“No one may starve in the British Empire”: Kwashiorkor, Protein and the Politics of Nutrition Between Britain and Africa

Abstract

Throughout the twentieth century it was widely assumed that African diets were grossly deficient in protein, that childhood protein deficiency was a natural result of this generalised diet and that a relative lack of meat and milk went some way to explaining African economic underdevelopment. This article explores why these conclusions took hold; the European deification of animal protein in previous centuries; structural changes to African diets and food economies under colonial government; and the political value of such a consensus. Unlike elsewhere in the world, where deficiency was removed from the exceptionalism of tropical medicine, protein malnutrition was constructed as a particularly African concern. Focusing this discussion on the history of the severe childhood deficiency, kwashiorkor, this article explores how the politically informed othering of African nutrition came to direct, or misdirect, the medicine of malnutrition in twentieth-century Africa.

Full text

“No one may starve in the British Empire”:
Kwashiorkor, Protein and the Politics of Nutrition
Between Britain and Africa
John Nott*
Summary. Throughout the twentieth century it was widely assumed that African diets were grossly
deficient in protein, that childhood protein deficiency was a natural result of this generalised diet
and that a relative lack of meat and milk went some way to explaining African economic underdevel-
opment. This article explores why these conclusions took hold; the European deification of animal
protein in previous centuries; structural changes to African diets and food economies under colonial
government; and the political value of such a consensus. Unlike elsewhere in the world, where
deficiency was removed from the exceptionalism of tropical medicine, protein malnutrition was con-
structed as a particularly African concern. Focusing this discussion on the history of the severe child-
hood deficiency, kwashiorkor, this article explores how the politically informed othering of African
nutrition came to direct, or misdirect, the medicine of malnutrition in twentieth-century Africa.
Keywords: malnutrition; kwashiorkor; protein; imperialism; Africa
In 1953, with the Gold Coast well on its way to independence, the British colonial gov-
ernment decided to release a cookbook. Intended to inform an educated readership on
the relationship between good food and good health, Gold Coast Nutrition and Cookery
epitomises the farce, tragedy and hubris which defined European attempts to influence
African domesticity.
1
Chapter 39 is, for instance, exclusively concerned with the minutiae
of that mainstay of British culture, the serving and drinking of tea.
2
While reminding the
reader that ‘many doctors agree that this is an unnecessary meal’, the author goes on to
describe one which is ‘dainty but light’, one in which ‘a small table and embroidered
cloth is used’. Cups and saucers and teaspoons ‘should be grouped round the teapot so
that the hostess may fill and hand them to each guest’. Sandwiches were seen as a suit-
able food for teatime, but only with the bread thinly cut and the crusts removed. In its
defence, Gold Coast Nutrition and Cookery also covered kenkey,fufu,tuo zaafi and the
various starchy paps and vegetable-heavy soups commonly consumed across the country.
John Nott is a Postdoctoral Fellow in the STS Research Group at Maastricht University. He is currently writing a
monograph on the long history of food and health in Ghana since the late nineteenth century.
*
Faculty of Arts and Social Sciences (FASoS), Maastricht University, Grote Gracht 90-92, 6211 SZ Maastricht, The
Netherlands. E-mail: j.nott@maastrichtuniversity.nl
1
See, for instance, Nancy Rose Hunt, A Colonial
Lexicon of Birth Ritual, Medicalization, and Mobility in
the Congo (Durham, NC: Duke University Press,
1999); Jean Allman, ‘Making Mothers: Missionaries,
Medical Officers and Women’s Work in Colonial
Asante, 1924-1945’, History Workshop, 1994, 38,
23–47.
2
Gold Coast Government, Gold Coast Nutrition and
Cookery (Edinburgh: Published for the Gold Coast
Government by T. Nelson and Sons, 1953), 270–71.
©The Author(s) 2019. Published by Oxford University Press on behalf of the Society for the Social History of Medicine.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creative
commons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium,
provided the original work is properly cited.
doi:10.1093/shm/hkz107
Social History of Medicine Vol. 0, No. 0 pp. 1–24
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Yet, as with the more complex cultural incongruities—such as pies, tarts, souffle´ s and
groundnut macaroons—many of the authors’ suggested sandwiches contain meat or
fish or cheese. Naturally, a proper cup of tea also required milk.
Assumptions regarding the need for animal milks were also extended to infant feeding
and the intimacies of African reproduction. Explaining that ‘breastmilk, even during the
first 6 months of a baby’s life, does not completely supply his needs, and must be supple-
mented by other foods’, the authors of Gold Coast Nutrition and Cookery also explicitly
promoted breastmilk substitutes and artificial feeding regimens for infants.
3
Today, medi-
cal advice encourages exclusive breastfeeding for the first 6 months of life, not only be-
cause breastmilk is optimal for child development but also because bottle-feeding
increases the risk of gastric infection, impeded nutrient absorption and acute malnutri-
tion. During the early twentieth century, however, bottle-feeding boomed across the co-
lonial world; the promotion of supplementary foods combining with increased demands
on maternal time and the general devaluation of domestic reproduction vis-a` -vis capitalist
production.
4
These pressures were most acute in centres of colonial commerce. In the
area around Kampala, for instance, the proportion of children receiving supplementary
bottle-feeds before 6 months of age increased from 14 per cent in 1950–52 to 42 per
cent only 10 years later.
5
At the same time, the amount of formula needed to adequately
replace breastmilk for one child cost one-third of a labourer’s salary.
6
The intersection of
economic pressures and medical cues combined to foster ‘bottle-feeding-diarrhoea syn-
drome’ and new epidemics of malnutrition by the mid-century.
7
These developments did not go unchallenged. As early as 1939, Cicely Williams had pub-
licly derided the promotion of breastmilk substitutes as ‘murder’ and ‘the most criminal form
of sedition’.
8
In 1972, Dick Jelliffe termed this phenomenon ‘commerciogenic malnutrition’.
9
The aggressive marketing of breastmilk by foreign multinationals—including by Nestle´, who
were then accused of dressing employees as nurses and operating from maternity wards—
led to increased public scrutiny, the beginnings of the Nestle´ boycott in the early 1970s and
the World Health Organisation (WHO)’s 1981 adoption of the International Code of
Marketing of Breast-milk Substitutes. Infant malnutrition remains a pressing problem and
3
Ibid., 280.
4
For economic and social changes to domestic repro-
duction under colonial rule, see Claude Meillassoux,
Maidens, Meal and Money: Capitalism and the
Domestic Community (Cambridge: Cambridge
University Press, 1981); Jean Comaroff and John L.
Comaroff, ‘Home-Made Hegemony: Modernity,
Domesticity, and Colonialism in South Africa’, in
Karen Hansen, ed., African Encounters with
Domesticity (New Brunswick, N.J.: Rutgers University
Press, 1992), 37–74; for the nutritional effects, see
Henrietta L. Moore and Megan Vaughan, Cutting
Down Trees: Gender, Nutrition, and Agricultural
Change in the Northern Province of Zambia, 1890-
1990 (London: James Currey, 1994); John Nott,
‘Malnutrition in a Modernising Economy: The
Changing Aetiology and Epidemiology of Malnutrition
in an African Kingdom, Buganda c.1940–73’, Medical
History, 2016, 60, 229–49.
5
D. B. Jelliffe, ‘Pediatrics in Uganda’, Clinical Pediatrics,
1965, 4, 55–61.
6
D. B. Jelliffe and F. J. Bennett, ‘Cultural and
Anthropological Factors in Infant and Maternal
Nutrition’, Federation Proceedings, 1961, 20, S185–87.
7
H. F. Welbourn, ‘Bottle Feeding: A Problem of
Modern Civilization’, Journal of Tropical Pediatrics,
1958, 3, 157–66; Nott, ‘Malnutrition’.
8
Cicely D. Williams, “Milk and Murder”: Reprint of a
Speech given to the Singapore Rotary Club, 1939
(Penang, Malaysia: International Organization of
Consumers Unions, 1986), 5.
9
D. B. Jelliffe, ‘Commerciogenic Malnutrition?’,
Nutrition Reviews, 1972, 30, 199–205.
2John Nott
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similar critiques remain relevant, repeated and updated in view of changes to food science,
food economics and medical preoccupation.
10
Protein, and its apparent absence, lies at the heart of this enduring history. As does the
prescience of Cicely Williams. During the early 1930s, and prior to her rallying against
breastmilk substitution, Williams had worked as a paediatrician in the Gold Coast
Medical Service. While in Accra she published two papers on a curious infantile illness,
one ‘in which some amino acid or protein deficiency cannot be excluded’ as its primary
cause.
11
Taking ‘kwashiorkor’, the name used by Accra’s indigenous Ga for a set of
symptoms which included oedema in the abdomen and extremities as well as changes in
behaviour and in skin and hair pigmentation, Williams added an acute form of protein
malnutrition to the pantheon of single-nutrient deficiencies which had emerged with the
science of nutrition in the nineteenth century.
12
From this point until past the end of em-
pire, kwashiorkor dominated research into and discourses around food and health in
Africa, its apparent prevalence confirming a continent-wide ‘protein deficit’, the wide-
spread need for protein supplementation and contributing, ironically, to the subsequent
increase in clinical deficiency.
13
The conceptual histories of kwashiorkor, protein and protein deficiency feature heavily in
the history of infant health in Africa. Yet these knotted histories have not been entirely
unpicked. This article takes the view that the history of kwashiorkor is inseparable from an
earlier British history of nutrition; from an enduring metropolitan image of African otherness;
and from the administration of an economically diverse and often fragile sub-Saharan Empire.
Although a number of studies have explored the colonial construction of good and bad
nutrition, the effects of cultural racism on scientific discourse and the use biomedicine in the
extension of imperial control, siting the history of protein deficiency in an earlier European
history of food and health adds necessary context to such ‘postcolonial’ analyses.
14
10
On the scale of nutrition mortality in contemporary
contexts, see Robert E. Black et al., ‘Maternal and
Child Undernutrition and Overweight in Low-Income
and Middle-Income Countries’, The Lancet, 2013,
382, 427–51; for the current relationship between
breastmilk substitutes and malnutrition, see Ellen G.
Piwoz and Sandra L. Huffman, ‘The Impact of
Marketing of Breast-Milk Substitutes on WHO-
Recommended Breastfeeding Practices’, Food and
Nutrition Bulletin, 2015, 36, 373–86; for the histori-
cal context of these trends, see Tehila Sasson,
‘Milking the Third World? Humanitarianism,
Capitalism, and the Moral Economy of the Nestle´
Boycott’, The American Historical Review, 2016, 121,
1196–224; John Nott, ‘“How Little Progress”? A
Political Economy of Postcolonial Nutrition’,
Population and Development Review, 2018, 60,
229–49.
