“We Have to Wait for Riots and Disturbances,” 1931–1941

This chapter demonstrates the recrudescence of neglect during and after the Great Depression. Waves of civil and labor unrest compelled the Colonial Office and Treasury to raise levels of health-care spending in many imperial holdings. But Nyasaland, viewed as a relatively insignificant and peaceful backwater, received little of this funding. A reformist colonial physician, H.S. de Boer, advocated for expanded government health services for subject Africans, but London officials largely dismissed these proposals as inappropriate applications of metropolitan living standards to colonial settings. Even new rhetoric and legislation in support of colonial welfare at the start of the Second World War did not bring meaningful improvements in health care for Nyasaland’s subject Africans.

A Freedom to Die For, 1964–1982

Chapter 6 explores the place of public-sector medicine in President Hastings Kamuzu Banda’s ideology of social protection in post-colonial Malawi. In the midst of internecine strife with his cabinet soon after independence, Banda abandoned health-care user fees, provided free food to hospital inpatients and promised new medical facilities. Later, Banda disregarded international advisers by refusing to promote contraception. Though some commentators attributed this policy to Banda’s conservatism, birth control also ran counter to his regime’s carefully constructed symbolism of abundance. Malawi’s government was not unique in opposing outside efforts at population control, but Banda’s ideology, which invoked what anthropologists of the 1970s called “wealth-in-people,” made birth control particularly unacceptable. Banda also made grand displays of his government’s new hospitals. While he would not devote significant domestic resources to health, he mobilized funds from external donors, particularly governments facing their own crises of legitimacy. While Banda did not consider health a priority, his reliance on symbols of abundance, health and fertility left him vulnerable to critique and compelled him to direct a modicum of resources toward public sector health facilities and to keep care at those facilities free of charge.

“The Partnership Between a Rider and His Horse,” 1953–1963

Chapter 5 demonstrates how the newfound potency of postwar medical technologies made it ever more difficult for colonial officials to deny them to colonized publics. With the arrival of novel and effective antibiotics, attendance at government health facilities rose precipitously. At the same time, a widely detested new Federation Government, based in Southern Rhodesia and dominated by white settlers, faced militant opposition from Nyasaland’s African population. The concomitant rise in popularity in government health-care facilities and a crescendo in civil unrest and repression impelled the Federation government to increase spending on health care in Nyasaland. When the United Kingdom dissolved the Federation and announced plans to grant Nyasaland its independence, Federation officials made drastic cuts to health care spending.

Drugs for the Tengatenga, 1861–1919

Chapter 1 draws a link between the conscription of hundreds of thousands of Nyasaland’s Africans into the British military’s carrier service during the First World War and the first efforts to provide some measure of government health care to rural colonial subjects during the 1920s. Prewar colonial civilian medical care was poor. During the First World War, hundreds of thousands of Africans were forcibly conscripted into the British war effort. For the most part, this experience consisted of brutal and often deadly labor. However, the experience of even threadbare medical care during the war years did lead to calls for better civilian government health facilities during the 1920s.

Introduction

This introduction explores the assumption, present in both the global public health literature and the historiography of biomedicine in Africa, that a low gross domestic product (GDP) is a sufficient explanation for woefully inadequate public-sector health care. This assumption is a product of colonial and postcolonial regimes, which sought to portray scarcity as an inevitable, inescapable fact, even as resources were being spent elsewhere. The arguments used to justify low levels of health-care spending, and the consequences of such paltry expenditures, are the focus of the rest of this work.

“Vaccines or Latrines?” 1983–2016

Chapter 7 explores how the history of neglect continued in the age of AIDS, only to be broken (at least temporarily) by a surge in global health-care spending. In the 1970s and early 1980s, economic collapse and the dictates of international economic institutions hastened the collapse of the health-care system in Malawi at a moment when the AIDS crisis was just beginning. Among global health experts, last two decades of the twentieth century were replete with claims of inescapable scarcity. During the mid-2000s, a surge in international aid, driven in large part by an unlikely cadre of global elites with a sentimental commitment to battling the AIDS pandemic, proved a boon to Malawi’s health system. But the 2008 global financial crisis halted the increase in aid. While political leaders in wealthy nations revisited the rhetorical arsenal of scarcity, doctors and nurses in Malawi implored them for the drugs and supplies necessary to care for their patients.

“Territories of Vast Potentiality,” 1919–1930

Chapter 2 details both the political economy of interwar colonial neglect of social services and the crucial role of moral commitments on the part of a few MPs in puncturing this neglect. The imposition of a burdensome loan for the uneconomical Trans-Zambesi Railway gave colonial officials an excuse to resist increased funding for health care. However, MPs with a commitment to colonial health care successfully argued for debt relief and increased funding for Nyasaland during the debate over the 1929 Colonial Development Act. As a result, the colonial physician John Owen Shircore authored a plan that, though never entirely realized, resulted in the establishment of dozens of new government medical facilities in Nyasaland during in the early 1930s. Still, these facilities were ill equipped and inadequately staffed.

Conclusion: Breaking the Spell of Scarcity

The conclusion begins with a personal story from the author, whose life was saved after his heart stopped as a child. Later, as a young man, he saw a young girl in Rwanda die of tuberculosis. Her avoidable death spurred him to study the global public health literature; he found that many in the field seemed focused less on remedying inequities than on the proper means of dividing up “inherently limited” resources. The assumption was that health-care spending in poor countries would remain, for the foreseeable future, at its current level. This work demonstrates both that this assumption is the product of history and that it continues to have mortal consequences.

Health in Wartime Development and Postwar Visions, 1941–1952

Chapter 4 explores how changes in political discourse within metropolitan Britain during and immediately after the Second World War altered debates about colonial provision of medical services. Enthusiasm for social protection in Britain, and the crisis of legitimacy that the war brought to imperial officials, led to increased interest in—if not always spending on—health care for the colonies. Members of the Fabian Colonial Bureau and other influential voices in colonial circles began to call for an extension of the newly discovered social rights to British colonial subjects. In response, officials began to stress that Africans already had their own traditional forms of social protection, obviating the need for government expenditure. Colonial medical officers in Nyasaland continued to complain that health spending was not at all sufficient to meet the needs of the populace.