A review of “A Healthy Child Comes from a Healthy Mother”: Mwanamugimu and Nutritional Science in Uganda, 1935-1973, by Jennifer Tappan.
The dissertation examines the science of nutrition, its development and establishment from the 1930s through to the 1970s, through a focus on the research and interventions developed around kwashiorkor among children in the Baganda kingdom of Uganda. In doing so it examines the relations between nutritional research in Uganda and the rise of international medicine, arguing against the dominant narrative of the post-war period as one in which public health was focused solely on narrow technical and biomedical approaches. The dissertation takes up recent interest in science studies in exploring scientific research outside of metropolitan centres. Tappan argues that “a focus upon the local and the international dimensions of [the] shifting conceptions of kwashiorkor uniquely positions Uganda as a site of knowledge production rather than simply a recipient of innovative public health knowledge and practice originating elsewhere” (p. 154). Refreshingly free from academic jargon, these arguments are based on archival research in London and Uganda, examination of scientific reports, published articles and policy documents, interviews with doctors, scientists, medical staff, and elderly members of the population served by the hospital and its nutritional health programs.
In following developments in nutritional science based on research and interventions into child malnutrition, Tappan charts both the discursive construction of kwashiorkor and malnutrition and the effects of these interventions on local practices surrounding motherhood and child health. She argues that the development of nutritional science had important effects on the society it intervened upon. To some extent, the development of scientific knowledge about childhood malnutrition in Ganda, and its relations to social, economic, political and cultural factors, reflected colonial assumptions about African societies, practices and “customs”. However, this is not a simple story of the power of colonial knowledge. Rather the author tracks the “entanglements” of scientific discourses and practices with Ganda categories of disease, practices and interventions surrounding child health and motherhood. She argues that the focus on nutritional science allows us to trace transformations in gender and generational relations that were caught up in colonial political economies and new arrangements around cash cropping and land ownership. Nutritional science was itself, Tappan argues, in flux. As a dynamic site of knowledge production and practice it did not simply impose new categories of knowledge and interventions upon Ganda mothers and caregivers. Rather, the local population interpreted and responded to the new biomedical knowledge in particular ways.
Influenced by the recent focus by Africanist historians on the “entanglements” between colonial discourse, biomedical practices and disease categories, and local ideas about disease and treatment (e.g. Steve Feierman, Julie Livingstone, Lynn Thomas and Nancy Rose Hunt), Tappan argues that Baganda incorporated biomedical terms and categories of disease like kwashiorkor on their own terms. Thus the dissertation moves beyond a simple critique of colonial biomedicine to examine local interpretations of biomedical innovations and the influence of biomedicine in changing local practices and patterns of disease around childhood nutrition. As biomedical and indigenous systems became increasingly entangled during the colonial period, novel categories of illness were incorporated into local lexicons of disease.
The Baganda kingdom became the centre of the British protectorate of Uganda, established in 1894. It was here in the early 1900s that British missionary Albert Cook founded the famous Mulago hospital on Mengo hill, and in the 1920s where a medical teaching centre was established at Makerere, one kilometre away. High infant mortality in this region was originally attributed to congenital syphilis, thought by colonial doctors to be endemic in the regions, and Mulago began originally as a venereal disease clinic, backed up by Cook’s “Social Purity Campaign” and his wife’s Maternity Training programme. This obsession with syphilis meant that infants with severe malnutrition were for a long time misdiagnosed. Dr. Hugh Trowell’s appointment to Makerere Medical School in 1933 was crucial in the development of research into malnutrition, but for years his work was unsuccessful. It was only after the Second World War that research conducted in various parts of the world on malnutrition began to be more widely published and read. Trowell knew of the pellagra research done by Dr. Hugh Stannus in Nyasaland, but he was unaware of Dr. Cicely Williams’ discovery (and naming) of kwashiorkor in Ghana as a disease of protein deficiency. Trowell’s diagnosis of “infantile pellagra” was wrong; the condition did not respond to pellagra treatments and many children given these treatments died. This failure made it difficult to convince the medical establishment in Mulago and elsewhere that infant mortality was caused by another nutritional disease.
It was in this context of “experimental therapies” and biomedical uncertainty and lack of therapeutic success (mortality rates among infants admitted to the ward continued above 30% into the early 1950s) that Tappan places the growing antipathy and ambivalence of Ganda parents to the hospitalisation of very sick children. Ganda parents used hospital admission as a last resort. While Mulago medics interpreted this as “ignorance” about biomedicine, Tappan discusses the wide range of associations behind Ganda conceptions of childhood illness, which meant that several alternative therapies could be tried at once. At the same time, biomedical treatment was inadequate and often even wrong during this period. Tensions around hospital practices, such as the taking of blood, led to rumours of colonial doctors’ nefarious practices. During the Baganda insurrection of 1949, when ordinary farmers protested against rising living standards and economic insecurity, the properties of Ganda elite were targeted, including one of the Ganda doctors at Mulago, who was accused of stealing children’s blood. These tensions led to a temporary break in research on child malnutrition in Mulago. Tappan thus places the anxieties about hospital treatment and childhood malnutrition in relation to the political economy of Baganda during the 1940s as well as the uncertain science of nutrition during this time.