11
Cicely D. Williams, ‘A Nutritional Disease of
Childhood Associated with a Maize Diet’, Archives of
Disease in Childhood, 1933, 8, 423–33, 432; Cicely
D. Williams, ‘Kwashiorkor: A Nutritional Disease of
Children Associated with a Maize Diet’, The Lancet,
1935, 226, 1151.
12
For the history of nutritional science, see, amongst
others, Harmke Kamminga and Andrew
Cunningham, eds, The Science and Culture of
Nutrition, 1840-1940 (Amsterdam: Brill Rodopi,
1995); E. C. Spary, Feeding France: New Sciences of
Food, 1760–1815 (Cambridge: Cambridge University
Press, 2014).
13
For the history of the ‘protein deficit’ and the longer
conceptual history of protein see, Kenneth J.
Carpenter, Protein and Energy (Cambridge:
Cambridge University Press, 1994).
14
For a general history of colonial medicine, see Megan
Vaughan, Curing Their Ills: Colonial Power and
African Illness (Stanford, CA: Stanford University
Press, 1991); for the ‘discovery’ of malnutrition, see
Michael Worboys, ‘The Discovery of Colonial
Malnutrition Between the Wars’, in David Arnold,
ed., Imperial Medicine and Indigenous Societies
(Manchester: Manchester University Press, 1988),
208–25; David Arnold, ‘The “Discovery” of
Malnutrition and Diet in Colonial India’, The Indian
Economic & Social History Review, 1994, 31, 1–26;
for the postcolonial history of nutrition in Africa, see
Diana Wylie, Starving on a Full Stomach: Hunger and
the Triumph of Cultural Racism in Modern South
Kwashiorkor, Protein and the Politics of Nutrition 3
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At the same time, a trans-imperial focus checks the tendency of postcolonial history to ad-
dress a coherent and politically consistent form of ‘colonial science’.
15
Although recognising
inconsistencies in the actions of individual scientists, colony administrations and Whitehall
mandarins, this article takes the view that nutritional science drew direction as well as a de-
gree of consistency from the passive weight of European experience.
Constructed as a timeless and endemic manifestation of a continental protein deficit,
concentration on kwashiorkor was born from this European history but also found favour
because it naturalised a politically expedient image of Africa. Drawing on assumptions re-
garding the pervasion of poverty and disease in base civilisations and primeval ecologies,
‘African exceptionalism’ was an important element of the ‘civilising mission’ and a valu-
able justification for the continent’s colonisation.
16
Such ideas have endured in the ‘single
story’ narratives of need which continue to dominate academic writing on African
health.
17
The invention of kwashiorkor flattened both European and African histories of
food and health while also contributing to a reductive construction of African alterity.
Indeed, scientific concentration on kwashiorkor meant that—in spite of a pervasive up-
turn in undernutrition, food insecurity and famine which accompanied the transition to
colonial capitalism—generalisations regarding continental patterns of deficiency were
drawn from unrepresentative areas later described as Africa’s ‘kwashiorkor belt’.
18
The
primary locus of Anglophone nutrition research (and the primary focus of this paper) os-
cillated between the southern Gold Coast, where Williams’ was based into the 1930s,
and southern Uganda, where the UK’s Medical Research Council (MRC) housed its tropi-
cal nutrition unit from the 1940s until the 1970s. Both areas enjoyed the remarkable se-
curity of rainforest food production, a relative absence of undernutrition and a high
incidence of kwashiorkor.
19
As ‘peasant’ economies with small settler populations, colo-
nial land alienation was also less visible in the social aetiology of deficiency. Yet spatially
specific conclusions regarding kwashiorkor were readily exported around the continent.
Africa (Charlottesville: University Press of Virginia,
2001); Cynthia Brantley, Feeding Families: African
Realities and British Ideas of Nutrition and
Development in Early Colonial Africa (Portsmouth,
NH: Heinemann, 2002); Jennifer Tappan, The Riddle
of Malnutrition: The Long Arc of Biomedical and
Public Health Interventions in Uganda (Athens, OH:
Ohio University Press, 2017).
15
Helen Tilley, Africa as a Living Laboratory: Empire,
Development, and the Problem of Scientific
Knowledge, 1870-1950 (Chicago: University of
Chicago Press, 2011).
16
The exceptionalism of African poverty has been
touched on here, Michael Watts, ‘Entitlements or
Empowerment? Famine and Starvation in Africa’,
Review of African Political Economy, 1991, 51, 9–26;
for the exceptionalism of African health, see Jean
Comaroff, ‘The Diseased Heart: Medicine,
Colonialism and the Black Body’, in Shirley
Lindenbaum and Margaret M. Lock, eds,
Knowledge, Power, and Practice: The Anthropology
of Medicine and Everyday Life (Berkeley: University of
California Press, 1993), 305–29.
17
Nolwazi Mkhwanazi, ‘Medical Anthropology in
Africa: The Trouble with a Single Story’, Medical
Anthropology, 2016, 35, 193–202.
18
F. I. D. Konotey-Ahulu, ‘Issues in Kwashiorkor’, The
Lancet, 1994, 343, 548; on the unresolved history of
famine, undernutrition and empire, see John Iliffe,
The African Poor: A History (Cambridge: Cambridge
University Press, 1987); Michael Watts, Silent
Violence: Food, Famine & Peasantry in Northern
Nigeria (Berkeley: University of California Press,
1983).
19
A history of nutrition research in Uganda has been a
long time coming, and only properly addressed in
Jennifer Tappan’s recent study. This paper re-treads
some of this history, and at times with similar source
material, although for very different ends. See
Tappan, Riddle. The economic history of nutrition in
southern Uganda can be found in Nott,
‘Malnutrition’; Jan Kuhanen, Poverty, Health, and
Reproduction in Early Colonial Uganda (University of
Joensuu: Faculty of Humanities, 2005).
4John Nott
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This article takes the view that kwashiorkor, as constructed in such spaces, offered valu-
able distance from more politically sensitive questions of food insecurity; its political utility
would influence the long-term development of nutritional science.
The Political Extension of Nutritional Science at Home and Abroad
Loosely defined, difficult to measure and poorly understood by politicians and consum-
ers, good and bad nutrition is remarkably subjective. According to Gyorgy Scrinis, this is a
fundamental aspect of the ‘nutritionist’ discourse—or the reductive concentration on in-
dividual nutrients at the expense of social interactions between food and health—which
dominated twentieth-century dietetics.
20
Under the nutritionist paradigm, appropriate
amounts of individual nutrients are quantified, the relevance of personal experience is de-
nied and the expertise of doctors, scientists and the state becomes paramount. Especially
problematic in the construction of an infant deficiency, such as kwashiorkor, is that con-
centration on the chemical makeup of food ignores the relevance of feeding in its overall
aetiology. The opacity derived from the nutritionist paradigm has meant that the concept
of malnutrition is easily appropriated and prone to vulgarisation. The recent history of
‘fad’ dieting and the wildly conflicting contemporary landscape of dietary advice high-
lights the instability of nutritionist discourse.
21
Although, as Worboys and Arnold have
explained, it was in the colonial world that clinical manifestations of malnutrition were
‘discovered’ following the First World War, these presentations occupied the far end of a
spectrum of nutritional value which had been developed and politicised in Britain.
22
Eating has always been political and dietetics, or the implementation of a certain die-
tary regimen, has always reflected the ideals of a given political economy.
23
Failure to live
up to any such ideals were naturalised in clinical manifestations of deficiency. At the end
of the seventeenth century, for instance, Ireland’s ‘hung’ring for the lazy root’ would be
used to explain and explain away the Great Hunger 50 years later. Potatoes were ‘food
for a contented slave, not for the hardy and the brave’.
24
Made politically relevant by the
metaphor of the body politic, health and virtue were bound together and promoted
through a moderate but considered diet.
25
Unprecedented social and economic change during the nineteenth century allowed
for the ready incorporation of nutrition with nascent understandings of epidemiology.
The Industrial Revolution had, from the mid-eighteenth century, promoted the diversifi-
cation of employment, the industrialisation and globalisation of food production and
widespread movements away from the land. Patterns of consumption changed rapidly in
response to huge structural changes in British food economies, while the incidence of
20
Gyorgy Scrinis, Nutritionism: The Science and Politics
of Dietary Advice (New York: Columbia University
Press, 2013).
21
Michale Pollan, In Defence of Food: The Myth of
Nutrition and the Pleasures of Eating (London: Allen
Lane, 2008).
22
Worboys, ‘Discovery of Colonial Malnutrition’.
23
Tripp Rebrovick, ‘The Politics of Diet “Eco-Dietetics,”
Neoliberalism, and the History of Dietetic
Discourses’, Political Research Quarterly, 68, 2015,
678–89.
24
William Drennan, ‘To Ireland’, in John Aikin and
Benson Earle Hill, eds, The Monthly Magazine
(London: R. Phillips, 1796), 404, 404.
25
Steven Shapin, ‘How to Eat Like a Gentleman:
Dietetics and Ethics in Early Modern England’, in C.
Rosenberg, eds, In Right Living: An Anglo-American
Tradition of Self-Help Medicine and Hygiene
(Baltimore: Johns Hopkins University Press, 2003),
21–58; Rebrovick, ‘The Politics of Diet “Eco-
Dietetics”’, 681.
Kwashiorkor, Protein and the Politics of Nutrition 5
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nutritional illness changed in response.
26
Although the economy grew rapidly through-
out the nineteenth century, the sporadic decline of average heights suggests that malnu-
trition was pervasive amongst the emergent working class.
27
Scurvy, beriberi, rickets and
pellagra were all linked to diet during these years. The discovery of vitamins during the
first decades of the twentieth century granted a satisfying chemical explanation for these
correlations and imbued nutritional science with considerable momentum in the medical
world.
28
It was in this context that nutritional medicine became an overtly political concern.
‘Physical deterioration’ during the later nineteenth century was so marked that height
requirements for British military recruits had to be dropped by six inches between 1845
and 1901; the failure rate for turn of the century recruits was estimated to be as high as
60 per cent.
29
Physical disparities between British and Boer infantrymen were assumed to
result from the meat-heavy diets of the South African veld and, following the British
army’s inauspicious display during the South African War, investments in the well-being
of the poor were increasingly understood as an indirect investment in Britain’s status as a
global power.
30
In response to fears regarding Britain’s declining ‘national efficiency’, in
1904, the government established an Inter-Departmental Committee on Physical
Deterioration. The Committee’s final report recommended greater state involvement in
nutrition including, amongst other things, the provision of school meals.
31
In Foucaultian
terms, nutritional science contributed to emergence of ‘biopolitics’, or the paternalistic
extension of state authority over the body of the individual and the collective bodies of
the wider populace.
32
By the start of the First World War, elemental nutrients had been
elevated to biopolitical objects, tools by which the government might solve problems of
wartime food supply and population health.
33
Funding followed nutrition’s newfound
status and, in the interwar years, nutrition-related research won around one-sixth of all
MRC grants.
34
As the primary element of human growth, protein was imbued with the
greatest biopolitical capital; in 1943, Winston Churchill announced that ‘there is no finer
investment for a community than putting milk into babies’.
