The Riddle of Malnutrition. Jennifer Tappan
used to designate sickness and disease, obulwadde, could be qualified in order to specify whether they were illnesses requiring consultation with local healers (basawo) and were thus endwadde ez’ekiganda, Ganda diseases, or illnesses that could be treated by a European doctor, known as endwadde ez’ekizungu (“European diseases”).97 Not all forms of sickness and disease required treatment, as in the case of the common cold, and not all illnesses could be treated. Forms of debility and disease for which little or nothing could be done were known in Buganda as olumbe.98 The emergence of a category of illness that required biomedical treatment rather than consultation with a healer points to a general willingness to seek hospital therapy when it was proven to work. This was especially evident across East and other regions of Africa with the introduction of highly effective yaws and syphilis treatments. As soon as people saw that a single shot rapidly reversed all visible symptoms, demand for injections skyrocketed. In Kenya such demands exceeded the capacity of existing facilities and treatment camps had to be erected.99 The popularity of injections for syphilis at the rural maternal and child welfare clinics in Uganda, was, as already noted, substantial enough to generate revenue supporting the work of the CMS-run Mengo Hospital, the largest medical mission station in East Africa.
But not all ailments could be effectively treated in the hospital. As one African medical worker at Mengo was quoted as saying, “My father has worked in the hospital for thirty-five years and he knows how many diseases Europeans cannot cope with.”100 Until mid-century, severely malnourished children were either diagnosed as syphilitic and, according to a physician at Mengo, were given “bismuth injections until they would end up in a toxic state with a blue line around the lips,” or they were treated with deworming medications or the newly discovered B vitamins, among a range of other largely ineffective forms of treatment and care.101 Only a small fraction of the severely malnourished children brought to the hospital in the period of diagnostic uncertainty survived. Parents and guardians of malnourished children who turned first to their local remedies were not acting according to an irrational or traditional mind set. Until effective therapies were developed in the early 1950s, they had little reason to have faith in hospital therapy. In fact, prior to the adoption of more ethical and cautious methods, parents and guardians had much to fear. The ongoing centrality of blood work even after the advent of effective therapies and a more cautious approach meant that anxieties surrounding the hospital treatment of severely malnourished children subsided more slowly than might have otherwise been the case.102
References to patients “absconding from hospital,” “running away,” or refusing specific procedures remained frequent through the early 1950s. Often such flight or noncompliance reflected uncertain outcomes, as Dean and others experimented with different therapies. One trial, for example, involved feeding children a variety of locally available foods, and in a number cases the child’s condition deteriorated or failed to improve. Parents reportedly and not surprisingly responded by removing their children from hospital care.103 Another trial, which achieved the highest degree of therapeutic success up to that point, saw over thirteen percent of the children removed from the hospital before making a full recovery.104 The trepidation with which many parents and guardians approached hospital treatment of severely malnourished children led, at times, to tragic consequences. One child, Mukandekeze, was just two years old when her parents brought her to Mulago Hospital suffering from severe acute malnutrition. Clearly uncertain about the range of procedures performed on malnourished children at Mulago, Mukandekeze’s parents refused to allow hospital staff to tube-feed her for very long. After three weeks and with little improvement in her condition, they removed Mukandekeze from the hospital. They continued to take their daughter to a child welfare clinic not far away, but Mukandekeze remained seriously ill and six months later she died.105
Not all decisions to remove children from the hospital prior to an official discharge were the result of dissatisfaction with the therapy provided or even unease with specific procedures, although this was often the case. Many parents or guardians of severely malnourished children chose to leave the hospital at the earliest sign of positive therapeutic outcome and their actions may simply reflect satisfaction with treatment and a desire to return home. Parents frequently demanded early discharge as soon as their child’s edema dissipated and their appetite improved.106 One child, Namadu, who had been brought to Mulago for treatment on a number of occasions, was admitted with severe acute malnutrition again in 1952. As soon as Namadu’s edema diminished and he showed clear signs of recovery, his parents removed him from the hospital, or in the typical biomedical shorthand of the time, they reportedly “ran away.”107 The vast majority of those who removed their children prior to an official discharge, however, reveal a lingering set of misgivings over procedures performed on severely malnourished children in Uganda. In the examination of pancreatic enzymes discussed above, for example, 20 percent of the children died and as many “ran away” before physicians could extract digestive enzymes a second time.108
The decision to bring a severely malnourished child to the hospital for treatment was not a decision parents and guardians took lightly. In addition to transportation 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