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

Even the most technically minded orthopaedic surgeon will be aware of the influence of social and cultural factors on the delivery of healthcare. Although modern medicine is supposedly evidence-based, its practitioners and subjects are resolutely human, with their own aspirations, desires and opinions. This engaging and at times contentious book explores the lives of Malawian medical students and, through their stories, questions our assumptions about medicine, Africa, colonialism and globalisation.

Extensive footnotes (almost as long as the main text, but presented in large blocks of challengingly tiny font) and a detailed reference list give the work the feel of a well-written PhD thesis; an impression that is reinforced by the appearance of a technical appendix. The main chapters follow the progression of a group of medical students through pre-clinical training to their first experiences on the wards, with the individual narratives of the students framed around themes pertinent to the stage of training being described.

These are voices we are rarely allowed to hear, and the juxtaposition of the familiar (the expectations, concerns and hopes of medical trainees) with the unfamiliar (fear of witchcraft, mass emigration) create a fascinating work that is more in the tradition of reportage than academic research. Anyone trained in medicine in the developed world will recognise many of the themes expressed by the students interviewed here. This commonality of experience is underlined by the comradeship felt towards foreign doctors visiting and working on the wards. But the contrast between the salaries, working conditions and dangers faced by doctors in Malawi and those from the wealthier North are clearly demonstrated, and there is an understandable anger running through the accounts given by the medics aware of these differences.

The narrative chapters are book-ended by an introduction and summary that are not entirely consistent and occasionally can seem confusing. There are almost too many ideas being explored. Is the technology-driven, pharmaceutical-laden biomedicine of the developed world really a tool of political oppression? Do its harms outweigh its benefits? What can we learn from medicine in Malawi?

There are, of course, no right or wrong answers and yet a clear overarching connection between the detailed introduction and the rather lighter conclusion is just out of reach. The practitioners of medicine within the developed world are presented as a relatively homogeneous group; apolitical, technology-driven and lacking cultural awareness.

This seems rather simplistic, given the campaigning roles taken up by many doctors in areas such as the environment and social justice. Although it is clear that the author holds no truck with entrenched points of view on the role and place of biomedicine in the developing world, one wonders whether it is the adequate and appropriate delivery of a scientifically validated approach, rather than its intrinsic process and properties, that should be held up for criticism.

To readers unfamiliar with the processes of anthropology, or indeed qualitative research, the engaging subject matter and clearly laid-out technical details are a reasonable introduction. Even without the thought-provoking theorising, there is a wealth of detail that stays long in the memory: the students' ideas of "looking deeply" to diagnose and treat their patients; the fact that while many basic supplies are in short supply there is no shortage of cadavers from which to learn; the extended family physician role the young doctors are expected to adopt on qualification; the struggle of daily life on the country's overstretched wards.

Beyond our sophisticated scans, exponentially growing array of molecular interventions and evidence-based care pathways there must be a heart to all of our work, wherever we may be, as this book so valuably reminds us.