indications suggest that the prevalence of less severe forms of childhood malnutrition decreased since the 1990s, with Africa as the only exception.10 Evidence from Uganda, where a 2010 survey found that 2 percent of children were severely malnourished and 6 percent showed signs of less severe wasting, corroborates this trend.11 In the mid-twentieth century, annual prevalence in Uganda was estimated at 1 percent, although statistics from the Ugandan Ministry of Health indicate that, based on the twenty-three thousand to thirty-six thousand children annually diagnosed with malnutrition between 1961 and 1966, the prevalence may have been closer to between 2 and 3 percent.12 Establishing even estimates of historical prevalence rates must confront a number of significant challenges. Prior to the 1950s, kwashiorkor was not widely recognized as a condition, and in Uganda, biomedical practitioners later equated a number of different locally recognized forms of illness as kwashiorkor.13 What is more, prevalence has often been assumed to be more or less static, meaning that, until fairly recently and except when assessing the success of specific interventions, little effort was made to investigate the shifting epidemiology of severe acute malnutrition.14 The result is that we are left with the knowledge that severe acute malnutrition remains a serious problem in many parts of the world, but have, at best, an incomplete understanding of how prevalence may have shifted over time. This gap in existing knowledge limits efforts to consider the role of contributing factors, including economic and social variables.15
In the postwar development era, when betterment schemes promised to lift entire populations out of poverty, severe acute malnutrition in Africa and other global regions did become a central international concern.16 It not only occupied the attention of biomedical experts and nutritionists, but, due in large part to the jarring images of severely malnourished children that Time Life Magazine published in 1968—photos of children from the refugee camps of Nigeria’s Biafra War—the condition also became the poster child for humanitarian aid and volunteerism. It became emblematic of one of the most pervasive tropes of the African continent: that of the starving African child. The Nigerian novelist Chimamanda Ngozi Adichie’s poetic critique of the fleeting philanthropy that such imagery inspires—“Did you see? Did you feel sorry briefly . . . ?”—speaks to the waxing and waning attention, and attendant funding, for such global health concerns.17 The fluctuating international interest and investment in the problem of severe acute malnutrition reveal the role of biomedical research and programming in global health faddism. International interest in severe acute malnutrition has proven to be fleeting, and as global concern waned in the late twentieth century, past efforts to combat the condition were swept under the rug, all but forgotten. Galvanized by therapeutic innovations, a new generation of global health workers, biomedical experts, and philanthropists has succeeded in returning severe acute malnutrition to the international limelight. Without knowledge of prior initiatives, their work cannot build on previous endeavors or avoid past mistakes.
Enduring Engagements
One of the most important facets of nutritional research and programming in Uganda is that it represents a largely uninterrupted effort to understand and contend with a single condition for the better part of a century. This is remarkable because many, if not most, biomedical interventions in Africa from the colonial period onward have been time-limited. Public health projects and programs with end dates seek to make a lasting impact through temporary measures, and these measures are seen to either succeed or fail. Historians of colonial medicine and global health have, especially in recent years, drawn attention to the many insights that emerge from an examination of these targeted endeavors. A key observation is that Africans on the receiving end of health-related work are not merely passive recipients or biomedical subjects. Instead, they interpret and make meaning of health provision in ways that are tied to a complex set of local, and very often historical and thus dynamic, perceptions and experiences.18 It has been shown that interpretations of both research and programming shape how people engage with biomedical projects and programs, how they are incorporated and thereby altered, or rejected and avoided.19 The result has very often been a number of unintended consequences that typically impede stated objectives. Among scientists and public health experts, failure signals the need to return to the drawing board in order to devise better tools and methods, and in the global health context this typically involves packing up and returning to North Atlantic centers of research and policy development. Prior public health programming, especially when unsuccessful, is frequently then forgotten, leaving the lessons of past mistakes sadly out of reach for those launching at times nearly identical initiatives at a later date.20 Yet, when these interventions come to the end of their time frame, they leave a trail of data and reports for later analysis and what historian Melissa Graboyes has recently referred to as “accumulated reflections.” Interpretations and perceptions of medical endeavors accumulate among populations in Africa and elsewhere, and the residue of these past experiences continues to influence their view of and response to future efforts for perhaps decades if not generations to come.21
Recognizing that health-related work leaves a residue of past interactions and encounters and that even time-limited projects have a social afterlife illustrates one of the fundamental shortcomings of neglecting historical epidemiology.22 Assuming that recipient populations are like blank slates in their perceptions of biomedical work overlooks how past experiences and programs influence future initiatives. While communities in Africa may at times be “biological blank slates,” and thus represent unparalleled opportunities for testing new vaccines and drugs, their interpretation of and engagement with such work filters through the residue of past medical projects and programs.23 The long history of nutrition research and programming in Uganda is an opportunity to examine how perceptions of biomedical research and treatment shaped the outcome of such endeavors. My analysis explores how the residue of past medical work fundamentally influenced how people engaged with biomedicine and public health. It asks how the residue of past experiences thereby influenced health-related research and programming. In tracing this influence it also reveals the dynamism inherent in local interpretations and interactions. Even “accumulated reflections” are open to change and, as nutritional work in Uganda shows, were highly responsive to the shifting research protocols and evolving programs of treatment and prevention that they themselves engendered.24
The nutritional work conducted in Uganda for the better part of a century challenges common definitions of global health. According to a recent volume titled Global Health in Africa, global health has its origins in colonial times, but emerged in the post–World War II period and can be defined “broadly to refer to the health initiatives launched within Africa by actors based outside of the continent.”25 Yet, in addition to the ways that local interactions influenced nutritional work in Uganda throughout the period under consideration, it is also true that Ugandans were pivotal to the nutrition research and especially the later programming that are at the center of this study. In fact, both biomedical training and infrastructure in Uganda proved crucial to the evolution and longevity of a public health program that continues to be of great significance to many Ugandans. The public health approach that emerged in Uganda was far more of a local endeavor than it was a global health initiative.26 When initial efforts failed, biomedical personnel returned to the drawing board, but it was a drawing board in Uganda. The research protocols and initiatives that were then devised explicitly harnessed local engagement with biomedicine—they put enduring engagements in the service of public health. In fact, the period of failure that preceded the advent of this novel public health approach was one marked by Uganda’s emergence as an international center of nutrition science and the post–World War II rise of global health.27 In launching Africa’s first nutrition rehabilitation program, the expatriate architects of the initiative saw the errors of existing global health models and devised a new one.
Mulago and the Kingdom of Buganda
The Mulago medical complex has long been the locus of biomedical research and provision in Uganda, and Mulago together with the region surrounding one rural health center constitute the two principal sites of fieldwork for this study. Mulago is one of the many hills that define the
