University of Chicago Press, 2010. 352 pp., US$27.50 (paperback).
In A Heart for the Work, Claire Wendland explores how biomedicine and its values are remade in an African context through an ethnographic study of the impact of medical training on students of Malawi’s College of Medicine. She opens by describing her introduction to medicine in Malawi, as an American medical student to whom the resource-poor hospital full of unfamiliar ailments offered a startling counterpoint to her own training experiences. Wendland later returns to Malawi in the years after the country developed its first medical school to try and understand how training in medicine in this context shaped Malawi’s newest doctors.
Wendland offers this work as a much-needed addition to the existing literature about the process and impact of medical education, a period of socialization that shapes the values and identities of doctors in ways that last well into medical practice. Wendland points out that while there is an extensive literature on this process in the global North, biomedicine has transcended its origins as a colonial institution to become its own entity in the South, where culture and training have been little explored. In order to more effectively convey the stories and personalities of her research subjects, she closes each chapter with an interview vignette that both captures the main point of the chapter and gives the reader a further glimpse into the motivations and futures of the individual who is speaking, whether a student, patient or physician.
Wendland begins by providing an overview of literature on biomedicine and the process of medical socialization that surround its training. Within this context, medical practitioners strive to represent medicine as neutral and beyond cultural influences. According to Wendland, “Medical knowledge and practice, because they are scientific and beyond culture, are thus eminently portable; as a faculty physician in Malawi’s College of Medicine put it, ‘If anything lends itself to globalization, medicine does’” (7). The deep impact of medical training on trainees’ sense of personal ethics and desensitization with regards to the personhood of patients has been well documented in the North, yet there has been little research into similar socialization processes in the locales to which biomedicine has been exported. Wendland argues that medical training does play an active role in shaping the value systems of medical students in Malawi, but rather than reproducing the trends seen in the global North, the Malawian students reveal the cultural specificity of medical socialization and how training in a resource poor setting is fundamentally distinct.
In the introduction Wendland describes her arrival in the field as both a researcher and a practicing obstetrician and gynecologist. In explaining her deep-seated concerns regarding biomedicine and the training process, Wendland describes her own training as traumatic, adding that she felt “as if the price of learning it was my soul” (30). While she depicts her professional move from clinical practice to anthropology as, in part, a means of preserving personal integrity, Wendland also acknowledges that her willingness to provide clinical care in the hospital throughout her time as a researcher was critical to arranging the logistics of her time there. Her role as a practicing clinician at the hospital also significantly shaped the findings of her research as her subjects saw her as “sharing a profession” (29) with them. Considering Wendland’s ethical qualms about practicing medicine, this tension between her ideals and the practices she knew would help her gain access to her research subjects, might have been discussed and explored more fully throughout the text beyond a few paragraphs in the introduction.
In the second chapter, “Medicine and Healing in a Postcolonial State,” Wendland explores the historical context of Malawi’s College of Medicine, beginning with traditional healing systems, through the introduction of biomedicine in the colonial era, to the relatively recent decision to establish a medical school in Malawi. She describes a location in which traditional healing continues to be the first of line care and where doctors and healers have social power in part due to a contentious history of both supporting and challenging dysfunctional governments. This history of social responsibility and political activism, in conjunction with the eroding state of public health, shapes who attends medical school, as well as their motivations for being there. Within this context, the local becomes blurred and intertwined with global knowledge, standards and expectations, and students “learn at the intersection of global curricula and local exigencies, the intersection of poverty and technology,” (58).
In the following chapter, Wendland describes who makes it to medical school in Malawi and how they come to be there. Students are predominantly male, Christian, urban and highly educated, and while ethnically diverse, are highly unrepresentative of the country’s population by other metrics (67). Wendland lays out in stark detail the few routes available through the public education system to medical school, and how many students who make it to the unlikely possibility of tertiary education believe medicine to be the only stable option. She also does an admirable job of representing the students’ differing personal motivations for entering medicine, ranging from extreme pragmatism about having no other viable options, and the sense of a personal calling born out of experiences as a health officer in a rural district, to family pressures to have a doctor to serve the needs of the extended family. These accounts highlight the important exceptionalities of the student population that influence how they view their country and their patients, as well as providing a sense of the group’s heterogeneity. This, in turn, provides the groundwork for Wendland’s subsequent examination of how this variation is reinforced or eroded through the process of medical education.
