7

Listening to the GaCicely Williamsrsquo Discovery

of Kwashiorkor on the Gold Coast

J Stanton

Cicely Williamsrsquo career illustrates several themes which are relevant tolsquowomen in modern medicinersquo As a woman doctor qualified at theend of the First World War when male doctors were returning fromthe front she faced impossible odds in securing a job in England soworked overseas and trained in tropical medicine In 1929 sheentered the Colonial Medical Service in a post specifically earmarkedfor women a Woman Medical Officer concerned with maternal andchild health in what was then the Gold Coast colony under Britishcontrol Since this was lsquowomenrsquos workrsquo she was paid at a lower ratethan equivalent male medical officers a discriminatory distinction towhich she strongly objected1 Her role was supposed to be to handout advice in clinics and treat acutely ill infants in hospital but sherapidly established the need for comprehensive medical services tosick infants and in addition conducted clinical research

As well as being a woman in a manrsquos world Cicely Williams inthe Gold Coast was a woman practising modern medicine which inthat place and time takes on particular dimensions She was arepresentative of Western medicine in a colonial setting wherewestern medicine opposed traditional medicine just as Westernreligion opposed traditional religion both medicine and religion canbe seen in different ways as lsquoambassadorsrsquo of the colonial enterprise2

Going a step further than many Western doctors she lsquodiscoveredrsquo anew disease using scientific methods which typify our notion oflsquomodern medicinersquo though operating within the restrictedcircumstances of the colony It was the rejection of her findings onkwashiorkor that revealed the gender biases in the medical professionmost strongly

The story of Cicely Williamsrsquo discovery of kwashiorkor followedby the prolonged opposition of members of the male medicalestablishment has been told before as a classic tale (in the mould

149

once popular in history of medicine) of a pioneer struggling forrecognition3 It can be read more specifically as an indictment ofprejudices against women and those on the peripheries ofprofessional power ndash here in two senses the colony as periphery tothe metropolis and maternal and child work as undervaluedperiphery to more central branches of medicine

But as suggested in the title of this paper there are other instructivelessons in Williamsrsquo approach lsquoListening to the Garsquo is here intended to

150

J Stanton

Fig 1[Map] The Gold Coast in the 1930s (From Bourret)With kind permission the Oxford University Press

imply sensitivity to both the language and the people of the GoldCoast Such sensitivity was not common either among doctors servingcolonial peoples or those treating the poorer classes at home nor wasit common among colonial officials more generally Cicely Williamswas not sensitive as in lsquodelicatersquo ndash she was an extremely strong-willedand tough woman ndash but perhaps partly thanks to her childhood inJamaica she seems to have responded to the Gold Coast people shemet in a far more empathetic way than most European colonials4

Thus she listened to the Ga language and used its term for thelsquodisease of the deposed childrsquo kwashiorkor a word she later saidnobody mentioned in front of her for her first three years because itcarried such dire associations5 And she listened to the Ga peoplemainly mothers and grandmothers she met in association with theinfants she treated but also nurses and traditional healers orlsquowitchdoctorsrsquo Though highly critical of many lsquotraditionalrsquo beliefsand customs Williams seems to have recognised that there waswisdom too to be gathered from local people Her use of thevernacular term for the disease which she described revealed respectfor local interpretations this may have been an additional reason shemet with such strong resistance from pillars of Harley Street

For readers unfamiliar with the disease it may be appropriate hereto offer a definition with the caveat that descriptions andinterpretations of kwashiorkor have changed over time This is a severeform of malnutrition in infants which differs from wasting The chiefsigns are oedema (watery swelling) lassitude and irritability adarkening and peeling of the skin at points of flexion and pressuresometimes accompanied by reddish colouration of the hair changes inthe liver and ndash without suitable treatment ndash rapid decline and deathArguments in the 1930s and 1940s centred on whether the diseasewas a distinct new entity or a form of pellagra while debate in recentdecades centred on whether this was lsquoprotein malnutritionrsquo asWilliams suggested or a form of calorie malnutrition This paper willnot attempt to discuss the recent arguments6

The Gold Coast colony background to infant welfare

The British (and French) had long been established on the coast ofWest Africa in ex-Portuguese or Dutch slaving or trading forts andcoastal enclaves The Gold Coast was finally demarcated and takenby the British at the Berlin Conference of 1884-5 the resolution ofthe lsquoScramble for Africarsquo between the imperial powers of Europe(Fig1)7 Despite the colonyrsquos name and continuing gold productionespecially in the Asante region8 by the early twentieth century gold

151

Listening to the Ga

was being overtaken as the main export by cocoa grown bythousands of independent peasant farmers9 (Fig2)10 The colonialgovernment did not encourage settlement by Europeans either nearthe coast nor inland where it operated a policy of lsquoindirect rulersquothrough local chiefs11 There was thus less displacement ofcommunities (in the post-slaving era) than in colonies under harshercolonial regimes but indirect European influence was visible in theintroduction of western trade goods (Fig 3)12 and the developmentof European-educated elites in the coastal towns and inland Kumasicapital of Asante (Fig 4)13

As in other West African colonies there were enormousvariations in living standards in the Gold Coast both within thecities where African doctors lawyers and teachers had alreadybecome established prior to British rule14 and also in the countrysidewhere chiefs and other wealthy men could afford large householdswith many wives and children while poorer families might struggleto survive Although cocoa farming by indigenous producers seemsto suggest widespread prosperity the effect on production of localfood crops was to create scarcity and drive up prices an instance of amore general pattern discussed in recent historiography15 It was also

152

J Stanton

Fig 2Local producers selling cocoa palm oil and rubber at trading station

Harry Martin Gold Coast 1902ndash6 With permission of Rhodes HouseLibrary University of Oxford

153

Listening to the Ga

Fig 4Untitled group of young women Harry Martin Gold Coast 1902ndash6

With permission of Rhodes House Library University of Oxford

Fig 3Onitsha store Harry Martin Gold Coast 1902ndash6

With permission of Rhodes House Library University of Oxford

noted by observers at the time in the case of the Gold Coast by WOrmsby-Gore Under-Secretary of State for the Colonies on a visitin 192616 He laid great stress on the food question and overtly linkedit with national efficiency and infant mortality

There are few parts of the world where the study of dietetics is moreimportant than in Africa It affects not only the question of theefficiency of labour but also public health and particularly infantmortality17

The aim of progress and development central to the colonialundertaking was seen to depend on better food supplies18 Whereas a

154

J Stanton

Fig 5 ldquoBeginyarsquo Bardquo (come-and-stay) child with father Photograph taken by

R S Rattray while Head of Anthropology Gold Coast 1921ndash32 Withpermission of Pitt Rivers Museum (School of Anthropology and Museum

of Ethnography) University of Oxford

major motive behind infant welfare in Britain was provision ofsoldiers to defend the Empire19 here it was primarily a matter ofeconomic advance

Along with many other British exports the Gold Coast receivedconcern over infant mortality Attempts to enumerate the populationndash very partial and inaccurate ndash were supplemented in 1917 by a surveyof infant mortality in Accra which generated alarming statisticsapparently nearly half the babies died in the first year of life20 Amonga tranche of welfare measures introduced by the progressive post-warGovernor F G Guggisberg was government provision for infantwelfare work previously the prerogative of missionary groups21

Reviewing the situation towards the end of his term of officeGuggisberg speculated on infant mortality at the turn of the centuryit lsquomust have been appallingrsquo in view of the crowded and insanitaryhousing conditions Still in 1921 as organised clinics were institutedsome towns reported infant mortality rates of over four hundred perthousand due in Guggisbergrsquos view to lsquothe housing the customs andthe habits of the peoplersquo22

The new facilities offered by the government were certainlypopular Infant welfare clinics which opened in the main towns withseveral in Accra rapidly attracted thousands of attendances a year23

In 1926 Princess Marie Louise Hospital for children opened inAccra to provide the main infant and child welfare (outpatient)centre as well as acute services Guggisberg placed these at the centreof his programme

The various clinics now opened for Infant Welfare work represent thebeginnings in the Gold Coast of the new Public Health and inconjunction with improved education will help to instil into theminds of the people that the quest and attainment of health should bea personal matter of supreme importance which if they are willing tolearn will change the whole history of their country for the better24

It was into this atmosphere of encouraging self-improvementreminiscent of lsquoeducating the mothersrsquo in the UK25 that CicelyWilliams was appointed Woman Medical Officer in 1929

Cicely Williams and kwashiorkor

Of course Cicely Williams was not alone in attempting tounderstand the language and beliefs of the Africans she workedamongst In the Gold Coast as in other colonies under each of thecolonial powers professional agents were appointed to interpret thealien world of lsquothe nativesrsquo for the colonisers government (and free-

155

Listening to the Ga

range) anthropologists can be seen as serving this function as well ascarrying out their own intellectual programme Nor was Williams theonly doctor to double as amateur anthropologist Colonial officials ofall grades seem to have dabbled in anthropology26 but doctors wereespecially tempted as the eugenic end of their scientificunderstanding alerted them to the fine line between racial andcultural difference27

Two specific examples may serve to illustrate Williamsrsquoapproach First we may examine a photograph taken in the 1920sby R S Rattray government anthropologist of a BeginyarsquoBa orlsquocome-and-stayrsquo child whose parents deliberately dressed heruntidily and left her hair dishevelled in the hope of deceiving thespirits who had taken their other children (Fig 5)28 Now comparethis with one taken by Williams in the 1930s of an older girldescribed as a fahit or fetish child (Fig 6)29 Rattrayrsquos picture placesthe child on her fond fatherrsquos lap it is a beautiful study of parentallove Williamsrsquo shot appears more clinical but the accompanyingnote that lsquo8 elder siblings diedrsquo shows that she enquired into thefamily circumstances while the recording of the childrsquos name(Ahana) indicates personal contact

Similarly Williams recorded names of nurses holding twoinfants whom she described as the only abandoned babies she eversaw in the Gold Coast (Fig 7)30 She believed abandonment wasextremely rare compared with European societies Correlating thelocations where these babies were found ndash one beside the railway andthe other on a golf course ndash with European infiltration Williams sawtheir fate as symbolic of the dislocation brought about by colonialrule a theme amply developed in contemporary anthropologicalwriting especially on southern Africa31

However Williams was not anti-colonial at this stage nor did shehold a rosy view of African mothersrsquo childrearing skills although shecommended maternal devotion she was critical of what she saw as theindulgent unregulated regime adopted towards young infants Muchcan be learned of her views from her MD thesis which permitted fullerexpansion than any of her articles Perhaps unconsciously drawing acontrast with her own heavy burden of work she likened mothersplaying with their babiesrsquo beads to neurotic chain smokers andascribed adults having an infantile craving to have something alwaysin their mouths to their constant snacking as infants Her observationson weaning are perhaps more objective

[The young infant is] carried about on the motherrsquos back a position

156

J Stanton

it loves it sleeps close beside her it is nourished whenever it criesand on the whole it does remarkably well on this treatment I haveseen the most uncomprehending indignation rage and bitterness ina child of three years old who found that his place on his motherrsquosback was suddenly usurped by a new baby32

The identification of a weaning crisis was intimately tied in withWilliamsrsquo recognition of kwashiorkor which in the main struckchildren between the ages of two and four and nearly always provedfatal

By the time she wrote her MD thesis in 1936 Williamscalculated that she had treated about 100000 children in clinics inthe Gold Coast Reasons for the high morbidity and mortality thesubject of her thesis were wide-ranging in many cases similar tothose in Europe and largely preventable in Williamsrsquo view33 On one

157

Listening to the Ga

Fig 6 lsquoFahitrsquo or fetish child Ahana Cicely Williams Gold Coast 1933ndash5

With kind permission of Contemporary Medical Archives Centre andMedical Photographic Library at the Wellcome Library

hand she indicated poverty was the underlying cause giving a radicalprescription lsquoThe function of a medical department conducted byany government is to raise the standard of living rather than toprovide orthodox medical attention for the individualrsquo34 On theother hand she held that the lsquounspeakablersquo loss of health and lifeamong children was lsquoall due to ignorance and dirt and diseasersquo35 Herunifying theme was the need for civilisation

The enlightened but paternalistic approach of the Guggisbergtype of progressive colonial is reflected in Williamsrsquo attitudesHowever her arguments for combining preventive and curativemedicine caused her to clash with her immediate superiors in whoseview the preventive work was not her job ndash although much laterWilliamsrsquo views won her the title of lsquoprimary health care pioneerrsquo36

Nutritional disorders amply illustrated the need for a combinedapproach As long as she worked in the Gold Coast treating sickchildren the hopelessness of cases of kwashiorkor drove Williams toseek to understand the syndrome which was not described in any of

158

J Stanton

Fig 7 Abandoned babies with nurses Cicely Williams Gold Coast 1933ndash5With kind permission of Contemporary Medical Archives Centre and

Medical Photographic Library at the Wellcome Library

the medical texts she consulted Her first published account appearedin the departmental report in 193237 and was so striking that herformer teacher Helen MacKay (of Queenrsquos Hospital London)encouraged her to seek publication in the prestigious journal Archivesof Disease in Childhood her first classic article appeared in 193338

Battle was joined immediately with H S Stannus an establishedexpert on nutrition countering Williamsrsquo view that this was a newdisease Stannus who had worked as a Medical Officer in Nyasaland(later Malawi) and Tanganyika between 1906 and 1918 and wasregarded as an expert on deficiency diseases among Africans claimedthat the condition must be simply an infantile form of pellagra39

Despite inclusion of photographs in Williamsrsquo 1933 article showinga distribution of darkened peeling skin on infants which was entirelyunlike that characteristic of pellagra Stannus without having himselfseen such cases dismissed her observations Williams assembleddetails of a further sixty cases and drew up a comparison betweenkwashiorkor as she now termed it and pellagra in a Lancet article in193540 Micrographs of skin and liver amplifying clinical and post-mortem observations represented lsquoscientificrsquo medicine at a fairlyadvanced level for an African colony available in the pathologylaboratory at Accrarsquos main hospital Again Stannus followedWilliams in print to challenge her interpretation41 Far from beingswayed by the scientific element in her presentation42 he seemedincensed by her adoption of a lsquonativersquo word for the condition

The association with a maize diet indicated by Williams has beenseen as misleading later recognition of the prevalence of the diseasein areas where other staples dominated showed that maize was in nosense the cause43 But Williams made an important connection whenshe pointed out that arkassa the fermented maize food usually givento infants contained yeast which was supposed to cure pellagra Oneof the leading investigators who followed Stannusrsquo line HughTrowell in Uganda administered nicotinic acid (the active anti-pellagra compound in yeast) to kwashiorkor sufferers in the early1940s without any success44 Nevertheless Trowell persisted inavoiding the term kwashiorkor switching from lsquoinfantile pellagrarsquo tolsquomalignant malnutritionrsquo

Possibly Williams drew attention to maize ndash knowing thatpellagra was associated with a chiefly maize diet in the southern USAndash in order to point out the differences between pellagra and thecondition she was observing Certainly she was careful to showdifferences in the skin lesions and other features of the two diseasesshe also offered differential diagnoses in relation to lsquopink diseasersquo

159

Listening to the Ga

vitamin A deficiency and vitamin B1 and B2 deficiencies She wascertainly thinking in terms of deficiency adding lsquoNo tests formineral or protein deficiency have yet been madersquo45 In her 1933paper she suggested several possible causes stating lsquoAs maize was theonly source of the supplementary food some amino-acid or proteindeficiency cannot be excluded as a causersquo46

As for treatment Williams tried varied diets without successcombinations with butter eggs tomato orange liver Marmiteyeast Bemax iron and arsenic failed to reverse the symptoms Theonly food that seemed to work and then in only a few cases wastinned milk lsquoNestleacutersquos sweetened condensed milk with cod-liver oiland malt seemed to be the most successful line of treatmentrsquo47 Soimpressed was she with these rare successes that she wanted to offera chart showing a child patientrsquos recovery for use by Nestleacute inpromoting milk consumption Her immediate superior in the HealthService saw lsquono reason why Messrs Nestleacutes should not make use ofthis chartrsquo but the Governor signalled disapproval lsquoThe value ofthese tinned milks is well knownrsquo and more importantly Nestleacute wasno better than other brands and was not a British firm48 (As willappear later by the end of the 1930s Williams reversed her views andcondemned tinned milk)

If a breastmilk substitute was needed Williams argued tinned milkwas the most convenient Tsetse-borne disease made cattle rearingnearly impossible in this region while goatsrsquo milk could theoreticallybe used the local goats lsquoare never milked and they do not look as if theidea of milking had ever been mentionedrsquo49 Advocacy of tinned milkwas widespread among colonial doctors although there seems not tohave been a concerted effort to dissuade mothers from breastfeeding inBritish colonies as there was in the Belgian Congo lsquoGouttes de Laitrsquo50

Purcell a male Medical Officer practising further west in the GoldCoast at Oda gave a glowing description of lsquobaby Kofirsquo whose motherhad died the day he was born and who was raised on tinned milk andorange juice lsquo plump robust and constantly cheerful The healthygleam of his eyes was sufficient to distinguish him from the otherbabies all of them breast fedrsquo51 Purcell mentioned the Belgian Congomodel to support his view

In describing cases very similar to those observed by WilliamsPurcell chose the heading lsquoInfantile pellagra (Akwashiokor ndashWilliams)rsquo52 He recorded an invariably fatal outcome despite largedoses of Marmite and admitted his lsquodescription tallies closely withthat of Dr Williams but my conclusions differ from hers as sheconsiders the condition distinct from pellagrarsquo53 Purcell paid attention

160

J Stanton

to local interpretations in his discussion of oedema which was one ofthe symptoms of kwashiorkor but also of many other diseases

In Akim the importance of oedema as a sign of disease may beinferred from the fact that my informant a reputable and intelligentldquonative doctorrdquo professes to recognise some five clinical varieties Owuo Mpumpungya is a name given to a disease in which the bodyswells gradually the skin peels off (This resembles the syndromeldquoakwashiorkorrdquo described by Williams)54

Purcell noted the informantrsquos view that the syndrome oftenappeared after a serious case of measles also strikingly the belief thatit was lsquocaused by witches who put the victim into ldquoinvisible firerdquo orboil himrsquo because the victim looks boiled55 In the 1950s whenWilliams visited Tanganyika she was shown the body of a child inDodoma Hospital mortuary described as lsquoa terrible burns casersquo butshe recognised the signs of kwashiorkor56 In this and possibly inmany similar cases Western doctors accused parents of scalding theirchildren through using over-hot bath water

By the time Purcell wrote his book Williams was no longer in theGold Coast Following a dispute with Dr G S Selwyn-ClarkeDeputy Director of Health Services regarding the treatment of oneof her infant patients she was summarily transferred in 1936 fromher Gold Coast post to Singapore Williams had admitted intohospital an infant with non-infectious tubercular peritonitis whomthe Deputy-Director then decided to exclude Williams hadprotested vociferously Although apparently concerned with theinterpretation of rules on admitting patients with tuberculosis thedispute was almost certainly fuelled by antagonism between twostrong characters with rather different ideologies57 Williams was onleave in England when news of her transfer reached her and she hadto depart without her belongings and many of her clinical noteshowever she had brought some with her for completion of her MDthesis Further observations on kwashiorkor were ruled out since itdid not appear to occur in Malaya where wasting (marasmus) was acommon form of severe infant malnutrition Williamsrsquo views on theuse of tinned milk evolved very rapidly in her new posting in 1939she delivered a stinging and prophetic talk to the Rotary Clubentitled lsquoMilk and Murderrsquo condemning promotion of tinned milkto local mothers in tenements by young women dressed like nurses58

Williams was imprisoned in Changi Gaol when the Japaneseoccupied Singapore Trowell greeted Williams on her release at theend of the war with a letter saying he would like to meet her lsquoif only

161

Listening to the Ga

to tell you that you were right Kwashiorkor is not pellagrarsquo59

However his latest article used the term lsquoThe kwashiorkor syndromeof malignant malnutritionrsquo to cover what he believed to be variantsof the condition in children and adults and his failure to absorb thelessons of Williamsrsquo work was reflected in his enthusiasm for trials ofdesiccated hogrsquos stomach as a cure Failure to appreciate Williams wasalso evident in the comments that ended his letter lsquoHow curious thatalmost all African tribes have their name for this disease + what a pitywe could not learn from them It affects millionsrsquo Williams hadshown an ability to lsquolearn from themrsquo throughout her spell in theGold Coast60

In 1948 Williams was appointed first head of the Maternal andChild Health (MCH) section at the World Health Organization(WHO) in Geneva Although she held the position briefly beforetransferring to head MCH for WHO in South East Asia her tenuremay be connected with the launch of a survey of kwashiorkorthroughout sub-Saharan Africa in 1950 resulting in a reportpublished in 195261 From evidence gathered in ten countries theauthors surmised that kwashiorkor was lsquothe most serious andwidespread nutritional disorder known to medical and nutritionalsciencersquo62 Williams was well and truly vindicated ndash as were the Gaand many other African peoples who had named the disease

Discussion

Baumslag opines that Williams fulfilled lsquoa physicianrsquos dream todiagnose find the causative agent and curersquo for a new disease shehad also discovered a means of prevention by supervision at MCHclinics63 Trowell paid respect to Williams in his book on kwashiorkorbut provided many other precedents among whom he cited Gelfandin Rhodesia and Altman in South Africa as lsquopioneersrsquo diminishingthe pre-eminence of Williams in providing the definitivedescription64 The balance probably lies somewhere between thesetwo since it is clear that Williams was still struggling to find the exactcause and an effective cure when she was transferred from the GoldCoast in 1936 On the other hand the 1952 WHO report by Brockand Autret (referred to above) which Trowell says was lsquocrucialrsquo inensuring recognition of the disease would probably not have comeabout without Williamsrsquo work

An equally important question for the historian ndash moreimportant for those not too worried about precedence ndash is this wheredoes Williamsrsquo work fit into the development of nutrition studiesDiscussing the general area of the discovery of colonial malnutrition

162

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

once popular in history of medicine) of a pioneer struggling forrecognition3 It can be read more specifically as an indictment ofprejudices against women and those on the peripheries ofprofessional power ndash here in two senses the colony as periphery tothe metropolis and maternal and child work as undervaluedperiphery to more central branches of medicine

But as suggested in the title of this paper there are other instructivelessons in Williamsrsquo approach lsquoListening to the Garsquo is here intended to

150

J Stanton

Fig 1[Map] The Gold Coast in the 1930s (From Bourret)With kind permission the Oxford University Press

imply sensitivity to both the language and the people of the GoldCoast Such sensitivity was not common either among doctors servingcolonial peoples or those treating the poorer classes at home nor wasit common among colonial officials more generally Cicely Williamswas not sensitive as in lsquodelicatersquo ndash she was an extremely strong-willedand tough woman ndash but perhaps partly thanks to her childhood inJamaica she seems to have responded to the Gold Coast people shemet in a far more empathetic way than most European colonials4

Thus she listened to the Ga language and used its term for thelsquodisease of the deposed childrsquo kwashiorkor a word she later saidnobody mentioned in front of her for her first three years because itcarried such dire associations5 And she listened to the Ga peoplemainly mothers and grandmothers she met in association with theinfants she treated but also nurses and traditional healers orlsquowitchdoctorsrsquo Though highly critical of many lsquotraditionalrsquo beliefsand customs Williams seems to have recognised that there waswisdom too to be gathered from local people Her use of thevernacular term for the disease which she described revealed respectfor local interpretations this may have been an additional reason shemet with such strong resistance from pillars of Harley Street

For readers unfamiliar with the disease it may be appropriate hereto offer a definition with the caveat that descriptions andinterpretations of kwashiorkor have changed over time This is a severeform of malnutrition in infants which differs from wasting The chiefsigns are oedema (watery swelling) lassitude and irritability adarkening and peeling of the skin at points of flexion and pressuresometimes accompanied by reddish colouration of the hair changes inthe liver and ndash without suitable treatment ndash rapid decline and deathArguments in the 1930s and 1940s centred on whether the diseasewas a distinct new entity or a form of pellagra while debate in recentdecades centred on whether this was lsquoprotein malnutritionrsquo asWilliams suggested or a form of calorie malnutrition This paper willnot attempt to discuss the recent arguments6

The Gold Coast colony background to infant welfare

The British (and French) had long been established on the coast ofWest Africa in ex-Portuguese or Dutch slaving or trading forts andcoastal enclaves The Gold Coast was finally demarcated and takenby the British at the Berlin Conference of 1884-5 the resolution ofthe lsquoScramble for Africarsquo between the imperial powers of Europe(Fig1)7 Despite the colonyrsquos name and continuing gold productionespecially in the Asante region8 by the early twentieth century gold

151

Listening to the Ga

was being overtaken as the main export by cocoa grown bythousands of independent peasant farmers9 (Fig2)10 The colonialgovernment did not encourage settlement by Europeans either nearthe coast nor inland where it operated a policy of lsquoindirect rulersquothrough local chiefs11 There was thus less displacement ofcommunities (in the post-slaving era) than in colonies under harshercolonial regimes but indirect European influence was visible in theintroduction of western trade goods (Fig 3)12 and the developmentof European-educated elites in the coastal towns and inland Kumasicapital of Asante (Fig 4)13

As in other West African colonies there were enormousvariations in living standards in the Gold Coast both within thecities where African doctors lawyers and teachers had alreadybecome established prior to British rule14 and also in the countrysidewhere chiefs and other wealthy men could afford large householdswith many wives and children while poorer families might struggleto survive Although cocoa farming by indigenous producers seemsto suggest widespread prosperity the effect on production of localfood crops was to create scarcity and drive up prices an instance of amore general pattern discussed in recent historiography15 It was also

152

J Stanton

Fig 2Local producers selling cocoa palm oil and rubber at trading station

Harry Martin Gold Coast 1902ndash6 With permission of Rhodes HouseLibrary University of Oxford

