The few children who were treated for extended periods with high-protein therapies gained weight at accelerated rates, which over time could eventually reverse their underweight and stunted stature. One child, Bandiho, weighed five kilograms below the American standard when she began her therapy, but grew three and a half times more quickly than normal and began to reach the typical weight for her age after a year of hospital treatment.11
FIGURE 2.2. “Kwashiorkor in a 17 month old Ganda boy, showing syringe feeding . . . through a fine polythene tube.” Source: D. B. Jelliffe and R. F. A. Dean, “Protein-Calorie Malnutrition in Early Childhood (Practical Notes),” Journal of Tropical Pediatrics, December 1959, 96–106, by permission of Oxford University Press.
Despite the lengthy period required to reach healthy measures of growth, the initial phase of recovery involved a highly visible and striking set of transformations in a child’s condition, all of which occurred at a phenomenal pace. Even in the very severe cases that were brought to the hospital, nearly all of the most prominent symptoms began to improve within ten days and in some cases by the end of the first week. The anorexia that frequently made intragastric tube feeding necessary subsided so rapidly that children rarely had to be tube-fed the high-protein formula for more than two days.12 The edema also promptly diminished, as did the rash or dermatosis and the fatty buildup beneath the skin. After only one week of Dean’s treatment, children who had been listless and apathetic began to clearly take an interest in their surroundings, and this improvement in their demeanor was interpreted as a clear sign that they were on the road to recovery.13 The formula’s capacity to rapidly and visibly resuscitate children who had been very near death did eventually contribute to shifts in local perceptions of hospital treatment even if the ongoing blood work at Dean’s MRC Unit on Mulago Hill meant that such shifts took longer than might otherwise have been the case.
In time local concerns over experimental procedures and reports of parents refusing treatment and absconding from the hospital gave way to signs of increasing acceptance of hospital therapy. By the early 1960s, if not before, growing local confidence became outright demand. Thus the development of the highly effective and highly curative emergency measures capable of saving the lives of severely malnourished children ushered in a distinct turning point in local views of and engagement with biomedical treatment of severe malnutrition. One of the physicians working in Uganda in this period, Mike Church, wrote for example that “the dramatic intravenous and intragastric therapies, which were often lifesaving, were expected by mothers. In fact, the fame of the hospital resulted in some mothers traveling hundreds of miles” in order to obtain treatment for their severely malnourished children.14 What had been an illness of olumbe, a condition for which there was no hope, became something else. What had been an illness prompting physicians and scientists to perform a myriad of highly extractive and experimental procedures on children who nonetheless died became a condition for which routine emergency measures could all but guarantee recovery and survival. No longer did physicians write of patients absconding from the hospital. Instead, the medicalization of malnutrition, the effective response to the severe condition in which children arrived, led to a growing local demand for life-saving hospital procedures.
The development of a novel therapy also signaled a new disease entity in both biomedical and Ganda diagnostic registers. For the biomedical community, the success of Dean’s high-protein therapy appeared to prove that the condition was a form of severe protein deficiency and, recognizing Williams’s earlier insight, the Ghanaian term kwashiorkor became the internationally recognized name for the condition. The condition for which Ugandan parents traveled great distances to obtain hospital treatment was known, for a brief period, as olbuwadde bw’eccupa or “bottle disease.” Like its Swahili counterpart, eccupa (pronounced “chupa”) is the Luganda term for “bottle” and the notion of eccupa disease reflects the bottles and tubes that were so central to the treatment of severely malnourished children. As Church later remembered,
We actually discovered that they had created a new mythology, they had a new word for kwashiorkor . . . they called it eccupa disease. Eccupa being the bottle and of course the bottle was the intravenous and intragastric feeding. So when they went into the pediatric wards they would immediately be put on drips, which would be intragastric feeding and intravenous fluids, and the mothers watched this with great wonder because of course, in the wards, that was what transformed them.15
In Ganda diagnostics and etiology, this transformation confirmed the diagnosis: olbuwadde bw’eccupa was a condition that required hospital treatment and a veritable barrage of therapeutic measures centered around bottles containing prescribed amounts of Dean’s skim milk formula. A new and effective treatment indicated the presence of a new disease, one that for both biomedical practitioners and Ganda observers was seen to require extensive and immediate medical attention. Whether known as kwashiorkor or eccupa disease, this medicalization of malnutrition was to have far-reaching consequences for child health and welfare, especially as it shaped both international perceptions of the condition, the resulting programs of prevention, and local engagement with these preventive measures.
Defining the Gap
Even before Dean’s high-protein formula appeared to provide the final confirmation that severe acute malnutrition was caused by protein deficiency, the condition was seen as a worldwide scourge demanding intervention. The international attention on protein malnutrition during the 1950s was such that one expert claimed that “in human nutritional studies and in international public health this has been a protein decade.”16 This view was also echoed by the head of the nutrition department in Bombay, who wrote, “We have moved from the era of vitamin research to the era of protein research.”17 The international response reflected particular interpretations of the mounting evidence implicating protein, and much of that evidence emerged from Uganda. The medicalization of malnutrition on Mulago Hill not only launched the “protein decade,” but continued to have an influence for many years. When the Joint FAO/WHO Expert Committee on Nutrition held its second meeting in 1952, the proceedings were dedicated entirely to the condition and Trowell, Davies, and Dean presented the findings of their latest research.18 Suddenly thrust onto the world stage as an international center of nutrition research, Dean’s MRC Infantile Malnutrition Research Unit was in a position to shape how the condition was understood and what was to be done about it. Moreover, the fact that the protein decade coincided with the postwar development era was far from coincidental. Efforts to contend with the problem of protein malnutrition reflect the international faith that was placed in scientific solutions to the problems facing so-called developing world regions. The potential promise of Dean’s high-protein therapy, its simplicity and visibly transformative impact on child health, emboldened those persuaded by the proverbial magic-bullet, one-size-fits-all approach. It was in this way that a specific framing of the problem of protein malnutrition, temporarily at least, foreclosed alternative ways of promoting nutritional health.
The first move in the increasingly narrow and highly medicalized definition of the condition was to confine the problem of severe malnutrition solely to young children. Initially people of all ages were included in studies of severe malnutrition and the steady stream of immigrants who came from present-day Rwanda and Burundi and arrived in severely malnourished states were, as we have seen, an important part of early studies of nutritional health in Uganda. In fact, research on protein malnutrition in adults was so central to the work carried out in Uganda that an entire part of the seminal text that Trowell, Davies, and Dean published on kwashiorkor in 1954 was devoted to protein malnutrition in adults and the symptoms observed in adult cases were not regarded as entirely distinct from the infantile syndrome.19 With the advent of an increasingly medicalized vision of kwashiorkor as a medical emergency, the focus shifted to young children. It was the WHO’s seminal report, Kwashiorkor in Africa, that first narrowly defined the condition exclusively as a childhood illness. Even while acknowledging that “a syndrome very similar to kwashiorkor
