On this episode Mark talks with Luke Messac, physician, historian, and author of ‘No More to Spend: Neglect and the Construction of Scarcity in Malawi's History of Health Care.’ They discuss how Malawi’s politics over the last century has - like in many countries - been defined by a rhetoric of scarcity and austerity. As Luke shows though, this scarcity is more often the product of political decisions rather than structural pressures, with devastating consequences for the country’s healthcare system. If you’re interested in how geopolitics and economics affect the health of nations, this is the book (and podcast) for you.

You can learn more about and purchase Luke’s book here.

MARK BLYTH: Welcome to the Rhodes Center Podcast. My name is Mark Blyth. I'm the director of the Rhodes Center for International Economics and Finance at the Watson Institute for International and Public Affairs at Brown University.

I'm delighted to have with us today, Luke Messac, who is an emergency room doctor. Who despite that, has written-- or perhaps because of that has written a wonderful book that's just come out with Oxford University Press entitled, No More to Spend-- Neglect and the Construction of Scarcity in Malawi's History of Health Care.

Luke is an emergency room doctor, but he's also someone who's got a PhD in history and the sociology of science from the University of Pennsylvania. And that's how this book came about. So when I think of doctors doing the medical training, I think of people working 70 hours a week. And then some of them go off and do PhDs simultaneously. So shapo, I'm very impressed. But what's also very impressive is the book. So welcome, Luke. Let's get into the book.

LUKE MESSAC: Thanks so much for having me. Really grateful to be here.

MARK BLYTH: So the key idea here-- let's get this on the table right at the start-- is the social construction of scarcity. Now, usually, we think of doctors-- you think of science empiricism. There's not much social construction going on there. But you take this very seriously.

Constraints can be very flexible things. And oftentimes-- yeah, there's a limited amount of money because you put your money somewhere else. You actually have other priorities. You're just not fessing up to the priorities.

So when we think of Malawi, which is very much a hard case in the sense that this is one of the poorest places on the planet, you nonetheless make a convincing case that runs for almost 100 years-- that what's going on here is something that isn't just simply constraints. There's a lot of constructing those constraints for political ends.

So just give us an overview. What do you mean by the construction of scarcity, and why do you think it's important in understanding global public health?

LUKE MESSAC: Yeah, the reason why I focus on scarcity is because it is the overarching ethos in global public health. The first and last thing you learn in any course on global public health is that we've got scarce resources. We've got to apportion them as well as we can. The utilitarian ethos is strong, and a lot of your learning and your thought process will be directed towards how do we best use the limited financial resources that we have?

One of the benefits of history is that we get to look more broadly and say, well, where did this scarcity come from? Is it, in fact, inevitable? And one of the things I realized in the course of doing this research was that even in Malawi, one of the poorest countries in the world, there was often more money to be found.

This idea of the social construction of scarcity came into being because while I do, like a doctor, like to focus on the hard facts and the hard evidence. I couldn't help but notice this refrain. There was no more to spend. We have scarce resources. We live in settings of scarcity. This is a resource-limited setting.

These refrains became seen as natural law partly as a result of how often they had been repeated and repeated over again even though, as the historical records showed, there was more to be spent. There was more to be found. So I was interested in how this became an unchallenged mantra in global health even though it isn't really supported by the record.

MARK BLYTH: What's really cool about the book is it shows how this emerges as a strategy of control in the colonial era. But the fact that you then move through the Federation period, which is nearly the post-colonial era, then into the era of independence-- and essentially, it continues right across-- suggests that this is a very, very powerful dynamic that isn't just tied to material conditions. Or at least the material conditions are not what you've been led to believe.

One of the reasons that poor countries are often told that they can't spend on health care is because you've got too much debt. And that was certainly true of Malawi, or as it was in the nineteen-twenties. And that came because of a railway, which was basically a giant confidence trick. Can you walk us through this one?

LUKE MESSAC: Yeah, so during the colonial era, Malawi-- what is today Malawi was then called Nyasaland. It was a British protectorate. And in the late 19-teens, actually, at the end of World War I, there was an idea that was floated by a Belgian financier named [INAUDIBLE]-- a shadowy figure. It's hard to find a picture of him or even to get more details on his life. Even during his life, he was known as this figure behind the scenes who had a lot of connections to British colonial officials.

