcium caseinate containing an 80 percent concentration of milk protein. Despite the added cost, this high-protein therapeutic formula was a resounding success. Even before cottonseed oil was added to the formula in order to compensate for the diminished caloric content, Dean and his team in Uganda were able to celebrate the development of the first effective therapy for severe childhood malnutrition (see fig 2.1).4
But the development of Dean’s high-protein formula was only part of the story. Given that the severely malnourished children brought to the hospital were already in such an acute state upon arrival and had considerably diminished capacities to digest and absorb even essential nutrients, Dean insisted on the institution of what he called “dietary discipline.” Coining the term “dietary discipline” emphasized that the provision of dietary therapy in severely malnourished patients was comparable to the provision of drug therapy to treat infection.5 In the regimented system of infant feeding that Dean developed, a precise amount of protein and calories, determined by the child’s weight, was prescribed and administered at specific intervals throughout the day and night. The high-protein therapy was prepared in a glass bottle that in order to avoid spoilage had to be replaced on six-hour rotations.6 In fact, under Dean’s direction all aspects of treatment then became standardized. Secondary infections were so prevalent that, in the initial week of treatment, routine therapeutic measures included daily injections of penicillin, whether or not an infection was evident. Children also automatically received treatment for malaria, anemia, dehydration, and potassium loss.7 In responding to the severe condition of the malnourished children brought to the hospital, dietary discipline transformed the treatment of severe acute malnutrition into a highly curative, hospital-centered experience involving tubes, formulas, syringes, IVs, and injections (see fig 2.2).
FIGURE 2.1. Child treated for kwashiorkor at the MRC Infantile Malnutrition Unit, Mulago Hill. Source: Annual Report of the Medical Department, for the year ended December 31st 1955, Ministry of Health, by permission of the Ugandan National Archives.
Only two years after arriving in Uganda, Dean could report in the Lancet that the concentrated milk-protein formula had already succeeded in reducing the mortality rate to between 10 and 20 percent, a significant achievement given the 75 to 90 percent mortality reported in the 1930s and 1940s by Trowell and others.8 Biochemical measures of recovery and rehabilitation provided equally compelling evidence of the formula’s therapeutic efficacy. Total levels of protein found in the blood, for instance, doubled within one week and reached expected levels for healthy children around the third week of treatment.9 For a child to achieve a full recovery required the resumption of weight gain and growth at rates that would facilitate the catch-up needed for a stunted child to reach the weight and height considered standard or normal for her age. Only in exceptional cases was it possible to keep a child in the hospital