35
26
Carole Shammas, ‘The Eighteenth-Century English
Diet and Economic Change’, Explorations in
Economic History, 1984, 21, 254–69.
27
John Komlos, ‘Shrinking in a Growing Economy? The
Mystery of Physical Stature During the Industrial
Revolution’, The Journal of Economic History, 1998,
58, 779–802.
28
Kenneth J. Carpenter, ‘A Short History of Nutritional
Science: Part 2 (1885–1912)’, The Journal of
Nutrition, 2003, 113, 975–84.
29
George F. Shee, ‘The Deterioration in National
Physique’, Nineteenth Century, 1903, 53, 797–805.
30
Richard Soloway, ‘Counting the Degenerates: The
Statistics of Race Deterioration in Edwardian
England’, Journal of Contemporary History, 1982,
17, 137–64, 142.
31
James Vernon, ‘The Ethics of Hunger and the
Assembly of Society: The Techno-Politics of the
School Meal in Modern Britain’, The American
Historical Review, 2005, 110, 693–725; these were
pan-European concerns which caught the attention
of the continent’s foremost scientists. See Justus von
Liebig, Animal Chemistry, or Organic Chemistry in Its
Applications to Physiology and Pathology (London:
Taylor and Walton, 1842).
32
Michel Foucault, The History of Sexuality. Vol. 1:
The Will to Knowledge (London: Penguin, 1979),
135–45.
33
Robyn Smith, ‘The Emergence of Vitamins as Bio-
Political Objects during World War I’, Studies in
History and Philosophy of Biological and Biomedical
Sciences, 2009, 40, 179–89.
34
Celia Petty, ‘Primary Research and Public Health: The
Prioritisation of Nutrition Research in Inter-War
Britain’, in J. Austoker and L. Bryder, eds, Historical
Perspectives on the Role of the MRC (Oxford: Oxford
University Press, 1989), 83–108.
35
Quoted in Deborah M. Valenze, Milk: A Local and
Global History (New Haven: Yale University Press,
2011), 254.
6John Nott
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Extending a politicised concept of nutrition beyond British borders was readily ac-
cepted in the context of empire. Investigations into nutrition in European possessions
overseas found favour amongst Whitehall politicians already primed to understand the
physical capital of the colonised as an extension of colonial power. Stimulated by the mili-
tarism of imperial conquest, nutrition research in the colonies initially consisted of
debates over what rations were necessary for the good health of white soldiers stationed
in the tropics.
36
In the mid-1920s, however, John Boyd Orr, later the first head of the
FAO, and John Gilks, then head of the Kenyan Medical Service, undertook a pioneering
comparison of the largely vegan diets of the Kikuyu and the meat, blood and milk-based
diets of their Maasai neighbours.
37
Although absent from their analyses, the seizure of
good agricultural land by European settlers backgrounded research which Orr and Gilks
hoped might ‘hasten the improvement of the physical condition of the native and to in-
crease his importance as an economic factor’.
38
During a 1926 visit to the Gold Coast,
William Ormsby-Gore, then Under-Secretary of State for the Colonies, explained that
‘the capacity of labour ... is bound up with the question of food. There are few parts of
the world where the study of dietetics is more important than in Africa’.
39
In later years,
knowledge of dietetics was integrated into civil engineering projects requiring hard, phys-
ical labour. From its inception in the 1940s, the Volta River Project employed dieticians to
monitor nutritional intake in view of worker’s productivity and to recommend dietary
substitutions as part of the ‘human element’ necessary for the construction of the Volta
Dam.
40
As in Britain, high-protein foods had the greatest biopolitical value. Research in
the Gold Coast found that, while adults in the forest-belt were not necessarily unhealthy,
they were weaker than their counterparts on the coast, where fish was a more consistent
element of diet.
41
The government’s conclusion was that ‘an increased consumption of
meat is desirable, especially for those engaged in hard physical labour’.
42
Similar conclu-
sions were drawn from the Orr and Gilks study, where calcium deficiency was seen as
the primary concern and where, as with later investigations into kwashiorkor, milk was
offered as a solution which would also provide an outlet for some of Britain’s milk
surplus.
43
As an extension of state authority over a given population, biopolitics is practised dif-
ferently depending upon the specific priorities of a given state. So, although the nutri-
tionist discourse emphasised ostensibly universal, scientific understandings of nutrition,
36
Philip D. Curtin, Death by Migration: Europe’s
Encounter with the Tropical World in the Nineteenth
Century (Cambridge: Cambridge University Press,
1989), 125–29.
37
For detailed discussion of this important study, see
Cynthia Brantley, ‘Kikuyu-Maasai Nutrition and
Colonial Science: The Orr and Gilks Study in Late
1920s Kenya Revisited’, The International Journal of
African Historical Studies, 1997, 30, 49–86; see also,
Worboys, ‘Discovery of Colonial Malnutrition’.
38
J. B. Orr and J. L. Gilks, Studies of Nutrition: The
Physique and Health of Two African Tribes (London:
HMSO, 1931), 12.
39
Quoted in G. E. Metcalfe, Great Britain and Ghana:
Documents of Ghana History, 1807-1957 (London:
Thomas Nelson & Sons for the University of Ghana,
1964), 613.
40
London School of Hygiene and Tropical Medicine ar-
chive, London, 0809/Nutrition/03, ’Volta River
Project – Ghana.’
41
Public Records and Archives Administration
Department (PRAAD), Accra, ADM/11/1/1294, F. M.
Purcell, ‘Report of the Standing Committee to
Study the Important Question of Human Nutrition,
1937–41’.
42
PRAAD/RG/3/5/600, A. Fulton, ‘Survey of Meat
Supplies and Distribution in the Gold Coast.’
43
Brantley, ‘Kikuyu-Maasai’, 77.
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nutrition in the Empire was inextricable from the politics of empire. Central to the prac-
tice of imperial rule was the distancing of the colonised ‘other’ from the metropolitan
norm.
44
Differences in diet provided valuable distance between Europeans and their co-
lonial subjects. As part of an imperialised form of ‘tropical medicine’, nutrition helped es-
tablish a stark contrast between the peripheral ‘white man’s grave’ and the vigour and
well-being of the metropole. With the Colonial Office’s endorsement, in the 1890s, the
London School of Hygiene and Tropical Medicine monopolised the production of health
science in Britain’s tropical colonies, establishing medicine as a formal element of imperial
government.
45
The spread of nutritionist dietetics and imperial biopower created an intel-
lectual environment that attracted anthropologists and doctors working in the colonies
to the ‘otherness’ of food and nutrition in the areas to which they had been posted.
46
Such research also helped to naturalise the relative value of the colonised. In India, the
wheat and dairy diets of the Sikhs and Pathans were seen as closer to European dietaries
and provided scientific credence for their eugenicist designation as ‘martial races’. David
McCay, Professor of Physiology at Calcutta’s Medical College, explained in 1912 that dif-
ferences in diet ‘appear to be the determining factor of the several causes that go to rele-
gate, fix and maintain the position of a people, tribe or race in the category of men’.
47
Orr and Gilks’ primary conclusion from Kenya was a similar validation of the view that
‘the physique of tropical native races is in no way superior, and frequently much inferior
to that in civilised communities’.
48
Although already dealing in oversimplification, the more detailed racialisation of early-
twentieth-century nutrition soon declined in favour of the broader generalities that cul-
tured kwashiorkor research.
49
In 1933, the League of Nations’ Health Organisation im-
plored Member States to investigate the nutritional status of their colonial subjects,
arguing that ‘the fact that the greater part of the population of Africa and Asia ...suffers
from insufficient or faulty feeding is no longer a secret, and there is more honour to be
gained in attempting to improve the situation than in concealing it’.
50
The British re-
sponse began in 1936 when Colonial Secretary, J.H. Thomas, sent a circular memo to
each British possession requesting information on the nutritional status of their popula-
tions, the state of nutritional research and possible ways to improve the diets of their sub-
jects. The resulting two-volume report, Nutrition in the Colonial Empire, was widely
publicised and distributed, its 1939 release promoted by Lord Dufferin on the BBC and
Lord Hailey in The Times.
51
In The Times, Hailey proudly announced that the report covers
‘an area of well over two million square miles and with a population ... divided into
44
See, Edward W. Said, Orientalism (London:
Routledge & Kegan Paul, 1978).
45
Douglas M. Haynes, Imperial Medicine: Patrick
Manson and the Conquest of Tropical Disease
(Philadelphia: University of Pennsylvania Press, 2001),
140–51.
46
See, for example, W. E. McCulloch, An Inquiry into
the Dietaries of the Hausas and Town Fulani of
Northern Nigeria, with Some Observations of the
Effects on the National Health, with
Recommendations Arising Therefrom (Lagos:
Government Printer, 1930); M. Fortes and S. L.
Fortes, ‘Food in the Domestic Economy of the
Tallensi’, Africa, 1936, 9, 237–76.
47
Quoted in Arnold, ‘The “Discovery”’, 12–13.
48
Orr and Gilks, Studies of Nutrition, 17.
49
Brantley, ‘Kikuyu-Maasai’, 80.
50
E. Burnet and W. R. Aykroyd, ‘Nutrition and Public
Health’, League of Nations: Quarterly Bulletin of the
Health Organisation, 1935, 4, 323–474, 452.
51
The National Archives, Kew (TNA) /CO/859/14/6,
G.C. Eastwood, Joint Secretary to the Committee on
Nutrition in the Colonial Empire, draft circular, 8
November 1939.
8John Nott
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countless groups having the most different food habits and customs that it is possible to
imagine’.
52
In spite of this enormous breadth, Nutrition in the Colonial Empire explained
that;
Diseases resulting from malnutrition ... prevail almost everywhere among tribal
races ... excess of carbohydrate, deficient of fat and first class protein and uncer-
tain or negligible supplies of milk and green vegetable are the outstanding
features.
53
Not only was this description grossly inaccurate, even in the context of contemporary
knowledge, but it understated the worth of vegetable matter, overstated the value of an-
imal produce and created a simple dichotomy between colonial and European diets.
54
This othering of non-European diets was the crux of colonial dietetics, providing scientific
justification for the colonisation of consumption as part of the colonial project.