And he was able to convince them, at a series of luncheons and banquets and wining and dining, to build a railway through land that he owned in Mozambique. And not only would they build this railway or give him a loan to build a railway, they would guarantee him a profit on the railway. So even if this railway failed, he would be guaranteed a 6% profit per annum for 25 years.

And the responsibility for repaying this loan initially sat with the UK treasury, but the Treasury insisted that this responsibility would actually lie with the Nyasaland's government and therefore the native population of Nyasaland through their hot taxes.

So the problem with the railway was that it was completely uneconomical. As a result of being built through his land, it was actually way too long to be economical-- to turn a profit. And so when it failed very quickly after it was completed, those loans fell hard on the backs of Nyasaland's population.

And as a result, about half of Nyasaland's revenue for the next quarter-century was devoted to repaying this debt-- debt that for them had no benefit. So while 6% of Nyasaland's spending was on health care during this period, almost half was on this pretty useless loan.

MARK BLYTH: And that's a perfect example of then of constraints. Because essentially, they could have spent multiples of what they were doing instead of which they had to basically pay up for a loan that the British government gave some dodgy Belgian financier. And none of that should have happened. But no-- that's your responsibility QED there's no health care spending.

LUKE MESSAC: Yeah, absolutely. So the language of scarcity-- the language of inevitability continued during that period. There was no more to spend. There couldn't be any more. There are these plaintive letters from the governor of Nyasaland, from doctors in Nyasaland, from provincial officials that found their way to the UK treasury, which for much of this period-- for some of this period was run by Winston Churchill.

And the response that they always got was always a rebuff saying you have this debt to repay. You have your own responsibilities. There's really no more for health care. No more can be done.

But when you look at where that debt came from, it was an odious debt. There is no reason why it should have been taken on in the first place, and why it had to constrain spending. So yeah, from the get-go-- from the start, Nyasaland was in a hole.

MARK BLYTH: There were moments when the colonial power-- the United Kingdom in this case-- thought, Oh, maybe we need to do something about health care for the natives, as they called it.

And the first instances is during World War I, when as, you described it, hundreds of thousands of men, women, and children are pressed into the carrier trade-- literally carrying 20 or 30 kilos of supplies to British and allied forces fighting German forces in East Africa during World War I-- the entire-- if you will, the forgotten front of the First World War.

And then in the nines, some 10 years later, there are actually people back in London who recognize that this may be more important for producing stability in these countries if nothing else than has hitherto been recognized. And they managed to actually open the past a little bit for this. Can you talk about these two episodes-- World War I, and then the reports of the late nineteen-twenties and early nineteen-thirties?

LUKE MESSAC: Yeah, there were a few moments when this stinginess was interrupted. And one of them was during the war, as you mentioned, when-- as a result of the carrier service, the death rate was-- even in the words of colonial officials-- was disgraceful. And there was very little in the way of any provision made for their safety or life.

But one of the things that was done was that these carrier hospitals were built. In their hospitals-- really in name only-- they were thatched-roofed huts staffed by nuns with no medical training. And they were providing the medical care, such as it was to the population of carriers.

But after the war, one of the few things that Malawians said was one of the few things worth carrying over from the war experience was these hospitals. And so as a result-- after some delay, the colonial government built this system of dispensaries around the country, which would provide medical care to what they called the native population.

And that remained the only source of medical care for much of the next few decades. And when health care did improve slightly in the nineteen-thirties and early nineteen-forties, it was in part as a result of these really strongly worded reports that were sent by the director of medical services-- first this gentleman named [INAUDIBLE] and then another one named [? De ?] [? Boer ?] about a decade apart.

When they toured the country-- they took these little tours of the country and said this is horrific. Most of them had worked in other parts of East Africa. Some of them worked in India. And they said that compared to those other colonial settings, Malawi or Nyasaland as it was called, was just dismal. That there was very little in the way of training-- very little in the way of provision, and that they could not meet their professional standards in any way unless they were provided more.

And so partly as a result of their elite protest or elite complaint, they got a measure of more resources. Some new hospitals were built. Some new training programs were set up. And even though health care spending remained paltry, there was some additional services provided. And it showed that one of the things that can increase health care spending is this well-placed elite complaint. That there is a role for that in the history of health care.

