The Riddle of Malnutrition: the long arc of biomedical and public health interventions in Uganda by Jennifer Tappan (review)

Jennifer Tappan's The Riddle of Malnutrition traces long-standing efforts to understand, treat and prevent severe malnutrition in Uganda and sheds light on how biomedical research shaped the way in which people engaged with biomedicine. In historicizing the epidemiology of malnutrition, Tappan dismantles any preconceptions that may see biomedicine in colonial times as one of certainty, efficacy and assurance. On the contrary, Tappan details the way in which biomedical research on the nutritional problems faced by a large number of children in colonial Uganda was based on uncertainty, improvisation and hesitation. Nutritional research was blurred by misdiagnoses, cultural bias and discourse focusing the blame on Ugandan food culture. Tappan demonstrates that, over time, the scientific debate questioning whether childhood malnutrition in African countries was due to protein or mineral deficiency came to depict malnutrition as a disease rather than a preventable condition, a framing that would further compromise nutritional health in Uganda.

Furthermore, Tappan demonstrates how the medicalization of malnutrition not only prevented alternative ways of promoting nutritional health but also engendered a breastfeeding crisis as the new programme advocated for a dried skimmed milk (DSM) therapy. Consequently, blame, confusion, contradiction and anxiety over breastfeeding and bottle-feeding made their way into nutritional health issues. Although the shift from breastfeeding to bottle-feeding became permanent, the incidence of children dying from nutritional health issues was not halted or reduced. In fact, as Tappan shows, it increased the prevalence of undernutrition and compromised child health and nutrition in Uganda. Although Tappan demonstrates how medical research and the misgivings over procedures performed (blood extraction), the medicalization of malnutrition and the unsatisfactory results (dying children) increased distrust of biomedical work and how local concerns compelled future research on malnutrition, The Riddle of Malnutrition moves away from the typical arguments on African suspicion and fear of biomedicine. Instead, Tappan argues that Ugandans were also concerned about 'the ethical performance of biomedicine' and that the local response was a mixture of 'complex and dynamic historical engagement' and 'accumulative reflection'.

Furthermore, Tappan also tackles the nutritional health problems in the early independence period in Uganda. While many scholars have emphasized the deterioration of biomedicine and medical infrastructure and services in postcolonial Africa, Tappan shows how, in postcolonial Uganda, 'not all things fell apart'; there was a shifting in medical thinking and practices concerning malnutrition. Rather than making biomedicine the solution to malnutrition issues, the new health programme known as Mwanamugimu emphasized social and cultural approaches to nutritional health and began the process of de-medicalizing malnutrition. Combining biomedicine and local feeding practices made Mwanamugimu one of the success stories of nutritional health in Uganda.

Last but not least, Tappan underscores the central role of local female role models in the postcolonial nutritional health programme. While colonial physicians and scientists blamed Ugandan women and portrayed them as responsible for the malnutrition problem, Tappan shows the indispensable role these women played at the interface of community work, medical care and advocacy. Rather than being passive recipients of nutritional healthcare, these women became active participants, teachers and critical components of the de-medicalization of malnutrition.

The Riddle of Malnutrition is a substantial book that relies on an impressive array of sources, including archival sources, oral histories and personal papers. The writing style is easy to follow and very accessible. However, the author's tour de force is the way she paints the complexity of health interventions in an African country – Uganda – that is far from the simplified image that we are often presented in the name of improving children's health. Tappan does not hesitate to attribute the success and rehabilitation of the nutritional health programme to national and local initiatives in Uganda rather than simply to international institutions and funds. In doing so, The Riddle of Malnutrition underscores...