153

Listening to the Ga

Fig 4Untitled group of young women Harry Martin Gold Coast 1902ndash6

With permission of Rhodes House Library University of Oxford

Fig 3Onitsha store Harry Martin Gold Coast 1902ndash6

With permission of Rhodes House Library University of Oxford

noted by observers at the time in the case of the Gold Coast by WOrmsby-Gore Under-Secretary of State for the Colonies on a visitin 192616 He laid great stress on the food question and overtly linkedit with national efficiency and infant mortality

There are few parts of the world where the study of dietetics is moreimportant than in Africa It affects not only the question of theefficiency of labour but also public health and particularly infantmortality17

The aim of progress and development central to the colonialundertaking was seen to depend on better food supplies18 Whereas a

154

J Stanton

Fig 5 ldquoBeginyarsquo Bardquo (come-and-stay) child with father Photograph taken by

R S Rattray while Head of Anthropology Gold Coast 1921ndash32 Withpermission of Pitt Rivers Museum (School of Anthropology and Museum

of Ethnography) University of Oxford

major motive behind infant welfare in Britain was provision ofsoldiers to defend the Empire19 here it was primarily a matter ofeconomic advance

Along with many other British exports the Gold Coast receivedconcern over infant mortality Attempts to enumerate the populationndash very partial and inaccurate ndash were supplemented in 1917 by a surveyof infant mortality in Accra which generated alarming statisticsapparently nearly half the babies died in the first year of life20 Amonga tranche of welfare measures introduced by the progressive post-warGovernor F G Guggisberg was government provision for infantwelfare work previously the prerogative of missionary groups21

Reviewing the situation towards the end of his term of officeGuggisberg speculated on infant mortality at the turn of the centuryit lsquomust have been appallingrsquo in view of the crowded and insanitaryhousing conditions Still in 1921 as organised clinics were institutedsome towns reported infant mortality rates of over four hundred perthousand due in Guggisbergrsquos view to lsquothe housing the customs andthe habits of the peoplersquo22

The new facilities offered by the government were certainlypopular Infant welfare clinics which opened in the main towns withseveral in Accra rapidly attracted thousands of attendances a year23

In 1926 Princess Marie Louise Hospital for children opened inAccra to provide the main infant and child welfare (outpatient)centre as well as acute services Guggisberg placed these at the centreof his programme

The various clinics now opened for Infant Welfare work represent thebeginnings in the Gold Coast of the new Public Health and inconjunction with improved education will help to instil into theminds of the people that the quest and attainment of health should bea personal matter of supreme importance which if they are willing tolearn will change the whole history of their country for the better24

It was into this atmosphere of encouraging self-improvementreminiscent of lsquoeducating the mothersrsquo in the UK25 that CicelyWilliams was appointed Woman Medical Officer in 1929

Cicely Williams and kwashiorkor

Of course Cicely Williams was not alone in attempting tounderstand the language and beliefs of the Africans she workedamongst In the Gold Coast as in other colonies under each of thecolonial powers professional agents were appointed to interpret thealien world of lsquothe nativesrsquo for the colonisers government (and free-

155

Listening to the Ga

range) anthropologists can be seen as serving this function as well ascarrying out their own intellectual programme Nor was Williams theonly doctor to double as amateur anthropologist Colonial officials ofall grades seem to have dabbled in anthropology26 but doctors wereespecially tempted as the eugenic end of their scientificunderstanding alerted them to the fine line between racial andcultural difference27

Two specific examples may serve to illustrate Williamsrsquoapproach First we may examine a photograph taken in the 1920sby R S Rattray government anthropologist of a BeginyarsquoBa orlsquocome-and-stayrsquo child whose parents deliberately dressed heruntidily and left her hair dishevelled in the hope of deceiving thespirits who had taken their other children (Fig 5)28 Now comparethis with one taken by Williams in the 1930s of an older girldescribed as a fahit or fetish child (Fig 6)29 Rattrayrsquos picture placesthe child on her fond fatherrsquos lap it is a beautiful study of parentallove Williamsrsquo shot appears more clinical but the accompanyingnote that lsquo8 elder siblings diedrsquo shows that she enquired into thefamily circumstances while the recording of the childrsquos name(Ahana) indicates personal contact

Similarly Williams recorded names of nurses holding twoinfants whom she described as the only abandoned babies she eversaw in the Gold Coast (Fig 7)30 She believed abandonment wasextremely rare compared with European societies Correlating thelocations where these babies were found ndash one beside the railway andthe other on a golf course ndash with European infiltration Williams sawtheir fate as symbolic of the dislocation brought about by colonialrule a theme amply developed in contemporary anthropologicalwriting especially on southern Africa31

However Williams was not anti-colonial at this stage nor did shehold a rosy view of African mothersrsquo childrearing skills although shecommended maternal devotion she was critical of what she saw as theindulgent unregulated regime adopted towards young infants Muchcan be learned of her views from her MD thesis which permitted fullerexpansion than any of her articles Perhaps unconsciously drawing acontrast with her own heavy burden of work she likened mothersplaying with their babiesrsquo beads to neurotic chain smokers andascribed adults having an infantile craving to have something alwaysin their mouths to their constant snacking as infants Her observationson weaning are perhaps more objective

[The young infant is] carried about on the motherrsquos back a position

156

J Stanton

it loves it sleeps close beside her it is nourished whenever it criesand on the whole it does remarkably well on this treatment I haveseen the most uncomprehending indignation rage and bitterness ina child of three years old who found that his place on his motherrsquosback was suddenly usurped by a new baby32

The identification of a weaning crisis was intimately tied in withWilliamsrsquo recognition of kwashiorkor which in the main struckchildren between the ages of two and four and nearly always provedfatal

By the time she wrote her MD thesis in 1936 Williamscalculated that she had treated about 100000 children in clinics inthe Gold Coast Reasons for the high morbidity and mortality thesubject of her thesis were wide-ranging in many cases similar tothose in Europe and largely preventable in Williamsrsquo view33 On one

157

Listening to the Ga

Fig 6 lsquoFahitrsquo or fetish child Ahana Cicely Williams Gold Coast 1933ndash5

With kind permission of Contemporary Medical Archives Centre andMedical Photographic Library at the Wellcome Library

hand she indicated poverty was the underlying cause giving a radicalprescription lsquoThe function of a medical department conducted byany government is to raise the standard of living rather than toprovide orthodox medical attention for the individualrsquo34 On theother hand she held that the lsquounspeakablersquo loss of health and lifeamong children was lsquoall due to ignorance and dirt and diseasersquo35 Herunifying theme was the need for civilisation

The enlightened but paternalistic approach of the Guggisbergtype of progressive colonial is reflected in Williamsrsquo attitudesHowever her arguments for combining preventive and curativemedicine caused her to clash with her immediate superiors in whoseview the preventive work was not her job ndash although much laterWilliamsrsquo views won her the title of lsquoprimary health care pioneerrsquo36

Nutritional disorders amply illustrated the need for a combinedapproach As long as she worked in the Gold Coast treating sickchildren the hopelessness of cases of kwashiorkor drove Williams toseek to understand the syndrome which was not described in any of

158

J Stanton

Fig 7 Abandoned babies with nurses Cicely Williams Gold Coast 1933ndash5With kind permission of Contemporary Medical Archives Centre and

Medical Photographic Library at the Wellcome Library

the medical texts she consulted Her first published account appearedin the departmental report in 193237 and was so striking that herformer teacher Helen MacKay (of Queenrsquos Hospital London)encouraged her to seek publication in the prestigious journal Archivesof Disease in Childhood her first classic article appeared in 193338

Battle was joined immediately with H S Stannus an establishedexpert on nutrition countering Williamsrsquo view that this was a newdisease Stannus who had worked as a Medical Officer in Nyasaland(later Malawi) and Tanganyika between 1906 and 1918 and wasregarded as an expert on deficiency diseases among Africans claimedthat the condition must be simply an infantile form of pellagra39

Despite inclusion of photographs in Williamsrsquo 1933 article showinga distribution of darkened peeling skin on infants which was entirelyunlike that characteristic of pellagra Stannus without having himselfseen such cases dismissed her observations Williams assembleddetails of a further sixty cases and drew up a comparison betweenkwashiorkor as she now termed it and pellagra in a Lancet article in193540 Micrographs of skin and liver amplifying clinical and post-mortem observations represented lsquoscientificrsquo medicine at a fairlyadvanced level for an African colony available in the pathologylaboratory at Accrarsquos main hospital Again Stannus followedWilliams in print to challenge her interpretation41 Far from beingswayed by the scientific element in her presentation42 he seemedincensed by her adoption of a lsquonativersquo word for the condition

The association with a maize diet indicated by Williams has beenseen as misleading later recognition of the prevalence of the diseasein areas where other staples dominated showed that maize was in nosense the cause43 But Williams made an important connection whenshe pointed out that arkassa the fermented maize food usually givento infants contained yeast which was supposed to cure pellagra Oneof the leading investigators who followed Stannusrsquo line HughTrowell in Uganda administered nicotinic acid (the active anti-pellagra compound in yeast) to kwashiorkor sufferers in the early1940s without any success44 Nevertheless Trowell persisted inavoiding the term kwashiorkor switching from lsquoinfantile pellagrarsquo tolsquomalignant malnutritionrsquo

Possibly Williams drew attention to maize ndash knowing thatpellagra was associated with a chiefly maize diet in the southern USAndash in order to point out the differences between pellagra and thecondition she was observing Certainly she was careful to showdifferences in the skin lesions and other features of the two diseasesshe also offered differential diagnoses in relation to lsquopink diseasersquo

159

Listening to the Ga

vitamin A deficiency and vitamin B1 and B2 deficiencies She wascertainly thinking in terms of deficiency adding lsquoNo tests formineral or protein deficiency have yet been madersquo45 In her 1933paper she suggested several possible causes stating lsquoAs maize was theonly source of the supplementary food some amino-acid or proteindeficiency cannot be excluded as a causersquo46

As for treatment Williams tried varied diets without successcombinations with butter eggs tomato orange liver Marmiteyeast Bemax iron and arsenic failed to reverse the symptoms Theonly food that seemed to work and then in only a few cases wastinned milk lsquoNestleacutersquos sweetened condensed milk with cod-liver oiland malt seemed to be the most successful line of treatmentrsquo47 Soimpressed was she with these rare successes that she wanted to offera chart showing a child patientrsquos recovery for use by Nestleacute inpromoting milk consumption Her immediate superior in the HealthService saw lsquono reason why Messrs Nestleacutes should not make use ofthis chartrsquo but the Governor signalled disapproval lsquoThe value ofthese tinned milks is well knownrsquo and more importantly Nestleacute wasno better than other brands and was not a British firm48 (As willappear later by the end of the 1930s Williams reversed her views andcondemned tinned milk)

If a breastmilk substitute was needed Williams argued tinned milkwas the most convenient Tsetse-borne disease made cattle rearingnearly impossible in this region while goatsrsquo milk could theoreticallybe used the local goats lsquoare never milked and they do not look as if theidea of milking had ever been mentionedrsquo49 Advocacy of tinned milkwas widespread among colonial doctors although there seems not tohave been a concerted effort to dissuade mothers from breastfeeding inBritish colonies as there was in the Belgian Congo lsquoGouttes de Laitrsquo50

Purcell a male Medical Officer practising further west in the GoldCoast at Oda gave a glowing description of lsquobaby Kofirsquo whose motherhad died the day he was born and who was raised on tinned milk andorange juice lsquo plump robust and constantly cheerful The healthygleam of his eyes was sufficient to distinguish him from the otherbabies all of them breast fedrsquo51 Purcell mentioned the Belgian Congomodel to support his view

In describing cases very similar to those observed by WilliamsPurcell chose the heading lsquoInfantile pellagra (Akwashiokor ndashWilliams)rsquo52 He recorded an invariably fatal outcome despite largedoses of Marmite and admitted his lsquodescription tallies closely withthat of Dr Williams but my conclusions differ from hers as sheconsiders the condition distinct from pellagrarsquo53 Purcell paid attention

160

J Stanton

to local interpretations in his discussion of oedema which was one ofthe symptoms of kwashiorkor but also of many other diseases

In Akim the importance of oedema as a sign of disease may beinferred from the fact that my informant a reputable and intelligentldquonative doctorrdquo professes to recognise some five clinical varieties Owuo Mpumpungya is a name given to a disease in which the bodyswells gradually the skin peels off (This resembles the syndromeldquoakwashiorkorrdquo described by Williams)54

Purcell noted the informantrsquos view that the syndrome oftenappeared after a serious case of measles also strikingly the belief thatit was lsquocaused by witches who put the victim into ldquoinvisible firerdquo orboil himrsquo because the victim looks boiled55 In the 1950s whenWilliams visited Tanganyika she was shown the body of a child inDodoma Hospital mortuary described as lsquoa terrible burns casersquo butshe recognised the signs of kwashiorkor56 In this and possibly inmany similar cases Western doctors accused parents of scalding theirchildren through using over-hot bath water

By the time Purcell wrote his book Williams was no longer in theGold Coast Following a dispute with Dr G S Selwyn-ClarkeDeputy Director of Health Services regarding the treatment of oneof her infant patients she was summarily transferred in 1936 fromher Gold Coast post to Singapore Williams had admitted intohospital an infant with non-infectious tubercular peritonitis whomthe Deputy-Director then decided to exclude Williams hadprotested vociferously Although apparently concerned with theinterpretation of rules on admitting patients with tuberculosis thedispute was almost certainly fuelled by antagonism between twostrong characters with rather different ideologies57 Williams was onleave in England when news of her transfer reached her and she hadto depart without her belongings and many of her clinical noteshowever she had brought some with her for completion of her MDthesis Further observations on kwashiorkor were ruled out since itdid not appear to occur in Malaya where wasting (marasmus) was acommon form of severe infant malnutrition Williamsrsquo views on theuse of tinned milk evolved very rapidly in her new posting in 1939she delivered a stinging and prophetic talk to the Rotary Clubentitled lsquoMilk and Murderrsquo condemning promotion of tinned milkto local mothers in tenements by young women dressed like nurses58

Williams was imprisoned in Changi Gaol when the Japaneseoccupied Singapore Trowell greeted Williams on her release at theend of the war with a letter saying he would like to meet her lsquoif only

161

Listening to the Ga

to tell you that you were right Kwashiorkor is not pellagrarsquo59

However his latest article used the term lsquoThe kwashiorkor syndromeof malignant malnutritionrsquo to cover what he believed to be variantsof the condition in children and adults and his failure to absorb thelessons of Williamsrsquo work was reflected in his enthusiasm for trials ofdesiccated hogrsquos stomach as a cure Failure to appreciate Williams wasalso evident in the comments that ended his letter lsquoHow curious thatalmost all African tribes have their name for this disease + what a pitywe could not learn from them It affects millionsrsquo Williams hadshown an ability to lsquolearn from themrsquo throughout her spell in theGold Coast60

In 1948 Williams was appointed first head of the Maternal andChild Health (MCH) section at the World Health Organization(WHO) in Geneva Although she held the position briefly beforetransferring to head MCH for WHO in South East Asia her tenuremay be connected with the launch of a survey of kwashiorkorthroughout sub-Saharan Africa in 1950 resulting in a reportpublished in 195261 From evidence gathered in ten countries theauthors surmised that kwashiorkor was lsquothe most serious andwidespread nutritional disorder known to medical and nutritionalsciencersquo62 Williams was well and truly vindicated ndash as were the Gaand many other African peoples who had named the disease

Discussion

Baumslag opines that Williams fulfilled lsquoa physicianrsquos dream todiagnose find the causative agent and curersquo for a new disease shehad also discovered a means of prevention by supervision at MCHclinics63 Trowell paid respect to Williams in his book on kwashiorkorbut provided many other precedents among whom he cited Gelfandin Rhodesia and Altman in South Africa as lsquopioneersrsquo diminishingthe pre-eminence of Williams in providing the definitivedescription64 The balance probably lies somewhere between thesetwo since it is clear that Williams was still struggling to find the exactcause and an effective cure when she was transferred from the GoldCoast in 1936 On the other hand the 1952 WHO report by Brockand Autret (referred to above) which Trowell says was lsquocrucialrsquo inensuring recognition of the disease would probably not have comeabout without Williamsrsquo work

An equally important question for the historian ndash moreimportant for those not too worried about precedence ndash is this wheredoes Williamsrsquo work fit into the development of nutrition studiesDiscussing the general area of the discovery of colonial malnutrition

162

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

imply sensitivity to both the language and the people of the GoldCoast Such sensitivity was not common either among doctors servingcolonial peoples or those treating the poorer classes at home nor wasit common among colonial officials more generally Cicely Williamswas not sensitive as in lsquodelicatersquo ndash she was an extremely strong-willedand tough woman ndash but perhaps partly thanks to her childhood inJamaica she seems to have responded to the Gold Coast people shemet in a far more empathetic way than most European colonials4

Thus she listened to the Ga language and used its term for thelsquodisease of the deposed childrsquo kwashiorkor a word she later saidnobody mentioned in front of her for her first three years because itcarried such dire associations5 And she listened to the Ga peoplemainly mothers and grandmothers she met in association with theinfants she treated but also nurses and traditional healers orlsquowitchdoctorsrsquo Though highly critical of many lsquotraditionalrsquo beliefsand customs Williams seems to have recognised that there waswisdom too to be gathered from local people Her use of thevernacular term for the disease which she described revealed respectfor local interpretations this may have been an additional reason shemet with such strong resistance from pillars of Harley Street

For readers unfamiliar with the disease it may be appropriate hereto offer a definition with the caveat that descriptions andinterpretations of kwashiorkor have changed over time This is a severeform of malnutrition in infants which differs from wasting The chiefsigns are oedema (watery swelling) lassitude and irritability adarkening and peeling of the skin at points of flexion and pressuresometimes accompanied by reddish colouration of the hair changes inthe liver and ndash without suitable treatment ndash rapid decline and deathArguments in the 1930s and 1940s centred on whether the diseasewas a distinct new entity or a form of pellagra while debate in recentdecades centred on whether this was lsquoprotein malnutritionrsquo asWilliams suggested or a form of calorie malnutrition This paper willnot attempt to discuss the recent arguments6

The Gold Coast colony background to infant welfare

The British (and French) had long been established on the coast ofWest Africa in ex-Portuguese or Dutch slaving or trading forts andcoastal enclaves The Gold Coast was finally demarcated and takenby the British at the Berlin Conference of 1884-5 the resolution ofthe lsquoScramble for Africarsquo between the imperial powers of Europe(Fig1)7 Despite the colonyrsquos name and continuing gold productionespecially in the Asante region8 by the early twentieth century gold

151

Listening to the Ga

was being overtaken as the main export by cocoa grown bythousands of independent peasant farmers9 (Fig2)10 The colonialgovernment did not encourage settlement by Europeans either nearthe coast nor inland where it operated a policy of lsquoindirect rulersquothrough local chiefs11 There was thus less displacement ofcommunities (in the post-slaving era) than in colonies under harshercolonial regimes but indirect European influence was visible in theintroduction of western trade goods (Fig 3)12 and the developmentof European-educated elites in the coastal towns and inland Kumasicapital of Asante (Fig 4)13

As in other West African colonies there were enormousvariations in living standards in the Gold Coast both within thecities where African doctors lawyers and teachers had alreadybecome established prior to British rule14 and also in the countrysidewhere chiefs and other wealthy men could afford large householdswith many wives and children while poorer families might struggleto survive Although cocoa farming by indigenous producers seemsto suggest widespread prosperity the effect on production of localfood crops was to create scarcity and drive up prices an instance of amore general pattern discussed in recent historiography15 It was also

152

J Stanton

Fig 2Local producers selling cocoa palm oil and rubber at trading station

Harry Martin Gold Coast 1902ndash6 With permission of Rhodes HouseLibrary University of Oxford

153

Listening to the Ga

Fig 4Untitled group of young women Harry Martin Gold Coast 1902ndash6

With permission of Rhodes House Library University of Oxford

Fig 3Onitsha store Harry Martin Gold Coast 1902ndash6

With permission of Rhodes House Library University of Oxford

noted by observers at the time in the case of the Gold Coast by WOrmsby-Gore Under-Secretary of State for the Colonies on a visitin 192616 He laid great stress on the food question and overtly linkedit with national efficiency and infant mortality

There are few parts of the world where the study of dietetics is moreimportant than in Africa It affects not only the question of theefficiency of labour but also public health and particularly infantmortality17

The aim of progress and development central to the colonialundertaking was seen to depend on better food supplies18 Whereas a

154

J Stanton

Fig 5 ldquoBeginyarsquo Bardquo (come-and-stay) child with father Photograph taken by

R S Rattray while Head of Anthropology Gold Coast 1921ndash32 Withpermission of Pitt Rivers Museum (School of Anthropology and Museum

of Ethnography) University of Oxford

major motive behind infant welfare in Britain was provision ofsoldiers to defend the Empire19 here it was primarily a matter ofeconomic advance

Along with many other British exports the Gold Coast receivedconcern over infant mortality Attempts to enumerate the populationndash very partial and inaccurate ndash were supplemented in 1917 by a surveyof infant mortality in Accra which generated alarming statisticsapparently nearly half the babies died in the first year of life20 Amonga tranche of welfare measures introduced by the progressive post-warGovernor F G Guggisberg was government provision for infantwelfare work previously the prerogative of missionary groups21

Reviewing the situation towards the end of his term of officeGuggisberg speculated on infant mortality at the turn of the centuryit lsquomust have been appallingrsquo in view of the crowded and insanitaryhousing conditions Still in 1921 as organised clinics were institutedsome towns reported infant mortality rates of over four hundred perthousand due in Guggisbergrsquos view to lsquothe housing the customs andthe habits of the peoplersquo22

The new facilities offered by the government were certainlypopular Infant welfare clinics which opened in the main towns withseveral in Accra rapidly attracted thousands of attendances a year23

In 1926 Princess Marie Louise Hospital for children opened inAccra to provide the main infant and child welfare (outpatient)centre as well as acute services Guggisberg placed these at the centreof his programme

The various clinics now opened for Infant Welfare work represent thebeginnings in the Gold Coast of the new Public Health and inconjunction with improved education will help to instil into theminds of the people that the quest and attainment of health should bea personal matter of supreme importance which if they are willing tolearn will change the whole history of their country for the better24

It was into this atmosphere of encouraging self-improvementreminiscent of lsquoeducating the mothersrsquo in the UK25 that CicelyWilliams was appointed Woman Medical Officer in 1929

Cicely Williams and kwashiorkor

Of course Cicely Williams was not alone in attempting tounderstand the language and beliefs of the Africans she workedamongst In the Gold Coast as in other colonies under each of thecolonial powers professional agents were appointed to interpret thealien world of lsquothe nativesrsquo for the colonisers government (and free-

155

Listening to the Ga

range) anthropologists can be seen as serving this function as well ascarrying out their own intellectual programme Nor was Williams theonly doctor to double as amateur anthropologist Colonial officials ofall grades seem to have dabbled in anthropology26 but doctors wereespecially tempted as the eugenic end of their scientificunderstanding alerted them to the fine line between racial andcultural difference27

Two specific examples may serve to illustrate Williamsrsquoapproach First we may examine a photograph taken in the 1920sby R S Rattray government anthropologist of a BeginyarsquoBa orlsquocome-and-stayrsquo child whose parents deliberately dressed heruntidily and left her hair dishevelled in the hope of deceiving thespirits who had taken their other children (Fig 5)28 Now comparethis with one taken by Williams in the 1930s of an older girldescribed as a fahit or fetish child (Fig 6)29 Rattrayrsquos picture placesthe child on her fond fatherrsquos lap it is a beautiful study of parentallove Williamsrsquo shot appears more clinical but the accompanyingnote that lsquo8 elder siblings diedrsquo shows that she enquired into thefamily circumstances while the recording of the childrsquos name(Ahana) indicates personal contact

Similarly Williams recorded names of nurses holding twoinfants whom she described as the only abandoned babies she eversaw in the Gold Coast (Fig 7)30 She believed abandonment wasextremely rare compared with European societies Correlating thelocations where these babies were found ndash one beside the railway andthe other on a golf course ndash with European infiltration Williams sawtheir fate as symbolic of the dislocation brought about by colonialrule a theme amply developed in contemporary anthropologicalwriting especially on southern Africa31

However Williams was not anti-colonial at this stage nor did shehold a rosy view of African mothersrsquo childrearing skills although shecommended maternal devotion she was critical of what she saw as theindulgent unregulated regime adopted towards young infants Muchcan be learned of her views from her MD thesis which permitted fullerexpansion than any of her articles Perhaps unconsciously drawing acontrast with her own heavy burden of work she likened mothersplaying with their babiesrsquo beads to neurotic chain smokers andascribed adults having an infantile craving to have something alwaysin their mouths to their constant snacking as infants Her observationson weaning are perhaps more objective

[The young infant is] carried about on the motherrsquos back a position

156

J Stanton

it loves it sleeps close beside her it is nourished whenever it criesand on the whole it does remarkably well on this treatment I haveseen the most uncomprehending indignation rage and bitterness ina child of three years old who found that his place on his motherrsquosback was suddenly usurped by a new baby32

The identification of a weaning crisis was intimately tied in withWilliamsrsquo recognition of kwashiorkor which in the main struckchildren between the ages of two and four and nearly always provedfatal

By the time she wrote her MD thesis in 1936 Williamscalculated that she had treated about 100000 children in clinics inthe Gold Coast Reasons for the high morbidity and mortality thesubject of her thesis were wide-ranging in many cases similar tothose in Europe and largely preventable in Williamsrsquo view33 On one

157

Listening to the Ga

Fig 6 lsquoFahitrsquo or fetish child Ahana Cicely Williams Gold Coast 1933ndash5