MARK BLYTH: We'll get onto that when we talk about AIDS in the nineteen-eighties and nineteen-nineties. But I want to take us beyond the nineteen-thirties into the post World War II period. There's a very interesting period because you have a reformist labor government running the United Kingdom.

They're not post-colonial-- they're not giving up empire. No one's in that mindset yet. We haven't had the East of Suez moment or any of this sort of stuff. But it was meant to be a very different form of colonial governments-- a partnership et cetera.

So in London, the British government is basically saying there are no constraints. We have inherited a gigantic debt after World War II, but we're not going to do austerity. Instead, we're going to nationalize industries, improve pensions, build a National Health Service, and basically transform the state.

You would expect the British Labour government to take a similar attitude towards colonial governance. They said that they were going to do this, but they did do the exact opposite. Once again, they brought in the language of constraints. Can you talk about that period, and how they did that?

LUKE MESSAC: Yeah, you mentioned how this was a transformative moment in the UK. It was a moment of tremendous hope in the colonies too. The colonial populations read the Beveridge report too. They were inspired by this war on want and war on disease that it promised, and they expected the same. And they had reason to expect it. The labor government promised the end of imperialism as we know it. They promised developmentalism as the new legitimate reason for the continuation of colonial rule.

And so when they talked to colonial officials-- when they went to hospitals, they expected more. And this was also the era where medicine itself became much more capable-- that we had new medicines. We had penicillin, streptomycin, chloroquine.

So much more was possible in medical care. But it wasn't reaching the colonies. And part of the reason is visible when you look at the labor party's own discussions amongst themselves about, well why weren't X-ray machines making their way to the colonies when they were finding their way to British hospitals?

And it was because this language of scarcity found its way in again. They were saying, well, if we end up spending our money on the colonies, then we're going to lose popular support among domestic populations. We're going to lose elections, and that would be even worse for the colonies. So really it's in the colonies interests for us to focus on the domestic-- focus on the UK and get what we can to the colonies. But we can't go overboard here.

So this language scarcely found its way in again, even at this moment of tremendous rhetorical change.

MARK BLYTH: So before we get to the post-colonial era, and the independence era, and Banda, there's a strange interregnum. The Federation with Southern Rhodesia, which understandably the citizens of Malawi at that point were not exactly in favor of being run by the most avowedly white supremacist government on the planet. But nonetheless, they gave it a go.

And what that did was quite interesting. It provoked, unsurprisingly, civil resistance. There were riots. There was political mobilization. And in response to that, the strangest thing happened. More health care spending. What's the connection?

LUKE MESSAC: I think it's a direct connection. The government was, as you said, came to be ruled by Southern Rhodesia. London basically handed control over to Southern Rhodesia for this Federation that would, in essence, save London money by handing over responsibility to Southern Rhodesia.

And Malawians hated this idea. I mean, if they didn't like the rulers from London, they certainly didn't like the rulers from Salisbury. This was even worse. And so these riots hit the streets. And as a result, a lot of voices in London were saying, well, what are we doing? Perhaps this is actually in the interest of Malawi's population. There was a lot of rising into colonial tide, and even in even in London there was a lot of concern and dissent about this decision.

But in order to continue this arrangement, which Southern Rhodesia definitely wanted to do because they saw it as a way to continue the rule in their own country, they said, no, wait, we're actually providing a lot for Malawi. And the thing that we're providing the most of is health care. We are protecting the health of the population. We're providing vaccines. We're providing hospitals. We're providing medical care-- the likes of which they've never seen before.

And they actually were providing more than London ever did. It wasn't much in absolute terms, and it certainly wasn't much in terms of what they were providing to the White population in Southern Rhodesia and Malawi, but the Native population, as they called it, was receiving more in part because they were trying to answer these concerns about legitimacy. That perhaps they would lose rule altogether if they didn't do more.

MARK BLYTH: Now, eventually, they do lose out. Resistance and anti-colonial struggles affects the entire continent. Malawi is no exception. We get then into the Banda era. He's a fascinating character above a globe-trotting entrepreneur with a dodgy background-- and a doctor.

