Reviewed Book
The Riddle of Malnutrition: The Long Arc of Biomedical and Public Health Interventions in Uganda. Jennifer Tappan, Athens: Ohio University Press, 2017, 218 pp.
Through field and archival research into Uganda’s long history of nutrition work, Jennifer Tappan has pieced together an ethnographic account of how perspectives and practices regarding severe acute malnutrition (SAM) have evolved over time. After considering Uganda’s recent history, its health initiatives, and their outcomes, Tappan arrives at the important conclusion that future efforts in SAM treatment and prevention must heed the lessons of the past. To reconstruct past interventions and lessons learned, mostly from the late 1940s through to the mid-1960s, the author trawls a range of sources: memoirs, reports, personal papers by physicians, and, through her interviews, oral testimonies from both biomedical personnel and recipients of care. These sources unlock a “human story” that finds no place in scientific publications and global health reports.
The long arc begins in the era of diagnostic uncertainty, roughly the first half of the 20th century, when biomedical experts routinely misdiagnosed SAM in children as a syphilis-related disease requiring emergency treatment. Then came the slow process of recognizing that the condition was not a disease, but the result of preventable protein deficiency. The transition from emergency treatment to prevention was delayed, however, by major political disturbances—notably the insurrection of 1949, an uprising against autocratic rule by the king of Buganda—and by mounting popular outcry at the way hospitalized SAM children were subjected to blood extractions before their almost inevitable death. Invariably, SAM children were brought to Kampala’s Mulago hospital as a last resort after local healers had failed to alleviate their symptoms. Most common was the condition known as obwosi, which affected breastfed children whose mothers abruptly stopped nursing because of a new pregnancy. Tappan stresses that parents did not act irrationally when they delayed hospitalization or decided against it. At the time, however, biomedical personnel portrayed mothers as ignorant and central to the problem of malnutrition; mothers did not figure in public health campaigns.
Local perceptions of biomedical SAM treatment changed in the late 1950s with the introduction of a high-protein concentrated milk-based therapy, which cut hospital mortality rates and made hospital treatment more effective. Although treatment of childhood SAM continued to rely on the locally frowned- on practice of taking blood samples—with its tubes, syringes, IVs, injections, and the like—the positive impact of high-protein therapy made the medicalization of malnutrition more acceptable. But medicalizing malnutrition implied that mothers and carers continued to be blamed, this time for failing to ensure that children consumed enough protein.
Biomedical practitioners unfamiliar with Buganda’s eating practices pointed to the very low ratios of protein to calories found in local staples, notably plantain (matooke). In their own ignorance, these experts never considered the high protein content of the sauces that accompanied meals. Their advice—matooke is bad for young children—did not convince; local people were only too aware that the majority of matooke-fed children never developed severe acute malnutrition. Ugandan researchers then experimented with groundnuts—integral to local diets— hoping to develop a commercially viable biscuit. When the project failed after aflatoxin was found in cereals and oilseeds, including groundnuts, the government nutrition advisor recommended that dried skimmed milk be distributed as a supplementary part of a child’s diet. The message did not get through: bottle-feeding displaced breastfeeding and increased the prevalence of undernutrition.
Although the belief in a narrow biomedical panacea lived on, public health programming embarked on a new approach. Treating the condition was de- medicalized. The turnaround came when biomedical personnel reflected on past failures and began collaborating with paediatricians who had fled apartheid South Africa. At the Kasangati rural health center, outside Kampala, future doctors learned to integrate curative medicine with prevention. Further cross-fertilization involving international experts and Makerere graduates—Josephine Nambose, East Africa’s first female doctor, among the latter—resulted in a hybrid tackling of the emerging problem of SAM relapse. Combining the work ethic of Kasangati with the tenets of nutrition rehabilitation as pioneered in South and Central America, Uganda then launched a nutritional rehabilitation unit at Mulago hospital. Its name, Mwanamugimu, drew on the Luganda proverb that a “A healthy child comes from a healthy mother.” Its mission was to distance nutrition education from hospital emergency treatment.
Mothers and recovering children, not biomedical staff, were Mwanamugimu’s chief instructors. In local hands and at low cost, the program replicated home life; reinstated matooke and sweet potatoes as suitable weaning foods; and promoted, with minor modification, the local practice of mixing different foods. A variety of foods, staples included, were mixed at the point of meal preparation, not during meal times. Known as kitobero, the technique was popularized via songs, photographs, cooking demonstrations, informal discussions, interactive story-telling, and plays. Photographs of recovered children effectively spread the message that kitobero could treat and prevent SAM.
By the mid-1960s, Mwanamugimu also ran a full outreach program at Luteete, north of Kampala. Tappan’s recent interviews at Luteete involved many grandmothers who had passed on their knowledge of kitobero. Their children and grandchildren testified to its lasting influence—a legacy that has outlived many of Uganda’s later health initiatives, which crumbled under the violence of the Obote and Amin regimes or under the weight of global interventions. Structural adjustment in the 1980s and the global response to HIV/AIDS temporarily eclipsed the international interest in SAM research.
Scientific publications and global health reports habitually omit human stories. By researching and contextualizing the Mwanamugimu program, Tappan has unearthed a comprehensive health initiative that built local capacity and proved remarkably resilient. But The Riddle of Malnutrition probes further. The longitudinal analysis of how local people engage with shifting biomedical protocols and programs and contribute to hybrid solutions points to the need for greater awareness that history matters. The long arc of nutrition work in Uganda, with Mwanamugimu at its core, is today all but forgotten outside Uganda. And yet, as this book so poignantly demonstrates, the lasting legacy of this nutritional rehabilitation unit makes it imperative that future initiatives—in Uganda as elsewhere—learn from prior programs and people’s engagement with them, lest the mistakes of the past are repeated or past successes become reinvented like the proverbial wheel.
In her epilogue, Tappan throws down the gauntlet by applying her findings to the current global trend of fighting severe acute malnutrition in children with “ready-to-use therapeutic food” (RUTF). Viewed through the lens of Uganda’s history of nutrition work, she proposes that RUTF therapy—or the “Plumpy’ Nut” revolution—represents a disempowering, potentially counterproductive, re- medicalization of malnutrition. While this suggestion may raise the hackles of dedicated nutrition workers, Tappan’s meticulously researched exploration of the long arc of biomedical and public health interventions in Uganda raises questions around RUTF—concerning cost, profits, local engagements, and dependency—that cannot be left unaddressed. Elegantly written and captivating, The Riddle of Malnutrition will strike a chord among biomedical researchers, policymakers, global health professionals, and medical anthropologists and anthropologists of development and their students. Like the Mwanamugimu program it so diligently analyzes, this book deserves to generate its own lasting influence.