With kind permission of Contemporary Medical Archives Centre andMedical Photographic Library at the Wellcome Library

hand she indicated poverty was the underlying cause giving a radicalprescription lsquoThe function of a medical department conducted byany government is to raise the standard of living rather than toprovide orthodox medical attention for the individualrsquo34 On theother hand she held that the lsquounspeakablersquo loss of health and lifeamong children was lsquoall due to ignorance and dirt and diseasersquo35 Herunifying theme was the need for civilisation

The enlightened but paternalistic approach of the Guggisbergtype of progressive colonial is reflected in Williamsrsquo attitudesHowever her arguments for combining preventive and curativemedicine caused her to clash with her immediate superiors in whoseview the preventive work was not her job ndash although much laterWilliamsrsquo views won her the title of lsquoprimary health care pioneerrsquo36

Nutritional disorders amply illustrated the need for a combinedapproach As long as she worked in the Gold Coast treating sickchildren the hopelessness of cases of kwashiorkor drove Williams toseek to understand the syndrome which was not described in any of

158

J Stanton

Fig 7 Abandoned babies with nurses Cicely Williams Gold Coast 1933ndash5With kind permission of Contemporary Medical Archives Centre and

Medical Photographic Library at the Wellcome Library

the medical texts she consulted Her first published account appearedin the departmental report in 193237 and was so striking that herformer teacher Helen MacKay (of Queenrsquos Hospital London)encouraged her to seek publication in the prestigious journal Archivesof Disease in Childhood her first classic article appeared in 193338

Battle was joined immediately with H S Stannus an establishedexpert on nutrition countering Williamsrsquo view that this was a newdisease Stannus who had worked as a Medical Officer in Nyasaland(later Malawi) and Tanganyika between 1906 and 1918 and wasregarded as an expert on deficiency diseases among Africans claimedthat the condition must be simply an infantile form of pellagra39

Despite inclusion of photographs in Williamsrsquo 1933 article showinga distribution of darkened peeling skin on infants which was entirelyunlike that characteristic of pellagra Stannus without having himselfseen such cases dismissed her observations Williams assembleddetails of a further sixty cases and drew up a comparison betweenkwashiorkor as she now termed it and pellagra in a Lancet article in193540 Micrographs of skin and liver amplifying clinical and post-mortem observations represented lsquoscientificrsquo medicine at a fairlyadvanced level for an African colony available in the pathologylaboratory at Accrarsquos main hospital Again Stannus followedWilliams in print to challenge her interpretation41 Far from beingswayed by the scientific element in her presentation42 he seemedincensed by her adoption of a lsquonativersquo word for the condition

The association with a maize diet indicated by Williams has beenseen as misleading later recognition of the prevalence of the diseasein areas where other staples dominated showed that maize was in nosense the cause43 But Williams made an important connection whenshe pointed out that arkassa the fermented maize food usually givento infants contained yeast which was supposed to cure pellagra Oneof the leading investigators who followed Stannusrsquo line HughTrowell in Uganda administered nicotinic acid (the active anti-pellagra compound in yeast) to kwashiorkor sufferers in the early1940s without any success44 Nevertheless Trowell persisted inavoiding the term kwashiorkor switching from lsquoinfantile pellagrarsquo tolsquomalignant malnutritionrsquo

Possibly Williams drew attention to maize ndash knowing thatpellagra was associated with a chiefly maize diet in the southern USAndash in order to point out the differences between pellagra and thecondition she was observing Certainly she was careful to showdifferences in the skin lesions and other features of the two diseasesshe also offered differential diagnoses in relation to lsquopink diseasersquo

159

Listening to the Ga

vitamin A deficiency and vitamin B1 and B2 deficiencies She wascertainly thinking in terms of deficiency adding lsquoNo tests formineral or protein deficiency have yet been madersquo45 In her 1933paper she suggested several possible causes stating lsquoAs maize was theonly source of the supplementary food some amino-acid or proteindeficiency cannot be excluded as a causersquo46

As for treatment Williams tried varied diets without successcombinations with butter eggs tomato orange liver Marmiteyeast Bemax iron and arsenic failed to reverse the symptoms Theonly food that seemed to work and then in only a few cases wastinned milk lsquoNestleacutersquos sweetened condensed milk with cod-liver oiland malt seemed to be the most successful line of treatmentrsquo47 Soimpressed was she with these rare successes that she wanted to offera chart showing a child patientrsquos recovery for use by Nestleacute inpromoting milk consumption Her immediate superior in the HealthService saw lsquono reason why Messrs Nestleacutes should not make use ofthis chartrsquo but the Governor signalled disapproval lsquoThe value ofthese tinned milks is well knownrsquo and more importantly Nestleacute wasno better than other brands and was not a British firm48 (As willappear later by the end of the 1930s Williams reversed her views andcondemned tinned milk)

If a breastmilk substitute was needed Williams argued tinned milkwas the most convenient Tsetse-borne disease made cattle rearingnearly impossible in this region while goatsrsquo milk could theoreticallybe used the local goats lsquoare never milked and they do not look as if theidea of milking had ever been mentionedrsquo49 Advocacy of tinned milkwas widespread among colonial doctors although there seems not tohave been a concerted effort to dissuade mothers from breastfeeding inBritish colonies as there was in the Belgian Congo lsquoGouttes de Laitrsquo50

Purcell a male Medical Officer practising further west in the GoldCoast at Oda gave a glowing description of lsquobaby Kofirsquo whose motherhad died the day he was born and who was raised on tinned milk andorange juice lsquo plump robust and constantly cheerful The healthygleam of his eyes was sufficient to distinguish him from the otherbabies all of them breast fedrsquo51 Purcell mentioned the Belgian Congomodel to support his view

In describing cases very similar to those observed by WilliamsPurcell chose the heading lsquoInfantile pellagra (Akwashiokor ndashWilliams)rsquo52 He recorded an invariably fatal outcome despite largedoses of Marmite and admitted his lsquodescription tallies closely withthat of Dr Williams but my conclusions differ from hers as sheconsiders the condition distinct from pellagrarsquo53 Purcell paid attention

160

J Stanton

to local interpretations in his discussion of oedema which was one ofthe symptoms of kwashiorkor but also of many other diseases

In Akim the importance of oedema as a sign of disease may beinferred from the fact that my informant a reputable and intelligentldquonative doctorrdquo professes to recognise some five clinical varieties Owuo Mpumpungya is a name given to a disease in which the bodyswells gradually the skin peels off (This resembles the syndromeldquoakwashiorkorrdquo described by Williams)54

Purcell noted the informantrsquos view that the syndrome oftenappeared after a serious case of measles also strikingly the belief thatit was lsquocaused by witches who put the victim into ldquoinvisible firerdquo orboil himrsquo because the victim looks boiled55 In the 1950s whenWilliams visited Tanganyika she was shown the body of a child inDodoma Hospital mortuary described as lsquoa terrible burns casersquo butshe recognised the signs of kwashiorkor56 In this and possibly inmany similar cases Western doctors accused parents of scalding theirchildren through using over-hot bath water

By the time Purcell wrote his book Williams was no longer in theGold Coast Following a dispute with Dr G S Selwyn-ClarkeDeputy Director of Health Services regarding the treatment of oneof her infant patients she was summarily transferred in 1936 fromher Gold Coast post to Singapore Williams had admitted intohospital an infant with non-infectious tubercular peritonitis whomthe Deputy-Director then decided to exclude Williams hadprotested vociferously Although apparently concerned with theinterpretation of rules on admitting patients with tuberculosis thedispute was almost certainly fuelled by antagonism between twostrong characters with rather different ideologies57 Williams was onleave in England when news of her transfer reached her and she hadto depart without her belongings and many of her clinical noteshowever she had brought some with her for completion of her MDthesis Further observations on kwashiorkor were ruled out since itdid not appear to occur in Malaya where wasting (marasmus) was acommon form of severe infant malnutrition Williamsrsquo views on theuse of tinned milk evolved very rapidly in her new posting in 1939she delivered a stinging and prophetic talk to the Rotary Clubentitled lsquoMilk and Murderrsquo condemning promotion of tinned milkto local mothers in tenements by young women dressed like nurses58

Williams was imprisoned in Changi Gaol when the Japaneseoccupied Singapore Trowell greeted Williams on her release at theend of the war with a letter saying he would like to meet her lsquoif only

161

Listening to the Ga

to tell you that you were right Kwashiorkor is not pellagrarsquo59

However his latest article used the term lsquoThe kwashiorkor syndromeof malignant malnutritionrsquo to cover what he believed to be variantsof the condition in children and adults and his failure to absorb thelessons of Williamsrsquo work was reflected in his enthusiasm for trials ofdesiccated hogrsquos stomach as a cure Failure to appreciate Williams wasalso evident in the comments that ended his letter lsquoHow curious thatalmost all African tribes have their name for this disease + what a pitywe could not learn from them It affects millionsrsquo Williams hadshown an ability to lsquolearn from themrsquo throughout her spell in theGold Coast60

In 1948 Williams was appointed first head of the Maternal andChild Health (MCH) section at the World Health Organization(WHO) in Geneva Although she held the position briefly beforetransferring to head MCH for WHO in South East Asia her tenuremay be connected with the launch of a survey of kwashiorkorthroughout sub-Saharan Africa in 1950 resulting in a reportpublished in 195261 From evidence gathered in ten countries theauthors surmised that kwashiorkor was lsquothe most serious andwidespread nutritional disorder known to medical and nutritionalsciencersquo62 Williams was well and truly vindicated ndash as were the Gaand many other African peoples who had named the disease

Discussion

Baumslag opines that Williams fulfilled lsquoa physicianrsquos dream todiagnose find the causative agent and curersquo for a new disease shehad also discovered a means of prevention by supervision at MCHclinics63 Trowell paid respect to Williams in his book on kwashiorkorbut provided many other precedents among whom he cited Gelfandin Rhodesia and Altman in South Africa as lsquopioneersrsquo diminishingthe pre-eminence of Williams in providing the definitivedescription64 The balance probably lies somewhere between thesetwo since it is clear that Williams was still struggling to find the exactcause and an effective cure when she was transferred from the GoldCoast in 1936 On the other hand the 1952 WHO report by Brockand Autret (referred to above) which Trowell says was lsquocrucialrsquo inensuring recognition of the disease would probably not have comeabout without Williamsrsquo work

An equally important question for the historian ndash moreimportant for those not too worried about precedence ndash is this wheredoes Williamsrsquo work fit into the development of nutrition studiesDiscussing the general area of the discovery of colonial malnutrition

162

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

was being overtaken as the main export by cocoa grown bythousands of independent peasant farmers9 (Fig2)10 The colonialgovernment did not encourage settlement by Europeans either nearthe coast nor inland where it operated a policy of lsquoindirect rulersquothrough local chiefs11 There was thus less displacement ofcommunities (in the post-slaving era) than in colonies under harshercolonial regimes but indirect European influence was visible in theintroduction of western trade goods (Fig 3)12 and the developmentof European-educated elites in the coastal towns and inland Kumasicapital of Asante (Fig 4)13

As in other West African colonies there were enormousvariations in living standards in the Gold Coast both within thecities where African doctors lawyers and teachers had alreadybecome established prior to British rule14 and also in the countrysidewhere chiefs and other wealthy men could afford large householdswith many wives and children while poorer families might struggleto survive Although cocoa farming by indigenous producers seemsto suggest widespread prosperity the effect on production of localfood crops was to create scarcity and drive up prices an instance of amore general pattern discussed in recent historiography15 It was also

152

J Stanton

Fig 2Local producers selling cocoa palm oil and rubber at trading station

Harry Martin Gold Coast 1902ndash6 With permission of Rhodes HouseLibrary University of Oxford

153

Listening to the Ga

Fig 4Untitled group of young women Harry Martin Gold Coast 1902ndash6

With permission of Rhodes House Library University of Oxford

Fig 3Onitsha store Harry Martin Gold Coast 1902ndash6

With permission of Rhodes House Library University of Oxford

noted by observers at the time in the case of the Gold Coast by WOrmsby-Gore Under-Secretary of State for the Colonies on a visitin 192616 He laid great stress on the food question and overtly linkedit with national efficiency and infant mortality

There are few parts of the world where the study of dietetics is moreimportant than in Africa It affects not only the question of theefficiency of labour but also public health and particularly infantmortality17

The aim of progress and development central to the colonialundertaking was seen to depend on better food supplies18 Whereas a

154

J Stanton

Fig 5 ldquoBeginyarsquo Bardquo (come-and-stay) child with father Photograph taken by

R S Rattray while Head of Anthropology Gold Coast 1921ndash32 Withpermission of Pitt Rivers Museum (School of Anthropology and Museum

of Ethnography) University of Oxford

major motive behind infant welfare in Britain was provision ofsoldiers to defend the Empire19 here it was primarily a matter ofeconomic advance

Along with many other British exports the Gold Coast receivedconcern over infant mortality Attempts to enumerate the populationndash very partial and inaccurate ndash were supplemented in 1917 by a surveyof infant mortality in Accra which generated alarming statisticsapparently nearly half the babies died in the first year of life20 Amonga tranche of welfare measures introduced by the progressive post-warGovernor F G Guggisberg was government provision for infantwelfare work previously the prerogative of missionary groups21

Reviewing the situation towards the end of his term of officeGuggisberg speculated on infant mortality at the turn of the centuryit lsquomust have been appallingrsquo in view of the crowded and insanitaryhousing conditions Still in 1921 as organised clinics were institutedsome towns reported infant mortality rates of over four hundred perthousand due in Guggisbergrsquos view to lsquothe housing the customs andthe habits of the peoplersquo22

The new facilities offered by the government were certainlypopular Infant welfare clinics which opened in the main towns withseveral in Accra rapidly attracted thousands of attendances a year23

In 1926 Princess Marie Louise Hospital for children opened inAccra to provide the main infant and child welfare (outpatient)centre as well as acute services Guggisberg placed these at the centreof his programme

The various clinics now opened for Infant Welfare work represent thebeginnings in the Gold Coast of the new Public Health and inconjunction with improved education will help to instil into theminds of the people that the quest and attainment of health should bea personal matter of supreme importance which if they are willing tolearn will change the whole history of their country for the better24

It was into this atmosphere of encouraging self-improvementreminiscent of lsquoeducating the mothersrsquo in the UK25 that CicelyWilliams was appointed Woman Medical Officer in 1929

Cicely Williams and kwashiorkor

Of course Cicely Williams was not alone in attempting tounderstand the language and beliefs of the Africans she workedamongst In the Gold Coast as in other colonies under each of thecolonial powers professional agents were appointed to interpret thealien world of lsquothe nativesrsquo for the colonisers government (and free-

155

Listening to the Ga

range) anthropologists can be seen as serving this function as well ascarrying out their own intellectual programme Nor was Williams theonly doctor to double as amateur anthropologist Colonial officials ofall grades seem to have dabbled in anthropology26 but doctors wereespecially tempted as the eugenic end of their scientificunderstanding alerted them to the fine line between racial andcultural difference27

Two specific examples may serve to illustrate Williamsrsquoapproach First we may examine a photograph taken in the 1920sby R S Rattray government anthropologist of a BeginyarsquoBa orlsquocome-and-stayrsquo child whose parents deliberately dressed heruntidily and left her hair dishevelled in the hope of deceiving thespirits who had taken their other children (Fig 5)28 Now comparethis with one taken by Williams in the 1930s of an older girldescribed as a fahit or fetish child (Fig 6)29 Rattrayrsquos picture placesthe child on her fond fatherrsquos lap it is a beautiful study of parentallove Williamsrsquo shot appears more clinical but the accompanyingnote that lsquo8 elder siblings diedrsquo shows that she enquired into thefamily circumstances while the recording of the childrsquos name(Ahana) indicates personal contact

Similarly Williams recorded names of nurses holding twoinfants whom she described as the only abandoned babies she eversaw in the Gold Coast (Fig 7)30 She believed abandonment wasextremely rare compared with European societies Correlating thelocations where these babies were found ndash one beside the railway andthe other on a golf course ndash with European infiltration Williams sawtheir fate as symbolic of the dislocation brought about by colonialrule a theme amply developed in contemporary anthropologicalwriting especially on southern Africa31

However Williams was not anti-colonial at this stage nor did shehold a rosy view of African mothersrsquo childrearing skills although shecommended maternal devotion she was critical of what she saw as theindulgent unregulated regime adopted towards young infants Muchcan be learned of her views from her MD thesis which permitted fullerexpansion than any of her articles Perhaps unconsciously drawing acontrast with her own heavy burden of work she likened mothersplaying with their babiesrsquo beads to neurotic chain smokers andascribed adults having an infantile craving to have something alwaysin their mouths to their constant snacking as infants Her observationson weaning are perhaps more objective

[The young infant is] carried about on the motherrsquos back a position

156

J Stanton

it loves it sleeps close beside her it is nourished whenever it criesand on the whole it does remarkably well on this treatment I haveseen the most uncomprehending indignation rage and bitterness ina child of three years old who found that his place on his motherrsquosback was suddenly usurped by a new baby32

The identification of a weaning crisis was intimately tied in withWilliamsrsquo recognition of kwashiorkor which in the main struckchildren between the ages of two and four and nearly always provedfatal

By the time she wrote her MD thesis in 1936 Williamscalculated that she had treated about 100000 children in clinics inthe Gold Coast Reasons for the high morbidity and mortality thesubject of her thesis were wide-ranging in many cases similar tothose in Europe and largely preventable in Williamsrsquo view33 On one

157

Listening to the Ga

Fig 6 lsquoFahitrsquo or fetish child Ahana Cicely Williams Gold Coast 1933ndash5

With kind permission of Contemporary Medical Archives Centre andMedical Photographic Library at the Wellcome Library

hand she indicated poverty was the underlying cause giving a radicalprescription lsquoThe function of a medical department conducted byany government is to raise the standard of living rather than toprovide orthodox medical attention for the individualrsquo34 On theother hand she held that the lsquounspeakablersquo loss of health and lifeamong children was lsquoall due to ignorance and dirt and diseasersquo35 Herunifying theme was the need for civilisation

The enlightened but paternalistic approach of the Guggisbergtype of progressive colonial is reflected in Williamsrsquo attitudesHowever her arguments for combining preventive and curativemedicine caused her to clash with her immediate superiors in whoseview the preventive work was not her job ndash although much laterWilliamsrsquo views won her the title of lsquoprimary health care pioneerrsquo36

Nutritional disorders amply illustrated the need for a combinedapproach As long as she worked in the Gold Coast treating sickchildren the hopelessness of cases of kwashiorkor drove Williams toseek to understand the syndrome which was not described in any of

158

J Stanton

Fig 7 Abandoned babies with nurses Cicely Williams Gold Coast 1933ndash5With kind permission of Contemporary Medical Archives Centre and

Medical Photographic Library at the Wellcome Library

the medical texts she consulted Her first published account appearedin the departmental report in 193237 and was so striking that herformer teacher Helen MacKay (of Queenrsquos Hospital London)encouraged her to seek publication in the prestigious journal Archivesof Disease in Childhood her first classic article appeared in 193338

Battle was joined immediately with H S Stannus an establishedexpert on nutrition countering Williamsrsquo view that this was a newdisease Stannus who had worked as a Medical Officer in Nyasaland(later Malawi) and Tanganyika between 1906 and 1918 and wasregarded as an expert on deficiency diseases among Africans claimedthat the condition must be simply an infantile form of pellagra39

Despite inclusion of photographs in Williamsrsquo 1933 article showinga distribution of darkened peeling skin on infants which was entirelyunlike that characteristic of pellagra Stannus without having himselfseen such cases dismissed her observations Williams assembleddetails of a further sixty cases and drew up a comparison betweenkwashiorkor as she now termed it and pellagra in a Lancet article in193540 Micrographs of skin and liver amplifying clinical and post-mortem observations represented lsquoscientificrsquo medicine at a fairlyadvanced level for an African colony available in the pathologylaboratory at Accrarsquos main hospital Again Stannus followedWilliams in print to challenge her interpretation41 Far from beingswayed by the scientific element in her presentation42 he seemedincensed by her adoption of a lsquonativersquo word for the condition

The association with a maize diet indicated by Williams has beenseen as misleading later recognition of the prevalence of the diseasein areas where other staples dominated showed that maize was in nosense the cause43 But Williams made an important connection whenshe pointed out that arkassa the fermented maize food usually givento infants contained yeast which was supposed to cure pellagra Oneof the leading investigators who followed Stannusrsquo line HughTrowell in Uganda administered nicotinic acid (the active anti-pellagra compound in yeast) to kwashiorkor sufferers in the early1940s without any success44 Nevertheless Trowell persisted inavoiding the term kwashiorkor switching from lsquoinfantile pellagrarsquo tolsquomalignant malnutritionrsquo

Possibly Williams drew attention to maize ndash knowing thatpellagra was associated with a chiefly maize diet in the southern USAndash in order to point out the differences between pellagra and thecondition she was observing Certainly she was careful to showdifferences in the skin lesions and other features of the two diseasesshe also offered differential diagnoses in relation to lsquopink diseasersquo

159

Listening to the Ga

vitamin A deficiency and vitamin B1 and B2 deficiencies She wascertainly thinking in terms of deficiency adding lsquoNo tests formineral or protein deficiency have yet been madersquo45 In her 1933paper she suggested several possible causes stating lsquoAs maize was theonly source of the supplementary food some amino-acid or proteindeficiency cannot be excluded as a causersquo46

As for treatment Williams tried varied diets without successcombinations with butter eggs tomato orange liver Marmiteyeast Bemax iron and arsenic failed to reverse the symptoms Theonly food that seemed to work and then in only a few cases wastinned milk lsquoNestleacutersquos sweetened condensed milk with cod-liver oiland malt seemed to be the most successful line of treatmentrsquo47 Soimpressed was she with these rare successes that she wanted to offera chart showing a child patientrsquos recovery for use by Nestleacute inpromoting milk consumption Her immediate superior in the HealthService saw lsquono reason why Messrs Nestleacutes should not make use ofthis chartrsquo but the Governor signalled disapproval lsquoThe value ofthese tinned milks is well knownrsquo and more importantly Nestleacute wasno better than other brands and was not a British firm48 (As willappear later by the end of the 1930s Williams reversed her views andcondemned tinned milk)

If a breastmilk substitute was needed Williams argued tinned milkwas the most convenient Tsetse-borne disease made cattle rearingnearly impossible in this region while goatsrsquo milk could theoreticallybe used the local goats lsquoare never milked and they do not look as if theidea of milking had ever been mentionedrsquo49 Advocacy of tinned milkwas widespread among colonial doctors although there seems not tohave been a concerted effort to dissuade mothers from breastfeeding inBritish colonies as there was in the Belgian Congo lsquoGouttes de Laitrsquo50

Purcell a male Medical Officer practising further west in the GoldCoast at Oda gave a glowing description of lsquobaby Kofirsquo whose motherhad died the day he was born and who was raised on tinned milk andorange juice lsquo plump robust and constantly cheerful The healthygleam of his eyes was sufficient to distinguish him from the otherbabies all of them breast fedrsquo51 Purcell mentioned the Belgian Congomodel to support his view

In describing cases very similar to those observed by WilliamsPurcell chose the heading lsquoInfantile pellagra (Akwashiokor ndashWilliams)rsquo52 He recorded an invariably fatal outcome despite largedoses of Marmite and admitted his lsquodescription tallies closely withthat of Dr Williams but my conclusions differ from hers as sheconsiders the condition distinct from pellagrarsquo53 Purcell paid attention

160

J Stanton

to local interpretations in his discussion of oedema which was one ofthe symptoms of kwashiorkor but also of many other diseases

In Akim the importance of oedema as a sign of disease may beinferred from the fact that my informant a reputable and intelligentldquonative doctorrdquo professes to recognise some five clinical varieties Owuo Mpumpungya is a name given to a disease in which the bodyswells gradually the skin peels off (This resembles the syndromeldquoakwashiorkorrdquo described by Williams)54

Purcell noted the informantrsquos view that the syndrome oftenappeared after a serious case of measles also strikingly the belief thatit was lsquocaused by witches who put the victim into ldquoinvisible firerdquo orboil himrsquo because the victim looks boiled55 In the 1950s whenWilliams visited Tanganyika she was shown the body of a child inDodoma Hospital mortuary described as lsquoa terrible burns casersquo butshe recognised the signs of kwashiorkor56 In this and possibly inmany similar cases Western doctors accused parents of scalding theirchildren through using over-hot bath water

By the time Purcell wrote his book Williams was no longer in theGold Coast Following a dispute with Dr G S Selwyn-ClarkeDeputy Director of Health Services regarding the treatment of oneof her infant patients she was summarily transferred in 1936 fromher Gold Coast post to Singapore Williams had admitted intohospital an infant with non-infectious tubercular peritonitis whomthe Deputy-Director then decided to exclude Williams hadprotested vociferously Although apparently concerned with theinterpretation of rules on admitting patients with tuberculosis thedispute was almost certainly fuelled by antagonism between twostrong characters with rather different ideologies57 Williams was onleave in England when news of her transfer reached her and she hadto depart without her belongings and many of her clinical noteshowever she had brought some with her for completion of her MDthesis Further observations on kwashiorkor were ruled out since itdid not appear to occur in Malaya where wasting (marasmus) was acommon form of severe infant malnutrition Williamsrsquo views on theuse of tinned milk evolved very rapidly in her new posting in 1939she delivered a stinging and prophetic talk to the Rotary Clubentitled lsquoMilk and Murderrsquo condemning promotion of tinned milkto local mothers in tenements by young women dressed like nurses58

Williams was imprisoned in Changi Gaol when the Japaneseoccupied Singapore Trowell greeted Williams on her release at theend of the war with a letter saying he would like to meet her lsquoif only