And you would think that the conditions would be right for a doctor-- the clue is in the name-- coming home, becoming the kind of figurehead president, making health care a priority, doing more with whatever we've got et cetera, et cetera. And that's not what happens at all. So why does he feel to pick up this ball.

LUKE MESSAC: Yeah, I think perhaps it's the obverse of what you saw during the Federation period. Malawi becomes independent. Banda becomes president-- then president for life. He's able to consolidate rule to the extent that there is a lot of political [INAUDIBLE] in the country. And so he doesn't have to worry too much about challenges to his rule-- at least for the first few decades.

And his personal priorities are otherwise. He builds personal palaces. He moves the capital city to his home district. He really wants to build a new International Airport, and with the money he has, he focuses on those resources.

Meanwhile, the UK wants out. They provide some resources, but they say they don't want to be providing financial assistance any longer than they have to. So they provide for a few years, and then they're out.

MARK BLYTH: But he wasn't averse to taking someone else's money to provide for health care. There's the lovely example of the Gulbenkian Foundation from Portugal. Can you talk about that?

LUKE MESSAC: Yeah, he had an interesting position in world affairs. Among countries ruled by majority populations in Africa-- so I'm exempting white-ruled governments in South Africa, and Portugal, and in Southern Rhodesia-- among the other countries in Africa that were independent, Malawi was alone in not standing against apartheid South Africa.

They continued to support Portuguese rule in Mozambique. They continued to support white rule in Southern Rhodesia. And in recompense for that loyalty to these pretty odious regimes, Banda said that he wanted some financial support.

And so he went to the Gulbenkian Foundation, which is this private foundation in Portugal that was allied with the Portuguese government, and he said, you know I'm very friendly with your government. I support you in the UN. I always speak in your favor even as all my neighbors are allied against you. And so in recompense, perhaps you could provide some money for health care.

And so he opened this hospital. And ends up using the foundation's money. And he bragged about this [INAUDIBLE] at the hospital opening. So yeah, he did make use of his unique political position in providing some modicum of health care to the population.

MARK BLYTH: So once we move into the post Banda era-- as we're getting there, this is when AIDS becomes a massive global public health crisis. And Malawi is one of the countries that's hit very, very hard with the AIDS crisis.

So there's two things going at this juncture, which I want to talk about. The first one is again, the notion of constraints. This is a real constraint. The drugs that you need to basically treat this-- antiviral therapies-- they're not there initially. And then when you do come online, they're beyond the expenditures of anyone in the whole Sub-Saharan African area. So there's the politics of basically how those medicines became effective.

But then there's also the fact that it became a global campaign. It was, in a way, the first global health campaign of the modern era. And that led to essentially a celebrity politics around us, which allowed external AIDS [INAUDIBLE] to come in a way that they hadn't done before. So what does the whole AIDS episode of Malawi tell us about constraints in global public health?

LUKE MESSAC: It began with-- austerity became the buzzword in Sub-Saharan Africa, especially in the nineteen-eighties and nineteen-nineties. There was no money for anything. Privatization was the name of the game. In the World Bank, the focus became on charging user fees for health care even as the AIDS epidemic ran rampant over the population.

And Malawi became one of the epicenters of the pandemic. The doctors and nurses spoke about how there was nothing that they could do other than preside over the deaths of their patients in the absence of getting the life-saving drugs that were saving lives in the US and Europe at the very same time.

And so yeah, during the late nineteen-nineties and early two-thousands, you saw this strange-- interesting agglomeration of AIDS activists, and Christian right faith leaders, and politicians, and African activists who helped push for a few things. One was the importation of generic AIDS drugs into Africa-- first with South Africa under Nelson Mandela's government-- over the objections of the United States and branding pharmaceutical companies.

After that success, Brazil did the same thing. And eventually, new funding became available through the president's emergency plan for AIDS relief in the United States and the Global Fund for AIDS, Tuberculosis, and Malaria. All this new money coming available at a time when before it, there was only talk of austerity. Now, they became talk that it was actually possible to treat AIDS in poor countries-- something that had seemed completely impossible and illogical in global health circles only a decade earlier.

So it was a new era of possibility-- one that gave the tight to a lot of the scarcity talk that had been going on for so long.

