AMERICAN ANTHROPOLOGISTMoral Maps and Medical Imaginaries.docx

AMERICAN ANTHROPOLOGIST
Moral Maps and Medical Imaginaries: Clinical Tourism at
Malawi’s College of Medicine
Claire L. Wendland
ABSTRACT At an understaffed and underresourced urban
African training hospital, Malawian medical students
learn to be doctors while foreign medical students, visiting
Malawi as clinical tourists on short-term electives, learn
about “global health.” Scientific ideas circulate fast there;
clinical tourists circulate readily from outside to Malawi
but not the reverse; medical technologies circulate slowly,
erratically, and sometimes not at all. Medicine’s uneven
globalization is on full display. I extend scholarship on moral
imaginations and medical imaginaries to propose that
students map these wards variously as places in which—or from
which—they seek a better medicine. Clinical
tourists, enacting their own moral maps, also become
representatives of medicine “out there”: points on the maps
of others. Ethnographic data show that for Malawians, clinical
tourists are colleagues, foils against whom they

construct ideas about a superior and distinctly Malawian
medicine and visions of possible alternative futures for
themselves. [biomedicine, tourism, Africa, imaginaries]
ZUSAMMENFASSUNG In einem unterbesetzten,
unterfinanzierten afrikanischen Lehrkrankenhaus werden
malaw-
ische Medizinstudenten zu Ärzten ausgebildet. Auch
ausländische Medizinstudenten studieren dort; sie besuchen
Malawi als “klinische Touristen” für kurzfristige Aufenthalte,
bei denen sie Wahlfächer belegen und etwas über
“globale Gesundheit” lernen. Wissenschaftliche Ideen
zirkulieren dort schnell. Medizinische Technologien verbre-
iten sich langsam, unregelmäßig, und manchmal überhaupt
nicht: die ungleiche Globalisierung der Medizin ist
unübersehbar. Ich erweitere die Literatur über moralische und
medizinische Imaginationen und argumentiere, dass
die Studenten sich diese Krankenhausabteilungen auf
“moralischen Karten” vorstellen, entweder als Orte wo—oder
von wo aus—sie eine “bessere Medizin” anstreben. Klinische
Touristen (die ihren eigenen moralischen Karten folgen)
repräsentieren außerdem die Medizin “da draußen”: Sie werden
zu Punkten auf den “moralischen Karten” Anderer.
Für malawische Medizinstudenten sind diese ausländischen
klinischen Touristen Kollegen, ein Hintergrund, vor dem

sie Ideen einer überlegenen und spezifisch malawischen
Medizin und alternative Zukunftsvisionen für sich selbst
konstruieren.
RÉSUMÉ Dans un hôpital d’enseignement africain, en sous-
effectif et manquant de ressources, les étudiants malaw-
iens apprennent à être médecins alors que les étudiants
étrangers, « touristes cliniques » en visite au Malawi,
s’informent sur la « santé publique mondiale ». Les idées
scientifiques circulent rapidement; les touristes circulent
facilement de l’étranger au Malawi mais pas vice-versa; quand
les technologies médicales circulent, c’est lente-
ment. La mondialisation inégale de la médecine est exposée.
J’accrois la recherche sur les imaginations morales
et imaginaires médicaux, argumentant que les étudiants
dépeignent cette expérience comme étant un lieu où,
et par l’intermédiaire duquel, ils recherchent une médecine
meilleure. Les touristes affichent leur schème moral
et représentent également la médecine de « là-bas »: des repères
pour les autres. Les données ethnographiques
démontrent que pour les Malawiens, les touristes sont des
collègues à travers qui ils construisent les concepts d’une
médecine malawienne supérieure et d’un avenir différent.
AMERICAN ANTHROPOLOGIST, Vol. 114, No. 1, pp. 108–
122, ISSN 0002-7294, online ISSN 1548-1433. c© 2012 by the

