Claire Wendland’s A Heart for the Work: Journeys through an African Medical School

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Medical anthropologist and physician, Claire Wendland’s A HeartFor the Work traces the development of medical students from their introduction into the University of Malawi, College of Medicine, through their preclinical training and into their lives as practicing physicians. Medical training is a distinct period of socialization that shapes the values and identities of trainees and influences how they will eventually practice medicine. While there is extensive literature on this topic in the developed world, there is a gap in the assessment of experiences of medical trainees from developing countries. Systemic injustices endemic in the global health community prevent biomedicine in sub-Saharan Africa from fully transitioning away from its colonial origins. When evaluating the lived experiences of young Malawian medical students, Wendland argues that medical training in a resource poor settings produces medical professionals whose moral attitudes are fundamentally distinct from clinicians in the developed world.

Doctors and scientists tend to view the stories they tell as objective, neutral, and transcending of culture. However, medicine and experimental results are hard to disentangle from the social and cultural structures that produce them. If knowledge is neutral, then how that knowledge is translated into practice and by whom, can reveal power structures and values in a society. How is the moral development of medical trainees shaped when the resources needed to practice biomedicine are unavailable? How are attitudes influenced when the lives of those who work in medicine are plagued by the same hardship and system failure that produces their patient’s suffering? Through rich narrative, detailed description, and personal anecdotes, Wendland offers insight to these questions.

In Malawi, traditional healing practices; witchcraft; colonization; the introduction of biomedicine; medical missions; and the creation of the first medical school represent a complex legacy of transnationalism and political struggle. The first Malawian medical students began their transformation into doctors at a time where the practice of biomedicine was seen as a tool for Africans moving towards independence and self-determination. The role of a physician was regarded as elite, humanitarian, and authoritarian and the class of Malawian medical students sampled in this work are mostly male, Christian, urban, educated, and unrepresentative of the country’s population. Primary motivations for entering medicine included altruism, pragmatism, and a sense of calling. Both the homogeneity in the group as well as the exceptionalities of the student population influenced how they came to view their role and their patients.

In chapter four, “Seeing Deeply and Seeing Through in the Basic Science Years,” Wendland describes how the medical students transform during the first few years as they began rigorous basic science training in their medical curriculum. Pressures to pass difficult barrier exams forced some students to choose between failing and cheating. Anatomy and physiology lessons gave students a new understanding of the body and many challenged traditional beliefs, giving them a sense of distinction from the general population and an identity as a scientist.

As the students transitioned into clinical trainees in “The World Made Flesh: Hospital Experience and Clinical Crisis,” Wendland describes how the social and economic realities of patients are fully intertwined with the workforce in the Malawian hospital. Staffing shortages and lack of basic supplies challenged student’s once held beliefs about the impact they may have on their patients and their community. As the developing clinician is confronted with nearly unbearable clinical challenges, hope and empowerment turned to doubt, anger, and resentment.

Wendlends argues that medicine has a moral economy that is constantly renegotiated based on social and economic conditions and those involved. Geographic, environmental, social, and economic determinants of population health vary vastly across the globe. Medical training cannot be regarded as universal, however, medical schools become accredited and physicians gain prestige by meeting “international” standards. These metrics, imported from the resource rich settings often include the number of papers published in elite journals, grant dollars funded, and awards won. Practically relevant matters like the number of lives saved and successful births under inadequate conditions do not count towards these standards. Therefore, the motivation to produce physicians of “international” caliber has left schools continuing colonial traditions relying on external exams and research “collaborations” that serve the interest of those seeking publication and funding over local needs.

While the modeling of standards imposed on medical institutions may stunt the progression of the Malawian health system, Wendland’s work reveals an inspiring key distinction between the Malawian students and doctors and their counterparts in the developed world. When clinicians in resource rich settings are pushed to the point of cynicism, they tend to become angry with their patients citing disgust and frustration with an individual’s treatment noncompliance, poor lifestyle habits, or an unwillingness to change behavior. The anger that Malawians feel is instead directed towards the inadequacies in the system claiming to care for their patients. While many clinicians in the developed world cope with this cynicism through emotional detachment or hardening, young Malawian doctors cling to emotion describing the “heart” needed to endure their work. This sense of solidarity with their patients is fundamental to the development of the Malawian doctor.

“When these doctors -to- be talked about their work, they used spirit (or love or heart) for the work interchangeably with spirit (or love or heart) for the people: ‘the people’ were Malawians, and the people were the work.”

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