161

Listening to the Ga

to tell you that you were right Kwashiorkor is not pellagrarsquo59

However his latest article used the term lsquoThe kwashiorkor syndromeof malignant malnutritionrsquo to cover what he believed to be variantsof the condition in children and adults and his failure to absorb thelessons of Williamsrsquo work was reflected in his enthusiasm for trials ofdesiccated hogrsquos stomach as a cure Failure to appreciate Williams wasalso evident in the comments that ended his letter lsquoHow curious thatalmost all African tribes have their name for this disease + what a pitywe could not learn from them It affects millionsrsquo Williams hadshown an ability to lsquolearn from themrsquo throughout her spell in theGold Coast60

In 1948 Williams was appointed first head of the Maternal andChild Health (MCH) section at the World Health Organization(WHO) in Geneva Although she held the position briefly beforetransferring to head MCH for WHO in South East Asia her tenuremay be connected with the launch of a survey of kwashiorkorthroughout sub-Saharan Africa in 1950 resulting in a reportpublished in 195261 From evidence gathered in ten countries theauthors surmised that kwashiorkor was lsquothe most serious andwidespread nutritional disorder known to medical and nutritionalsciencersquo62 Williams was well and truly vindicated ndash as were the Gaand many other African peoples who had named the disease

Discussion

Baumslag opines that Williams fulfilled lsquoa physicianrsquos dream todiagnose find the causative agent and curersquo for a new disease shehad also discovered a means of prevention by supervision at MCHclinics63 Trowell paid respect to Williams in his book on kwashiorkorbut provided many other precedents among whom he cited Gelfandin Rhodesia and Altman in South Africa as lsquopioneersrsquo diminishingthe pre-eminence of Williams in providing the definitivedescription64 The balance probably lies somewhere between thesetwo since it is clear that Williams was still struggling to find the exactcause and an effective cure when she was transferred from the GoldCoast in 1936 On the other hand the 1952 WHO report by Brockand Autret (referred to above) which Trowell says was lsquocrucialrsquo inensuring recognition of the disease would probably not have comeabout without Williamsrsquo work

An equally important question for the historian ndash moreimportant for those not too worried about precedence ndash is this wheredoes Williamsrsquo work fit into the development of nutrition studiesDiscussing the general area of the discovery of colonial malnutrition

162

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

153

Listening to the Ga

Fig 4Untitled group of young women Harry Martin Gold Coast 1902ndash6

With permission of Rhodes House Library University of Oxford

Fig 3Onitsha store Harry Martin Gold Coast 1902ndash6

With permission of Rhodes House Library University of Oxford

noted by observers at the time in the case of the Gold Coast by WOrmsby-Gore Under-Secretary of State for the Colonies on a visitin 192616 He laid great stress on the food question and overtly linkedit with national efficiency and infant mortality

There are few parts of the world where the study of dietetics is moreimportant than in Africa It affects not only the question of theefficiency of labour but also public health and particularly infantmortality17

The aim of progress and development central to the colonialundertaking was seen to depend on better food supplies18 Whereas a

154

J Stanton

Fig 5 ldquoBeginyarsquo Bardquo (come-and-stay) child with father Photograph taken by

R S Rattray while Head of Anthropology Gold Coast 1921ndash32 Withpermission of Pitt Rivers Museum (School of Anthropology and Museum

of Ethnography) University of Oxford

major motive behind infant welfare in Britain was provision ofsoldiers to defend the Empire19 here it was primarily a matter ofeconomic advance

Along with many other British exports the Gold Coast receivedconcern over infant mortality Attempts to enumerate the populationndash very partial and inaccurate ndash were supplemented in 1917 by a surveyof infant mortality in Accra which generated alarming statisticsapparently nearly half the babies died in the first year of life20 Amonga tranche of welfare measures introduced by the progressive post-warGovernor F G Guggisberg was government provision for infantwelfare work previously the prerogative of missionary groups21

Reviewing the situation towards the end of his term of officeGuggisberg speculated on infant mortality at the turn of the centuryit lsquomust have been appallingrsquo in view of the crowded and insanitaryhousing conditions Still in 1921 as organised clinics were institutedsome towns reported infant mortality rates of over four hundred perthousand due in Guggisbergrsquos view to lsquothe housing the customs andthe habits of the peoplersquo22

The new facilities offered by the government were certainlypopular Infant welfare clinics which opened in the main towns withseveral in Accra rapidly attracted thousands of attendances a year23

In 1926 Princess Marie Louise Hospital for children opened inAccra to provide the main infant and child welfare (outpatient)centre as well as acute services Guggisberg placed these at the centreof his programme

The various clinics now opened for Infant Welfare work represent thebeginnings in the Gold Coast of the new Public Health and inconjunction with improved education will help to instil into theminds of the people that the quest and attainment of health should bea personal matter of supreme importance which if they are willing tolearn will change the whole history of their country for the better24

It was into this atmosphere of encouraging self-improvementreminiscent of lsquoeducating the mothersrsquo in the UK25 that CicelyWilliams was appointed Woman Medical Officer in 1929

Cicely Williams and kwashiorkor

Of course Cicely Williams was not alone in attempting tounderstand the language and beliefs of the Africans she workedamongst In the Gold Coast as in other colonies under each of thecolonial powers professional agents were appointed to interpret thealien world of lsquothe nativesrsquo for the colonisers government (and free-

155

Listening to the Ga

range) anthropologists can be seen as serving this function as well ascarrying out their own intellectual programme Nor was Williams theonly doctor to double as amateur anthropologist Colonial officials ofall grades seem to have dabbled in anthropology26 but doctors wereespecially tempted as the eugenic end of their scientificunderstanding alerted them to the fine line between racial andcultural difference27

Two specific examples may serve to illustrate Williamsrsquoapproach First we may examine a photograph taken in the 1920sby R S Rattray government anthropologist of a BeginyarsquoBa orlsquocome-and-stayrsquo child whose parents deliberately dressed heruntidily and left her hair dishevelled in the hope of deceiving thespirits who had taken their other children (Fig 5)28 Now comparethis with one taken by Williams in the 1930s of an older girldescribed as a fahit or fetish child (Fig 6)29 Rattrayrsquos picture placesthe child on her fond fatherrsquos lap it is a beautiful study of parentallove Williamsrsquo shot appears more clinical but the accompanyingnote that lsquo8 elder siblings diedrsquo shows that she enquired into thefamily circumstances while the recording of the childrsquos name(Ahana) indicates personal contact

Similarly Williams recorded names of nurses holding twoinfants whom she described as the only abandoned babies she eversaw in the Gold Coast (Fig 7)30 She believed abandonment wasextremely rare compared with European societies Correlating thelocations where these babies were found ndash one beside the railway andthe other on a golf course ndash with European infiltration Williams sawtheir fate as symbolic of the dislocation brought about by colonialrule a theme amply developed in contemporary anthropologicalwriting especially on southern Africa31

However Williams was not anti-colonial at this stage nor did shehold a rosy view of African mothersrsquo childrearing skills although shecommended maternal devotion she was critical of what she saw as theindulgent unregulated regime adopted towards young infants Muchcan be learned of her views from her MD thesis which permitted fullerexpansion than any of her articles Perhaps unconsciously drawing acontrast with her own heavy burden of work she likened mothersplaying with their babiesrsquo beads to neurotic chain smokers andascribed adults having an infantile craving to have something alwaysin their mouths to their constant snacking as infants Her observationson weaning are perhaps more objective

[The young infant is] carried about on the motherrsquos back a position

156

J Stanton

it loves it sleeps close beside her it is nourished whenever it criesand on the whole it does remarkably well on this treatment I haveseen the most uncomprehending indignation rage and bitterness ina child of three years old who found that his place on his motherrsquosback was suddenly usurped by a new baby32

The identification of a weaning crisis was intimately tied in withWilliamsrsquo recognition of kwashiorkor which in the main struckchildren between the ages of two and four and nearly always provedfatal

By the time she wrote her MD thesis in 1936 Williamscalculated that she had treated about 100000 children in clinics inthe Gold Coast Reasons for the high morbidity and mortality thesubject of her thesis were wide-ranging in many cases similar tothose in Europe and largely preventable in Williamsrsquo view33 On one

157

Listening to the Ga

Fig 6 lsquoFahitrsquo or fetish child Ahana Cicely Williams Gold Coast 1933ndash5

With kind permission of Contemporary Medical Archives Centre andMedical Photographic Library at the Wellcome Library

hand she indicated poverty was the underlying cause giving a radicalprescription lsquoThe function of a medical department conducted byany government is to raise the standard of living rather than toprovide orthodox medical attention for the individualrsquo34 On theother hand she held that the lsquounspeakablersquo loss of health and lifeamong children was lsquoall due to ignorance and dirt and diseasersquo35 Herunifying theme was the need for civilisation

The enlightened but paternalistic approach of the Guggisbergtype of progressive colonial is reflected in Williamsrsquo attitudesHowever her arguments for combining preventive and curativemedicine caused her to clash with her immediate superiors in whoseview the preventive work was not her job ndash although much laterWilliamsrsquo views won her the title of lsquoprimary health care pioneerrsquo36

Nutritional disorders amply illustrated the need for a combinedapproach As long as she worked in the Gold Coast treating sickchildren the hopelessness of cases of kwashiorkor drove Williams toseek to understand the syndrome which was not described in any of

158

J Stanton

Fig 7 Abandoned babies with nurses Cicely Williams Gold Coast 1933ndash5With kind permission of Contemporary Medical Archives Centre and

Medical Photographic Library at the Wellcome Library

the medical texts she consulted Her first published account appearedin the departmental report in 193237 and was so striking that herformer teacher Helen MacKay (of Queenrsquos Hospital London)encouraged her to seek publication in the prestigious journal Archivesof Disease in Childhood her first classic article appeared in 193338

Battle was joined immediately with H S Stannus an establishedexpert on nutrition countering Williamsrsquo view that this was a newdisease Stannus who had worked as a Medical Officer in Nyasaland(later Malawi) and Tanganyika between 1906 and 1918 and wasregarded as an expert on deficiency diseases among Africans claimedthat the condition must be simply an infantile form of pellagra39

Despite inclusion of photographs in Williamsrsquo 1933 article showinga distribution of darkened peeling skin on infants which was entirelyunlike that characteristic of pellagra Stannus without having himselfseen such cases dismissed her observations Williams assembleddetails of a further sixty cases and drew up a comparison betweenkwashiorkor as she now termed it and pellagra in a Lancet article in193540 Micrographs of skin and liver amplifying clinical and post-mortem observations represented lsquoscientificrsquo medicine at a fairlyadvanced level for an African colony available in the pathologylaboratory at Accrarsquos main hospital Again Stannus followedWilliams in print to challenge her interpretation41 Far from beingswayed by the scientific element in her presentation42 he seemedincensed by her adoption of a lsquonativersquo word for the condition

The association with a maize diet indicated by Williams has beenseen as misleading later recognition of the prevalence of the diseasein areas where other staples dominated showed that maize was in nosense the cause43 But Williams made an important connection whenshe pointed out that arkassa the fermented maize food usually givento infants contained yeast which was supposed to cure pellagra Oneof the leading investigators who followed Stannusrsquo line HughTrowell in Uganda administered nicotinic acid (the active anti-pellagra compound in yeast) to kwashiorkor sufferers in the early1940s without any success44 Nevertheless Trowell persisted inavoiding the term kwashiorkor switching from lsquoinfantile pellagrarsquo tolsquomalignant malnutritionrsquo

Possibly Williams drew attention to maize ndash knowing thatpellagra was associated with a chiefly maize diet in the southern USAndash in order to point out the differences between pellagra and thecondition she was observing Certainly she was careful to showdifferences in the skin lesions and other features of the two diseasesshe also offered differential diagnoses in relation to lsquopink diseasersquo

159

Listening to the Ga

vitamin A deficiency and vitamin B1 and B2 deficiencies She wascertainly thinking in terms of deficiency adding lsquoNo tests formineral or protein deficiency have yet been madersquo45 In her 1933paper she suggested several possible causes stating lsquoAs maize was theonly source of the supplementary food some amino-acid or proteindeficiency cannot be excluded as a causersquo46

As for treatment Williams tried varied diets without successcombinations with butter eggs tomato orange liver Marmiteyeast Bemax iron and arsenic failed to reverse the symptoms Theonly food that seemed to work and then in only a few cases wastinned milk lsquoNestleacutersquos sweetened condensed milk with cod-liver oiland malt seemed to be the most successful line of treatmentrsquo47 Soimpressed was she with these rare successes that she wanted to offera chart showing a child patientrsquos recovery for use by Nestleacute inpromoting milk consumption Her immediate superior in the HealthService saw lsquono reason why Messrs Nestleacutes should not make use ofthis chartrsquo but the Governor signalled disapproval lsquoThe value ofthese tinned milks is well knownrsquo and more importantly Nestleacute wasno better than other brands and was not a British firm48 (As willappear later by the end of the 1930s Williams reversed her views andcondemned tinned milk)

If a breastmilk substitute was needed Williams argued tinned milkwas the most convenient Tsetse-borne disease made cattle rearingnearly impossible in this region while goatsrsquo milk could theoreticallybe used the local goats lsquoare never milked and they do not look as if theidea of milking had ever been mentionedrsquo49 Advocacy of tinned milkwas widespread among colonial doctors although there seems not tohave been a concerted effort to dissuade mothers from breastfeeding inBritish colonies as there was in the Belgian Congo lsquoGouttes de Laitrsquo50

Purcell a male Medical Officer practising further west in the GoldCoast at Oda gave a glowing description of lsquobaby Kofirsquo whose motherhad died the day he was born and who was raised on tinned milk andorange juice lsquo plump robust and constantly cheerful The healthygleam of his eyes was sufficient to distinguish him from the otherbabies all of them breast fedrsquo51 Purcell mentioned the Belgian Congomodel to support his view

In describing cases very similar to those observed by WilliamsPurcell chose the heading lsquoInfantile pellagra (Akwashiokor ndashWilliams)rsquo52 He recorded an invariably fatal outcome despite largedoses of Marmite and admitted his lsquodescription tallies closely withthat of Dr Williams but my conclusions differ from hers as sheconsiders the condition distinct from pellagrarsquo53 Purcell paid attention

160

J Stanton

to local interpretations in his discussion of oedema which was one ofthe symptoms of kwashiorkor but also of many other diseases

In Akim the importance of oedema as a sign of disease may beinferred from the fact that my informant a reputable and intelligentldquonative doctorrdquo professes to recognise some five clinical varieties Owuo Mpumpungya is a name given to a disease in which the bodyswells gradually the skin peels off (This resembles the syndromeldquoakwashiorkorrdquo described by Williams)54

Purcell noted the informantrsquos view that the syndrome oftenappeared after a serious case of measles also strikingly the belief thatit was lsquocaused by witches who put the victim into ldquoinvisible firerdquo orboil himrsquo because the victim looks boiled55 In the 1950s whenWilliams visited Tanganyika she was shown the body of a child inDodoma Hospital mortuary described as lsquoa terrible burns casersquo butshe recognised the signs of kwashiorkor56 In this and possibly inmany similar cases Western doctors accused parents of scalding theirchildren through using over-hot bath water

By the time Purcell wrote his book Williams was no longer in theGold Coast Following a dispute with Dr G S Selwyn-ClarkeDeputy Director of Health Services regarding the treatment of oneof her infant patients she was summarily transferred in 1936 fromher Gold Coast post to Singapore Williams had admitted intohospital an infant with non-infectious tubercular peritonitis whomthe Deputy-Director then decided to exclude Williams hadprotested vociferously Although apparently concerned with theinterpretation of rules on admitting patients with tuberculosis thedispute was almost certainly fuelled by antagonism between twostrong characters with rather different ideologies57 Williams was onleave in England when news of her transfer reached her and she hadto depart without her belongings and many of her clinical noteshowever she had brought some with her for completion of her MDthesis Further observations on kwashiorkor were ruled out since itdid not appear to occur in Malaya where wasting (marasmus) was acommon form of severe infant malnutrition Williamsrsquo views on theuse of tinned milk evolved very rapidly in her new posting in 1939she delivered a stinging and prophetic talk to the Rotary Clubentitled lsquoMilk and Murderrsquo condemning promotion of tinned milkto local mothers in tenements by young women dressed like nurses58

Williams was imprisoned in Changi Gaol when the Japaneseoccupied Singapore Trowell greeted Williams on her release at theend of the war with a letter saying he would like to meet her lsquoif only

161

Listening to the Ga

to tell you that you were right Kwashiorkor is not pellagrarsquo59

However his latest article used the term lsquoThe kwashiorkor syndromeof malignant malnutritionrsquo to cover what he believed to be variantsof the condition in children and adults and his failure to absorb thelessons of Williamsrsquo work was reflected in his enthusiasm for trials ofdesiccated hogrsquos stomach as a cure Failure to appreciate Williams wasalso evident in the comments that ended his letter lsquoHow curious thatalmost all African tribes have their name for this disease + what a pitywe could not learn from them It affects millionsrsquo Williams hadshown an ability to lsquolearn from themrsquo throughout her spell in theGold Coast60

In 1948 Williams was appointed first head of the Maternal andChild Health (MCH) section at the World Health Organization(WHO) in Geneva Although she held the position briefly beforetransferring to head MCH for WHO in South East Asia her tenuremay be connected with the launch of a survey of kwashiorkorthroughout sub-Saharan Africa in 1950 resulting in a reportpublished in 195261 From evidence gathered in ten countries theauthors surmised that kwashiorkor was lsquothe most serious andwidespread nutritional disorder known to medical and nutritionalsciencersquo62 Williams was well and truly vindicated ndash as were the Gaand many other African peoples who had named the disease

Discussion

Baumslag opines that Williams fulfilled lsquoa physicianrsquos dream todiagnose find the causative agent and curersquo for a new disease shehad also discovered a means of prevention by supervision at MCHclinics63 Trowell paid respect to Williams in his book on kwashiorkorbut provided many other precedents among whom he cited Gelfandin Rhodesia and Altman in South Africa as lsquopioneersrsquo diminishingthe pre-eminence of Williams in providing the definitivedescription64 The balance probably lies somewhere between thesetwo since it is clear that Williams was still struggling to find the exactcause and an effective cure when she was transferred from the GoldCoast in 1936 On the other hand the 1952 WHO report by Brockand Autret (referred to above) which Trowell says was lsquocrucialrsquo inensuring recognition of the disease would probably not have comeabout without Williamsrsquo work

An equally important question for the historian ndash moreimportant for those not too worried about precedence ndash is this wheredoes Williamsrsquo work fit into the development of nutrition studiesDiscussing the general area of the discovery of colonial malnutrition

162

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

noted by observers at the time in the case of the Gold Coast by WOrmsby-Gore Under-Secretary of State for the Colonies on a visitin 192616 He laid great stress on the food question and overtly linkedit with national efficiency and infant mortality

There are few parts of the world where the study of dietetics is moreimportant than in Africa It affects not only the question of theefficiency of labour but also public health and particularly infantmortality17

The aim of progress and development central to the colonialundertaking was seen to depend on better food supplies18 Whereas a

154

J Stanton

Fig 5 ldquoBeginyarsquo Bardquo (come-and-stay) child with father Photograph taken by

R S Rattray while Head of Anthropology Gold Coast 1921ndash32 Withpermission of Pitt Rivers Museum (School of Anthropology and Museum

of Ethnography) University of Oxford

major motive behind infant welfare in Britain was provision ofsoldiers to defend the Empire19 here it was primarily a matter ofeconomic advance

Along with many other British exports the Gold Coast receivedconcern over infant mortality Attempts to enumerate the populationndash very partial and inaccurate ndash were supplemented in 1917 by a surveyof infant mortality in Accra which generated alarming statisticsapparently nearly half the babies died in the first year of life20 Amonga tranche of welfare measures introduced by the progressive post-warGovernor F G Guggisberg was government provision for infantwelfare work previously the prerogative of missionary groups21

Reviewing the situation towards the end of his term of officeGuggisberg speculated on infant mortality at the turn of the centuryit lsquomust have been appallingrsquo in view of the crowded and insanitaryhousing conditions Still in 1921 as organised clinics were institutedsome towns reported infant mortality rates of over four hundred perthousand due in Guggisbergrsquos view to lsquothe housing the customs andthe habits of the peoplersquo22

The new facilities offered by the government were certainlypopular Infant welfare clinics which opened in the main towns withseveral in Accra rapidly attracted thousands of attendances a year23

In 1926 Princess Marie Louise Hospital for children opened inAccra to provide the main infant and child welfare (outpatient)centre as well as acute services Guggisberg placed these at the centreof his programme

The various clinics now opened for Infant Welfare work represent thebeginnings in the Gold Coast of the new Public Health and inconjunction with improved education will help to instil into theminds of the people that the quest and attainment of health should bea personal matter of supreme importance which if they are willing tolearn will change the whole history of their country for the better24

It was into this atmosphere of encouraging self-improvementreminiscent of lsquoeducating the mothersrsquo in the UK25 that CicelyWilliams was appointed Woman Medical Officer in 1929

Cicely Williams and kwashiorkor

Of course Cicely Williams was not alone in attempting tounderstand the language and beliefs of the Africans she workedamongst In the Gold Coast as in other colonies under each of thecolonial powers professional agents were appointed to interpret thealien world of lsquothe nativesrsquo for the colonisers government (and free-

155

Listening to the Ga

range) anthropologists can be seen as serving this function as well ascarrying out their own intellectual programme Nor was Williams theonly doctor to double as amateur anthropologist Colonial officials ofall grades seem to have dabbled in anthropology26 but doctors wereespecially tempted as the eugenic end of their scientificunderstanding alerted them to the fine line between racial andcultural difference27

Two specific examples may serve to illustrate Williamsrsquoapproach First we may examine a photograph taken in the 1920sby R S Rattray government anthropologist of a BeginyarsquoBa orlsquocome-and-stayrsquo child whose parents deliberately dressed heruntidily and left her hair dishevelled in the hope of deceiving thespirits who had taken their other children (Fig 5)28 Now comparethis with one taken by Williams in the 1930s of an older girldescribed as a fahit or fetish child (Fig 6)29 Rattrayrsquos picture placesthe child on her fond fatherrsquos lap it is a beautiful study of parentallove Williamsrsquo shot appears more clinical but the accompanyingnote that lsquo8 elder siblings diedrsquo shows that she enquired into thefamily circumstances while the recording of the childrsquos name(Ahana) indicates personal contact

Similarly Williams recorded names of nurses holding twoinfants whom she described as the only abandoned babies she eversaw in the Gold Coast (Fig 7)30 She believed abandonment wasextremely rare compared with European societies Correlating thelocations where these babies were found ndash one beside the railway andthe other on a golf course ndash with European infiltration Williams sawtheir fate as symbolic of the dislocation brought about by colonialrule a theme amply developed in contemporary anthropologicalwriting especially on southern Africa31

However Williams was not anti-colonial at this stage nor did shehold a rosy view of African mothersrsquo childrearing skills although shecommended maternal devotion she was critical of what she saw as theindulgent unregulated regime adopted towards young infants Muchcan be learned of her views from her MD thesis which permitted fullerexpansion than any of her articles Perhaps unconsciously drawing acontrast with her own heavy burden of work she likened mothersplaying with their babiesrsquo beads to neurotic chain smokers andascribed adults having an infantile craving to have something alwaysin their mouths to their constant snacking as infants Her observationson weaning are perhaps more objective

[The young infant is] carried about on the motherrsquos back a position

156

J Stanton

it loves it sleeps close beside her it is nourished whenever it criesand on the whole it does remarkably well on this treatment I haveseen the most uncomprehending indignation rage and bitterness ina child of three years old who found that his place on his motherrsquosback was suddenly usurped by a new baby32

The identification of a weaning crisis was intimately tied in withWilliamsrsquo recognition of kwashiorkor which in the main struckchildren between the ages of two and four and nearly always provedfatal

By the time she wrote her MD thesis in 1936 Williamscalculated that she had treated about 100000 children in clinics inthe Gold Coast Reasons for the high morbidity and mortality thesubject of her thesis were wide-ranging in many cases similar tothose in Europe and largely preventable in Williamsrsquo view33 On one

157

Listening to the Ga

Fig 6 lsquoFahitrsquo or fetish child Ahana Cicely Williams Gold Coast 1933ndash5

With kind permission of Contemporary Medical Archives Centre andMedical Photographic Library at the Wellcome Library

hand she indicated poverty was the underlying cause giving a radicalprescription lsquoThe function of a medical department conducted byany government is to raise the standard of living rather than toprovide orthodox medical attention for the individualrsquo34 On theother hand she held that the lsquounspeakablersquo loss of health and lifeamong children was lsquoall due to ignorance and dirt and diseasersquo35 Herunifying theme was the need for civilisation

The enlightened but paternalistic approach of the Guggisbergtype of progressive colonial is reflected in Williamsrsquo attitudesHowever her arguments for combining preventive and curativemedicine caused her to clash with her immediate superiors in whoseview the preventive work was not her job ndash although much laterWilliamsrsquo views won her the title of lsquoprimary health care pioneerrsquo36

Nutritional disorders amply illustrated the need for a combinedapproach As long as she worked in the Gold Coast treating sickchildren the hopelessness of cases of kwashiorkor drove Williams toseek to understand the syndrome which was not described in any of

158

J Stanton

Fig 7 Abandoned babies with nurses Cicely Williams Gold Coast 1933ndash5With kind permission of Contemporary Medical Archives Centre and

Medical Photographic Library at the Wellcome Library

the medical texts she consulted Her first published account appearedin the departmental report in 193237 and was so striking that herformer teacher Helen MacKay (of Queenrsquos Hospital London)encouraged her to seek publication in the prestigious journal Archivesof Disease in Childhood her first classic article appeared in 193338

Battle was joined immediately with H S Stannus an establishedexpert on nutrition countering Williamsrsquo view that this was a newdisease Stannus who had worked as a Medical Officer in Nyasaland(later Malawi) and Tanganyika between 1906 and 1918 and wasregarded as an expert on deficiency diseases among Africans claimedthat the condition must be simply an infantile form of pellagra39