American Anthropological
Association. All rights reserved. DOI: 10.1111/j.1548-
1433.2011.01400.x
Wendland • Clinical Tourism at Malawi’s College of Medicine
109
Dr. Crispin Kamwendo arrived late.1 He had crossedthe dirt
courtyard directly from the minor surgical
theater, where the morning’s list of abscesses to drain
and wounds to clean had been long. Dr. Kamwendo was
an intern on the surgical service at “Queens”—Queen
Elizabeth Central Hospital, a large public hospital in Blan-
tyre, Malawi—and these minor cases were the intern’s job.
So he was late, and apologetic, but I was later and more
apologetic. No other doctors had made it to antenatal clinic.
I had been working since early morning through a queue of
chitenje-wrapped women waiting on the wooden benches:
diagnosing twins, making insulin adjustments for diabetic
patients, doing the little evaluation possible for women re-
ferred with “bad obstetric history”—an umbrella diagno-
sis that covered everything from recurrent miscarriage to
chronic syphilis to several children dead of malnutrition or
malaria. The last woman finally left, headed for the Johns
Hopkins research project to get an HIV test. At that time,
in February of 2003, the hospital’s own laboratory had been
out of the test reagents for months. I hung up my physi-
cian’s white coat, slipped my anthropologist’s notebook and
tape recorder out of the coat pocket, and welcomed Dr.
Kamwendo into the now-empty exam room.
We had already met on the wards. A thin man, neatly
dressed, he carried in a stack of books: an ancient battered
Guide to Patient Evaluation was on the bottom, a memoir by

the U.S. Christian inspirational writer Catherine Marshall on
top. As we talked, the open window allowed a fresh breeze to
chase away the sweat and soap smells of clinic while admitting
the occasional mosquito and the omnipresent kraaak of pied
crows. Late in the interview, Dr. Kamwendo’s conversation
turned to the European and U.S. students who circulated
through Queens on short-term visits. “We look at them as
very, very privileged people,” he said. He had read about
magnetic resonance imaging (MRI) machines in textbooks,
he noted; the visitors had used them. He had failed to arrange
an elective abroad to learn about medicine elsewhere; the
visitors had succeeded.
They have so much advanced technology, and medicine is quite
a—is quite a field which requires quite a big advancement in
technology. And we look at our friends as being so fortunate to
have all those technological advances at their disposal. Again,
the
other thing, we see most of them coming here for electives. I
don’t
know how that is there, but when I was a student I actually
wanted
to do that elective, but I couldn’t do that because I couldn’t find
the funds. So we look at our friends as being so much fortunate.
[interview, February 11, 2003]
Dr. Kamwendo looked ahead to years as a poorly paid gen-
eral practitioner. The visiting students, he imagined, would
have good salaries and abundant specialty-training prospects
awaiting them.
In funds, they are far much better paid than here. And that is
why
many [Malawian] doctors want to work outside—yeah, but most
of them tend to stay because of their extended families, because
of

lack of opportunities to go outside or what. And I guess the
other
thing is, the opportunities are so many. If you finish the medical
school [elsewhere] and you want to specialize, you will
eventually
sort out what you want to do and you will find a way to do it.
So
you will specialize in something you really wanted to do. And
like
here, where scholarships are hard to find, hard to come by,
some
people take just only a specialty course because the opportunity
was there. Not because the—not that the doctor really wanted to
specialize in that. But he thought that if he doesn’t jump on that
chance, then he might never find it again.
Dr. Kamwendo spoke from experience: although drawn to
internal medicine, he intended to jump on chances for ad-
vanced training in any specialty. Specialty certification was
an “open door to self-advancement,” he said, a gateway to
better jobs and bigger salaries. There was some urgency to
the task. Both of his parents were dead, and he was stretching
his internship pay—“a peanut salary,” he scoffed—to cover
four siblings’ school fees.2 For Crispin Kamwendo, the vis-
iting students were “our friends.” They were also measures
against which his own access to technology, money, and
opportunity appeared painfully limited.3
CLINICAL TOURISM
The foreign students that Dr. Kamwendo encountered at
Queens represented a wider phenomenon, a demand for
“global health experiences” growing so rapidly that medi-
cal schools have had difficulty keeping up. By 2000, over a
third of graduating medical students in the United States and
Canada reported such experiences (Thompson et al. 2003),

