The Riddle of Malnutrition. Jennifer Tappan

      PREFACE

      In 2012, I returned to the East African country of Uganda to continue an investigation of past efforts to prevent a severe form of childhood malnutrition. My objective was to interview a new set of informants and follow up with the elderly women and men who had generously shared their time and memories with me in 2004. Even though nearly eight years had elapsed, both Nabanja Kaloli and Ephraim Musoke greeted me as an old friend. Musoke even skipped the customary handshake, welcomed me with a highly uncharacteristic embrace, and then held my hand through our entire visit. What was most striking was the number of young children in many of these households. Musoke, Kaloli, and others spoke to me about this either directly by telling me of their struggles to provide for the growing number of grandchildren in their care, or by joking that I should take this or that child with me. They were only half-joking. I was there to ask about severe acute childhood malnutrition. They politely answered my questions and provided the information I asked for, but they made sure I heard about the children orphaned by HIV/AIDS and how this was weighing on them in the final years of their lives. This misalignment of interests between foreign researchers and those on the ground is such a common critique of global health that it has become cliché. When I first interviewed Musoke in 2004 and asked him what people in this part of Uganda did when a child became malnourished, he responded almost in exasperation. He would teach the parents to prepare a special food that both alleviates and prevents malnutrition. His exasperation spoke to the obviousness of the matter. It spoke to the fact that severe malnutrition was not a major problem in his community anymore, I should be asking about other things. But how severe acute malnutrition went from a major concern to one that invited exasperation is also a story that needs to be told.

      In 2003, when I first decided to visit the Luteete Health Center, approximately thirty miles north of Uganda’s capital city, Kampala, and several miles off the main tarmac road, I did not expect to find anything, I did not anticipate that I would ever return, and I certainly did not contemplate making Luteete the primary field site for this study. The Luteete Health Center was worth visiting, even if only once, because in the mid-1960s, a few years after Uganda achieved independence from British colonial rule, the health center became the first rural extension of Africa’s first nutrition rehabilitation program. A year later Luteete also became an epicenter of the violence perpetrated by Uganda’s first prime minister, and for this reason it seemed unreasonable to expect the program to have made a lasting impact in the region. The program, which continues to serve severely malnourished children from the Mulago medical complex in the Ugandan capital, has been known since the mid-1960s as Mwanamugimu, the first word in a Luganda proverb (Mwanamugimu ava ku ngozi) often translated as “A healthy child comes from a healthy mother.” When I arrived at the Luteete Health Center and began inquiring about Mwanamugimu, I was repeatedly told that she was dead. After confirming that the problem was not one of translation and my fledgling facility with the Luganda language, I learned that one of the midwives who had spent much of her life working at the Luteete Health Center was known to the people who lived in this region as “Mwanamugimu.” Florence Mukasa had been so devoted to preventing severe acute malnutrition in young children that she continued teaching parents the principles of the Mwanamugimu program until the year she died. According to the women and men who have shared their stories with me over the years since that first visit, Florence Mukasa, and the Mwanamugimu program for which she was known, have had a considerable impact on nutritional health and wellbeing in the region served by the Luteete Health Center.

      The Mwanamugimu program was part of a long history of nutrition work in Uganda and tracing that history involved weaving together highly disparate bodies of evidence. Archival materials that typically form the backbone of historical analysis, including memoirs, reports, and other documents held in England, Uganda, and the United States, have been key to my understanding of this history and its significance. The personal papers of physicians involved in the Mwanamugimu program and its extension to the Luteete Health Center furnished invaluable information on the innovative public health approach and its initial evolution. This material is complemented by a vast array of scientific publications and global health reports. Like the colonial archives that must be read with an eye to the imperial imperatives of their production, articles published in medical and scientific journals emphasize methods and results that make them rich in details of specific procedures and findings, but poor sources of information on the highly situated and variable nature of biomedical research. Individual people, dates, and other contingent factors are explicitly absent in accounts that present data as conclusive and universal. Extracting evidence from such sources entails unearthing a human story that is intentionally left out. Reports published by international agencies like the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) also extrapolate data of universal application from the local specificity of medical work and require a methodological approach intent on reading the local back in. My methodology also involved remaining attentive to the different registers of scale on which the history of nutrition work in Uganda operated, from the local, to the colonial and later national, to the global, and back again.

      Over the course of three separate visits to Uganda since 2002, I conducted over fifty interviews with two distinct groups of people, whose testimony figure in the following analysis in very different ways. Interviews with Ugandan and expatriate physicians and scientists identified based on their involvement in Mwanamugimu and related nutrition work provided vivid accounts of the research that made Uganda an important international center of nutritional science in the mid-twentieth century. Extensive interviews and conversations with now elderly women and men living in the area surrounding Luteete foreground local memories of the health center’s expansion as part of the Mwanamugimu program, the postcolonial violence that blunted this public health initiative, and the ongoing importance that the program continues to have in their everyday lives. Those interviewed in and around Luteete fall into two categories: first, a number of the elderly women and men were identified through photographs and by other informants as instrumental to the rural incarnation of the program; but I also interviewed individuals who were randomly selected based on their willingness and availability, as my translators and I walked along the roads and paths weaving through Luteete and the neighboring villages. I understood all of my interviews to be marked by a set of intertwining factors, including my own position as a young, white, female researcher from the United States. My apparent youth and the fact that, in 2003 and 2004, I was a both a graduate student and married created unanticipated confusion for many of the elders I interviewed in Luteete and its environs. The idea of a historian interested in medical work was equally perplexing for a number of the biomedically trained personnel whose memories also helped me piece together this history.

      Memories of Mwanamugimu were inevitably influenced by the intervening period of insecurity and violence, especially for those who lived near the Luteete Health Center where political upheaval and war disrupted their lives in two distinct periods since the program began. I therefore developed a methodological approach that considered the realities of their more recent experiences as a filter or litmus test of what mattered most. In the course of the interviews that I conducted in 2004, I used photographs documenting the program at Luteete as a mnemonic device to remind informants of the less viable and meaningful aspects of the program—aspects that had long faded from their memories. Other components of the program were, notably, both widely remembered and remained a part of the living memory and social practice within the surrounding community.¹ These aspects of the program were often discussed with very little prompting and without the need of photos to jog memories—they had become an ongoing part of daily life. Applying Megan Vaughan’s concept of social practice as a form of living memory to infant feeding, water collection, and intergenerational knowledge transfer revealed that aspects of the Mwanamugimu program were not difficult to remember, because they were not yet resigned to the realm of memory. I interpreted these more readily discussed and more widely known components of the program as aspects of Mwanamugimu that had an ongoing impact in the health and wellbeing of children in this part of Uganda.

      A brief part of the research conducted for this study involved ethnographic methods of participant observation. During both my preliminary research in Uganda in 2002 and