Defining Kwashiorkor: The European Roots of an African Disease
Initially understood as a severe manifestation of a simple protein deficiency, kwashiorkor
would, in later years, come to sit at one extreme of a spectrum of childhood malnutrition
described as Protein-Energy or Protein-Calorie Malnutrition (PEM or PCM). At the other
extreme is ‘marasmus’, a total-calorie deficiency synonymous with ‘undernutrition’ or
‘wasting’. Resulting from a lack of food or the inability to digest food—as in ‘bottle-feed-
ing-diarrhoea syndrome’—marasmus is usually seen to occur in infants. Kwashiorkor is
usually diagnosed in older children, usually during or after weaning. Alongside the re-
tarded growth common across the spectrum of PEM, symptoms of kwashiorkor include
oedema, changes in skin and hair pigmentation, diarrhoea, loss of appetite, irritability,
lethargy, anaemia and the fatty degeneration of the liver. A visually dramatic disease
with a complicated pathology and a much poorer prognosis than marasmus, kwashiorkor
offered a worthy challenge for mid-century science—its treatment remained a protracted
inpatient process even into the early twenty-first century. Today, dualistic explanations of
PEM are not often used. Moderate or Severe Acute Malnutrition (MAM or SAM) is in-
stead defined according to deviation away from growth standards. The telltale oedema
associated with kwashiorkor still suggests a ‘severe’ or ‘complicated’ form of
malnutrition.
55
As a fundamental element of the contemporary construction of PEM, colonial conclu-
sions regarding kwashiorkor are alive in the contemporary consensus. ‘Constructivist’
philosophies of science and medicine explain that scientific fact does not simply exist in
52
Malcolm Hailey, ‘Nutrition in the Colonies’, The
Times, 26 July 1939.
53
TNA/CO/323/1571/5, ‘Nutrition in the British
Colonial Empire: Summary of Replies’, November
1937.
54
Emily Klancher Merchant, ‘The Imperial Politics of
(Mal)Nutrition in Colonial Gold Coast’ (Unpublished
working paper, University of Michigan, 2005).
55
It should be recognised that the science of kwashior-
kor is far from settled. See, for instance, M. H.
Golden, ‘The Development of Concepts of
Malnutrition’, The Journal of Nutrition, 2002, 132,
2117S–2122S; for a textbook discussion of PEM as
understood today, see A. Stewart Truswell, ‘Protein-
Energy Malnutrition’, in A. Stewart Truswell and Jim
Mann, eds, Essentials of Human Nutrition (Oxford:
Oxford University Press, 2012), 301–09; for current
approaches to the management of malnutrition, see
Steve Collins et al., ‘Management of Severe Acute
Malnutrition in Children’, The Lancet, 2006, 368,
1992–2000; for historical context, see Nott, ‘“How
Little Progress”?’
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the natural world but is instead created by consensus and maintained by a network of so-
cial, cultural and political alliances.
56
A disease can, likewise, be understood as a social
construct, an agreement to recognise a set of symptoms as a named concern.
57
Although wary of ontological issues bound up in retrospective diagnoses as well as in the
current construction of PEM, it is still worth considering why kwashiorkor was invented
in Africa, and why analogous presentations had been largely ignored in Europe.
58
Although this surely resulted from spatial and temporal variations in food supply and do-
mestic economics, it also relates to spatially- and temporally specific understandings of
food and health. In this respect, the ‘discovery’ of kwashiorkor in the 1920s and Brock
and Autret’s WHO-sponsored 1952 conclusion—that kwashiorkor is ‘the most serious
and widespread nutritional disorder known to medical and nutritional science’—was de-
rived as much from the social construction of nutrition in Europe as it was from the
African disease environment.
59
In biomedical literature, the incidence of kwashiorkor is usually taken to be determined
by weaning practices, and only then influenced by the food environment. It is likely that
the same can also be said for Europe. The ‘danger period during weaning’ that Hebe
Welbourn associated with kwashiorkor in Uganda was certainly well known in Europe—
recorded since at least pre-Christian Greece.
60
In seventeenth-century England, stunted
growth, rickets, gastroenteritis and teething were all associated with weaning. ‘Teething’
was often cited as a cause of death and the ‘weaning illness’—diarrhoeal infections as a
result of sudden dietary change and increased susceptibility to infection—was common
enough to be regarded as ‘normal and inevitable’.
61
In the distinct socio-medical environ-
ment of proto-industrial London, the London Bills of Mortality began to record rickets in
1634, as well as its marked increase in subsequent years. Such diagnoses likely combined
a number of bone-deforming illnesses of infancy, including wasting, scurvy and kwashi-
orkor. This may explain the emphasis laid by other writers on the occurrence of hepato-
megaly—or the enlarged liver later seen as typical in kwashiorkor patients—in cases
categorised as rickets. John Graunt’s pioneering work of epidemiology, the 1662
Observations on the Bills of Mortality, includes discussion of rickets and its relationship
with, or confusion for, ‘livergrown’, another disease recorded in the Bills.
62
It seems that
symptomatic disorders analogous with kwashiorkor were present in the children of pre-
56
See, for example, Bruno Latour, Science in Action:
How to Follow Scientists and Engineers Through
Society (Milton Keynes: Open University Press, 1987).
57
See, for example, Charles E. Rosenberg, ‘Disease in
History: Frames and Framers’, The Milbank Quarterly,
1989, 670, 1–15.
58
For a discussion of retrospective diagnosis see,
amongst others, Bruno Latour, ‘On the Partial
Existence of Existing and Nonexisting Objects’, in
Lorraine Daston, ed., Biographies of Scientific Objects
(Chicago: University of Chicago Press, 2000), 247–
69; Piers D. Mitchell, ‘Retrospective Diagnosis and
the Use of Historical Texts for Investigating Disease in
the Past’, International Journal of Paleopathology,
2011, 1, 81–88.
59
J. F. Brock and M. Autret, Kwashiorkor in Africa
(Rome: FAO, Nutritional Studies, no. 8, 1952), 72.
60
H. F. Welbourn, ‘The Danger Period During
Weaning’, Journal of Tropical Pediatrics, 1955, 1,
34–46; Valerie A. Fildes, Breasts, Bottles and Babies:
A History of Infant Feeding (Edinburgh: Edinburgh
University Press, 1985), 365–66.
61
Fildes, ibid., 390–93.
62
Edwin Clarke, ‘Whistler and Glisson on Rickets’,
Bulletin of the History of Medicine, 1962, 36, 45–61,
48; John Graunt, Natural and Political Observations
Mentioned in a Following Index, and Made upon the
Bills of Mortality (London: Thomas Roycroft, 1662).
10 John Nott
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and early-modern Europe, but that contemporary medical discourse could not explain its
incidence or speak to its symptoms.
Under similar social and economic pressures to those seen in colonial Africa a century
later, localised food economies and the domestic economy of childrearing changed enor-
mously throughout during the Industrial Revolution.
63
As a result, symptoms later associ-
ated with kwashiorkor are more visible in European medical literature. By the 1700s,
accounts of oedematous malnutrition were commonly listed in paediatric textbooks and,
from the nineteenth century, medical attention began to explicitly address food, feeding
and deficiency in the modernising economy.
64
Symptoms later associated with kwashior-
kor—such as wasting; oedema in the legs, arms and stomach; fatty livers; skin disorders;
loose stools and other intestinal problems—were regularly described in irritable and apa-
thetic children that had been weaned too early or onto insubstantial diets.
65
In the early
twentieth century, diagnoses of such disorders emphasised the overconsumption of
starch, rather than a deficiency of protein. In 1909, Czerny and Keller described
Mehlna¨ hrschaden, or ‘damage by starch’.
66
In subsequent years, reports came from
Europe and the USA further detailing ‘injuries produced by starch’ and ‘diseases of
infants due to prolonged feeding with excess carbohydrates’.
67
By this time, however, low-protein diets were becoming less common, at least in
Western Europe. Although not often consumed by the majority of the population, animal
produce was central to European perceptions of dietary value, something at least in part
related to the history of class stratification. In his classic elucidation of this point, Jack
Goody references Walter Scott’s Ivanhoe;
‘Swine is good Saxon’ said the Jester ‘but ... pork, I think, is good Norman-French;
and so when the brute lives, and is in charge of a Saxon slave, she goes by her
Saxon name, but becomes a Norman ... when she is carried to the Castel-hall.’
68
The same being true for sheep and mutton, cows and beef, calves and veal, meat had
long been an aspirational expenditure. As average income increased, the consumption of
animal produce grew in tandem. The ‘democratisation’ of meat consumption over the
course of the nineteenth century has been said to have constituted a ‘food revolution’
which greatly increased the relative protein content of European diets and more firmly
aligned meat and health in European medicine.
69
By the mid-1800s, the medical consen-
sus was that meat ‘exceed[s] all other foods in nutritional power’ and access to meat
63
Stephen Nicholas and Deborah Oxley, ‘The Living
Standards of Women During the Industrial
Revolution, 1795-1820’, The Economic History
Review, 1993, 46, 723–49.
64
See, for example, George Armstrong, An Essay on
the Diseases Most Fatal to Infants (London: T. Cadell,
1771); Eustace Smith, On the Wasting Diseases of
Infants and Children (London: J. & A. Churchill,
1868).
65
Rijpma, Livingstone.
66
A. Czerny and A. Keller, Des Kindes Erna¨ hrung,
Erna¨ hrungssto¨ rungen Und Erna¨ hrungstherapie
(Leipzig: Franz Deuticke, 1906).
67
C.E. Bloch, ‘Diseases of Infants Due to Prolonged
Feeding With Excess of Carbohydrates’, British
Medical Journal, 1921, 1, 293–95; I.A. Abt, ‘Injuries
Produced by Starch’, Journal of the American
Medical Association, 1913, 61, 1275–77.
68
Jack Goody, Cooking, Cuisine and Class: A Study in
Comparative Sociology (Cambridge: Cambridge
University Press, 1982), 136.
69
Vincent J. Knapp, ‘The Democratization of Meat and
Protein in Late Eighteenth- and Nineteenth-Century
Europe’, Historian, 1997, 59, 541–51.
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became thought of as a fundamental right.
70
Products such as Liebig’s Extract of Meat,
now Oxo, and Johnston’s Fluid Beef, now Bovril, emerged from the 1840s in order to
provide the poor with affordable animal protein, sparking the long-standing trend of
marketing manufactured food-like supplements to the poor, rather than addressing
shortcomings in the supply of unreconstructed food.
71
In the years following the First World War, protein deficiencies became increasingly interest-
ing to a medical community recently exposed to the destitution of the poor in the ghettos of
Europe and in the dustbowls of North America.
72
Primed to ascribe particular importance to
protein, research suggested that ‘hunger oedema’ or ‘war dropsy’ was the result of inade-
quate protein intake.
73
The question of protein in the presentation of oedema appeared to be
confirmed in the later 1920s when low-protein diets produced an analogous form of kwashi-
orkor in white rats.
74
It was only in the later 1940s, in the unique clinical environments of the
wartime Minnesota Starvation Study and in post-war German orphanages, that oedema was
seen in undernourished patients with relatively high-protein diets.
75
Prior to this, researchers
were naturally drawn to these curious, oedematous presentations of want and, in the
European cultural environment, diets deficient in protein were seen to be particularly flawed.
These developments accompanied the expansion of European involvement in Africa
and served to highlight the differences between the democratised European dietetic and
latterly constructed ideas of the ‘average’ African diet. Early European administrators and
physicians stationed in Africa highlighted the lack of meat as a chief cause of European
ill-health on the continent. In the opinion of Joseph Dupuis, a long-time British adminis-
trator working in the Gold Coast, ‘many fall victim to the climate from the adoption of a
course of training improperly termed prudential; viz. a sudden change of diet, from ship’s
fare to a scanty sustenance of vegetable matter’.