a three-fold increase in 20 years. Proportions in the United
Kingdom are higher. Some students travel to industrial-
ized countries; most favor poorer nations. African hospitals
are popular destinations. Returnees’ stories, recounted in
conferences and classrooms, alumni magazines and blogs,
contribute to popular understandings of global health. Their
clinical journeys also have effects at destination sites, as
Crispin Kamwendo’s wistful reflections suggest. In this ar-
ticle, I examine those effects at Queens, an urban African
hospital that was both a popular site for expatriate medi-
cal students on educational electives and the major teaching
hospital for medical students from the University of Malawi
College of Medicine.
Transnational travels of many kinds characterize
21st-century biomedicine, and the burgeoning literature that
documents such movements features a confusing and over-
lapping set of terms. A detailed taxonomy is beyond the scope
of this article. One way to distinguish among these travels,
however, is by length. The longest-term journeys are per-
manent migrations of nurses and doctors, overwhelmingly
from poorer nations to wealthier ones: the medical brain
drain. Medium-term travels include health professionals’
paid stints in humanitarian or mission organizations, both
typically requiring require two- or three-year contracts, and
the multi-year sojourns for specialty credentialing that grad-
uates like Crispin Kamwendo seek when such training is
not available domestically. Only the shortest-term transna-
tional medical journeys, whether undertaken by those
seeking medical care or those seeking to provide it, have
110 American Anthropologist • Vol. 114, No. 1 • March 2012
been labeled “tourism” (see, e.g., Bezruchka 2000; Turner

2007).
In this article, I use the term clinical tourism to indicate the
activities of health-professions students and clinicians who
learn or volunteer (a distinction that is often unclear) for pe-
riods of less than a year outside their home countries.4 Clinical
tourism avoids the ambiguities attending medical tourism—a
phrase that more commonly applies to patients than to doc-
tors, referencing travels undertaken in pursuit of pharma-
ceutical, surgical, or experimental treatments unavailable or
prohibitively expensive at home. More importantly, clinical
tourism directs our attention to those places where the tourist
gaze (Urry 2002) and the clinical gaze (Foucault 1975) come
together. Thinking about those intersecting gazes, as I argue
below, advances our theorizing of global biomedicine—and
of the many other entanglements of expert knowledges and
technologies with the movements of actual people.
Clinical tourism should also interest anthropologists for
practical reasons. Future doctors, nurses, and others who
aspire to be without borders all show up at our office hours
looking for advice, in our classrooms preparing for their
journeys, and at our workplaces and field sites mingling
with other expatriate experts, tourists, trainees, researchers,
and missionaries. Many of us are called on to administer
prophylactic doses of cultural preparation to clinical and
nonclinical students headed abroad—for clinical tourism is
only one manifestation of a larger push for service-learning
projects in poor places that blur easy distinctions between
humanitarian action, educational experience, and adventure
travel.
I first considered the effects of clinical tourism while con-
ducting ethnographic research on medical training in Malawi
over three fieldwork periods between 2001 and 2007. In the
teaching hospital where I worked and studied, visiting med-

ical students came and went in a stream that at some times
threatened to become a flood and at others slowed to a
trickle. I was at Queens not to study the visitors, however,
but to understand the experiences of Malawian students.
That project began with focus groups involving a total of
23 students at four different stages of their training. Sixty-
one semistructured interviews followed, most with Univer-
sity of Malawi College of Medicine students and interns,
some with faculty and graduates. Working in the hospital as
an obstetrician over 15 months provided me ample oppor-
tunities for participant-observation and enabled hundreds of
informal conversations and encounters with approximately
60 local and 20 visiting medical students.5 Although I never
asked explicitly about clinical tourism in formal research
settings, the issue arose spontaneously in half of the focus
groups and over a third of the formal interviews. The anal-
ysis I present, then, is preliminary. In particular, because I
collected no systematic data from the tourists themselves, I
cannot generalize about their experiences.
Even this preliminary analysis reveals that the wards
of Queens, where both clinical tourists and their Malawian
counterparts learn, become sites of contestation over the
meaning and location of good medical work. On these wards,
medical students try to imagine meaningful professional fu-
tures. In the process, I argue, they plot imagined times
past and times future, locations “outside” and “here,” on
moral maps that chart their quests for good lives and good
work.
The concept of “moral maps” draws from theories of
value-laden imaginaries while attending explicitly to path-
ways across time and space in those imaginaries. Julie
Livingston (2005), in examining Tswana concepts of “de-
bility” from colonial to contemporary times, used the