Despite inclusion of photographs in Williamsrsquo 1933 article showinga distribution of darkened peeling skin on infants which was entirelyunlike that characteristic of pellagra Stannus without having himselfseen such cases dismissed her observations Williams assembleddetails of a further sixty cases and drew up a comparison betweenkwashiorkor as she now termed it and pellagra in a Lancet article in193540 Micrographs of skin and liver amplifying clinical and post-mortem observations represented lsquoscientificrsquo medicine at a fairlyadvanced level for an African colony available in the pathologylaboratory at Accrarsquos main hospital Again Stannus followedWilliams in print to challenge her interpretation41 Far from beingswayed by the scientific element in her presentation42 he seemedincensed by her adoption of a lsquonativersquo word for the condition

The association with a maize diet indicated by Williams has beenseen as misleading later recognition of the prevalence of the diseasein areas where other staples dominated showed that maize was in nosense the cause43 But Williams made an important connection whenshe pointed out that arkassa the fermented maize food usually givento infants contained yeast which was supposed to cure pellagra Oneof the leading investigators who followed Stannusrsquo line HughTrowell in Uganda administered nicotinic acid (the active anti-pellagra compound in yeast) to kwashiorkor sufferers in the early1940s without any success44 Nevertheless Trowell persisted inavoiding the term kwashiorkor switching from lsquoinfantile pellagrarsquo tolsquomalignant malnutritionrsquo

Possibly Williams drew attention to maize ndash knowing thatpellagra was associated with a chiefly maize diet in the southern USAndash in order to point out the differences between pellagra and thecondition she was observing Certainly she was careful to showdifferences in the skin lesions and other features of the two diseasesshe also offered differential diagnoses in relation to lsquopink diseasersquo

159

Listening to the Ga

vitamin A deficiency and vitamin B1 and B2 deficiencies She wascertainly thinking in terms of deficiency adding lsquoNo tests formineral or protein deficiency have yet been madersquo45 In her 1933paper she suggested several possible causes stating lsquoAs maize was theonly source of the supplementary food some amino-acid or proteindeficiency cannot be excluded as a causersquo46

As for treatment Williams tried varied diets without successcombinations with butter eggs tomato orange liver Marmiteyeast Bemax iron and arsenic failed to reverse the symptoms Theonly food that seemed to work and then in only a few cases wastinned milk lsquoNestleacutersquos sweetened condensed milk with cod-liver oiland malt seemed to be the most successful line of treatmentrsquo47 Soimpressed was she with these rare successes that she wanted to offera chart showing a child patientrsquos recovery for use by Nestleacute inpromoting milk consumption Her immediate superior in the HealthService saw lsquono reason why Messrs Nestleacutes should not make use ofthis chartrsquo but the Governor signalled disapproval lsquoThe value ofthese tinned milks is well knownrsquo and more importantly Nestleacute wasno better than other brands and was not a British firm48 (As willappear later by the end of the 1930s Williams reversed her views andcondemned tinned milk)

If a breastmilk substitute was needed Williams argued tinned milkwas the most convenient Tsetse-borne disease made cattle rearingnearly impossible in this region while goatsrsquo milk could theoreticallybe used the local goats lsquoare never milked and they do not look as if theidea of milking had ever been mentionedrsquo49 Advocacy of tinned milkwas widespread among colonial doctors although there seems not tohave been a concerted effort to dissuade mothers from breastfeeding inBritish colonies as there was in the Belgian Congo lsquoGouttes de Laitrsquo50

Purcell a male Medical Officer practising further west in the GoldCoast at Oda gave a glowing description of lsquobaby Kofirsquo whose motherhad died the day he was born and who was raised on tinned milk andorange juice lsquo plump robust and constantly cheerful The healthygleam of his eyes was sufficient to distinguish him from the otherbabies all of them breast fedrsquo51 Purcell mentioned the Belgian Congomodel to support his view

In describing cases very similar to those observed by WilliamsPurcell chose the heading lsquoInfantile pellagra (Akwashiokor ndashWilliams)rsquo52 He recorded an invariably fatal outcome despite largedoses of Marmite and admitted his lsquodescription tallies closely withthat of Dr Williams but my conclusions differ from hers as sheconsiders the condition distinct from pellagrarsquo53 Purcell paid attention

160

J Stanton

to local interpretations in his discussion of oedema which was one ofthe symptoms of kwashiorkor but also of many other diseases

In Akim the importance of oedema as a sign of disease may beinferred from the fact that my informant a reputable and intelligentldquonative doctorrdquo professes to recognise some five clinical varieties Owuo Mpumpungya is a name given to a disease in which the bodyswells gradually the skin peels off (This resembles the syndromeldquoakwashiorkorrdquo described by Williams)54

Purcell noted the informantrsquos view that the syndrome oftenappeared after a serious case of measles also strikingly the belief thatit was lsquocaused by witches who put the victim into ldquoinvisible firerdquo orboil himrsquo because the victim looks boiled55 In the 1950s whenWilliams visited Tanganyika she was shown the body of a child inDodoma Hospital mortuary described as lsquoa terrible burns casersquo butshe recognised the signs of kwashiorkor56 In this and possibly inmany similar cases Western doctors accused parents of scalding theirchildren through using over-hot bath water

By the time Purcell wrote his book Williams was no longer in theGold Coast Following a dispute with Dr G S Selwyn-ClarkeDeputy Director of Health Services regarding the treatment of oneof her infant patients she was summarily transferred in 1936 fromher Gold Coast post to Singapore Williams had admitted intohospital an infant with non-infectious tubercular peritonitis whomthe Deputy-Director then decided to exclude Williams hadprotested vociferously Although apparently concerned with theinterpretation of rules on admitting patients with tuberculosis thedispute was almost certainly fuelled by antagonism between twostrong characters with rather different ideologies57 Williams was onleave in England when news of her transfer reached her and she hadto depart without her belongings and many of her clinical noteshowever she had brought some with her for completion of her MDthesis Further observations on kwashiorkor were ruled out since itdid not appear to occur in Malaya where wasting (marasmus) was acommon form of severe infant malnutrition Williamsrsquo views on theuse of tinned milk evolved very rapidly in her new posting in 1939she delivered a stinging and prophetic talk to the Rotary Clubentitled lsquoMilk and Murderrsquo condemning promotion of tinned milkto local mothers in tenements by young women dressed like nurses58

Williams was imprisoned in Changi Gaol when the Japaneseoccupied Singapore Trowell greeted Williams on her release at theend of the war with a letter saying he would like to meet her lsquoif only

161

Listening to the Ga

to tell you that you were right Kwashiorkor is not pellagrarsquo59

However his latest article used the term lsquoThe kwashiorkor syndromeof malignant malnutritionrsquo to cover what he believed to be variantsof the condition in children and adults and his failure to absorb thelessons of Williamsrsquo work was reflected in his enthusiasm for trials ofdesiccated hogrsquos stomach as a cure Failure to appreciate Williams wasalso evident in the comments that ended his letter lsquoHow curious thatalmost all African tribes have their name for this disease + what a pitywe could not learn from them It affects millionsrsquo Williams hadshown an ability to lsquolearn from themrsquo throughout her spell in theGold Coast60

In 1948 Williams was appointed first head of the Maternal andChild Health (MCH) section at the World Health Organization(WHO) in Geneva Although she held the position briefly beforetransferring to head MCH for WHO in South East Asia her tenuremay be connected with the launch of a survey of kwashiorkorthroughout sub-Saharan Africa in 1950 resulting in a reportpublished in 195261 From evidence gathered in ten countries theauthors surmised that kwashiorkor was lsquothe most serious andwidespread nutritional disorder known to medical and nutritionalsciencersquo62 Williams was well and truly vindicated ndash as were the Gaand many other African peoples who had named the disease

Discussion

Baumslag opines that Williams fulfilled lsquoa physicianrsquos dream todiagnose find the causative agent and curersquo for a new disease shehad also discovered a means of prevention by supervision at MCHclinics63 Trowell paid respect to Williams in his book on kwashiorkorbut provided many other precedents among whom he cited Gelfandin Rhodesia and Altman in South Africa as lsquopioneersrsquo diminishingthe pre-eminence of Williams in providing the definitivedescription64 The balance probably lies somewhere between thesetwo since it is clear that Williams was still struggling to find the exactcause and an effective cure when she was transferred from the GoldCoast in 1936 On the other hand the 1952 WHO report by Brockand Autret (referred to above) which Trowell says was lsquocrucialrsquo inensuring recognition of the disease would probably not have comeabout without Williamsrsquo work

An equally important question for the historian ndash moreimportant for those not too worried about precedence ndash is this wheredoes Williamsrsquo work fit into the development of nutrition studiesDiscussing the general area of the discovery of colonial malnutrition

162

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

major motive behind infant welfare in Britain was provision ofsoldiers to defend the Empire19 here it was primarily a matter ofeconomic advance

Along with many other British exports the Gold Coast receivedconcern over infant mortality Attempts to enumerate the populationndash very partial and inaccurate ndash were supplemented in 1917 by a surveyof infant mortality in Accra which generated alarming statisticsapparently nearly half the babies died in the first year of life20 Amonga tranche of welfare measures introduced by the progressive post-warGovernor F G Guggisberg was government provision for infantwelfare work previously the prerogative of missionary groups21

Reviewing the situation towards the end of his term of officeGuggisberg speculated on infant mortality at the turn of the centuryit lsquomust have been appallingrsquo in view of the crowded and insanitaryhousing conditions Still in 1921 as organised clinics were institutedsome towns reported infant mortality rates of over four hundred perthousand due in Guggisbergrsquos view to lsquothe housing the customs andthe habits of the peoplersquo22

The new facilities offered by the government were certainlypopular Infant welfare clinics which opened in the main towns withseveral in Accra rapidly attracted thousands of attendances a year23

In 1926 Princess Marie Louise Hospital for children opened inAccra to provide the main infant and child welfare (outpatient)centre as well as acute services Guggisberg placed these at the centreof his programme

The various clinics now opened for Infant Welfare work represent thebeginnings in the Gold Coast of the new Public Health and inconjunction with improved education will help to instil into theminds of the people that the quest and attainment of health should bea personal matter of supreme importance which if they are willing tolearn will change the whole history of their country for the better24

It was into this atmosphere of encouraging self-improvementreminiscent of lsquoeducating the mothersrsquo in the UK25 that CicelyWilliams was appointed Woman Medical Officer in 1929

Cicely Williams and kwashiorkor

Of course Cicely Williams was not alone in attempting tounderstand the language and beliefs of the Africans she workedamongst In the Gold Coast as in other colonies under each of thecolonial powers professional agents were appointed to interpret thealien world of lsquothe nativesrsquo for the colonisers government (and free-

155

Listening to the Ga

range) anthropologists can be seen as serving this function as well ascarrying out their own intellectual programme Nor was Williams theonly doctor to double as amateur anthropologist Colonial officials ofall grades seem to have dabbled in anthropology26 but doctors wereespecially tempted as the eugenic end of their scientificunderstanding alerted them to the fine line between racial andcultural difference27

Two specific examples may serve to illustrate Williamsrsquoapproach First we may examine a photograph taken in the 1920sby R S Rattray government anthropologist of a BeginyarsquoBa orlsquocome-and-stayrsquo child whose parents deliberately dressed heruntidily and left her hair dishevelled in the hope of deceiving thespirits who had taken their other children (Fig 5)28 Now comparethis with one taken by Williams in the 1930s of an older girldescribed as a fahit or fetish child (Fig 6)29 Rattrayrsquos picture placesthe child on her fond fatherrsquos lap it is a beautiful study of parentallove Williamsrsquo shot appears more clinical but the accompanyingnote that lsquo8 elder siblings diedrsquo shows that she enquired into thefamily circumstances while the recording of the childrsquos name(Ahana) indicates personal contact

Similarly Williams recorded names of nurses holding twoinfants whom she described as the only abandoned babies she eversaw in the Gold Coast (Fig 7)30 She believed abandonment wasextremely rare compared with European societies Correlating thelocations where these babies were found ndash one beside the railway andthe other on a golf course ndash with European infiltration Williams sawtheir fate as symbolic of the dislocation brought about by colonialrule a theme amply developed in contemporary anthropologicalwriting especially on southern Africa31

However Williams was not anti-colonial at this stage nor did shehold a rosy view of African mothersrsquo childrearing skills although shecommended maternal devotion she was critical of what she saw as theindulgent unregulated regime adopted towards young infants Muchcan be learned of her views from her MD thesis which permitted fullerexpansion than any of her articles Perhaps unconsciously drawing acontrast with her own heavy burden of work she likened mothersplaying with their babiesrsquo beads to neurotic chain smokers andascribed adults having an infantile craving to have something alwaysin their mouths to their constant snacking as infants Her observationson weaning are perhaps more objective

[The young infant is] carried about on the motherrsquos back a position

156

J Stanton

it loves it sleeps close beside her it is nourished whenever it criesand on the whole it does remarkably well on this treatment I haveseen the most uncomprehending indignation rage and bitterness ina child of three years old who found that his place on his motherrsquosback was suddenly usurped by a new baby32

The identification of a weaning crisis was intimately tied in withWilliamsrsquo recognition of kwashiorkor which in the main struckchildren between the ages of two and four and nearly always provedfatal

By the time she wrote her MD thesis in 1936 Williamscalculated that she had treated about 100000 children in clinics inthe Gold Coast Reasons for the high morbidity and mortality thesubject of her thesis were wide-ranging in many cases similar tothose in Europe and largely preventable in Williamsrsquo view33 On one

157

Listening to the Ga

Fig 6 lsquoFahitrsquo or fetish child Ahana Cicely Williams Gold Coast 1933ndash5

With kind permission of Contemporary Medical Archives Centre andMedical Photographic Library at the Wellcome Library

hand she indicated poverty was the underlying cause giving a radicalprescription lsquoThe function of a medical department conducted byany government is to raise the standard of living rather than toprovide orthodox medical attention for the individualrsquo34 On theother hand she held that the lsquounspeakablersquo loss of health and lifeamong children was lsquoall due to ignorance and dirt and diseasersquo35 Herunifying theme was the need for civilisation

The enlightened but paternalistic approach of the Guggisbergtype of progressive colonial is reflected in Williamsrsquo attitudesHowever her arguments for combining preventive and curativemedicine caused her to clash with her immediate superiors in whoseview the preventive work was not her job ndash although much laterWilliamsrsquo views won her the title of lsquoprimary health care pioneerrsquo36

Nutritional disorders amply illustrated the need for a combinedapproach As long as she worked in the Gold Coast treating sickchildren the hopelessness of cases of kwashiorkor drove Williams toseek to understand the syndrome which was not described in any of

158

J Stanton

Fig 7 Abandoned babies with nurses Cicely Williams Gold Coast 1933ndash5With kind permission of Contemporary Medical Archives Centre and

Medical Photographic Library at the Wellcome Library

the medical texts she consulted Her first published account appearedin the departmental report in 193237 and was so striking that herformer teacher Helen MacKay (of Queenrsquos Hospital London)encouraged her to seek publication in the prestigious journal Archivesof Disease in Childhood her first classic article appeared in 193338

Battle was joined immediately with H S Stannus an establishedexpert on nutrition countering Williamsrsquo view that this was a newdisease Stannus who had worked as a Medical Officer in Nyasaland(later Malawi) and Tanganyika between 1906 and 1918 and wasregarded as an expert on deficiency diseases among Africans claimedthat the condition must be simply an infantile form of pellagra39

Despite inclusion of photographs in Williamsrsquo 1933 article showinga distribution of darkened peeling skin on infants which was entirelyunlike that characteristic of pellagra Stannus without having himselfseen such cases dismissed her observations Williams assembleddetails of a further sixty cases and drew up a comparison betweenkwashiorkor as she now termed it and pellagra in a Lancet article in193540 Micrographs of skin and liver amplifying clinical and post-mortem observations represented lsquoscientificrsquo medicine at a fairlyadvanced level for an African colony available in the pathologylaboratory at Accrarsquos main hospital Again Stannus followedWilliams in print to challenge her interpretation41 Far from beingswayed by the scientific element in her presentation42 he seemedincensed by her adoption of a lsquonativersquo word for the condition

The association with a maize diet indicated by Williams has beenseen as misleading later recognition of the prevalence of the diseasein areas where other staples dominated showed that maize was in nosense the cause43 But Williams made an important connection whenshe pointed out that arkassa the fermented maize food usually givento infants contained yeast which was supposed to cure pellagra Oneof the leading investigators who followed Stannusrsquo line HughTrowell in Uganda administered nicotinic acid (the active anti-pellagra compound in yeast) to kwashiorkor sufferers in the early1940s without any success44 Nevertheless Trowell persisted inavoiding the term kwashiorkor switching from lsquoinfantile pellagrarsquo tolsquomalignant malnutritionrsquo

Possibly Williams drew attention to maize ndash knowing thatpellagra was associated with a chiefly maize diet in the southern USAndash in order to point out the differences between pellagra and thecondition she was observing Certainly she was careful to showdifferences in the skin lesions and other features of the two diseasesshe also offered differential diagnoses in relation to lsquopink diseasersquo

159

Listening to the Ga

vitamin A deficiency and vitamin B1 and B2 deficiencies She wascertainly thinking in terms of deficiency adding lsquoNo tests formineral or protein deficiency have yet been madersquo45 In her 1933paper she suggested several possible causes stating lsquoAs maize was theonly source of the supplementary food some amino-acid or proteindeficiency cannot be excluded as a causersquo46

As for treatment Williams tried varied diets without successcombinations with butter eggs tomato orange liver Marmiteyeast Bemax iron and arsenic failed to reverse the symptoms Theonly food that seemed to work and then in only a few cases wastinned milk lsquoNestleacutersquos sweetened condensed milk with cod-liver oiland malt seemed to be the most successful line of treatmentrsquo47 Soimpressed was she with these rare successes that she wanted to offera chart showing a child patientrsquos recovery for use by Nestleacute inpromoting milk consumption Her immediate superior in the HealthService saw lsquono reason why Messrs Nestleacutes should not make use ofthis chartrsquo but the Governor signalled disapproval lsquoThe value ofthese tinned milks is well knownrsquo and more importantly Nestleacute wasno better than other brands and was not a British firm48 (As willappear later by the end of the 1930s Williams reversed her views andcondemned tinned milk)

If a breastmilk substitute was needed Williams argued tinned milkwas the most convenient Tsetse-borne disease made cattle rearingnearly impossible in this region while goatsrsquo milk could theoreticallybe used the local goats lsquoare never milked and they do not look as if theidea of milking had ever been mentionedrsquo49 Advocacy of tinned milkwas widespread among colonial doctors although there seems not tohave been a concerted effort to dissuade mothers from breastfeeding inBritish colonies as there was in the Belgian Congo lsquoGouttes de Laitrsquo50

Purcell a male Medical Officer practising further west in the GoldCoast at Oda gave a glowing description of lsquobaby Kofirsquo whose motherhad died the day he was born and who was raised on tinned milk andorange juice lsquo plump robust and constantly cheerful The healthygleam of his eyes was sufficient to distinguish him from the otherbabies all of them breast fedrsquo51 Purcell mentioned the Belgian Congomodel to support his view

In describing cases very similar to those observed by WilliamsPurcell chose the heading lsquoInfantile pellagra (Akwashiokor ndashWilliams)rsquo52 He recorded an invariably fatal outcome despite largedoses of Marmite and admitted his lsquodescription tallies closely withthat of Dr Williams but my conclusions differ from hers as sheconsiders the condition distinct from pellagrarsquo53 Purcell paid attention

160

J Stanton

to local interpretations in his discussion of oedema which was one ofthe symptoms of kwashiorkor but also of many other diseases

In Akim the importance of oedema as a sign of disease may beinferred from the fact that my informant a reputable and intelligentldquonative doctorrdquo professes to recognise some five clinical varieties Owuo Mpumpungya is a name given to a disease in which the bodyswells gradually the skin peels off (This resembles the syndromeldquoakwashiorkorrdquo described by Williams)54

Purcell noted the informantrsquos view that the syndrome oftenappeared after a serious case of measles also strikingly the belief thatit was lsquocaused by witches who put the victim into ldquoinvisible firerdquo orboil himrsquo because the victim looks boiled55 In the 1950s whenWilliams visited Tanganyika she was shown the body of a child inDodoma Hospital mortuary described as lsquoa terrible burns casersquo butshe recognised the signs of kwashiorkor56 In this and possibly inmany similar cases Western doctors accused parents of scalding theirchildren through using over-hot bath water

By the time Purcell wrote his book Williams was no longer in theGold Coast Following a dispute with Dr G S Selwyn-ClarkeDeputy Director of Health Services regarding the treatment of oneof her infant patients she was summarily transferred in 1936 fromher Gold Coast post to Singapore Williams had admitted intohospital an infant with non-infectious tubercular peritonitis whomthe Deputy-Director then decided to exclude Williams hadprotested vociferously Although apparently concerned with theinterpretation of rules on admitting patients with tuberculosis thedispute was almost certainly fuelled by antagonism between twostrong characters with rather different ideologies57 Williams was onleave in England when news of her transfer reached her and she hadto depart without her belongings and many of her clinical noteshowever she had brought some with her for completion of her MDthesis Further observations on kwashiorkor were ruled out since itdid not appear to occur in Malaya where wasting (marasmus) was acommon form of severe infant malnutrition Williamsrsquo views on theuse of tinned milk evolved very rapidly in her new posting in 1939she delivered a stinging and prophetic talk to the Rotary Clubentitled lsquoMilk and Murderrsquo condemning promotion of tinned milkto local mothers in tenements by young women dressed like nurses58

Williams was imprisoned in Changi Gaol when the Japaneseoccupied Singapore Trowell greeted Williams on her release at theend of the war with a letter saying he would like to meet her lsquoif only

161

Listening to the Ga

to tell you that you were right Kwashiorkor is not pellagrarsquo59

However his latest article used the term lsquoThe kwashiorkor syndromeof malignant malnutritionrsquo to cover what he believed to be variantsof the condition in children and adults and his failure to absorb thelessons of Williamsrsquo work was reflected in his enthusiasm for trials ofdesiccated hogrsquos stomach as a cure Failure to appreciate Williams wasalso evident in the comments that ended his letter lsquoHow curious thatalmost all African tribes have their name for this disease + what a pitywe could not learn from them It affects millionsrsquo Williams hadshown an ability to lsquolearn from themrsquo throughout her spell in theGold Coast60

In 1948 Williams was appointed first head of the Maternal andChild Health (MCH) section at the World Health Organization(WHO) in Geneva Although she held the position briefly beforetransferring to head MCH for WHO in South East Asia her tenuremay be connected with the launch of a survey of kwashiorkorthroughout sub-Saharan Africa in 1950 resulting in a reportpublished in 195261 From evidence gathered in ten countries theauthors surmised that kwashiorkor was lsquothe most serious andwidespread nutritional disorder known to medical and nutritionalsciencersquo62 Williams was well and truly vindicated ndash as were the Gaand many other African peoples who had named the disease

Discussion

Baumslag opines that Williams fulfilled lsquoa physicianrsquos dream todiagnose find the causative agent and curersquo for a new disease shehad also discovered a means of prevention by supervision at MCHclinics63 Trowell paid respect to Williams in his book on kwashiorkorbut provided many other precedents among whom he cited Gelfandin Rhodesia and Altman in South Africa as lsquopioneersrsquo diminishingthe pre-eminence of Williams in providing the definitivedescription64 The balance probably lies somewhere between thesetwo since it is clear that Williams was still struggling to find the exactcause and an effective cure when she was transferred from the GoldCoast in 1936 On the other hand the 1952 WHO report by Brockand Autret (referred to above) which Trowell says was lsquocrucialrsquo inensuring recognition of the disease would probably not have comeabout without Williamsrsquo work

An equally important question for the historian ndash moreimportant for those not too worried about precedence ndash is this wheredoes Williamsrsquo work fit into the development of nutrition studiesDiscussing the general area of the discovery of colonial malnutrition

162

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

range) anthropologists can be seen as serving this function as well ascarrying out their own intellectual programme Nor was Williams theonly doctor to double as amateur anthropologist Colonial officials ofall grades seem to have dabbled in anthropology26 but doctors wereespecially tempted as the eugenic end of their scientificunderstanding alerted them to the fine line between racial andcultural difference27

Two specific examples may serve to illustrate Williamsrsquoapproach First we may examine a photograph taken in the 1920sby R S Rattray government anthropologist of a BeginyarsquoBa orlsquocome-and-stayrsquo child whose parents deliberately dressed heruntidily and left her hair dishevelled in the hope of deceiving thespirits who had taken their other children (Fig 5)28 Now comparethis with one taken by Williams in the 1930s of an older girldescribed as a fahit or fetish child (Fig 6)29 Rattrayrsquos picture placesthe child on her fond fatherrsquos lap it is a beautiful study of parentallove Williamsrsquo shot appears more clinical but the accompanyingnote that lsquo8 elder siblings diedrsquo shows that she enquired into thefamily circumstances while the recording of the childrsquos name(Ahana) indicates personal contact

Similarly Williams recorded names of nurses holding twoinfants whom she described as the only abandoned babies she eversaw in the Gold Coast (Fig 7)30 She believed abandonment wasextremely rare compared with European societies Correlating thelocations where these babies were found ndash one beside the railway andthe other on a golf course ndash with European infiltration Williams sawtheir fate as symbolic of the dislocation brought about by colonialrule a theme amply developed in contemporary anthropologicalwriting especially on southern Africa31

However Williams was not anti-colonial at this stage nor did shehold a rosy view of African mothersrsquo childrearing skills although shecommended maternal devotion she was critical of what she saw as theindulgent unregulated regime adopted towards young infants Muchcan be learned of her views from her MD thesis which permitted fullerexpansion than any of her articles Perhaps unconsciously drawing acontrast with her own heavy burden of work she likened mothersplaying with their babiesrsquo beads to neurotic chain smokers andascribed adults having an infantile craving to have something alwaysin their mouths to their constant snacking as infants Her observationson weaning are perhaps more objective