MARK BLYTH: You've just reminded me of something that's at the end of the book, which I nearly fell off my chair when I was reading. You mentioned privatization, which, of course, was one of the other policies that was very popular with developmental agencies in the nineteen-eighties in particular.

And there's this incredible little vignette close to the end of the book where you talk about-- there was a couple of years of crop failures. And normally, this would have been relieved by these giant grain silos that the Banda government had built. And they basically bought tons and tons of grain as an emergency reserve that they would then sell at below-market prices to make sure no one starved to death. And of course, as part of a condition of refinancing a World Bank or IMF loan, I forget which one it was, these things were privatized.

So all the grain was essentially sold off to speculators. And then, mass hunger ensued. It's just such a shocking-- like Oh my God, [INAUDIBLE] privatization makes things efficient. Really? Maybe there's more to life than efficiency. Maybe insurance and robustness might be considered health care issues as well.

LUKE MESSAC: Yeah, if we look beyond health care proper-- the hospitals and health care centers-- and you look at actually what determines the health of the population, certainly nutrition is a huge source.

And even for all the faults of the Banda regime, one of the things that they were known for was protecting against famine. In fact, he put those grain silos on the currency. So you were reminded of the work he was doing to protect the population against famine, an ever-present concern throughout his regime.

But those silos-- they were emptied of grain as soon as the agency was privatized. And a huge famine ensued. And people spoke about it as the time when no one came to help. There was no assistance during this period. It's one of-- aside from the AIDS epidemic, it's one of the most dismal periods that people recounted to me. And it was completely unnecessary.

MARK BLYTH: But it's also one of the examples of-- we created another constraint by this policy of-- no, no. The market will take care of the grain supply. And of course, it did. It went off to people who could afford to pay the market rate, and it created famine. So again, even the most hard constraint-- basically you have nothing to eat-- itself has a political origin.

LUKE MESSAC: Yeah, and to prove that even more, a few years later-- by the late two-thousands-- the new president came in. And he made subsidies for agricultural fertilizer-- a huge platform in his pitch to the population. And in fact, he ended up spending a huge amount of money on it over the objections of the World Bank. And it led to a huge increase in production-- in agricultural production.

And eventually, the World Bank said, actually you know what? Perhaps this is a good idea. Perhaps this is something we can live within perhaps a limited form. So these things are malleable. These things are not inevitable. And the political history of this one small little country that a lot of us don't think too much about her or visit can throw light on it quite a bit.

MARK BLYTH: So let's finish by taking exactly the insight. What can Malawi tell the rest of the world? We're so used to global North conversations whereby we sit around and diagnose and tell them what to do, and look at our experiences, how it's relevant to them.

You spent time there. You worked there as a doctor as well as working there as a historian-- going through the archives, and putting together the research for this great book. So what do you think Malawi tells the rest of the world, the developed North in particular, about constraints and politics.

LUKE MESSAC: Yeah, I mean, first of all, I was still a medical student at the time. So I wasn't providing direct care. But I did spend a lot of time with patients. And I do think it has a lot to teach us. I mean, if scarcity is at least in part a construction in Malawi, one of the poorest countries in the world, then certainly it is often a construction in other places.

And today I'm a doctor. I work in emergency departments in the United States. I work in Rhode Island. And there I see-- as a result of this pandemic in part, and people losing their jobs and health insurance-- I see all sorts of scarcity. People without enough food to eat. People without the insurance they need to afford medical care. And the language of scarcity returns. And we're told that some of it can't be helped when in fact, there is-- as your work has shown-- there's plenty more that can be done.

Looking at Malawi teaches us both about Malawi, and about the broader world in that if more can be done there, certainly more can be done here.

MARK BLYTH: I think we'll leave it at that point. Congratulations on the book, No More to Spend-- Neglect and the Construction of Scarcity and Malawi's History of Health Care. Even if you don't think you're interested in health care-- even if you don't think you're that interested in Malawi, honestly read it. It's a great book. It's a great walk of political economy as well as being about public health and public policy. Thank you very much, Luke.

LUKE MESSAC: Thanks so much for having me.

MARK BLYTH: This episode of the Rhodes Center Podcast was produced by Dan Richards. For more information, go to watson.brown.edu/rhodes. Thanks for listening.