term moral imagination to describe how people conceived
other possible social worlds, past or future. Moral simply
meant imbued with value: judged as good or bad.6 Because
Livingston’s informants often compared those imaginings
with “the way things are now,” however, moral imagina-
tions also produced temporal trajectories of improvement
or decline. Other times were not just good or bad but,
rather, better or worse.
Moral maps incorporate space as well as time, chart-
ing paths to better or worse among known locations and
unknown destinations. Tim Ingold notes that “every some-
where must lie on one or several paths of movement to and
from places elsewhere” (2007:2). Along those paths, people
live their lives, learn to know their world, and compare that
world to others. A person who moves physically along a path
also moves through time and selects among alternatives; one
can follow only a single path at a time. On a map, however,
one may plot out several journeys and imagine several possi-
ble destinations at the same time. The ethnographic material
I present shows students doing exactly that and mapping
those destinations—and the clinically needy bodies to be
found there—onto ideas of medical progress.
The metaphor of moral maps trains our attention on how
actual travels of people, ideas, and things suture notions of
poverty and privilege, suffering and good work, to places
(specific or generic) and to times (past, present, or future).
I hope that the concept will be useful not just to medical
anthropologists but also to others working on development,
tourism, humanitarian relief, technology transfer, and other
forms of global exchange in which notions of place-based
potential or pathology prevail.
Although their precise definitions are specific to this ar-
ticle, neither moral map nor clinical tourism is a new term:

the theoretical contribution of this article does not entail
addition of neologisms to the anthropological lexicon. In the
medical literature, a few authors have used clinical tourism
to refer to short-term travel by health professionals or stu-
dents (see, e.g., Levi 2009). Richard Shweder (2000) has
used moral maps to critique analyses that plot problematic
ideas of socioeconomic progress or decline against prob-
lematic notions of national culture. I build here on that
work and on scholarship from many others who have found
topographic metaphors—scapes, paths, fields—useful in
111
considering the effects of global exchanges and excursions
(see, e.g., Appadurai 1996; Sparke 2009; Whiteford and
Manderson 2000). The contribution of this ethnographic
case study is, first, to show how the uneven terrain of such
exchanges shapes the moral imaginations of people caught in
the middle: in this case Malawian medical students who are
at once subjects training their clinical gazes on the bodies of
their fellow citizens and, with those fellow citizens, objects
of the tourist gaze. Second, it is to show how the imaginations
trained by these two gazes layer together place, value, and
time such that a good past can be found far away, or a better
or worse present here, or a good future elsewhere—with
implications both analytical and pragmatic.
MALAWI AS DESTINATION
Malawi is a particularly attractive destination for foreign
medical students, who every year travel east from the United
States and Canada, south from Western Europe, and north-
west from Australia on the same global currents that carry
tourists on safari, secondhand clothes, and donated medical

equipment. The country is peaceful, friendly, small, and a
relatively inexpensive place to travel. In this polyglot nation,
once a British protectorate, all postprimary education is in
English, so English-speaking travelers can get by without
learning any local languages. The prevalence and severity
of various “tropical” diseases has made the nation a favored
site for international medical research ever since the Lon-
don School of Tropical Medicine opened a malaria study
ward in Blantyre in the 19th century (King and King 1992);
long-term clinical research projects and Christian medical
missions laid down institutional and social tracks that clini-
cal tourists follow to Malawi.7
Biomedicine is no recent import here: transnational
movements of researchers, clinicians, pharmaceuticals, and
technologies date back well over a hundred years. Africans
were learning microscopy, dispensing medicines, and dress-
ing wounds by the late 19th century in the area now known
as Malawi. Formal nursing training was available by the
1930s, but training for doctors took much longer. Although
a very few students were sent abroad for medical education,
Malawi’s own College of Medicine did not open until the
1990s (King and King 1992; Muula and Broadhead 2001). Its
establishment was controversial: medical schools are expen-
sive, and standard economic measures place Malawi among
the world’s poorest nations.
Health indicators, like poverty statistics, tend to be most
uncertain where life (and record keeping) is most precarious.
Official estimates of disease in Malawi, however wide their
uncertainty ranges, are typically worse than average even
for the region. AIDS, respiratory illness, malaria, diarrheal
diseases, and malnutrition all make the top-ten list of killers.8
Word on the street corroborates the overall picture, if not
always the specific causes: people in and out of the hospitals