[The young infant is] carried about on the motherrsquos back a position

156

J Stanton

it loves it sleeps close beside her it is nourished whenever it criesand on the whole it does remarkably well on this treatment I haveseen the most uncomprehending indignation rage and bitterness ina child of three years old who found that his place on his motherrsquosback was suddenly usurped by a new baby32

The identification of a weaning crisis was intimately tied in withWilliamsrsquo recognition of kwashiorkor which in the main struckchildren between the ages of two and four and nearly always provedfatal

By the time she wrote her MD thesis in 1936 Williamscalculated that she had treated about 100000 children in clinics inthe Gold Coast Reasons for the high morbidity and mortality thesubject of her thesis were wide-ranging in many cases similar tothose in Europe and largely preventable in Williamsrsquo view33 On one

157

Listening to the Ga

Fig 6 lsquoFahitrsquo or fetish child Ahana Cicely Williams Gold Coast 1933ndash5

With kind permission of Contemporary Medical Archives Centre andMedical Photographic Library at the Wellcome Library

hand she indicated poverty was the underlying cause giving a radicalprescription lsquoThe function of a medical department conducted byany government is to raise the standard of living rather than toprovide orthodox medical attention for the individualrsquo34 On theother hand she held that the lsquounspeakablersquo loss of health and lifeamong children was lsquoall due to ignorance and dirt and diseasersquo35 Herunifying theme was the need for civilisation

The enlightened but paternalistic approach of the Guggisbergtype of progressive colonial is reflected in Williamsrsquo attitudesHowever her arguments for combining preventive and curativemedicine caused her to clash with her immediate superiors in whoseview the preventive work was not her job ndash although much laterWilliamsrsquo views won her the title of lsquoprimary health care pioneerrsquo36

Nutritional disorders amply illustrated the need for a combinedapproach As long as she worked in the Gold Coast treating sickchildren the hopelessness of cases of kwashiorkor drove Williams toseek to understand the syndrome which was not described in any of

158

J Stanton

Fig 7 Abandoned babies with nurses Cicely Williams Gold Coast 1933ndash5With kind permission of Contemporary Medical Archives Centre and

Medical Photographic Library at the Wellcome Library

the medical texts she consulted Her first published account appearedin the departmental report in 193237 and was so striking that herformer teacher Helen MacKay (of Queenrsquos Hospital London)encouraged her to seek publication in the prestigious journal Archivesof Disease in Childhood her first classic article appeared in 193338

Battle was joined immediately with H S Stannus an establishedexpert on nutrition countering Williamsrsquo view that this was a newdisease Stannus who had worked as a Medical Officer in Nyasaland(later Malawi) and Tanganyika between 1906 and 1918 and wasregarded as an expert on deficiency diseases among Africans claimedthat the condition must be simply an infantile form of pellagra39

Despite inclusion of photographs in Williamsrsquo 1933 article showinga distribution of darkened peeling skin on infants which was entirelyunlike that characteristic of pellagra Stannus without having himselfseen such cases dismissed her observations Williams assembleddetails of a further sixty cases and drew up a comparison betweenkwashiorkor as she now termed it and pellagra in a Lancet article in193540 Micrographs of skin and liver amplifying clinical and post-mortem observations represented lsquoscientificrsquo medicine at a fairlyadvanced level for an African colony available in the pathologylaboratory at Accrarsquos main hospital Again Stannus followedWilliams in print to challenge her interpretation41 Far from beingswayed by the scientific element in her presentation42 he seemedincensed by her adoption of a lsquonativersquo word for the condition

The association with a maize diet indicated by Williams has beenseen as misleading later recognition of the prevalence of the diseasein areas where other staples dominated showed that maize was in nosense the cause43 But Williams made an important connection whenshe pointed out that arkassa the fermented maize food usually givento infants contained yeast which was supposed to cure pellagra Oneof the leading investigators who followed Stannusrsquo line HughTrowell in Uganda administered nicotinic acid (the active anti-pellagra compound in yeast) to kwashiorkor sufferers in the early1940s without any success44 Nevertheless Trowell persisted inavoiding the term kwashiorkor switching from lsquoinfantile pellagrarsquo tolsquomalignant malnutritionrsquo

Possibly Williams drew attention to maize ndash knowing thatpellagra was associated with a chiefly maize diet in the southern USAndash in order to point out the differences between pellagra and thecondition she was observing Certainly she was careful to showdifferences in the skin lesions and other features of the two diseasesshe also offered differential diagnoses in relation to lsquopink diseasersquo

159

Listening to the Ga

vitamin A deficiency and vitamin B1 and B2 deficiencies She wascertainly thinking in terms of deficiency adding lsquoNo tests formineral or protein deficiency have yet been madersquo45 In her 1933paper she suggested several possible causes stating lsquoAs maize was theonly source of the supplementary food some amino-acid or proteindeficiency cannot be excluded as a causersquo46

As for treatment Williams tried varied diets without successcombinations with butter eggs tomato orange liver Marmiteyeast Bemax iron and arsenic failed to reverse the symptoms Theonly food that seemed to work and then in only a few cases wastinned milk lsquoNestleacutersquos sweetened condensed milk with cod-liver oiland malt seemed to be the most successful line of treatmentrsquo47 Soimpressed was she with these rare successes that she wanted to offera chart showing a child patientrsquos recovery for use by Nestleacute inpromoting milk consumption Her immediate superior in the HealthService saw lsquono reason why Messrs Nestleacutes should not make use ofthis chartrsquo but the Governor signalled disapproval lsquoThe value ofthese tinned milks is well knownrsquo and more importantly Nestleacute wasno better than other brands and was not a British firm48 (As willappear later by the end of the 1930s Williams reversed her views andcondemned tinned milk)

If a breastmilk substitute was needed Williams argued tinned milkwas the most convenient Tsetse-borne disease made cattle rearingnearly impossible in this region while goatsrsquo milk could theoreticallybe used the local goats lsquoare never milked and they do not look as if theidea of milking had ever been mentionedrsquo49 Advocacy of tinned milkwas widespread among colonial doctors although there seems not tohave been a concerted effort to dissuade mothers from breastfeeding inBritish colonies as there was in the Belgian Congo lsquoGouttes de Laitrsquo50

Purcell a male Medical Officer practising further west in the GoldCoast at Oda gave a glowing description of lsquobaby Kofirsquo whose motherhad died the day he was born and who was raised on tinned milk andorange juice lsquo plump robust and constantly cheerful The healthygleam of his eyes was sufficient to distinguish him from the otherbabies all of them breast fedrsquo51 Purcell mentioned the Belgian Congomodel to support his view

In describing cases very similar to those observed by WilliamsPurcell chose the heading lsquoInfantile pellagra (Akwashiokor ndashWilliams)rsquo52 He recorded an invariably fatal outcome despite largedoses of Marmite and admitted his lsquodescription tallies closely withthat of Dr Williams but my conclusions differ from hers as sheconsiders the condition distinct from pellagrarsquo53 Purcell paid attention

160

J Stanton

to local interpretations in his discussion of oedema which was one ofthe symptoms of kwashiorkor but also of many other diseases

In Akim the importance of oedema as a sign of disease may beinferred from the fact that my informant a reputable and intelligentldquonative doctorrdquo professes to recognise some five clinical varieties Owuo Mpumpungya is a name given to a disease in which the bodyswells gradually the skin peels off (This resembles the syndromeldquoakwashiorkorrdquo described by Williams)54

Purcell noted the informantrsquos view that the syndrome oftenappeared after a serious case of measles also strikingly the belief thatit was lsquocaused by witches who put the victim into ldquoinvisible firerdquo orboil himrsquo because the victim looks boiled55 In the 1950s whenWilliams visited Tanganyika she was shown the body of a child inDodoma Hospital mortuary described as lsquoa terrible burns casersquo butshe recognised the signs of kwashiorkor56 In this and possibly inmany similar cases Western doctors accused parents of scalding theirchildren through using over-hot bath water

By the time Purcell wrote his book Williams was no longer in theGold Coast Following a dispute with Dr G S Selwyn-ClarkeDeputy Director of Health Services regarding the treatment of oneof her infant patients she was summarily transferred in 1936 fromher Gold Coast post to Singapore Williams had admitted intohospital an infant with non-infectious tubercular peritonitis whomthe Deputy-Director then decided to exclude Williams hadprotested vociferously Although apparently concerned with theinterpretation of rules on admitting patients with tuberculosis thedispute was almost certainly fuelled by antagonism between twostrong characters with rather different ideologies57 Williams was onleave in England when news of her transfer reached her and she hadto depart without her belongings and many of her clinical noteshowever she had brought some with her for completion of her MDthesis Further observations on kwashiorkor were ruled out since itdid not appear to occur in Malaya where wasting (marasmus) was acommon form of severe infant malnutrition Williamsrsquo views on theuse of tinned milk evolved very rapidly in her new posting in 1939she delivered a stinging and prophetic talk to the Rotary Clubentitled lsquoMilk and Murderrsquo condemning promotion of tinned milkto local mothers in tenements by young women dressed like nurses58

Williams was imprisoned in Changi Gaol when the Japaneseoccupied Singapore Trowell greeted Williams on her release at theend of the war with a letter saying he would like to meet her lsquoif only

161

Listening to the Ga

to tell you that you were right Kwashiorkor is not pellagrarsquo59

However his latest article used the term lsquoThe kwashiorkor syndromeof malignant malnutritionrsquo to cover what he believed to be variantsof the condition in children and adults and his failure to absorb thelessons of Williamsrsquo work was reflected in his enthusiasm for trials ofdesiccated hogrsquos stomach as a cure Failure to appreciate Williams wasalso evident in the comments that ended his letter lsquoHow curious thatalmost all African tribes have their name for this disease + what a pitywe could not learn from them It affects millionsrsquo Williams hadshown an ability to lsquolearn from themrsquo throughout her spell in theGold Coast60

In 1948 Williams was appointed first head of the Maternal andChild Health (MCH) section at the World Health Organization(WHO) in Geneva Although she held the position briefly beforetransferring to head MCH for WHO in South East Asia her tenuremay be connected with the launch of a survey of kwashiorkorthroughout sub-Saharan Africa in 1950 resulting in a reportpublished in 195261 From evidence gathered in ten countries theauthors surmised that kwashiorkor was lsquothe most serious andwidespread nutritional disorder known to medical and nutritionalsciencersquo62 Williams was well and truly vindicated ndash as were the Gaand many other African peoples who had named the disease

Discussion

Baumslag opines that Williams fulfilled lsquoa physicianrsquos dream todiagnose find the causative agent and curersquo for a new disease shehad also discovered a means of prevention by supervision at MCHclinics63 Trowell paid respect to Williams in his book on kwashiorkorbut provided many other precedents among whom he cited Gelfandin Rhodesia and Altman in South Africa as lsquopioneersrsquo diminishingthe pre-eminence of Williams in providing the definitivedescription64 The balance probably lies somewhere between thesetwo since it is clear that Williams was still struggling to find the exactcause and an effective cure when she was transferred from the GoldCoast in 1936 On the other hand the 1952 WHO report by Brockand Autret (referred to above) which Trowell says was lsquocrucialrsquo inensuring recognition of the disease would probably not have comeabout without Williamsrsquo work

An equally important question for the historian ndash moreimportant for those not too worried about precedence ndash is this wheredoes Williamsrsquo work fit into the development of nutrition studiesDiscussing the general area of the discovery of colonial malnutrition

162

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

it loves it sleeps close beside her it is nourished whenever it criesand on the whole it does remarkably well on this treatment I haveseen the most uncomprehending indignation rage and bitterness ina child of three years old who found that his place on his motherrsquosback was suddenly usurped by a new baby32

The identification of a weaning crisis was intimately tied in withWilliamsrsquo recognition of kwashiorkor which in the main struckchildren between the ages of two and four and nearly always provedfatal

By the time she wrote her MD thesis in 1936 Williamscalculated that she had treated about 100000 children in clinics inthe Gold Coast Reasons for the high morbidity and mortality thesubject of her thesis were wide-ranging in many cases similar tothose in Europe and largely preventable in Williamsrsquo view33 On one

157

Listening to the Ga

Fig 6 lsquoFahitrsquo or fetish child Ahana Cicely Williams Gold Coast 1933ndash5

With kind permission of Contemporary Medical Archives Centre andMedical Photographic Library at the Wellcome Library

hand she indicated poverty was the underlying cause giving a radicalprescription lsquoThe function of a medical department conducted byany government is to raise the standard of living rather than toprovide orthodox medical attention for the individualrsquo34 On theother hand she held that the lsquounspeakablersquo loss of health and lifeamong children was lsquoall due to ignorance and dirt and diseasersquo35 Herunifying theme was the need for civilisation

The enlightened but paternalistic approach of the Guggisbergtype of progressive colonial is reflected in Williamsrsquo attitudesHowever her arguments for combining preventive and curativemedicine caused her to clash with her immediate superiors in whoseview the preventive work was not her job ndash although much laterWilliamsrsquo views won her the title of lsquoprimary health care pioneerrsquo36

Nutritional disorders amply illustrated the need for a combinedapproach As long as she worked in the Gold Coast treating sickchildren the hopelessness of cases of kwashiorkor drove Williams toseek to understand the syndrome which was not described in any of

158

J Stanton

Fig 7 Abandoned babies with nurses Cicely Williams Gold Coast 1933ndash5With kind permission of Contemporary Medical Archives Centre and

Medical Photographic Library at the Wellcome Library

the medical texts she consulted Her first published account appearedin the departmental report in 193237 and was so striking that herformer teacher Helen MacKay (of Queenrsquos Hospital London)encouraged her to seek publication in the prestigious journal Archivesof Disease in Childhood her first classic article appeared in 193338

Battle was joined immediately with H S Stannus an establishedexpert on nutrition countering Williamsrsquo view that this was a newdisease Stannus who had worked as a Medical Officer in Nyasaland(later Malawi) and Tanganyika between 1906 and 1918 and wasregarded as an expert on deficiency diseases among Africans claimedthat the condition must be simply an infantile form of pellagra39

Despite inclusion of photographs in Williamsrsquo 1933 article showinga distribution of darkened peeling skin on infants which was entirelyunlike that characteristic of pellagra Stannus without having himselfseen such cases dismissed her observations Williams assembleddetails of a further sixty cases and drew up a comparison betweenkwashiorkor as she now termed it and pellagra in a Lancet article in193540 Micrographs of skin and liver amplifying clinical and post-mortem observations represented lsquoscientificrsquo medicine at a fairlyadvanced level for an African colony available in the pathologylaboratory at Accrarsquos main hospital Again Stannus followedWilliams in print to challenge her interpretation41 Far from beingswayed by the scientific element in her presentation42 he seemedincensed by her adoption of a lsquonativersquo word for the condition

The association with a maize diet indicated by Williams has beenseen as misleading later recognition of the prevalence of the diseasein areas where other staples dominated showed that maize was in nosense the cause43 But Williams made an important connection whenshe pointed out that arkassa the fermented maize food usually givento infants contained yeast which was supposed to cure pellagra Oneof the leading investigators who followed Stannusrsquo line HughTrowell in Uganda administered nicotinic acid (the active anti-pellagra compound in yeast) to kwashiorkor sufferers in the early1940s without any success44 Nevertheless Trowell persisted inavoiding the term kwashiorkor switching from lsquoinfantile pellagrarsquo tolsquomalignant malnutritionrsquo

Possibly Williams drew attention to maize ndash knowing thatpellagra was associated with a chiefly maize diet in the southern USAndash in order to point out the differences between pellagra and thecondition she was observing Certainly she was careful to showdifferences in the skin lesions and other features of the two diseasesshe also offered differential diagnoses in relation to lsquopink diseasersquo

159

Listening to the Ga

vitamin A deficiency and vitamin B1 and B2 deficiencies She wascertainly thinking in terms of deficiency adding lsquoNo tests formineral or protein deficiency have yet been madersquo45 In her 1933paper she suggested several possible causes stating lsquoAs maize was theonly source of the supplementary food some amino-acid or proteindeficiency cannot be excluded as a causersquo46

As for treatment Williams tried varied diets without successcombinations with butter eggs tomato orange liver Marmiteyeast Bemax iron and arsenic failed to reverse the symptoms Theonly food that seemed to work and then in only a few cases wastinned milk lsquoNestleacutersquos sweetened condensed milk with cod-liver oiland malt seemed to be the most successful line of treatmentrsquo47 Soimpressed was she with these rare successes that she wanted to offera chart showing a child patientrsquos recovery for use by Nestleacute inpromoting milk consumption Her immediate superior in the HealthService saw lsquono reason why Messrs Nestleacutes should not make use ofthis chartrsquo but the Governor signalled disapproval lsquoThe value ofthese tinned milks is well knownrsquo and more importantly Nestleacute wasno better than other brands and was not a British firm48 (As willappear later by the end of the 1930s Williams reversed her views andcondemned tinned milk)

If a breastmilk substitute was needed Williams argued tinned milkwas the most convenient Tsetse-borne disease made cattle rearingnearly impossible in this region while goatsrsquo milk could theoreticallybe used the local goats lsquoare never milked and they do not look as if theidea of milking had ever been mentionedrsquo49 Advocacy of tinned milkwas widespread among colonial doctors although there seems not tohave been a concerted effort to dissuade mothers from breastfeeding inBritish colonies as there was in the Belgian Congo lsquoGouttes de Laitrsquo50

Purcell a male Medical Officer practising further west in the GoldCoast at Oda gave a glowing description of lsquobaby Kofirsquo whose motherhad died the day he was born and who was raised on tinned milk andorange juice lsquo plump robust and constantly cheerful The healthygleam of his eyes was sufficient to distinguish him from the otherbabies all of them breast fedrsquo51 Purcell mentioned the Belgian Congomodel to support his view

In describing cases very similar to those observed by WilliamsPurcell chose the heading lsquoInfantile pellagra (Akwashiokor ndashWilliams)rsquo52 He recorded an invariably fatal outcome despite largedoses of Marmite and admitted his lsquodescription tallies closely withthat of Dr Williams but my conclusions differ from hers as sheconsiders the condition distinct from pellagrarsquo53 Purcell paid attention

160

J Stanton

to local interpretations in his discussion of oedema which was one ofthe symptoms of kwashiorkor but also of many other diseases

In Akim the importance of oedema as a sign of disease may beinferred from the fact that my informant a reputable and intelligentldquonative doctorrdquo professes to recognise some five clinical varieties Owuo Mpumpungya is a name given to a disease in which the bodyswells gradually the skin peels off (This resembles the syndromeldquoakwashiorkorrdquo described by Williams)54

Purcell noted the informantrsquos view that the syndrome oftenappeared after a serious case of measles also strikingly the belief thatit was lsquocaused by witches who put the victim into ldquoinvisible firerdquo orboil himrsquo because the victim looks boiled55 In the 1950s whenWilliams visited Tanganyika she was shown the body of a child inDodoma Hospital mortuary described as lsquoa terrible burns casersquo butshe recognised the signs of kwashiorkor56 In this and possibly inmany similar cases Western doctors accused parents of scalding theirchildren through using over-hot bath water

By the time Purcell wrote his book Williams was no longer in theGold Coast Following a dispute with Dr G S Selwyn-ClarkeDeputy Director of Health Services regarding the treatment of oneof her infant patients she was summarily transferred in 1936 fromher Gold Coast post to Singapore Williams had admitted intohospital an infant with non-infectious tubercular peritonitis whomthe Deputy-Director then decided to exclude Williams hadprotested vociferously Although apparently concerned with theinterpretation of rules on admitting patients with tuberculosis thedispute was almost certainly fuelled by antagonism between twostrong characters with rather different ideologies57 Williams was onleave in England when news of her transfer reached her and she hadto depart without her belongings and many of her clinical noteshowever she had brought some with her for completion of her MDthesis Further observations on kwashiorkor were ruled out since itdid not appear to occur in Malaya where wasting (marasmus) was acommon form of severe infant malnutrition Williamsrsquo views on theuse of tinned milk evolved very rapidly in her new posting in 1939she delivered a stinging and prophetic talk to the Rotary Clubentitled lsquoMilk and Murderrsquo condemning promotion of tinned milkto local mothers in tenements by young women dressed like nurses58

Williams was imprisoned in Changi Gaol when the Japaneseoccupied Singapore Trowell greeted Williams on her release at theend of the war with a letter saying he would like to meet her lsquoif only

161

Listening to the Ga

to tell you that you were right Kwashiorkor is not pellagrarsquo59

However his latest article used the term lsquoThe kwashiorkor syndromeof malignant malnutritionrsquo to cover what he believed to be variantsof the condition in children and adults and his failure to absorb thelessons of Williamsrsquo work was reflected in his enthusiasm for trials ofdesiccated hogrsquos stomach as a cure Failure to appreciate Williams wasalso evident in the comments that ended his letter lsquoHow curious thatalmost all African tribes have their name for this disease + what a pitywe could not learn from them It affects millionsrsquo Williams hadshown an ability to lsquolearn from themrsquo throughout her spell in theGold Coast60

In 1948 Williams was appointed first head of the Maternal andChild Health (MCH) section at the World Health Organization(WHO) in Geneva Although she held the position briefly beforetransferring to head MCH for WHO in South East Asia her tenuremay be connected with the launch of a survey of kwashiorkorthroughout sub-Saharan Africa in 1950 resulting in a reportpublished in 195261 From evidence gathered in ten countries theauthors surmised that kwashiorkor was lsquothe most serious andwidespread nutritional disorder known to medical and nutritionalsciencersquo62 Williams was well and truly vindicated ndash as were the Gaand many other African peoples who had named the disease

Discussion

Baumslag opines that Williams fulfilled lsquoa physicianrsquos dream todiagnose find the causative agent and curersquo for a new disease shehad also discovered a means of prevention by supervision at MCHclinics63 Trowell paid respect to Williams in his book on kwashiorkorbut provided many other precedents among whom he cited Gelfandin Rhodesia and Altman in South Africa as lsquopioneersrsquo diminishingthe pre-eminence of Williams in providing the definitivedescription64 The balance probably lies somewhere between thesetwo since it is clear that Williams was still struggling to find the exactcause and an effective cure when she was transferred from the GoldCoast in 1936 On the other hand the 1952 WHO report by Brockand Autret (referred to above) which Trowell says was lsquocrucialrsquo inensuring recognition of the disease would probably not have comeabout without Williamsrsquo work

An equally important question for the historian ndash moreimportant for those not too worried about precedence ndash is this wheredoes Williamsrsquo work fit into the development of nutrition studiesDiscussing the general area of the discovery of colonial malnutrition

162

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

hand she indicated poverty was the underlying cause giving a radicalprescription lsquoThe function of a medical department conducted byany government is to raise the standard of living rather than toprovide orthodox medical attention for the individualrsquo34 On theother hand she held that the lsquounspeakablersquo loss of health and lifeamong children was lsquoall due to ignorance and dirt and diseasersquo35 Herunifying theme was the need for civilisation

The enlightened but paternalistic approach of the Guggisbergtype of progressive colonial is reflected in Williamsrsquo attitudesHowever her arguments for combining preventive and curativemedicine caused her to clash with her immediate superiors in whoseview the preventive work was not her job ndash although much laterWilliamsrsquo views won her the title of lsquoprimary health care pioneerrsquo36

Nutritional disorders amply illustrated the need for a combinedapproach As long as she worked in the Gold Coast treating sickchildren the hopelessness of cases of kwashiorkor drove Williams toseek to understand the syndrome which was not described in any of

158

J Stanton

Fig 7 Abandoned babies with nurses Cicely Williams Gold Coast 1933ndash5With kind permission of Contemporary Medical Archives Centre and

Medical Photographic Library at the Wellcome Library

the medical texts she consulted Her first published account appearedin the departmental report in 193237 and was so striking that herformer teacher Helen MacKay (of Queenrsquos Hospital London)encouraged her to seek publication in the prestigious journal Archivesof Disease in Childhood her first classic article appeared in 193338

Battle was joined immediately with H S Stannus an establishedexpert on nutrition countering Williamsrsquo view that this was a newdisease Stannus who had worked as a Medical Officer in Nyasaland(later Malawi) and Tanganyika between 1906 and 1918 and wasregarded as an expert on deficiency diseases among Africans claimedthat the condition must be simply an infantile form of pellagra39

Despite inclusion of photographs in Williamsrsquo 1933 article showinga distribution of darkened peeling skin on infants which was entirelyunlike that characteristic of pellagra Stannus without having himselfseen such cases dismissed her observations Williams assembleddetails of a further sixty cases and drew up a comparison betweenkwashiorkor as she now termed it and pellagra in a Lancet article in193540 Micrographs of skin and liver amplifying clinical and post-mortem observations represented lsquoscientificrsquo medicine at a fairlyadvanced level for an African colony available in the pathologylaboratory at Accrarsquos main hospital Again Stannus followedWilliams in print to challenge her interpretation41 Far from beingswayed by the scientific element in her presentation42 he seemedincensed by her adoption of a lsquonativersquo word for the condition

The association with a maize diet indicated by Williams has beenseen as misleading later recognition of the prevalence of the diseasein areas where other staples dominated showed that maize was in nosense the cause43 But Williams made an important connection whenshe pointed out that arkassa the fermented maize food usually givento infants contained yeast which was supposed to cure pellagra Oneof the leading investigators who followed Stannusrsquo line HughTrowell in Uganda administered nicotinic acid (the active anti-pellagra compound in yeast) to kwashiorkor sufferers in the early1940s without any success44 Nevertheless Trowell persisted inavoiding the term kwashiorkor switching from lsquoinfantile pellagrarsquo tolsquomalignant malnutritionrsquo