76
The relative disinterest in meat as a
staple in Africa was also considered particularly curious. In the early 1800s, Thomas
Winterbottom, a British physician stationed in Sierra Leone, noted that;
An African, who has been feasted with every delicacy which an European table can
afford, yet if rice has not constituted a part of his entertainment, will say, he has
had no meat for so long a time, and on his return home will recur to his beloved
food with redoubled ardour.
77
70
Jonathan Pereira, quoted in Ibid., 546.
71
Mark R. Finlay, ‘Early Marketing of the Theory of
Nutrition: The Science and Culture of Liebig’s Extract
of Meat’, in Harmke Kamminga and Andrew
Cunningham, eds, The Science and Culture of
Nutrition, 1840-1940 (Amsterdam: Brill Rodopi,
1995), 48–74; for the earlier French history see,
Spary, 203–34; for analogous trends today see, for
instance, Alice Street, ‘Food as Pharma: Marketing
Nutraceuticals to India’s Rural Poor’, Critical Public
Health, 2015, 25, 361–72.
72
Golden, S2117.
73
J.A. Nixon, ‘Famine Dropsy as a Food-Deficiency
Disease’, Bristol Medico-Chirurgical Journal, 1920,
37, 137–48; A.D. Bigland, ‘Oedema as a Symptom in
So-Called Food Deficiency Diseases’, The Lancet,
1920, 195, 243–47.
74
R. A. Frisch, Lafayette B. Mendel, and John P. Peters,
‘The Production of Edema and Serum Protein
Deficiency in White Rats by Low Protein Diets’,
Journal of Biological Chemistry, 1929, 84, 167–77.
75
A. Keys and others, The Biology of Human Starvation
(Minneapolis: University of Minnesota Press, 1950),
921–65; R.A. McCance, ‘The History, Significance
and Aetiology of Hunger Oedema’, in Department of
Experimental Medicine, University of Cambridge,
eds, Studies of Undernutrition, Wuppertal 1946-9
(London: HMSO, 1951), 21–82.
76
Joseph Dupuis, Journal of a Residence in Ashantee
(London: H. Colburn, 1824), v–vi.
77
T.M. Winterbottom, An account of the native
Africans in the neighbourhood of Sierra Leone
(London: C. Whittingham, 1803), 66.
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Linguistics clearly offers insight into the culturally specific value of food. In French,
‘meat’, viande, derives from the Latin, ‘to live’. For the Tallensi of north-eastern Ghana,
meat is delicious, certainly, but it is not ‘food’ in the same way as porridge. Instead, meat
is valeg, or ‘gluttony’. In this often food-insecure savannah economy, Meyer Fortes, writ-
ing in the 1930s, found that meat was shared widely while arable produce was com-
monly secreted away.
78
By the 1920s, vegetable-based diets in the Gold Coast’s Akan
rainforest were seen by some British observers as actively ‘dangerous’.
79
The advent of tropical medicine facilitated the spread of nutrition research into the fer-
tile ground of the Global South, where oedematous malnutrition was found to be partic-
ularly prevalent. In Latin America, symptoms later defined as kwashiorkor were described
in a number of articles from 1908.
80
In literature emanating from the French Empire,
doctors described the ‘Swelling [disease] of Vietnam’ as early as 1913.
81
Similar groups
of symptoms were also being described in the British Empire at least by the 1920s.
82
Yet
it was the work of Cicely Williams which cemented ‘kwashiorkor’ as an illness undocu-
mented in Western medical literature or Western epidemiology. Despite its global inci-
dence, her construction would spark decades of debate and research into primarily
African presentations of the illness.
In earlier years, however, European doctors in Africa had been relatively dismissive of
such symptoms, even though they were readily apparent. In the 1870s, a German doctor
travelling in the Loango Kingdom (now part of the Democratic Republic of Congo) found
children with protruding abdomens, ‘just as white children, who had consumed large
quantities of carbohydrate-rich food in early youth’.
83
Early doctor-explorers like David
Livingstone and Thomas Winterbottom had received their medical training in the particu-
lar nutrition environment of the Industrial Revolution. However, as Sjoerd Rijpma
explains, by the 1920s it was ‘not surprising that [Williams] called it a “new disease”: the
symptoms were hardly seen in Europe then’.
84
In the absence of effective medical communication, it was not until later in the twenti-
eth century that the numerous descriptions of kwashiorkor began to be brought to-
gether.
85
Williams’ work was particularly attractive because it emphasised an absence of
dietary protein, rather than an excess of starch. Dermatological signs—sometimes de-
scribed as ‘crazy-pavement dermatitis’—were also made more dramatic by their presen-
tation on black skin, as well as by the white-colonial obsession with blackness.
86
In later
78
Fortes and Fortes, 267.
79
F. M. Purcell, Diet and Ill-Health in the Forest Country
of the Gold Coast (London: Lewis, 1939), 14.
80
M. Autret and M. Behar, Sı´ndrome Policarencial
Infantil (Kwashiorkor) and Its Prevention in Central
America (Rome: FAO Nutritional Studies, no. 13,
1954).
81
L. Normet, ‘La Bouffissure d’Annam’, Bulletin de La
Socie´te´ de Pathologie Exotique, 1926, 3, 207–13.
82
R.A.W. Procter, ‘Medical Work in a Native Reserve’,
Kenya Medical Journal, 1926, 3, 284–89.
83
J. Falkenstein, quoted in Sjoerd Rijpma, ‘Malnutrition
in the History of Tropical Africa’, Civilisations, 1996,
43, 45–63.
84
Sjoerd Rijpma, David Livingstone and the Myth of
African Poverty and Disease: A Close Examination of
His Writing on the Pre-Colonial Era (Leiden: Brill,
2015), 436–37.
85
For the history of kwashiorkor’s ‘discovery’ see, H. C.
Trowell, J. N. P. Davies, and R. F. A. Dean,
Kwashiorkor (London: Edward Arnold, 1954); for a
more critical history see, Tappan, Riddle, 11–36.
86
See, for instance, H. C. Trowell, ‘Infantile Pellagra’,
Transactions of The Royal Society of Tropical
Medicine and Hygiene, 1940, 33, 389–404.
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accounts, ‘the degree to which dyspigmentation can be taken as evidence of kwashior-
kor’ would be forwarded as a potential indicator ‘in studying the frequency and impor-
tance of the syndrome’ at the population level.
87
In general, Williams’ lengthy
descriptions of kwashiorkor stood out because, through the prism of British tropical med-
icine, this definition fit with the established otherness of African life, something which
was only exacerbated by William’s use of and, subsequently, the global adoption of Ga
nomenclature.
Williams’ somewhat punitive 1936 transfer to Malaya restricted her ability to work on
kwashiorkor. Research, however, intensified under the industry of Hugh Trowell and the
cohort collected around Kampala’s Mengo Hospital. Trowell’s progress was slow and
frustrated by the complicated pathology of kwashiorkor. In 1937, after feeding patients
with cow’s milk, liver and all known vitamins and continuing to lose around 40 per cent
of patients, Trowell was convinced that kwashiorkor was not a simple single nutrient de-
ficiency.
88
The mysterious aetiology of the disease only began to unfold in 1942, after
Jack Davies, Mengo’s new pathologist, showed up degenerated pancreases in post-
mortem examinations. This, Trowell and Davis would go on to explain, suggested that
patients were unable to digest their food due to a shortage of pancreatic secretions; it
also explained why supplements failed to relieve patients in advanced cases. By 1946 it
was suggested that a lack of protein could severely harm the tissues and organs of the
body because it restricted the ability to create new tissue. The functioning of the liver
and the pancreas were gradually undermined, leading to a decline in enzyme production
and the restriction of nutrient absorption. The subsequent failure to digest led to diar-
rhoea and, because of excessive fat, an enlarged liver.
89
Trowell’s research was, however, hindered by the reservations of colonial administra-
tors. In Uganda, R.S.F. Hennessey, a politically minded pathologist, who would later be-
come Principle Medical Officer of the Uganda Protectorate, took little interest in
kwashiorkor. Prior to his promotion, Hennessey would perform a number of autopsies in
the space of an hour, mainly on vital organs extracted by students and medical assistants.
Jack Davies, taking 50 sections of one cadaver, found the critical pancreatic degenera-
tions on his first attempt.
90
It is difficult to say whether Hennessey’s failure to do more to
investigate the pathology of kwashiorkor was due to incompetence or wilful ignorance.
In any case, he was certainly resistant to Trowell’s investigations. Trowell describes
Hennessey as saying;
Oh, there’s nothing in Kwashiorkor. It’s just that they’re not very well fed, then
they pick up malaria, hookworms, and all the rest of it. What’s the mystery? There
is no new complaint here.
91
Both Hennessey and John Hall, the Governor of Uganda, tried to privately dissuade
Trowell from keeping on with his kwashiorkor work, Hall once asking ‘where will all this
87
Brock and Autret, Kwashiorkor in Africa, 21.
88
Trowell, ‘Infantile Pellagra’.
89
H. C. Trowell, J. N. P. Davies, and R. F. A. Dean,
‘Kwashiorkor—II. Clinical Picture, Pathology, and
Diagnosis’, British Medical Journal, 1952, 2, 798–
801.
90
Rhodes House, Oxford (RH)/MSS.Afr.S.1872, Box XX,
J.N.P. Davies, Personal Reminiscences.
91
RH/MSS.Afr.S.1872, Box XXXV, H.C. Trowell,
Interview, 1982.
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racket end?’
92
Citing Roger Whitehead, a long-time director of the MRC nutrition unit in
Uganda and then the Gambia, Tappan suggests that, unlike previously unknown vitamin
and mineral deficiencies which provided opportunities for science to improve the lives of
colonial subjects, ‘protein malnutrition pointed to the poverty of colonial populations’.
93
It is, however, important to realise that the concerns of the administrations inside indi-
vidual colonies were not necessarily the same as those in Whitehall. While in-country
administrators were understandably reluctant to draw attention to a high incidence of
kwashiorkor, protein deficiencies were still more palatable than a fundamental lack of
food, especially if they could be presented as an endemic problem of the African environ-
ment. Emphasising that ‘the native food problem is not so much one of quantity as one
of quality’, Whitehall promoted a narrative in which the presence of kwashiorkor could
actively alleviate metropolitan responsibility for malnutrition in the colonies.
94
Since sub-
sequent research concentrated on areas with highly-visible burdens of kwashiorkor and a
relative lack of undernutrition, much of the resultant literature emphasised a cultural
proximity to malnutrition. Accounts such as Welbourn’s late 1950s survey of Ugandan
kwashiorkor patients found that no families appeared poor, while some seemed compar-
atively well-to-do.