often commented that life was shorter and more insecure
nowadays, that many young adults were dying, and that poor
health was more widespread.
These challenges overwhelm the threadbare govern-
ment health sector that provides medical care for most cit-
izens. Over the two decades since I first visited Malawi,
public hospitals and clinics have visibly deteriorated under
the triple pressures of budget austerity measures, increas-
ing population, and a huge surge in HIV-related illnesses.
Nearly every medication and supply—including such basics
as sutures and iodine—ran out on a regular basis during the
years of my fieldwork there. Staffing was so skeletal that
one clinical officer might care for several hundred inpatients
in a district hospital, and one nurse might be responsible
for a ward of 60.9 Queen Elizabeth Central Hospital held
1,100 hospital beds and 1,600–2,000 patients—on, under,
and between beds, in overcrowded wards sometimes staffed
solely by trainees.10
Spread among those wards at any given time were 30
to 60 Malawian medical students, plus clinical officer stu-
dents, nurse-midwifery students, and interns. In addition,
one could find anywhere from 2 to 20 clinical tourists.11
Although most foreign students stayed for five to six weeks,
their journeys could be as short as a week or as long as
several months. Malawian medical students lived together
in student hostels, paid tuition to the College of Medicine,
attended classes and clinical trainings, and were accountable
to strict attendance, exam, and clinical-work documentation
that required long hours at work. Visiting students stayed
in “guest houses” or with faculty from their home institu-
tions, paid a small (US$50) affiliation fee to the College
of Medicine (their tuition went to their own universities),
and were generally supervised quite informally. Their ac-

tivities and hours at the hospital varied widely. Two Dutch
students kept our obstetrical operating theater running for
a week when three theater nurses were absent. A student
from the United States assigned to the same theater turned
up late on his first day, enthused about the “great cases” he
had seen on surgery, and then never appeared again. Some
clinical tourists cherry-picked procedures of interest, those
they would never see—or be allowed to do—at home.
Others excused themselves from any procedure involving
blood, acting on their universities’ risk-reduction guidelines
or their own fears of contracting HIV. Still others worked
and learned for long hours, following a staff doctor or at-
taching themselves to a single ward, as did a U.S. student
who worked in the pediatric nutritional rehabilitation unit
daily for months.
Foreign and Malawian students occasionally drank to-
gether at the Cactus Bar or the more sedate Blue Elephant
nightclub, but most Malawians were too busy and had too
little money for clubbing. Their contacts within the hospital
were frequent but usually superficial. Malawian trainees who
talked about medical student visitors, even when they spoke
of them warmly as “our friends” and “our brothers,” never
referred to any by name. Encounters of clinical visitors and
their Malawian counterparts seemed to produce a mutual
recognition that was more generic—sometimes verging on
caricature—than specific.
MEDICAL IMAGINARIES, CLINICAL REALITIES
Malawian medical students and the clinical tourists who
joined them at Queens were all in the process of becoming
doctors. Ethnographic studies of that process show it to be

marked by uncertainty, frustration, fleeting triumphs, and
devastating failures (see, e.g., Good 1994; Sinclair 1997).
Medical students must manage incongruities between what
they expect of medicine and what they experience in clinical
practice. Mary-Jo Delvecchio Good’s concept of the “med-
ical imaginary” (2007:362) can be helpful in understand-
ing this disjunction. The phrase indicates an affect-laden
vision of biomedical science in which limitless potential for
high-technology cures lies just ahead. It is an imaginary that
shapes professional subjectivities and popular expectations as
it circulates globally in “a political economy of hope” (Good
2007:364). This future, a medical version of the moral imag-
ination that Livingston described, is always both near and not
yet; its promise alters clinicians’ perceptions of the present.
In the United States, as Good shows, imagined technolo-
gies of hope obscure realities of toxicity, as when cancer
patients and their doctors normalize experimental science as
“therapy” and downplay both questions about its efficacy and
painful experience of its dangers. In Malawi, imaginaries of
medical abundance serve to highlight realities of scarcity.12
At the College of Medicine, the imaginary of high-
technology biomedicine was richly available, but the diagnos-
tic and therapeutic tools ubiquitous in virtual worlds were
generally absent in fact. Nearly all available medical litera-
ture, like that Dr. Kamwendo carried, was English-language
material from abroad. Technologies like fluoroscopy or gene
assays cropped up in textbooks, in lectures from visiting fac-
ulty, and in diagnostic algorithms students memorized for
exams but not in the laboratories where they did “practi-
cals” or the wards where they saw patients. In the medical
school’s small library, it took me over a month to track down
a recent study of region-wide causes of maternal death in
the Malawi Medical Journal but mere seconds to locate a re-
view of advances in prenatal genetic diagnosis (unavailable
in Malawi) in the British Journal of Obstetrics and