Possibly Williams drew attention to maize ndash knowing thatpellagra was associated with a chiefly maize diet in the southern USAndash in order to point out the differences between pellagra and thecondition she was observing Certainly she was careful to showdifferences in the skin lesions and other features of the two diseasesshe also offered differential diagnoses in relation to lsquopink diseasersquo

159

Listening to the Ga

vitamin A deficiency and vitamin B1 and B2 deficiencies She wascertainly thinking in terms of deficiency adding lsquoNo tests formineral or protein deficiency have yet been madersquo45 In her 1933paper she suggested several possible causes stating lsquoAs maize was theonly source of the supplementary food some amino-acid or proteindeficiency cannot be excluded as a causersquo46

As for treatment Williams tried varied diets without successcombinations with butter eggs tomato orange liver Marmiteyeast Bemax iron and arsenic failed to reverse the symptoms Theonly food that seemed to work and then in only a few cases wastinned milk lsquoNestleacutersquos sweetened condensed milk with cod-liver oiland malt seemed to be the most successful line of treatmentrsquo47 Soimpressed was she with these rare successes that she wanted to offera chart showing a child patientrsquos recovery for use by Nestleacute inpromoting milk consumption Her immediate superior in the HealthService saw lsquono reason why Messrs Nestleacutes should not make use ofthis chartrsquo but the Governor signalled disapproval lsquoThe value ofthese tinned milks is well knownrsquo and more importantly Nestleacute wasno better than other brands and was not a British firm48 (As willappear later by the end of the 1930s Williams reversed her views andcondemned tinned milk)

If a breastmilk substitute was needed Williams argued tinned milkwas the most convenient Tsetse-borne disease made cattle rearingnearly impossible in this region while goatsrsquo milk could theoreticallybe used the local goats lsquoare never milked and they do not look as if theidea of milking had ever been mentionedrsquo49 Advocacy of tinned milkwas widespread among colonial doctors although there seems not tohave been a concerted effort to dissuade mothers from breastfeeding inBritish colonies as there was in the Belgian Congo lsquoGouttes de Laitrsquo50

Purcell a male Medical Officer practising further west in the GoldCoast at Oda gave a glowing description of lsquobaby Kofirsquo whose motherhad died the day he was born and who was raised on tinned milk andorange juice lsquo plump robust and constantly cheerful The healthygleam of his eyes was sufficient to distinguish him from the otherbabies all of them breast fedrsquo51 Purcell mentioned the Belgian Congomodel to support his view

In describing cases very similar to those observed by WilliamsPurcell chose the heading lsquoInfantile pellagra (Akwashiokor ndashWilliams)rsquo52 He recorded an invariably fatal outcome despite largedoses of Marmite and admitted his lsquodescription tallies closely withthat of Dr Williams but my conclusions differ from hers as sheconsiders the condition distinct from pellagrarsquo53 Purcell paid attention

160

J Stanton

to local interpretations in his discussion of oedema which was one ofthe symptoms of kwashiorkor but also of many other diseases

In Akim the importance of oedema as a sign of disease may beinferred from the fact that my informant a reputable and intelligentldquonative doctorrdquo professes to recognise some five clinical varieties Owuo Mpumpungya is a name given to a disease in which the bodyswells gradually the skin peels off (This resembles the syndromeldquoakwashiorkorrdquo described by Williams)54

Purcell noted the informantrsquos view that the syndrome oftenappeared after a serious case of measles also strikingly the belief thatit was lsquocaused by witches who put the victim into ldquoinvisible firerdquo orboil himrsquo because the victim looks boiled55 In the 1950s whenWilliams visited Tanganyika she was shown the body of a child inDodoma Hospital mortuary described as lsquoa terrible burns casersquo butshe recognised the signs of kwashiorkor56 In this and possibly inmany similar cases Western doctors accused parents of scalding theirchildren through using over-hot bath water

By the time Purcell wrote his book Williams was no longer in theGold Coast Following a dispute with Dr G S Selwyn-ClarkeDeputy Director of Health Services regarding the treatment of oneof her infant patients she was summarily transferred in 1936 fromher Gold Coast post to Singapore Williams had admitted intohospital an infant with non-infectious tubercular peritonitis whomthe Deputy-Director then decided to exclude Williams hadprotested vociferously Although apparently concerned with theinterpretation of rules on admitting patients with tuberculosis thedispute was almost certainly fuelled by antagonism between twostrong characters with rather different ideologies57 Williams was onleave in England when news of her transfer reached her and she hadto depart without her belongings and many of her clinical noteshowever she had brought some with her for completion of her MDthesis Further observations on kwashiorkor were ruled out since itdid not appear to occur in Malaya where wasting (marasmus) was acommon form of severe infant malnutrition Williamsrsquo views on theuse of tinned milk evolved very rapidly in her new posting in 1939she delivered a stinging and prophetic talk to the Rotary Clubentitled lsquoMilk and Murderrsquo condemning promotion of tinned milkto local mothers in tenements by young women dressed like nurses58

Williams was imprisoned in Changi Gaol when the Japaneseoccupied Singapore Trowell greeted Williams on her release at theend of the war with a letter saying he would like to meet her lsquoif only

161

Listening to the Ga

to tell you that you were right Kwashiorkor is not pellagrarsquo59

However his latest article used the term lsquoThe kwashiorkor syndromeof malignant malnutritionrsquo to cover what he believed to be variantsof the condition in children and adults and his failure to absorb thelessons of Williamsrsquo work was reflected in his enthusiasm for trials ofdesiccated hogrsquos stomach as a cure Failure to appreciate Williams wasalso evident in the comments that ended his letter lsquoHow curious thatalmost all African tribes have their name for this disease + what a pitywe could not learn from them It affects millionsrsquo Williams hadshown an ability to lsquolearn from themrsquo throughout her spell in theGold Coast60

In 1948 Williams was appointed first head of the Maternal andChild Health (MCH) section at the World Health Organization(WHO) in Geneva Although she held the position briefly beforetransferring to head MCH for WHO in South East Asia her tenuremay be connected with the launch of a survey of kwashiorkorthroughout sub-Saharan Africa in 1950 resulting in a reportpublished in 195261 From evidence gathered in ten countries theauthors surmised that kwashiorkor was lsquothe most serious andwidespread nutritional disorder known to medical and nutritionalsciencersquo62 Williams was well and truly vindicated ndash as were the Gaand many other African peoples who had named the disease

Discussion

Baumslag opines that Williams fulfilled lsquoa physicianrsquos dream todiagnose find the causative agent and curersquo for a new disease shehad also discovered a means of prevention by supervision at MCHclinics63 Trowell paid respect to Williams in his book on kwashiorkorbut provided many other precedents among whom he cited Gelfandin Rhodesia and Altman in South Africa as lsquopioneersrsquo diminishingthe pre-eminence of Williams in providing the definitivedescription64 The balance probably lies somewhere between thesetwo since it is clear that Williams was still struggling to find the exactcause and an effective cure when she was transferred from the GoldCoast in 1936 On the other hand the 1952 WHO report by Brockand Autret (referred to above) which Trowell says was lsquocrucialrsquo inensuring recognition of the disease would probably not have comeabout without Williamsrsquo work

An equally important question for the historian ndash moreimportant for those not too worried about precedence ndash is this wheredoes Williamsrsquo work fit into the development of nutrition studiesDiscussing the general area of the discovery of colonial malnutrition

162

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

the medical texts she consulted Her first published account appearedin the departmental report in 193237 and was so striking that herformer teacher Helen MacKay (of Queenrsquos Hospital London)encouraged her to seek publication in the prestigious journal Archivesof Disease in Childhood her first classic article appeared in 193338

Battle was joined immediately with H S Stannus an establishedexpert on nutrition countering Williamsrsquo view that this was a newdisease Stannus who had worked as a Medical Officer in Nyasaland(later Malawi) and Tanganyika between 1906 and 1918 and wasregarded as an expert on deficiency diseases among Africans claimedthat the condition must be simply an infantile form of pellagra39

Despite inclusion of photographs in Williamsrsquo 1933 article showinga distribution of darkened peeling skin on infants which was entirelyunlike that characteristic of pellagra Stannus without having himselfseen such cases dismissed her observations Williams assembleddetails of a further sixty cases and drew up a comparison betweenkwashiorkor as she now termed it and pellagra in a Lancet article in193540 Micrographs of skin and liver amplifying clinical and post-mortem observations represented lsquoscientificrsquo medicine at a fairlyadvanced level for an African colony available in the pathologylaboratory at Accrarsquos main hospital Again Stannus followedWilliams in print to challenge her interpretation41 Far from beingswayed by the scientific element in her presentation42 he seemedincensed by her adoption of a lsquonativersquo word for the condition

The association with a maize diet indicated by Williams has beenseen as misleading later recognition of the prevalence of the diseasein areas where other staples dominated showed that maize was in nosense the cause43 But Williams made an important connection whenshe pointed out that arkassa the fermented maize food usually givento infants contained yeast which was supposed to cure pellagra Oneof the leading investigators who followed Stannusrsquo line HughTrowell in Uganda administered nicotinic acid (the active anti-pellagra compound in yeast) to kwashiorkor sufferers in the early1940s without any success44 Nevertheless Trowell persisted inavoiding the term kwashiorkor switching from lsquoinfantile pellagrarsquo tolsquomalignant malnutritionrsquo

Possibly Williams drew attention to maize ndash knowing thatpellagra was associated with a chiefly maize diet in the southern USAndash in order to point out the differences between pellagra and thecondition she was observing Certainly she was careful to showdifferences in the skin lesions and other features of the two diseasesshe also offered differential diagnoses in relation to lsquopink diseasersquo

159

Listening to the Ga

vitamin A deficiency and vitamin B1 and B2 deficiencies She wascertainly thinking in terms of deficiency adding lsquoNo tests formineral or protein deficiency have yet been madersquo45 In her 1933paper she suggested several possible causes stating lsquoAs maize was theonly source of the supplementary food some amino-acid or proteindeficiency cannot be excluded as a causersquo46

As for treatment Williams tried varied diets without successcombinations with butter eggs tomato orange liver Marmiteyeast Bemax iron and arsenic failed to reverse the symptoms Theonly food that seemed to work and then in only a few cases wastinned milk lsquoNestleacutersquos sweetened condensed milk with cod-liver oiland malt seemed to be the most successful line of treatmentrsquo47 Soimpressed was she with these rare successes that she wanted to offera chart showing a child patientrsquos recovery for use by Nestleacute inpromoting milk consumption Her immediate superior in the HealthService saw lsquono reason why Messrs Nestleacutes should not make use ofthis chartrsquo but the Governor signalled disapproval lsquoThe value ofthese tinned milks is well knownrsquo and more importantly Nestleacute wasno better than other brands and was not a British firm48 (As willappear later by the end of the 1930s Williams reversed her views andcondemned tinned milk)

If a breastmilk substitute was needed Williams argued tinned milkwas the most convenient Tsetse-borne disease made cattle rearingnearly impossible in this region while goatsrsquo milk could theoreticallybe used the local goats lsquoare never milked and they do not look as if theidea of milking had ever been mentionedrsquo49 Advocacy of tinned milkwas widespread among colonial doctors although there seems not tohave been a concerted effort to dissuade mothers from breastfeeding inBritish colonies as there was in the Belgian Congo lsquoGouttes de Laitrsquo50

Purcell a male Medical Officer practising further west in the GoldCoast at Oda gave a glowing description of lsquobaby Kofirsquo whose motherhad died the day he was born and who was raised on tinned milk andorange juice lsquo plump robust and constantly cheerful The healthygleam of his eyes was sufficient to distinguish him from the otherbabies all of them breast fedrsquo51 Purcell mentioned the Belgian Congomodel to support his view

In describing cases very similar to those observed by WilliamsPurcell chose the heading lsquoInfantile pellagra (Akwashiokor ndashWilliams)rsquo52 He recorded an invariably fatal outcome despite largedoses of Marmite and admitted his lsquodescription tallies closely withthat of Dr Williams but my conclusions differ from hers as sheconsiders the condition distinct from pellagrarsquo53 Purcell paid attention

160

J Stanton

to local interpretations in his discussion of oedema which was one ofthe symptoms of kwashiorkor but also of many other diseases

In Akim the importance of oedema as a sign of disease may beinferred from the fact that my informant a reputable and intelligentldquonative doctorrdquo professes to recognise some five clinical varieties Owuo Mpumpungya is a name given to a disease in which the bodyswells gradually the skin peels off (This resembles the syndromeldquoakwashiorkorrdquo described by Williams)54

Purcell noted the informantrsquos view that the syndrome oftenappeared after a serious case of measles also strikingly the belief thatit was lsquocaused by witches who put the victim into ldquoinvisible firerdquo orboil himrsquo because the victim looks boiled55 In the 1950s whenWilliams visited Tanganyika she was shown the body of a child inDodoma Hospital mortuary described as lsquoa terrible burns casersquo butshe recognised the signs of kwashiorkor56 In this and possibly inmany similar cases Western doctors accused parents of scalding theirchildren through using over-hot bath water

By the time Purcell wrote his book Williams was no longer in theGold Coast Following a dispute with Dr G S Selwyn-ClarkeDeputy Director of Health Services regarding the treatment of oneof her infant patients she was summarily transferred in 1936 fromher Gold Coast post to Singapore Williams had admitted intohospital an infant with non-infectious tubercular peritonitis whomthe Deputy-Director then decided to exclude Williams hadprotested vociferously Although apparently concerned with theinterpretation of rules on admitting patients with tuberculosis thedispute was almost certainly fuelled by antagonism between twostrong characters with rather different ideologies57 Williams was onleave in England when news of her transfer reached her and she hadto depart without her belongings and many of her clinical noteshowever she had brought some with her for completion of her MDthesis Further observations on kwashiorkor were ruled out since itdid not appear to occur in Malaya where wasting (marasmus) was acommon form of severe infant malnutrition Williamsrsquo views on theuse of tinned milk evolved very rapidly in her new posting in 1939she delivered a stinging and prophetic talk to the Rotary Clubentitled lsquoMilk and Murderrsquo condemning promotion of tinned milkto local mothers in tenements by young women dressed like nurses58

Williams was imprisoned in Changi Gaol when the Japaneseoccupied Singapore Trowell greeted Williams on her release at theend of the war with a letter saying he would like to meet her lsquoif only

161

Listening to the Ga

to tell you that you were right Kwashiorkor is not pellagrarsquo59

However his latest article used the term lsquoThe kwashiorkor syndromeof malignant malnutritionrsquo to cover what he believed to be variantsof the condition in children and adults and his failure to absorb thelessons of Williamsrsquo work was reflected in his enthusiasm for trials ofdesiccated hogrsquos stomach as a cure Failure to appreciate Williams wasalso evident in the comments that ended his letter lsquoHow curious thatalmost all African tribes have their name for this disease + what a pitywe could not learn from them It affects millionsrsquo Williams hadshown an ability to lsquolearn from themrsquo throughout her spell in theGold Coast60

In 1948 Williams was appointed first head of the Maternal andChild Health (MCH) section at the World Health Organization(WHO) in Geneva Although she held the position briefly beforetransferring to head MCH for WHO in South East Asia her tenuremay be connected with the launch of a survey of kwashiorkorthroughout sub-Saharan Africa in 1950 resulting in a reportpublished in 195261 From evidence gathered in ten countries theauthors surmised that kwashiorkor was lsquothe most serious andwidespread nutritional disorder known to medical and nutritionalsciencersquo62 Williams was well and truly vindicated ndash as were the Gaand many other African peoples who had named the disease

Discussion

Baumslag opines that Williams fulfilled lsquoa physicianrsquos dream todiagnose find the causative agent and curersquo for a new disease shehad also discovered a means of prevention by supervision at MCHclinics63 Trowell paid respect to Williams in his book on kwashiorkorbut provided many other precedents among whom he cited Gelfandin Rhodesia and Altman in South Africa as lsquopioneersrsquo diminishingthe pre-eminence of Williams in providing the definitivedescription64 The balance probably lies somewhere between thesetwo since it is clear that Williams was still struggling to find the exactcause and an effective cure when she was transferred from the GoldCoast in 1936 On the other hand the 1952 WHO report by Brockand Autret (referred to above) which Trowell says was lsquocrucialrsquo inensuring recognition of the disease would probably not have comeabout without Williamsrsquo work

An equally important question for the historian ndash moreimportant for those not too worried about precedence ndash is this wheredoes Williamsrsquo work fit into the development of nutrition studiesDiscussing the general area of the discovery of colonial malnutrition

162

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

vitamin A deficiency and vitamin B1 and B2 deficiencies She wascertainly thinking in terms of deficiency adding lsquoNo tests formineral or protein deficiency have yet been madersquo45 In her 1933paper she suggested several possible causes stating lsquoAs maize was theonly source of the supplementary food some amino-acid or proteindeficiency cannot be excluded as a causersquo46

As for treatment Williams tried varied diets without successcombinations with butter eggs tomato orange liver Marmiteyeast Bemax iron and arsenic failed to reverse the symptoms Theonly food that seemed to work and then in only a few cases wastinned milk lsquoNestleacutersquos sweetened condensed milk with cod-liver oiland malt seemed to be the most successful line of treatmentrsquo47 Soimpressed was she with these rare successes that she wanted to offera chart showing a child patientrsquos recovery for use by Nestleacute inpromoting milk consumption Her immediate superior in the HealthService saw lsquono reason why Messrs Nestleacutes should not make use ofthis chartrsquo but the Governor signalled disapproval lsquoThe value ofthese tinned milks is well knownrsquo and more importantly Nestleacute wasno better than other brands and was not a British firm48 (As willappear later by the end of the 1930s Williams reversed her views andcondemned tinned milk)

If a breastmilk substitute was needed Williams argued tinned milkwas the most convenient Tsetse-borne disease made cattle rearingnearly impossible in this region while goatsrsquo milk could theoreticallybe used the local goats lsquoare never milked and they do not look as if theidea of milking had ever been mentionedrsquo49 Advocacy of tinned milkwas widespread among colonial doctors although there seems not tohave been a concerted effort to dissuade mothers from breastfeeding inBritish colonies as there was in the Belgian Congo lsquoGouttes de Laitrsquo50

Purcell a male Medical Officer practising further west in the GoldCoast at Oda gave a glowing description of lsquobaby Kofirsquo whose motherhad died the day he was born and who was raised on tinned milk andorange juice lsquo plump robust and constantly cheerful The healthygleam of his eyes was sufficient to distinguish him from the otherbabies all of them breast fedrsquo51 Purcell mentioned the Belgian Congomodel to support his view

In describing cases very similar to those observed by WilliamsPurcell chose the heading lsquoInfantile pellagra (Akwashiokor ndashWilliams)rsquo52 He recorded an invariably fatal outcome despite largedoses of Marmite and admitted his lsquodescription tallies closely withthat of Dr Williams but my conclusions differ from hers as sheconsiders the condition distinct from pellagrarsquo53 Purcell paid attention

160

J Stanton

to local interpretations in his discussion of oedema which was one ofthe symptoms of kwashiorkor but also of many other diseases

In Akim the importance of oedema as a sign of disease may beinferred from the fact that my informant a reputable and intelligentldquonative doctorrdquo professes to recognise some five clinical varieties Owuo Mpumpungya is a name given to a disease in which the bodyswells gradually the skin peels off (This resembles the syndromeldquoakwashiorkorrdquo described by Williams)54

Purcell noted the informantrsquos view that the syndrome oftenappeared after a serious case of measles also strikingly the belief thatit was lsquocaused by witches who put the victim into ldquoinvisible firerdquo orboil himrsquo because the victim looks boiled55 In the 1950s whenWilliams visited Tanganyika she was shown the body of a child inDodoma Hospital mortuary described as lsquoa terrible burns casersquo butshe recognised the signs of kwashiorkor56 In this and possibly inmany similar cases Western doctors accused parents of scalding theirchildren through using over-hot bath water

By the time Purcell wrote his book Williams was no longer in theGold Coast Following a dispute with Dr G S Selwyn-ClarkeDeputy Director of Health Services regarding the treatment of oneof her infant patients she was summarily transferred in 1936 fromher Gold Coast post to Singapore Williams had admitted intohospital an infant with non-infectious tubercular peritonitis whomthe Deputy-Director then decided to exclude Williams hadprotested vociferously Although apparently concerned with theinterpretation of rules on admitting patients with tuberculosis thedispute was almost certainly fuelled by antagonism between twostrong characters with rather different ideologies57 Williams was onleave in England when news of her transfer reached her and she hadto depart without her belongings and many of her clinical noteshowever she had brought some with her for completion of her MDthesis Further observations on kwashiorkor were ruled out since itdid not appear to occur in Malaya where wasting (marasmus) was acommon form of severe infant malnutrition Williamsrsquo views on theuse of tinned milk evolved very rapidly in her new posting in 1939she delivered a stinging and prophetic talk to the Rotary Clubentitled lsquoMilk and Murderrsquo condemning promotion of tinned milkto local mothers in tenements by young women dressed like nurses58

Williams was imprisoned in Changi Gaol when the Japaneseoccupied Singapore Trowell greeted Williams on her release at theend of the war with a letter saying he would like to meet her lsquoif only

161

Listening to the Ga

to tell you that you were right Kwashiorkor is not pellagrarsquo59

However his latest article used the term lsquoThe kwashiorkor syndromeof malignant malnutritionrsquo to cover what he believed to be variantsof the condition in children and adults and his failure to absorb thelessons of Williamsrsquo work was reflected in his enthusiasm for trials ofdesiccated hogrsquos stomach as a cure Failure to appreciate Williams wasalso evident in the comments that ended his letter lsquoHow curious thatalmost all African tribes have their name for this disease + what a pitywe could not learn from them It affects millionsrsquo Williams hadshown an ability to lsquolearn from themrsquo throughout her spell in theGold Coast60

In 1948 Williams was appointed first head of the Maternal andChild Health (MCH) section at the World Health Organization(WHO) in Geneva Although she held the position briefly beforetransferring to head MCH for WHO in South East Asia her tenuremay be connected with the launch of a survey of kwashiorkorthroughout sub-Saharan Africa in 1950 resulting in a reportpublished in 195261 From evidence gathered in ten countries theauthors surmised that kwashiorkor was lsquothe most serious andwidespread nutritional disorder known to medical and nutritionalsciencersquo62 Williams was well and truly vindicated ndash as were the Gaand many other African peoples who had named the disease

Discussion

Baumslag opines that Williams fulfilled lsquoa physicianrsquos dream todiagnose find the causative agent and curersquo for a new disease shehad also discovered a means of prevention by supervision at MCHclinics63 Trowell paid respect to Williams in his book on kwashiorkorbut provided many other precedents among whom he cited Gelfandin Rhodesia and Altman in South Africa as lsquopioneersrsquo diminishingthe pre-eminence of Williams in providing the definitivedescription64 The balance probably lies somewhere between thesetwo since it is clear that Williams was still struggling to find the exactcause and an effective cure when she was transferred from the GoldCoast in 1936 On the other hand the 1952 WHO report by Brockand Autret (referred to above) which Trowell says was lsquocrucialrsquo inensuring recognition of the disease would probably not have comeabout without Williamsrsquo work

An equally important question for the historian ndash moreimportant for those not too worried about precedence ndash is this wheredoes Williamsrsquo work fit into the development of nutrition studiesDiscussing the general area of the discovery of colonial malnutrition

162

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

to local interpretations in his discussion of oedema which was one ofthe symptoms of kwashiorkor but also of many other diseases

In Akim the importance of oedema as a sign of disease may beinferred from the fact that my informant a reputable and intelligentldquonative doctorrdquo professes to recognise some five clinical varieties Owuo Mpumpungya is a name given to a disease in which the bodyswells gradually the skin peels off (This resembles the syndromeldquoakwashiorkorrdquo described by Williams)54

Purcell noted the informantrsquos view that the syndrome oftenappeared after a serious case of measles also strikingly the belief thatit was lsquocaused by witches who put the victim into ldquoinvisible firerdquo orboil himrsquo because the victim looks boiled55 In the 1950s whenWilliams visited Tanganyika she was shown the body of a child inDodoma Hospital mortuary described as lsquoa terrible burns casersquo butshe recognised the signs of kwashiorkor56 In this and possibly inmany similar cases Western doctors accused parents of scalding theirchildren through using over-hot bath water

By the time Purcell wrote his book Williams was no longer in theGold Coast Following a dispute with Dr G S Selwyn-ClarkeDeputy Director of Health Services regarding the treatment of oneof her infant patients she was summarily transferred in 1936 fromher Gold Coast post to Singapore Williams had admitted intohospital an infant with non-infectious tubercular peritonitis whomthe Deputy-Director then decided to exclude Williams hadprotested vociferously Although apparently concerned with theinterpretation of rules on admitting patients with tuberculosis thedispute was almost certainly fuelled by antagonism between twostrong characters with rather different ideologies57 Williams was onleave in England when news of her transfer reached her and she hadto depart without her belongings and many of her clinical noteshowever she had brought some with her for completion of her MDthesis Further observations on kwashiorkor were ruled out since itdid not appear to occur in Malaya where wasting (marasmus) was acommon form of severe infant malnutrition Williamsrsquo views on theuse of tinned milk evolved very rapidly in her new posting in 1939she delivered a stinging and prophetic talk to the Rotary Clubentitled lsquoMilk and Murderrsquo condemning promotion of tinned milkto local mothers in tenements by young women dressed like nurses58

Williams was imprisoned in Changi Gaol when the Japaneseoccupied Singapore Trowell greeted Williams on her release at theend of the war with a letter saying he would like to meet her lsquoif only