95
Earlier, in the mid-1940s, the Ugandan administration stated that
‘the majority of children in Buganda show signs of malnutrition’. This was not necessarily
a problem for the government of the day. Malnutrition, the same report would explain,
‘is not due so much to absolute poverty as to ignorance, conservatism and supersti-
tion’.
96
These were enduring and malleable conclusions that could be shaped to fit vari-
ous political spaces around the continent. In 1962, under Apartheid, the South African
minister of health spoke in parliament in order to explain that there was no famine or un-
dernutrition in the country but, because of custom, ignorance and immorality, kwashior-
kor was still present.
97
Unlike kwashiorkor, hunger presented a more difficult conceptual problem for imperial
administrations. Although the extension of food relief had dampened famine mortality, it
is John Iliffe’s enduring generalisation that, across Africa, ‘epidemic starvation for all but
the rich gave way to endemic undernutrition for the very poor’.
98
Despite this, discourse
regarding nutrition focussed not on shifting continental patterns of hunger, or undernu-
trition, but on kwashiorkor, defined as protein malnutrition, and enveloped in the scien-
tific and political opacity of nutritionist discourse. While ‘malnutrition’ acknowledges
some problem with the nutrient composition in an individual diet, it fails to explain pre-
cisely what is wrong.
99
Instead, malnutrition suggests a dichotomy between good and
bad diets, as well as the capacity for improvement. As a fundamental lack of nutrients,
undernutrition is a much more substantive failure, one which exists beyond the nutrition-
ist paradigm. The ready conflation of ‘undernutrition’ and ’malnutrition’ can be seen in
92
Ibid.
93
Tappan, Riddle, 15.
94
‘Nutrition in the British Colonial Empire’.
95
H. F. Welbourn, ‘Backgrounds and Follow-up of
Children with Kwashiorkor’, Journal of Tropical
Pediatrics, 1959, 5, 91.
96
Nutrition Sub-Committee, Review of Nutrition in
Uganda: A Summary of Previous Work and an
Appreciation of the Present Position (Entebbe:
Government Printer, 1945), 3–5.
97
Wylie, Starving on a Full Stomach, 223.
98
Iliffe, The African Poor, 6; these ideas are not univer-
sally accepted. For instance, Watts takes the view
that famine became more common if less severe un-
der colonial government. Watts, Silent Violence.
99
Rijpma, Livingstone, 12.
Kwashiorkor, Protein and the Politics of Nutrition 15
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many histories of African nutrition.
100
Such distinctions were, by contrast, recognised by
imperial administrations. The construction of kwashiorkor as the clinical manifestation of
a continental protein deficit offered valuable distance from any upturn in undernutrition.
The history of kwashiorkor, therefore, has just as much to do with an absence of food as
it does with an absence of high-protein foods.
There was a year between the receipt of replies to the 1936 Thomas circular and the fi-
nal publication of Nutrition in the Colonial Empire. Over the course of that year, represen-
tative preliminary reports were ‘depoliticised’ by the Colonial Office to remove any
suggestion that low wages, inadequate returns from cash-crops and declines in food pro-
duction were complicit in the pervasive pattern of malnutrition.
101
In the Gold Coast, as
elsewhere, reports circulated after the Colonial Office’s initial request for information
suggested that, contrary to the conclusions which were published later, the colony’s
greatest nutritional problem was not a deficiency of quality foods (although that was a
concern) but endemic undernutrition and the recurrent threat of famine in particular
areas.
102
In response to Whitehall’s request for information on colonial nutrition, the Gold
Coast government seconded F.M. Purcell to undertake a detailed investigation into nutri-
tion across the colony’s three main agro-economic regions—the dry northern savannah,
the rainforest and the coastal plain. Inaction and official indifference marred Purcell’s in-
vestigation.
103
Audrey Richards, the pioneering anthropologist and sometime colonial of-
ficer, later explained that, ‘in spite of our circulars, the Heads of the technical services
(medicine, agriculture and education), do not seem to have cooperated very closely’.
104
After 2 years and some 200 pages, Purcell’s foremost concern was that, throughout the
savannah, ‘there is a severe shortage of every kind of food during several months
yearly’.
105
On the completion of his report, ‘a senior officer’ had told him that ‘“this re-
port will not be sent home ... as it reveals neglect on the part of the local administration
in the Northern Territories”... unofficially it was explained to me that “no one may starve
in the British Empire.”’
106
It was, in fact, sent to London, although nearly 2 years after its completion. On receipt
of the report, S. Culwick, the Nutrition Officer assigned to the Colonial Office, noted that
‘two and a half years ago the [Gold Coast] Nutrition Committee agreed to ...immediate
measures to meet these local shortages ... it would appear that has not been followed
up’.
107
Disappointed by the official response to his work, Purcell had already resigned his
position and gone to the press. ‘Venting his grievances’ in a 1943 letter to the editor of
100
This is even the case in very fine histories, see, for
example, Wylie, Starving on a Full Stomach;
Brantley, Feeding Families; James Vernon, Hunger:
A Modern History (Cambridge, MA: Harvard
University Press, 2007).
101
Worboys, ‘Discovery of Colonial Malnutrition’, 220.
102
PRAAD/ADM/11/1/1294, F. M. Purcell, ‘Report.’
103
The fascinating history of the Purcell survey is also
detailed here, Jeroˆ me Destombes, Nutrition and
Economic Destitution in Northern Ghana, 1930-
1957. A Historical Perspective on Nutritional
Economics, Economic History Working Papers
(London: Department of Economic History, LSE,
1999), pp. 1–63
104
TNA/CO/859/68/1, A.I. Richards, ‘Notes on Dr.
Purcell’s reports on Nutrition in the Gold Coast,
1940’, 17 September 1941.
105
PRAAD/ADM/11/1/1294, F. M. Purcell, ‘Report.’
106
F. M. Purcell, ‘The Gold Coast Government, the
Colonial Office, and Nutrition: Facts of an
Astonishing Colonial Episode, Letters to the Editor’,
West Africa, 4 December 1943, p. 1095.
107
TNA/CO/859/115/3, Note by S. Culwick, 5
December, 1943.
16 John Nott
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West Africa, Purcell’s revelations were notable because they jarred with official represen-
tations of nutritional health in the colonies.
108
Purcell’s findings were reprinted a number
of times between 1943 and 1946. In 1946, the West African Review took it upon itself to
remind readers that ‘we must avoid the error of supposing that shortage of vital foods,
present and pending, is something affecting Germans alone’.
109
In their response, the
Colonial Office explained that ‘short term, local relief measures operate for the periodical
acute hunger in the villages of the territories, but the solution of the problem is a matter
for long-term development’.
110
At the behest of Oliver Stanley, the Secretary of State for
the Colonies, Governor Alan Burns was asked to explain the state of nutrition in the
north. Assuring Stanley that ‘I am by no means complacent about the situation which
the Purcell Report reveals’, Burns stressed that ‘the problems of nutrition can only be
tackled effectively on a long term basis and in conjunction with the many other problems
with which we are faced’.
111
Starvation was a difficult problem for governments to contend with. Humanitarianism
had come of age and absolute failures of subsistence were widely seen as a governmen-
tal responsibility, if not a direct failure of imperial government.
112
In his unpublished reply
to the 1936 Thomas circular, the Director of the Gold Coast’s Medical Department sug-
gested as much, since ‘so much attention has been devoted to the cocoa and mining in-
dustries ... food produced on their farms is apt to be overlooked’.
113
Similar critiques
were common throughout the 1930s.
114
In 1939, Audrey Richards summed up the opin-
ion of many scholars, writing that the diet and health of the colonised ‘has deteriorated
in contact with white civilisation rather than the reverse’.
115
However, as Michael
Worboys has explained, through publications like Nutrition in the Colonial Empire,
Whitehall sought to reframe malnutrition from an epidemic, structural problem resulting
from colonialism ‘to an endemic one for which colonialism had little responsibility and
over which it could exercise little control’.
116
The promotion of protein malnutrition as Africa’s greatest nutritional concern comple-
mented this more general process. Constructed as a problem of ignorance and back-
wardness, the high incidence of kwashiorkor in Uganda never earned much
consternation from London. Despite reservations from Hennessey and Hall inside the
Protectorate, the research undertaken in Uganda came to be considered a boon to the
British Empire. At the end of his speech inaugurating Kampala’s new Makerere Medical
School in 1951, the then Colonial Secretary James Griffith announced that ‘the medical
school is known throughout the whole of Africa ...for the magnificent research work of
108
TNA/CO/859/68/1, Note by S. Culwick regarding
the West Africa article, 21 July 1943.
109
‘Colonies and Calories’, West African Review,
March 1946.
110
‘Nutrition in West Africa’, West African Review,
June 1946.
111
TNA/CO/859/115/3, Letter from Sir Alan Burns,
Governor of the Gold Coast, to Oliver Stanley,
Secretary of State for the Colonies, 16 February,
1944.
112
Vernon, Hunger, 18–80.
113
TNA/CO/323/1570/7, Response from the Gold
Coast government to a circular requesting ‘A sum-
mary of information regarding nutrition in the
Colonial Empire’, 29 June 1938.
114
Worboys, ‘Discovery of Colonial Malnutrition’, 218.
115
A. I. Richards, Land, Labour and Diet in Northern
Rhodesia: An Economic Study of the Bemba Tribe
(London: Oxford University Press, 1939), 3; see also
Monica Hunter, Reaction to Conquest: Effects of
Contact with Europeans on the Pondo of South
Africa (Oxford: Oxford University Press, 1936).
116
Worboys, ‘Discovery of Colonial Malnutrition’, 221–
23.
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Dr Hugh Trowell’.
117
As Tappan has explained, Makerere was taken by the MRC’s chief
executive, Sir Harold Himsworth, to be a ‘model for medical research in the tropics’.
118
Although Himsworth expected Makerere to be built on universalistic understandings of
health, kwashiorkor research found political favour because it also fit with exceptionalist
ideas of African primitivism, African diet and the African disease environment.
This is a distinction that deserves to be stressed. Although, as Tilley has argued, we
cannot speak of a coherent ‘imperial science’, the delicate politics of famine and the
emotive politics of food did shape medical discourse.
119
Research into nutrition was char-
acterised by political and scientific dissonance at all levels of administration, but the influ-
ence of systemic pressures—not only the contemporary politics of empire but also the
weight of the European past and of past scientific consensus—was borne out in the med-
icine of malnutrition. In the Gold Coast, Purcell’s gravest concerns were reserved for the
hungry in the northern savannah. Although oedematous infant malnutrition was appar-
ently endemic in the rainforest—‘known everywhere as “ahonhon”’—his tone is much
lighter when the focus shifts to Akim;
Then to consider fruits; the ignorance and indifference to fruits is astonishing.
There are oranges, bananas, pineapples, pawpaw, mango, guava &c – yet no Akan
housewife would think of making a banana fritter; and they have never even heard
of a pineapple souffle´!