While Chapter One covers these early, uncertain years of research into malnutrition, Chapter Two turns to the growing international consensus among scientists that kwashiorkor was indeed a disease and that it was defined by protein deficiency. It explores how protein deficiency came, during the 1950s and early 1960s, to shape conceptions of the “third world”, and thus how the science of nutrition joined an emerging discourse of development involving technical fixes. While Trowell’s research in Uganda on protein deficiency was largely ignored or rejected in the 1940s, in the 1950s it received critical support and funding from the British Medical Research Council (MRC). Chapters Two and Three trace this development of Makerere in the 1950s as a leading centre of scientific research in the tropics and of nutritional science. This articulated a vision of the fundamental and universal knowledge that could emerge from further nutritional work in Uganda, as the narrow focus on protein and on kwashiorkor as a single disease came to be replaced by the recognition of its multifaceted etiology.
While this research contributed to the successful treatment of kwashiorkor in Uganda and a huge reduction in infant mortality in the 1950s, it also had unintended consequences, ironically leading to more widespread under-nutrition. These are explored further in Chapter Four. In the 1950s British scientist Dr. Dean introduced a strict regimen for treating infants and children on the ward, based on skimmed milk, gastric tubes and bottle-feeding. This led to vastly improved recovery of children, and mothers were given skimmed milk powder and advised to add this to their children’s food. However, the emphasis in the hospital on bottle-feeding and on the inadequacy of the Ganda dietary customs and weaning foods for child, led Ganda mothers to increasingly turn to bottle-feed as a supplement to breast-feeding, with dire results. Under-nutrition, or marasmas, became more widespread in the 1950s, which Tappan attributes partly to the decrease in length of breast-feeding among Ganda mothers.
Tappan thus uncovers unanticipated outcomes of the focus of scientific research in Uganda on malnutrition. She suggests that the narrow focus on kwashiorkor and protein deficiency disease obscured recognition of other forms of nutritional ill-health and indeed may have led to the increased severity of severe under nutrition or miasmas in the region. Such an outcome, she argues, chimes with Marc Dawson’s work on yaws treatment in colonial Kenya, in which he tracks how biomedical treatment of yaws disrupted local ecologies of immunity leading, ironically, to the increased prevalence of venereal syphilis. The narrow focus on one disease overlooks the biological interrelations between related forms of illness and disease. It also reflects a scientific obsession with certain disease conditions as being endemic to African societies rather than the effects of the experience of colonial rule. Although the development of nutritional science carried with it critiques of colonial political economy, the impoverishment of colonial subjects and the effects of changing political economies on systems of production and reproduction, these approaches were often ignored or played down in favour of a focus on African customs and “ignorance”.
The advantage of the longer time-line taken by Jennifer Tappan is that she can also track changing priorities and approaches in nutritional science. While the post-war period saw the consolidation of technical and vertical approaches to disease, at the same time, critiques of these approaches led to novel approaches that appeared during 1970s under the remit of international organizations like WHO and UNICEF. In Chapter Five Tappan turns again to the shift in nutritional science during the 1960s away from protein thesis, and away from kwashiorkor as a distinct disease, to a recognition of multifactorial nature of the condition and lack of distinct boundary between malnutrition and under-nutrition. She again stresses the influence of the Baganda context – the “Ugandan school” – in shaping nutritional science as it emerged in 1970s. In Chapter Five, Tappan explores how a new science of health promotion began to gain a footing, particular in the postcolonial context, which was explicitly interdisciplinary, aiming at prevention of nutritional disease, and at finding locally sustainable solutions. She explores two Nutrition Rehabilitation programs initiated by doctors at Makerere and backed by the Ugandan government, which sought to enroll and empower Ganda mothers in changing weaning practices and weaning diets through demonstrations. Although the scientific research at Makerere supported by the MRC was abruptly curtailed by Ida Amin’s coup, Tappan finds that the prevention and health promotion messages of what was termed the Mwanamugimu program (from the Ganda proverb Mwanamugimu ava ku ngozi – “A healthy child comes from a healthy mother”) continued to be passed from mother to daughter in the area, and were remembered fondly be residents she interviewed over two decades later. This, she argues, attests to the ways in which local and biomedical ideas intersected to create a successful and sustainable program of prevention.
This is a fresh and original piece of research, which opens up a historiography of scientific research in Uganda and the development of the science of nutrition while remaining sensitive to the particulars of the political, economic and cultural situations and events in which the research operated. It offers a innovative contribution to postcolonial studies of science, charting the tensions, negotiations and contingencies, personalities and interests that shaped scientific research as well as a subtle treatment of their entanglements with colonial and postcolonial racism, politics and economy on the one hand, and with Ganda parents’ concerns for a better life on the other.
Ruth J. Prince
Department of History and Philosophy of Science and Centre of African Studies
University of Cambridge
1. Archival sources:
Archival research in Uganda at the Albert Cook Medical Library as well as the Libraries of Makerere University and Makerere’s Child Health and Development Centre. The National Archives in Uganda were visited but they were not in a very good state.
National Archives of the UK; the Wellcome Library; the London School of Economics Library; the Bodleian Library of Commonwealth and African Studies at Rhodes House, Oxford (focusing on memoirs and personal papers of biomedical practitioners that were commissioned by the Rhodes House Library); the Rockefeller Foundation Archive Center.
2. Scientific publications and reports obtained primarily from Columbia University’s Health Sciences Library and the personal papers of Drs. Paget Stanfield and Mike Church.
3. Oral testimony recorded in interviews with biomedical personnel in Uganda and the United Kingdom as well as conversations with elderly residents in the region surrounding the Luteete Health Center.
Columbia University. 2010. 335pp. Primary Advisor: Marcia Wright.