161

Listening to the Ga

to tell you that you were right Kwashiorkor is not pellagrarsquo59

However his latest article used the term lsquoThe kwashiorkor syndromeof malignant malnutritionrsquo to cover what he believed to be variantsof the condition in children and adults and his failure to absorb thelessons of Williamsrsquo work was reflected in his enthusiasm for trials ofdesiccated hogrsquos stomach as a cure Failure to appreciate Williams wasalso evident in the comments that ended his letter lsquoHow curious thatalmost all African tribes have their name for this disease + what a pitywe could not learn from them It affects millionsrsquo Williams hadshown an ability to lsquolearn from themrsquo throughout her spell in theGold Coast60

In 1948 Williams was appointed first head of the Maternal andChild Health (MCH) section at the World Health Organization(WHO) in Geneva Although she held the position briefly beforetransferring to head MCH for WHO in South East Asia her tenuremay be connected with the launch of a survey of kwashiorkorthroughout sub-Saharan Africa in 1950 resulting in a reportpublished in 195261 From evidence gathered in ten countries theauthors surmised that kwashiorkor was lsquothe most serious andwidespread nutritional disorder known to medical and nutritionalsciencersquo62 Williams was well and truly vindicated ndash as were the Gaand many other African peoples who had named the disease

Discussion

Baumslag opines that Williams fulfilled lsquoa physicianrsquos dream todiagnose find the causative agent and curersquo for a new disease shehad also discovered a means of prevention by supervision at MCHclinics63 Trowell paid respect to Williams in his book on kwashiorkorbut provided many other precedents among whom he cited Gelfandin Rhodesia and Altman in South Africa as lsquopioneersrsquo diminishingthe pre-eminence of Williams in providing the definitivedescription64 The balance probably lies somewhere between thesetwo since it is clear that Williams was still struggling to find the exactcause and an effective cure when she was transferred from the GoldCoast in 1936 On the other hand the 1952 WHO report by Brockand Autret (referred to above) which Trowell says was lsquocrucialrsquo inensuring recognition of the disease would probably not have comeabout without Williamsrsquo work

An equally important question for the historian ndash moreimportant for those not too worried about precedence ndash is this wheredoes Williamsrsquo work fit into the development of nutrition studiesDiscussing the general area of the discovery of colonial malnutrition

162

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

to tell you that you were right Kwashiorkor is not pellagrarsquo59

However his latest article used the term lsquoThe kwashiorkor syndromeof malignant malnutritionrsquo to cover what he believed to be variantsof the condition in children and adults and his failure to absorb thelessons of Williamsrsquo work was reflected in his enthusiasm for trials ofdesiccated hogrsquos stomach as a cure Failure to appreciate Williams wasalso evident in the comments that ended his letter lsquoHow curious thatalmost all African tribes have their name for this disease + what a pitywe could not learn from them It affects millionsrsquo Williams hadshown an ability to lsquolearn from themrsquo throughout her spell in theGold Coast60

In 1948 Williams was appointed first head of the Maternal andChild Health (MCH) section at the World Health Organization(WHO) in Geneva Although she held the position briefly beforetransferring to head MCH for WHO in South East Asia her tenuremay be connected with the launch of a survey of kwashiorkorthroughout sub-Saharan Africa in 1950 resulting in a reportpublished in 195261 From evidence gathered in ten countries theauthors surmised that kwashiorkor was lsquothe most serious andwidespread nutritional disorder known to medical and nutritionalsciencersquo62 Williams was well and truly vindicated ndash as were the Gaand many other African peoples who had named the disease

Discussion

Baumslag opines that Williams fulfilled lsquoa physicianrsquos dream todiagnose find the causative agent and curersquo for a new disease shehad also discovered a means of prevention by supervision at MCHclinics63 Trowell paid respect to Williams in his book on kwashiorkorbut provided many other precedents among whom he cited Gelfandin Rhodesia and Altman in South Africa as lsquopioneersrsquo diminishingthe pre-eminence of Williams in providing the definitivedescription64 The balance probably lies somewhere between thesetwo since it is clear that Williams was still struggling to find the exactcause and an effective cure when she was transferred from the GoldCoast in 1936 On the other hand the 1952 WHO report by Brockand Autret (referred to above) which Trowell says was lsquocrucialrsquo inensuring recognition of the disease would probably not have comeabout without Williamsrsquo work

An equally important question for the historian ndash moreimportant for those not too worried about precedence ndash is this wheredoes Williamsrsquo work fit into the development of nutrition studiesDiscussing the general area of the discovery of colonial malnutrition

162

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

in the interwar period Worboys poses three rival interpretations65

First there had long been problems of inadequate diet in the tropicsbut these were hidden until the new science of nutrition revealedthem Second population growth was outstripping the food supply(the neo-malthusian argument) perhaps because western medicineand colonial development was allowing more rapid populationgrowth Third the dynamics of colonial intervention especially theshift away from food crops towards cash crops for export created anepidemic of malnutrition Was there an old problem newly revealeda new problem due to population growth or a new problem due todislocation

These interpretations were current at the time and lingered oninto post-colonial consciousness Worboys shows that in the 1930sthe supposed objectivity of the science of nutrition could be used inopposite ways to argue for radical programmes or on the contraryto depoliticise the problem of nutrition He concentrates on thetransfer of a scientific tool the dietary survey from the centre to theperiphery especially the series of surveys conducted between 1936and 1939 for the Report on Nutrition in the Colonial Empire66

Britainrsquos concern with the world economic recession and its desire torationalise agricultural production in its dominions and coloniesinfluenced the outcome Evidence gathered by the surveys tended topoint towards a recent origin for the problem of malnutrition andsuggested it had only recently been identified but this did notemerge in the final report Worboys argues that the problem wasredefined before final drafting the emphasis moving from politicaleconomy to lsquonative educationrsquo in matters of agriculture and dietlsquoColonial malnutrition was rapidly and readily reconstructed frombeing seen as an epidemic problem to an endemic one for whichcolonialism had little responsibility and over which it could exerciselittle controlrsquo67 Thus the critique was shifted away frominappropriate structures of the colonial state towards inadequateknowledge of the local population

Though nutrition was a more universal science than tropicalmedicine or tropical agriculture colonial medical officers workinglsquoon the groundrsquo differed from nutrition experts in Britain accordingto Worboys With a general concern over the lowering effects of apoor diet many saw a preoccupation with deficiency diseases aslsquoEurocentricrsquo Williams and Purcell in the Gold Coast Trowell inUganda and others in southern Africa do not seem to fit thischaracterisation as they searched for the missing factor inkwashiorkor But these researchers each had their own account of

163

Listening to the Ga

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

larger questions underlying malnutrition Williams and Purcellshowed striking differences fitting two of Worboysrsquo three rivalinterpretations

Williams regarded the Gold Coast as a prosperous country withadequate food supplies she included in her thesis a list of food pricesin Kumasi market to demonstrate the affordability of tinned milkFailure to provide weanlings with a balanced diet was due toignorance milk could be provided for orphans or as a supplement byany family Purcell in contrast saw dislocation under colonial rule ascreating new problems He drew an association between cases ofsevere malnutrition ndash probably kwashiorkor ndash in Koforidua and thecocoa hold-up of 1937 which lsquocaused much economic hardshiplabourers were not paid As a class the local Kotokolis were underfedinfantile pellagra among them in 1938 was probably associatedrsquo68

But when it came to prescriptions for change in health provisionWilliams offered a radical programme in her vision of health centresoffering integrated preventive and curative services taking the placeof hospitals69 Purcell also radical was employed to conduct the GoldCoast nutrition survey and ran into trouble with pictures he took inthe Northern Territories indicating that people were starving thegovernment suppressed their publication70

Neither Williams nor Purcell opted for the lsquotechnical fixrsquo ofagricultural programmes to counter malnutrition nor did Williamsfor all her emphasis on health education neglect the need for medicaltreatment alongside advice ndash and she saw the need for improvementsin living standards too71 Two doctors holding opposinginterpretations (nutrition problems old due to ignorance or newdue to colonial intervention) could challenge the colonial authoritiesin different ways

In terms of practice Williamsrsquo ability to head for the centre of aproblem untrammelled by awe of lsquoexpertsrsquo enabled her to develop aplan for primary health care as well as to discover for westernmedicine kwashiorkor Trowellrsquos gender-conscious formulation wasunfortunately patronising lsquoBeing a lady and a very gracious lady atthat she arrived by instinct at the correct answerrsquo72 In the midst ofthe discovery of colonial malnutrition kwashiorkor went unheededfor reasons which this paper has suggested were connected withWilliamsrsquo peripheralization as a woman medical officer in thecolonial medical service But while the Report on Nutrition in theColonial Empire sank almost without trace under wartimebombardment of more urgent issues Williamsrsquo discovery emergedmore strongly after the war than before while her views on primary

164

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

health care became almost gospel for the next generation Thequestion we end with is probably unanswerable did Cicely Williamsevolve her views on primary health care through listening to localpeople or did she listen to people because of her views Certainly inthe case of kwashiorkor she marked her respect through using the Ganame for a disease that people in many parts of Africa (as well asSouth America) had long recognised

Acknowledgements

Wellcome Trust Grant No 16043111 supported research on whichthis paper is based Versions of the paper benefited from discussion byseminar audiences at the Wellcome Unit for the History of Medicineand the Department of Paediatrics at Oxford the London School ofHygiene and Tropical Medicine and the former Wellcome Institutefor the History of Medicine in London I would also like to thankWilliam Beinart for helpful comments on a draft of the chapter

Notes

CMAC = Contemporary Medical Archives Centre at the WellcomeTrust Library London

RCS = Royal Commonwealth Society LondonRH = Rhodes House Oxford

1 K David Patterson Health in Colonial Ghana Disease Medicine andSocio-economic Change 1900-1955 (Waltham Mass CrossroadsPress 1981) 15 she reminded her superiors that lsquomedical trainingfor a woman costs as much as for a manrsquo

2 On medicine see D R Headrick Tools of Empire Technology andEuropean Imperialism in the Nineteenth Century (New York 1981) ndashbut Headrick overemphasises the role of quinine prophylaxis inlsquoopeningrsquo West Africa On religion see R I Rotberg ChristianMissionaries and the Creation of Northern Rhodesia (PrincetonUniversity of California Press 1965) On both see T O RangerlsquoGodly medicine the ambiguities of medical mission in south-eastern Tanzania 1900-1945rsquo in S Feierman and J M Janzen (eds)The Social Basis of Health and Healing in Africa (Berkeley Universityof California Press 1992) 256ndash82

3 Sally Craddock Retired Except on Demand the Life of Dr CicelyWilliams (Oxford Green College 1983) H Trowell J Davies andR Dean Kwashiorkor (New York and London Academic Press1982 Nutrition Foundation Reprint original edition LondonEdward Arnold 1954) opens with Hugh Trowell lsquoThe beginning of

165

Listening to the Ga

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

the kwashiorkor story in Africarsquo which proffers something of anapology for his resistance to Williamsrsquo ideas

4 Interviews with Dr Cicely D Williams in Oxford 16 April and 4September 1985 See also J Beinart with Robert King and SimonBinney lsquoCicely Williams memoirs of a doctorrsquo History WorkshopCentre for Social History Newsletter 3 (Dec 1985) 69ndash80

5 Ibid When a version of this paper was given at the WellcomeSymposium in Nov 1994 the daughter of a former Medical Officerin the Gold Coast commented that Williams did not actually speakGa She would have had local staff to translate but her biographerasserts that as well as being required to pass an exam in a locallanguage to satisfy government regulations Williams wished lsquotocommunicate freelyrsquo with patients in their homes Craddock op cit (note 3) 56

6 My understanding is that kwashiorkor came to be regarded asprotein-calorie malnutrition

7 From F M Bourret The Gold Coast A Survey of the Gold Coast andBritish Togoland 1919-1946 (London Geoffrey Cumberlege forOxford University Press 1949) 5

8 A W Cardinall In Ashanti and Beyond (London Seeley Service ampCo 1927) H J Bevin Economic History of the Gold Coast 1874-1914 (Legon University of Ghana Press 1960) Asante wastranscribed lsquoAshantirsquo during the colonial period

9 Polly Hill Migrant Cocoa Farmers of Southern Ghana (CambridgeCambridge University Press 1963)

10 RHMSS Afrs611(1)10 H Martin Gold Coast 1902-1906lsquoSmall chief bringing in cocoa palm oil and rubber for salersquo

11 Largely due to opposition to land alienation by Aborigines RightsProtection Society an alliance of local elite and traditional rulersformed in Cape Coast in 1897 Under indirect rule chiefs wereappointed by the British in the case of acephalous societies or whereexisting rulers were troublesome to the colonial powers

12 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 lsquoOnitshastorersquo two mothers with babies one breastfeeding girl with tins ofcorned beef on verandah

13 RHMSSAfrs611(3) H Martin Gold Coast 1902-6 untitledphotograph of group of Gold Coast young women dressed in whiteEdwardian-style dress

14 M J Sampson Gold Coast Men of Affairs (London Dawsons 1969first published 1937) provides a splendid review

15 J Tosh lsquoThe cash crop revolution in Tropical Africa an agriculturalreappraisalrsquo African Affairs 79 (1980) 79ndash94

166

J Stanton

16 Cmd2744 (1926) Report by Hon W G A Ormsby-Gore on hisVisit to West Africa in G E Metcalfe Great Britain and GhanaDocuments of Ghana History 1807-1957 (London Thos Nelson ampSons 1964 for University of Ghana) 613

17 Ibid18 For analysis of gender dimension of food and cash-cropping highly

relevant to child health see Jane Guyer lsquoFood cocoa and thedivision of labour by sex in two West African societiesrsquo ComparativeStudies in Society and History 22 (1980) 255ndash73

19 Anna Davin lsquoImperialism and motherhoodrsquo History WorkshopJournal 5 (1978) 9ndash65

20 Patterson op cit (note 1) 23 refers ndash without IMR figures ndash tolsquoReport of the Committee on Infant Mortality in Accrarsquo 31 August1917 and lsquoConference on Infant Mortality in the Gold Coastrsquo 14September 1920 (both in Ghana National Archives) ibid 91 givesAccrarsquos IMR as 483 in 1918 405 in 1920 ndash with caveat that birthswere less completely registered than deaths from 1930 till 1950 levelwas around 110 per thousand

21 Patterson op cit (note 1) 23 Jennifer Stanton lsquoThe rise and fall ofstate provision of infant welfare services in the Gold Coast 1919-1939rsquo paper for Health and Empire seminar Institute ofCommonwealth Studies London 4 December 1992

22 Sir Frederick Gordon Guggisberg Governor of the Gold CoastColony and its dependencies [1919-1926] Review 1900-1926prospects for 1927-1928 (Accra 3 March 1927) 189

23 Stanton op cit (note 21)24 Guggisberg op cit (note 22) 19025 Among the large literature on this the classic remains Davin

lsquoImperialism and motherhoodrsquo 26 Though not to the extent that they indulged in shooting animals an

extraordinarily prevalent pastime27 Megan Vaughan Curing Their Ills Colonial Power and African Illness

(Stanford Ca Stanford University Press 1991) The taste for thesensational among some such doctors is graphically present in a seriesof photographs showing a consultation over a sick child involving awitch-doctor and spider ndash described as lsquoNgam the tarantularsquo ndashending with flogging of childrsquos mother RCSY3043BB184-192 TH Dalrymple [Medical Officer on semi-anthropological safari]British Cameroons Banso 9 June 1939

28 Pitt-Rivers Museum RYA454 R S Rattray Gold Coast 1921-1932 A BeginyarsquoBa or lsquocome-and-stayrsquo child on her fatherrsquos lap

29 CMAC PPCDWM245 C D Williams Gold Coast 193335

167

Listening to the Ga

lsquoFahit (fetish) child Ahana 8 elder siblings diedrsquo30 CMAC PPCDWM243 C D Williams Note in Williamsrsquo hand

gives names as Janet Mensah (holding Kadu) and Comfort Quenor(holding Eleanor) also authorrsquos interviews with Williams op cit(note 4)

31 For example Eileen Krige lsquoChanging conditions in marital relationsand parental duties among urbanized nativesrsquo Africa 9 (1936)1ndash23 based on research in three Pretoria townships discussesbreakdown of customary relations and very high level ofillegitimacy with burden of childrearing often thrown entirely ontowomanrsquos family

32 C D Williams lsquoThe mortality and morbidity of the children of theGold Coastrsquo Thesis for Doctorate of Medicine Oxford (1936) 3235 these observations parallel to work on child psychology inEurope may show influence of Williamsrsquo training as a Montessoriteacher or that of Donald Winnicot who worked at the QueenrsquosHospital for Children in London when Williams had a house jobthere

33 However including lsquotropicalrsquo diseases especially malaria whichremains a major cause of infant deaths to the present

34 Williams op cit (note 32) 19135 Ibid 19036 Some fifty years later Naomi Baumslag (ed) Primary Health Care

Pioneer the Selected Works of Dr Cicely D Williams (Geneva WorldFederation of Public Health Associations and UNICEF 1986)

37 C D Williams lsquoDeficiency diseases in infantsrsquo Appendix E (HealthBranch) Report on the Medical Department for the year 1931-32(Accra Gold Coast Govt Press 1932) 93ndash9

38 C D Williams lsquoA nutritional disease of childhood associated with amaize dietrsquo Archives of Disease in Childhood 8 (1933) 423ndash33

39 H S Stannus lsquoA nutritional disease of childhood associated with amaize diet ndash and pellagrarsquo Archives of Disease in Childhood 9 (1934)115

40 C D Williams lsquoKwashiorkor a nutritional disease of childrenassociated with a maize dietrsquo Lancet 2 (1935) 1151ndash2

41 H S Stannus Letter to the Editor Lancet 2 (1935) 1207ndash842 See Trowell op cit (note 3) lsquoBeginning of kwashiorkor storyrsquo xxiii

on showing his own material to Stannus lsquoI climbed the steps of theHarley Street consulting room of Dr Stannus in 1935 He lookedlong and lovingly at the photographs of the dermatosis but herefused to look at the sections of skin liver and other organsrsquo

43 For example Beatrice Russell lsquoMalnutrition in children under three

168

J Stanton

lsquoFahit (fetish) child Ahana 8 elder siblings diedrsquo30 CMAC PPCDWM243 C D Williams Note in Williamsrsquo hand

gives names as Janet Mensah (holding Kadu) and Comfort Quenor(holding Eleanor) also authorrsquos interviews with Williams op cit(note 4)

31 For example Eileen Krige lsquoChanging conditions in marital relationsand parental duties among urbanized nativesrsquo Africa 9 (1936)1ndash23 based on research in three Pretoria townships discussesbreakdown of customary relations and very high level ofillegitimacy with burden of childrearing often thrown entirely ontowomanrsquos family

32 C D Williams lsquoThe mortality and morbidity of the children of theGold Coastrsquo Thesis for Doctorate of Medicine Oxford (1936) 3235 these observations parallel to work on child psychology inEurope may show influence of Williamsrsquo training as a Montessoriteacher or that of Donald Winnicot who worked at the QueenrsquosHospital for Children in London when Williams had a house jobthere

33 However including lsquotropicalrsquo diseases especially malaria whichremains a major cause of infant deaths to the present

34 Williams op cit (note 32) 19135 Ibid 19036 Some fifty years later Naomi Baumslag (ed) Primary Health Care

Pioneer the Selected Works of Dr Cicely D Williams (Geneva WorldFederation of Public Health Associations and UNICEF 1986)

37 C D Williams lsquoDeficiency diseases in infantsrsquo Appendix E (HealthBranch) Report on the Medical Department for the year 1931-32(Accra Gold Coast Govt Press 1932) 93ndash9

38 C D Williams lsquoA nutritional disease of childhood associated with amaize dietrsquo Archives of Disease in Childhood 8 (1933) 423ndash33

39 H S Stannus lsquoA nutritional disease of childhood associated with amaize diet ndash and pellagrarsquo Archives of Disease in Childhood 9 (1934)115

40 C D Williams lsquoKwashiorkor a nutritional disease of childrenassociated with a maize dietrsquo Lancet 2 (1935) 1151ndash2

41 H S Stannus Letter to the Editor Lancet 2 (1935) 1207ndash842 See Trowell op cit (note 3) lsquoBeginning of kwashiorkor storyrsquo xxiii

on showing his own material to Stannus lsquoI climbed the steps of theHarley Street consulting room of Dr Stannus in 1935 He lookedlong and lovingly at the photographs of the dermatosis but herefused to look at the sections of skin liver and other organsrsquo

43 For example Beatrice Russell lsquoMalnutrition in children under three

168

J Stanton

years of age in Ashanti West Africarsquo Archives of Disease in Childhood21 (1946) 110-12 Inland from the coast in Asante (Ashanti) thestaples were root crops such as cassava and cocoyam rather thanmaize Russell who had been influenced by Williams before the wardescribed a condition which seemed lsquoidenticalrsquo with kwashiorkor butshe hesitated to apply the term because she had lsquonot found it to beassociated with a maize dietrsquo

44 Trowell et al op cit (note 3) 2145 Williams op cit (note 40) 115246 Williams op cit (note 38) 43347 Williams op cit (note 40) 1151 Later it was established that

absorption of food is impaired in the later stages of kwashiorkor sothat skimmed milk was a better treatment than full cream milk

48 GNA 9832 Memorandum from C D Williams Child WelfareClinic PMLH [Princess Marie Louise Hospital] to J M MackayDeputy Director Health Service Accra 18 Jan 1932 forwardedwith favourable comment by Mackay Governorrsquos response

49 Williams op cit (note 32) 9950 Nancy Rose Hunt lsquoldquoLe beacutebeacute en brousserdquo European women African

birth spacing and colonial intervention in breast feeding in theBelgian Congorsquo International Journal of African Historical Studies 21(1988) 401-32

51 F M Purcell Diet and Ill-health in the Forest Country of the GoldCoast (London H K Lewis 1939) 15

52 Ibid 34 Note his mis-spelling53 Ibid 41 Purcell cited pre-First World War and very recent papers

by Stannus on pellagra54 Ibid 3055 Ibid idem56 Baumslag Primary Health Care Pioneer 26-7 says this occurred on a

lsquoNuffield Visitrsquo in 1954 Craddock however dates her NuffieldFoundation Visiting Fellowship to 1952 Craddock op cit (note 3)147 lsquoCongenital syphilisrsquo was another very common misdiagnosis ofkwashiorkor in E Africa

57 Williams interviews op cit (note 4) Craddock op cit (note 3) 71Selwyn-Clarke is said to have favoured segregation thus representinga widespread colonial ethos Craddock op cit (note 3) 58 quotingfrom Selwyn-Clarkersquos contribution to Yellow Fever ConferenceDakar April 1928

58 Williams interviews op cit (note 4) Patterson op cit (note 1)59 C D Williams personal papers Hugh Trowell to Cicely Williams

16 September 1945 (A section of these papers were on loan to the

169

Listening to the Ga

author when notes were taken they are now in CMAC WellcomeTrust Library London)

60 In more ways than one as well as the terminology for kwashiorkorWilliams was investigating local cures for diseases like tetanus beforeshe was transferred arguing that research on the lsquointricate systems ofmedicationrsquo practised by lsquobush doctorsrsquo would be rewardingWilliams op cit (note 32) 51

61 J F Brock and M Autret Kwashiorkor in Africa (Geneva WHOMonograph Series No 8 1952) summary states (71) that surveywas instigated by Joint FAOWHO Expert Committee on Nutritionin October 1949 I have not seen the papers of this committee butwould hazard that Williams had input

62 Ibid 7263 Baumslag Primary Health Care Pioneer 16 Williams often gave

visual demonstration of her belief in the value of supervision via apicture of three infants one clinic attender aged four looking healthyand strong flanked by two smaller six year olds miserable and illwho had been brought up lsquoin bushrsquo without the benefit of clinics

64 Trowell et al op cit (note 3) 2ndash8 lists about 260 reports frommore than 50 countries of lsquoprobable cases of kwashiorkorrsquo usinglocal and lsquoscientificrsquo names an appendix 283 lists over 30vernacular names for the condition but in discussion ofterminology 8-11 authors conclude that Williamsrsquo choice oflsquokwashiorkorrsquo was apt

65 Michael Worboys lsquoThe discovery of colonial malnutrition betweenthe warsrsquo in David Arnold (ed) Imperial Medicine and IndigenousSocieties (Manchester and New York Manchester University Press1988) 208ndash225

66 Economic Advisory Council Committee on Nutrition in theColonial Empire First Report Parts I and II 1939 Cmd 6050 andCmd 6051 Worboys cites work by John Boyd Orr and the Leagueof Nations as antecedents for this project

67 Worboys op cit (note 65) 222ndash3 See also J Illiffe The AfricanPoor (Cambridge Cambridge University Press 1987) 160ndash1 onspread of drought-resistant root crops like manioc associated withshift from famine to chronic malnutrition

68 Purcell Diet and Ill-health 43 his views hold echoes of Ormsby-Gorersquos discussed above

69 Williams op cit (note 32) 194ndash870 For fuller discussion see Jennifer Beinart (Stanton) lsquoDarkly through

a lens changing perceptions of the African child in sickness andhealth 1900-1945rsquo in R Cooter (ed) In the Name of the Child

170

J Stanton

Health and Welfare 1880-1940 (London Routledge 1992) 233Purcell resigned lsquoin disgustrsquo in 1944 Patterson op cit (note 1) 99

71 Williams op cit (note 32) 190 links this with the Malthusianargument in her view improved living standards lead to increasedself-respect which in turn leads to voluntary limitation of family sizendash a view she developed and promoted to the end of her long life

72 Trowell op cit (note 3) xxi

171

Listening to the Ga

Health and Welfare 1880-1940 (London Routledge 1992) 233Purcell resigned lsquoin disgustrsquo in 1944 Patterson op cit (note 1) 99

71 Williams op cit (note 32) 190 links this with the Malthusianargument in her view improved living standards lead to increasedself-respect which in turn leads to voluntary limitation of family sizendash a view she developed and promoted to the end of her long life

72 Trowell op cit (note 3) xxi

171

Listening to the Ga