120
The relative abundance of food meant that there was nothing sombre to be said about
nutrition here and, as in Gold Coast Nutrition and Cookery, the souffle´ again appears as a
touchstone of civility. As a problem of ignorance and indifference, malnutrition here was
to be remedied with the slow march of European civilisation and the slow spread of
European science.
Colonising Kwashiorkor: Tropical Medicine and Indigenous Knowledge
As with most pre-colonial understandings of illness in Africa, infantile deficiencies were
conceptualised and prevented within social frameworks.
121
However, science and scien-
tism—as well as the more specific correlates of nutrition and nutritionism—fundamen-
tally undermined any such social construction of kwashiorkor. Its subsequent
medicalisation would go on to mar the prevention of malnutrition at the same time as
promoting commercial salves and technical treatments for a symptom of social disloca-
tion.
122
Cicely Williams was remarkable in part because she recognised this, listening to
her patients and responding to the cultures she encountered with a degree of curiosity
and sensitivity uncommon in colonial physicians.
123
In her second paper on kwashiorkor,
she began by explaining that such symptoms were understood by the Ga as ‘the disease
117
RH/MSS.Afr.S.1872, Box XXXV, Trowell, Interview.
118
Jennifer Tappan, ‘“A Healthy Child Comes from a
Healthy Mother”: Mwanamugimu and Nutritional
Science in Uganda, 1935-1973’ (unpublished PhD
thesis, Columbia University, 2010), 99–106.
119
Tilley, Africa as a Living Laboratory.
120
PRAAD/ADM/11/1/1294, F.M. Purcell, ‘Report.’
121
Steven Feierman and John M. Janzen, eds, The
Social Basis of Health and Healing in Africa
(Berkeley, CA: University of California Press, 1992).
122
Worboys, ‘Discovery of Colonial Malnutrition’, 222.
123
J. Stanton, ‘Listening to the Ga: Cicely Williams’
Discovery of Kwashiorkor on the Gold Coast’, Clio
Medica, 2001, 61, 149–71; Sally Craddock, Retired
Except on Demand: The Life of Doctor Cicely
Williams (Oxford: Green College, 1983).
18 John Nott
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the deposed baby gets when the next one is born’.
124
In her MD thesis, she recognised
‘the most uncomprehending indignation, rage and bitterness in a child of three years old
who found that his place on his mother’s back was suddenly usurped by a new baby’.
125
As part of his broader disregard for Williams’ work, Hugh Stannus, then the Empire’s
leading authority on nutrition, brushed the social epidemiology aside, stating that the
transliteration of kwashiorkor was irrelevant and a ‘common superstition’ since, even
‘among the Wa-yao of Central Africa the disease, whatever it may be, is called litango lya
kututa – each successive child is said to push (kututa) the previous one into its grave’.
126
Operating within the nutritionist dietetic, and in view of exceptionalist ideas of African
health, scientific consensus narrowly framed kwashiorkor as a simple deficiency of pro-
tein. Clearly, however, the aetiology of kwashiorkor was understood by the colonised in
a very different way. In 1954, Trowell et al. listed some 32 names for kwashiorkor taken
from a handful of African and Asian countries, most of which suggest the same social
aetiology of the disease—short birth spacing and short breastfeeding durations.
127
For
those prone to the disease, kwashiorkor did not necessarily relate to diet but was instead
tied to household makeup, conjugal responsibility and the highly personal intricacies of
childrearing.
If protein deficiency was indeed endemic during the early twentieth century, it
may more accurately be seen as the result of relatively recent changes to African domes-
tic economies. Using the writings of David Livingstone and other European physician-
explorers, Sjoerd Rijpma has suggested that, at least in the early nineteenth century,
social and sexual tradition encouraged low birth rates and long breastfeeding
durations, actively protecting children from deficiency. In Missionary Travels, Livingstone
noted that many illnesses common in England were absent in Africa and that ‘in the
more central parts the people were remarkably kind and civil and free from disease’.
128
On the coasts, as well as in central areas under heavy pressure from the slave trade,
epidemic disease was brought in by ship, while the pull of trade goods and foreign
wealth stoked slaving, conflict and social disintegration. Although the generality of
Rijpma’s argument undoubtedly paves over significant variations across the continent,
studies of historical anthropometry have found similar statures on all three Old
World continents in the late eighteenth and early nineteenth century, suggesting that
Africa was not a nutritional backwater in the years before more direct European
involvement.
129
As a reaction to the gendered pressures of colonial government, protracted breast-
feeding and sexual abstinence were increasingly untenable throughout the twentieth
century, with birth spacing durations declining almost universally across the
124
Williams, ‘Kwashiorkor’, 1151.
125
Cicely D. Williams, ‘The Mortality and Morbidity of
the Children of the Gold Coast’ (unpublished MD
thesis, University of Oxford, 1936), 35.
126
Williams, ‘Kwashiorkor’; Hugh S. Stannus,
‘Kwashiorkor’, The Lancet, 1935, 226, 1207–08,
1207.
127
Trowell, Davies, and Dean, Kwashiorkor, 283.
128
Quoted in, Rijpma, Livingstone, 447.
129
Joerg Baten and Matthias Blum, ‘Growing Tall But
Unequal: New Findings and New Background
Evidence on Anthropometric Welfare in 156
Countries, 1810–1989’, Economic History of
Developing Regions, 2012, 27, S66–85; Gareth
Austin, Joerg Baten, and Bas Van Leeuwen, ‘The
Biological Standard of Living in Early Nineteenth-
Century West Africa: New Anthropometric Evidence
for Northern Ghana and Burkina Faso’, The
Economic History Review, 2012, 65, 1280–302.
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continent.
130
This was, in part, a result of colonial biopolitics. In the Belgian Congo,
Africa’s most extreme example of engineered pronatalism, ‘birth bonuses’ worth 5
days’ pay were given to contracted labourers working on plantations and in mines
across the colony.
131
Even in less invasive spaces, such as the Gold Coast, state-
sponsored baby shows formed a mechanism of ‘social regulation, if not social control’
as early as the 1920s. Mothers were encouraged to bring up children according to
western ideals and rewarded with sugar, soap and children’s clothes when these condi-
tions were met.
132
The systemic influence of capitalist development compounded such
policies. Again in the Gold Coast, male ownership of extra-subsistence produce se-
verely undermined the value of childbearing, childrearing and food production, the bio-
logically and socially ascribed outputs of female labour.
133
Accompanying the pervasive
devaluation of such labour was a similarly pervasive pattern of gendered conflict.
134
While domestic pressures reflected the various ideals of colonial governments and the
shifting and spatially-bounded demands of capital formation, domestic compromise
was a fairly universal phenomenon across imperial Africa.
Endemic kwashiorkor could be utilised as a tool for colonial governance partly because
the medicalisation of the disease stripped it of its social and economic context.
135
Reducing kwashiorkor to a deficiency of protein allowed for its presentation as a failure
on the part of African mothers, communities and cultures. In this respect, kwashiorkor
helped justify European cultural hegemony and the paternalism of imperial government.
As with other manifestations of African illness, kwashiorkor was explained in terms of de-
viance from metropolitan ideals.
136
Even Cicely Williams used the existence of kwashior-
kor to explain that ‘the idea that the “simple savage” has instinctive knowledge in caring
for her children is without foundation’.
137
It took two decades for ‘kwashiorkor’ to be accepted into the medical lexicon. When it
was, the medicalised use of the word erased much of its original meaning at the same
time as adding new import. A 1949 editorial in The Lancet explained that ‘“kwashiorkor”
has the merit of neutrality: it offers no explanation and its use prejudices no issue’.
138
The neutrality of the word was, however, sited entirely in the otherness of African lan-
guage and its apparent incoherence, something which, ironically, entirely undermined
any such neutrality. For the Ga, ‘kwashiorkor’ had a spiritual meaning which was not of-
ten said aloud. Williams had been stationed in the Gold Coast for 3 years before she
heard the local name for a condition she had been seeing with some regularity.
139
130
R. Schoenmaeckers et al., ‘The Child-Spacing
Tradition and the Postpartum Taboo in Tropical
Africa: Anthropological Evidence’, in H. J. Page and
R. Schoenmaeckers, eds, Child-Spacing in Tropical
Africa: Traditions and Change (New York: Academic
Press, 1981), 25–71.
131
Hunt, A Colonial Lexicon of Birth Ritual, 237–38.
132
Allman, ‘Making Mothers’, 23.
133
Jean Allman and Victoria Tashjian, ‘I Will Not Eat
Stone’: A Women’s History of Colonial Asante
(Oxford: James Currey, 2000).
134
See, for example, Jean Allman, ‘Rounding up
Spinsters: Gender Chaos and Unmarried Women in
Colonial Asante’, Journal of African History, 1996,
37, 195–214; Margrethe Silberschmidt, ‘Women
Forget That Men Are the Masters’: Gender
Antagonism and Socio-Economic Change in Kisii
District, Kenya (Uppsala: Nordiska Afrikainstitutet,
1999).
135
For a more detailed discussion of the medicalisation
of malnutrition see, Tappan, Riddle, 37–67.
136
Vaughan, Curing Their Ills, 1–29.
137
Cicely D. Williams, ‘Child Health in the Gold Coast’,
The Lancet, 1938, 231, 97–102, 99.
138
‘Kwashiorkor’, The Lancet, 1949, 253, 188–89,
188.
139
Craddock, Retired Except on Demand, 62.
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In 1960s Uganda, Mary Ainsworth expanded John Bowlby’s ‘attachment theory’ of child
development to explain kwashiorkor in relation to anorexia nervosa, caused by the child’s
perceived abandonment after the abrupt cessation of breastfeeding.
140
Similar psycho-
social definitions also underpinned Ga understandings of kwashiorkor. One doctor
explained that kwashiorkor ‘applies to the psychological condition ... in general conversa-
tion, if a child is crying, one might say to it, “what is your mother pregnant, are you getting
kwashiorkor?”’
141
In the 1930s, and apparently independent of Williams, the anthropolo-
gist Margaret Field described ‘kwasi
c
k
c
’ as ‘a special kind of jealousy. Young children and
babies can perceive far more than grown people and the first child soon begins to know
that there is another one coming’.
142
When the second baby is born, the first ‘resents the
withdrawal of the mother’s attention ... and may even die from sheer chagrin’. Children at
risk were to be ‘treated with great patience, understanding, and humour’.
143
In this con-
text, kwashiorkor seems to have more properly suggested a broken taboo. Indeed, in the
early 1960s, Akan respondents further north explained that ‘intercourse may affect the
quality of the mother’s milk and it is said that many children die as a result of this ... If such
a thing happens, public opinion turns against the parents, especially the father; people say
that he cannot control himself’.
144
Whatever the exact definition, kwashiorkor was part of
a complex system of social welfare based around religion, spirituality and those communal-
istic ideas of health which were often discarded with the ascendency of colonial medicine.
