A Heart for the Work: Journeys through an African Medical School (review)

Claire Wendland provides a compelling account of medical training in Africa in A Heart for the Work. In her analyses of the socialization of Malawian physicians and the practice of African biomedicine, Wendland makes a valuable contribution to the literature on medical power/knowledge, particularly in poor and postcolonial contexts, and provides an all too rare example of anthropology “studying up” in Africa. Herself a Northern-trained obstetrician-gynecologist and anthropologist, Wendland uses her case to argue that biomedical professionals everywhere are shaped as much by the social, cultural, and material conditions in which they train and practice as by the characteristics of biomedicine in hegemonic form. This coproduction, then, has important consequences for individual physicians and, through their medical practice, for their patients and their nation.

Wendland writes accessibly to distill complicated social theory, and biomedical knowledge and experience, into an effortless prose that most any reader could easily engage with. The book deserves to be read far and wide: while Wendland clearly writes with her undergraduate anthropology, sociology, and premedical students in mind, professionals in medical education, international public health and development, and international public administration broadly will also find a trove of useful analysis and insight. Scholars of biomedicine and scientific expertise will find the case of Malawian physicians a compelling counterpoint to the Eurocentric literature. Finally, as Wendland keeps the contemporary history and context of southern Africa at the forefront of her work, her analysis of modern African biomedicine is useful for Africanists of all stripes.

The book is cogently arranged in seven chapters that follow the progress of medical students through their course of study at the University of Malawi’s College of Medicine. Wendland’s data comes from a year of intensive fieldwork (2002–3) combined with shorter trips before and after; her view of student progress through the training program is thus cross-sectional rather than longitudinal. Instead of following one cohort through the five-year program and beyond, Wendland creates comparative “snapshots” of different cohorts at various stages of becoming competent physicians. This organization allows her to correlate students’ experience with historical phenomena as well as with changing policies in the university system. Beyond medical training and practice, Wendland provides an incisive account of the postcolonial situation of advanced education in the global South, grounding her survey and interview data in the particular case of Malawi at the end of the Banda dictatorship, through the first several years of a wary democracy, and at all times in a context of severely restricted resources. Wendland is a responsible ethnographer, transparent about her methods (the detailed appendix on research design and her local collaborations will be invaluable to students) and honest, even conservative, about their limitations. More strident assertions about the utility of her methods and findings would have been quite welcome, in fact, but it seems Wendland is that rare scholar who would have her readers and ultimately her study subjects pass final judgment on her work.

Wendland situates the book within wider anthropological debates on the construction of knowledge and the power dynamics of biomedicine with a masterful introduction to the theoretical literature on medical training and the scholarly critiques of scientific/biomedical knowledge. Her ethnographic material then begins by assessing who, in fact, attends medical school in Malawi. There were non-Malawians—mostly from other African countries—as well as a few Malawians from rural areas, but most of the students in Wendland’s study were from urban families. These students were better able to attain the preparatory education necessary to enter into advanced study. The urban composition of the student body surprised many of the College’s faculty members and government officials, who kept little demographic data on students and tended to assume that those with poorer English or different manners of dress, for instance, were from rural backgrounds. In fact, many students had never visited a truly rural...