The Riddle of Malnutrition. Jennifer Tappan
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 long enough to observe this final phase of rehabilitation.10 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