Under European government, indigenous knowledge was progressively devalued and
replaced by biomedical frameworks that exalted scientific understandings of illness and
promoted technical approaches to its relief. Michael Worboys has suggested that colonial
interest in deficiency was notable because it ‘did not involve the creation of an exception-
alist, tropical nutritional science’.
145
Yet such conclusions are not true of kwashiorkor.
Following the popularisation of the Ga word, both the history and the terminology of the
disease have tied protein deficiency specifically to the African continent. In their 1952
continent-wide survey for WHO, Brock and Autret explained that kwashiorkor is ‘a nutri-
tional syndrome (or syndromes) found among indigenous Africans’, later explaining that
‘any clinical syndrome which includes these five characters and occurs in Africa can un-
doubtedly be called kwashiorkor’.
146
Although they acknowledge that kwashiorkor may
occur elsewhere, an African origin had become a core part of its pathology. The concep-
tualisation of kwashiorkor as an inherently African illness complemented an ahistorical
understanding of the disease. Yarom and McFie’s 1963 conclusion, that ‘kwashiorkor
has always been prevalent in the Kasai Province of South-East Congo’, denied the disease
any history in the Congo, let alone a history relevant to its relief.
147
This was part of a
140
Mary D. Salter Ainsworth, Infancy in Uganda: Infant
Care and the Growth of Love (Baltimore: Johns
Hopkins Press, 1967).
141
Wellcome Library (WL), London, PP/CDW/L.1, G.
Saunders to M. Autret, 9 October 1953.
142
M. J. Field, Religion and Medicine of the G~
a People
(Oxford: Oxford University Press, 1937), 165.
Although publishing after Williams, it seems Field is
unaware of Williams’ work. She also has some expe-
rience in mental health, working at Maudsley
Hospital ‘on the Biochemical aspect of Mental
Pathology’ in 1927 (Field, v).
143
Ibid., 177.
144
Barrington Kaye, Bringing up Children in Ghana: An
Impressionistic Survey (London: George Allen &
Unwin, 1962), 67.
145
Worboys, ‘Discovery of Colonial Malnutrition’, 222.
146
Brock and Autret, Kwashiorkor in Africa, 11, 30.
147
R. Yarom and J. McFie, ‘Kwashiorkor in the Congo:
A Clinical Survey of a Hundred Successive Cases in
the Kasai Province’, The Journal of Tropical
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more general pattern which promoted Africa as a place of perpetual want. Speaking in
Johannesburg in 1979, Jack Davies, the pathologist most closely concerned with the early
biology of kwashiorkor, explained that the history of Africa had always been marred by
‘inadequacies of diet’. Davies went on to explain that ‘most of the foods which constitute
the current dietary staples of African people have been developed elsewhere ... it has
puzzled some investigators as to just what were the dietary staples prior to the introduc-
tion of these foods’.
148
The promotion of kwashiorkor as both the world’s gravest nutri-
tional concern and as a uniquely African tropical disease sits comfortably within this
narrative. Framing deficiency as Africa’s natural lot obstructs any critical appreciation of
nutritional change. It also contributes to the fetishisation of an ahistorical form of African
poverty entirely dissociated from the effects of colonial rule.
Considered ‘so common that many doctors would regard it as almost normal’, en-
demic kwashiorkor offered scientific and eugenicist justifications for colonial authority.
149
Playing on long-held assumptions regarding the idleness of African populations, a
continent-wide deficiency of protein went some way to explain African underdevelop-
ment.
150
In the Gold Coast, Purcell had explained that ‘the men of Akim are generally
regarded as being weak-willed, lazy and cowardly ... such inferiority may be attributed
to their diet’.
151
Brock and Autrets’ 1952 WHO report extended similar speculations
across the continent, stating that ‘it would not be too far-fetched to attribute to that pro-
tein deficiency, at least in part, the backwardness of the African people’.
152
Even in
1979, Jack Davies would ask his Johannesburg audience ‘how much did this
nutritionally-induced apathy contribute to the docility of Negro slaves?’
153
If protein deficiency naturalised African underdevelopment, whiggish understandings
of economic and technological modernisation offered a reprieve. Working from the as-
sumption that ‘cow’s milk [is] normally the most convenient source of protein for the
child during the post-weaning period’, colonial veterinary services promoted the intensifi-
cation of livestock cultivation.
154
Although morbidity and mortality improved in cattle
populations, limited tangible success left significant room for imported produce.
155
Building on the model developed by Bovril, Oxo and other nineteenth-century nutraceuti-
cals, similar solutions were sought to fill gaps in colonial diets and ply colonial markets. In
a 1929 ‘Index to the Literature of Food Investigation’, 27 pages detail scientific advances
in the manufacture, preservation and distribution of meat and animal products, 18 ex-
plore fruits and vegetables and 4 consider grains, crops and seeds. ‘At the charge of the
Pediatrics and Environmental Child Health, 1963, 9,
56–63, 56.
148
J. N. P. Davies, Pestilence and Disease in the History
of Africa (Johannesburg: Witwatersrand University
Press, 1979), 4, 7–8.
149
Brock and Autret, Kwashiorkor in Africa, 34.
150
Klas Ro¨ nnba¨ ck, ‘The Idle and the Industrious –
European Ideas about the African Work Ethic in
Precolonial West Africa’, History in Africa, 2014, 41,
117–45.
151
Quoted in Trowell, Davies, and Dean, Kwashiorkor,
243.
152
Brock and Autret, Kwashiorkor in Africa, 32–33.
153
Davies, Pestilence and Disease,8.
154
Brock and Autret, Kwashiorkor in Africa, 58.
155
K. David Patterson, ‘The Veterinary Department and
the Animal Industry in the Gold Coast, 1909-1955’,
The International Journal of African Historical
Studies, 1980, 13, 457–91; the relationship be-
tween nutritional science and the development of
both human and animal capital deserves more
work, especially given the recent ‘animal turn’ in
historiography. An interesting exception is,
Jonathan Saha, ‘Milk to Mandalay: Dairy
Consumption, Animal History and the Political
Geography of Colonial Burma’, Journal of Historical
Geography, 2016, 54, 1–12.
22 John Nott
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Empire Marking Board’ these pamphlets were ‘distributed gratis to the Colonial
Governments’.
156
The promotion of breastmilk substitutes were part of this broader
trend. In the Gold Coast, Purcell explained that ‘the condition of the infants indicate
strongly that breastmilk is often of poor quality’. However, at the Oda Weighing Clinic,
bottle-fed Baby Kofi ‘differed from all the other babies in that he was plump, robust and
constantly cheerful.... The healthy gleam of his eyes was sufficient to distinguish him
from the other babies, all of them breast-fed’.
157
In 1937, only 2 years prior to her ‘milk
and murder’ speech, even Cicely Williams would recommend that ‘milk should be given
with every feed until a child is eighteen months old and every day till he is ten years
old’.
158
In fact, Williams was so optimistic about the potential for artificial feeding that
she sought to acquire an official endorsement of Nestle´’s tinned milk.
159
Conclusion
Cicely Williams’ early faith in the potential of infant formula was cultured in both metro-
politan and imperialist discourses regarding the relative value of food. In the 1930s, the
science of nutrition pledged an objective valuation of diet, while technological develop-
ments appeared to offer a ready reprieve from deficiency. These ideas underpinned a bio-
politics of nutrition that was based on earlier histories of class and cuisine, hunger,
humanitarianism and noblesse oblige. Born from these conventions, kwashiorkor was
taken to be a natural result of the deviant diets and food cultures encountered by
Europeans in Africa. Made endemic both by the pressures of colonisation and the reifica-
tion of nutritionist dietetics, kwashiorkor was cast as a pervasive and timeless burden of
African incivility. While this construction was not apolitical, it reflects the latent politics of
European history on the later development of colonial medicine.
Working from these assumptions, and working out of atypical rainforest food econo-
mies, early-twentieth-century nutrition research could only ever offer partial insight into
the aetiology and epidemiology of deficiency during this period. In spite of this, conclu-
sions drawn from these areas were extended into savannah areas and then across the
continent. Gold Coast Nutrition and Cookery, like the infant formula which it endorsed,
was one of many solutions to this construction of deficiency. Taking up this mantel, the
UN’s Protein Advisory Group, created in 1955 to ‘fight to close the protein gap’ between
Global North and South, continued to promote modernist, technical and technocratic
solutions to an imagined protein crisis until long after the end of empire.
160
It was only in
1975, in a word-for-word reversal of the conclusions forwarded in Nutrition in the
Colonial World, that Nature carried an article explaining that ‘the problem is mainly one
of quantity rather than quality of food’, and that ‘the protein gap is a myth ... what re-
ally exists, even for vulnerable groups, is a food gap and an energy gap’.
161
156
PRAAD/CSO/11/1/337, ‘Index to the literature of
food investigation’, 1929.
157
Purcell, Diet and Ill-Health, 15.
158
WL/PP/CDW/B.1/3, Gold Coast Handbook of
Nursing, Children’s Section, Accra, 1937.
159
PRAAD/CSO/11/6/4, Cicely D. Williams to Deputy
Director of Health Services, 18 January 1932.
160
Quoted in Carpenter, Protein and Energy, 162; see
also Tom Scott-Smith, ‘Beyond the “Raw” and the
“Cooked”: A History of Fortified Blended Foods’,
Disasters, 2015, 39, 244–60; Nott, ‘“How Little
Progress”?’
161
J. C. Waterlow and P. R. Payne, ‘The Protein Gap’,
Nature, 1975, 258, 113–17, 113, 117.
Kwashiorkor, Protein and the Politics of Nutrition 23
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Kwashiorkor had emerged and endured also because its construction covered this up.
Given that ‘no-one may starve in the British Empire’, kwashiorkor offered a generalisation
of African deficiency which was politically benign. Unlike the more problematic politics of
hunger and undernutrition, kwashiorkor actively bolstered the racialised hierarchies
which lay at the foundations of empire. The apparent absence of kwashiorkor in
European epidemiology—as well as its complex biological pathology—challenged the sci-
ence of nutrition, justified European authority over African health and naturalised narra-
tives of African exceptionalism. These singular narratives have been hard to shift and, as
Chimamanda Ngozi Adichie has explained, ‘create stereotypes, and the problem with
stereotypes is not that they are untrue, but that they are incomplete’.
162
This does not
mean to deny Africa’s burden of nutritional illness, or even the uniqueness of African ill-
health, but seeks to instead stress that both malnutrition and African alterity have long
conceptual histories relevant to contemporary problems; stories which were often spun
in view of a metropolitan audience and, at times, for imperialist ends.
Acknowledgements
Thanks are due to Shane Doyle, Emily Klancher Merchant, Carina Truyts and Eline
Schmeets for comments on earlier drafts of this paper.
Funding
This research was funded by an ESRC PhD studentship.
162
Quoted in Mkhwanazi, ‘Medical Anthropology in
Africa’, 194.
24 John Nott
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