In “Seeing Deeply and Seeing Through in the Basic Science Years,” Wendland describes the initial stage of transformation that the medical students undergo in the two basic science years at the start of the medical curriculum. She illustrates how limited resources and harsh passing requirements force students to pick between cheating or failing, and how pressures to conform begin to chip away at social differences between members of the class. In addition to social tensions over language and experience in clinical setting, the preclinical curriculum leads to important shifts and remaking in students’ understanding of the body. Through courses in physiology and anatomy, students learn to “see deeper and deeper into the human body,” and begin to ‘“see through’ traditional health beliefs, a capacity made possible by their new scientific knowledge” (93, 109). This epistemological shift is markedly different from the training experiences in the global North where biomedical knowledge dominates even the lay-person’s understanding of the body and of illness. The Malawian students see this shift as a critical component of their developing identity as doctors. For Wendland, this has important implications for how they relate to their patient population, many of whom do not share their experiences or educational background.
Following her analysis of the preclinical years, Wendland explores the even more transformational clinical experiences of Malawian medical students. She describes how the social and economic realities of their patients are intertwined in the Malawian hospital to the extent that attempting to separate them simply does not make sense. Within this context, “social facts, typically, [are] all too relevant,” as they determine not only how the patient came to be in this state but also what treatment was possible (122). Wendland describes how clinical experience in a woefully understaffed and undersupplied hospital can be demoralizing for students, as it challenges their idea that armed with specialist knowledge they would not only know what to do but would actually be able to carry out such interventions. Students “were already aware of the magnitude of poverty and suffering in their country, but they were not used to facing it as those charged to heal yet unable to do so,” (133). Confronted with nearly unbearable clinical challenges, the students began to lose faith in religion, the government, and even the physicians tasked with teaching them. Within this context, the hope and empowerment of the preclinical years gives way to anger and resentment.
Despite their frustrations with the clinical experience, both patients and doctors learn to cobble together whatever resources are available to form innovative solutions to the challenges they face. Indeed, as Wendland describes in chapter six, in Malawi the word “resource” has become a verb designating such practices of working through difficulties. Moreover, while Malawian medical graduates face tremendous challenges in their early years of practice, Wendland notes the absence of one of the most persistent behaviors noted elsewhere; “although cynical talk about patients is among the most consistent findings in medical socialization research, … in well over a year at the hospital, I never once heard a student or an intern speak cynically or in a derogatory fashion about patients – not in interviews, not in meetings, not on wards or in the clinics” (172). Wendland attributes this not to inherent cultural differences towards kindness, but rather that in this resource-poor setting, students’ anger was directed at the system and the government rather than at patients. Rather than seeking the emotional detachment that is frequently striven for in Nothern medical contexts, young Malawian doctors described “heart” or passion for their work, which Wendland defines as “a sort of responsible empathy, or empathetic responsibility,” and a critical feature of being a good physician (177). When asked to describe why such a quality was valued so highly, Malawians attributed it to the circumstances under which they were forced to work; in order to be able to work in such unbearable conditions you had to love your patients (179).
In the conclusion, Wendland reflects on the impact of Malawian medical training on personal ethics and values. While this medical education imbues students with a set of ethical and moral beliefs, these beliefs and practices are notable in their differences from what has been documented elsewhere. Against claims that biomedicine is neutral and beyond culture, Wendland argues that medicine has a distinctive moral economy that is constantly being renegotiated based on social and economic conditions and actors. Wendland emphasizes this work as a starting point for the recognition that the studies of medical training conducted in the North are not universal and should no longer be discussed and applied as though they are (207).
Liese Pruitt is a medical student at the University of Chicago, Pritzker School of Medicine. Her current research seeks to understand cultural and social barriers to breast cancer care in southern Nigeria.