Gynaecology.
A rich virtual medicine from “outside,” as students typically
referred to wealthy places, pressed on their materially poor
actual world.13
Further weighting the sense of the medical near and not
yet, internationally sponsored research projects and foreign
NGOs made enclaves for some technologies, pragmatically
inaccessible to students and their patients even though tan-
talizingly close by.14 In 2003, viral loads and CD-4 counts
could be measured in the Johns Hopkins research labs, an-
tiretrovirals were available in projects run by Médicins sans
Frontières (MSF) in Thyolo and Chiradzulu, and one kidney
dialysis unit existed in Lilongwe for the use of one gov-
ernment official. None of these were available to patients
outside the enclaves’ boundaries. The priorities of donors,
transnational research projects, and politicians could pro-
duce a bizarre hodgepodge of resources. There were no
pregnancy tests at Queens, for instance, but by 2008 the
hospital had the MRI of which Dr. Kamwendo dreamed:
a research consortium imported one at great expense and
difficulty to aid in studies of cerebral malaria. Students were
particularly conscious of the lack of day-to-day necessities:
gloves, soap, resuscitation equipment, thermometers, blood
pressure cuffs, catheters. As their discussions will show, they
knew such supplies were well provided in the practice worlds
from which the clinical tourists came.
International Doctors
Although a third of the comments students made about
clinical tourism reflected Malawians’ desire to be tourists—
medical spectators rather than medical spectacle—none of
the medical students I interviewed had yet done any medical
training in hospitals beyond Malawi’s borders. Dr. Ellen
Mchenga, who had never managed an outside elective,

thought such opportunities were critical: “Even if it might
mean maybe just to go to Tanzania to see how the medical
college is like there. Or to Zambia or Kenya. . . . It would be
good, rather than just being trained in Malawi. We would be
trained as international doctors, not just as national doctors”
(interview, May 16, 2003).
Sponsorships for prolonged postgraduate studies, a vi-
tal means to train Malawian faculty in the college’s earli-
est years, were increasingly scarce after 2000: they opened
doors to emigration, seen as a threat to the medical corps.
Without certification beyond the general-practice license is-
sued after internship, one was likely to be excluded from
international networks of circulating experts and to remain
in Malawi indefinitely—a “national doctor.”
Although well supplied with imaginaries of biomedicine,
students had limited sources for understanding the clinical
practice lives of doctors elsewhere. Some referred to the
few physician biographies available locally: an inspirational
account of missionary doctors who worked (and died) in
Uganda; a locally produced history of the medical school
featuring seven influential physicians, all of whom trained
outside Malawi, and only one Malawian. No student cited
fiction or images of television or film doctors.15 In a place
with scant outside imagery, clinical tourists provided impor-
tant glimpses of “international doctors.”
If their most frequent comments on the subject re-
ported the wish to be tourists themselves, nearly as common
were reflections on the riches available to the tourists. Some
differences caught the eye. Clinical tourists’ white coats
bulged with stethoscopes, penlights, pocket medical guides,
and other accoutrements. One Malawian student initially
claimed to be undaunted by working with scant materials,
telling himself to “seek more knowledge, and in the very

end you’ll be able to do something, however basic it might
be” (interview, April 3, 2003). Later he worried about what
knowledge alone could not do:
I had the chance of meeting some electives from Michigan.
They
had all the equipments! The only thing I had was a thermometer
and my stethoscope. I didn’t have, I never had a BP machine
[blood pressure cuff]. I didn’t have a [reflex] hammer or any of
113
that. Yeah, but then you are required to do everything on the
patient! So if the limitation would be the equipment, I’m sure
you
will turn out to miss some things which would have given you
clues. [interview, April 3, 2003]
As Ellen Mchenga noted, “In Malawi it’s really hard, un-
like some other countries, as we can see from you people”
(interview, May 16, 2003).
Dirty Work
A Malawian doctor’s working life, even as it appeared very
high status to most ordinary Malawians, tended to look hard
and dangerous when compared to the working lives of the
visitors. The medical students I interviewed were well aware
that they were among their nation’s elites. Their status was
extraordinary, their education unmatched among their age-
mates, and their income—by Malawian standards—would
be high. But very few could buy a plane ticket and none
had a car. Their visiting “brothers” could look forward to
high salaries, abundant gloves, postexposure prophylaxis for

HIV, and plenty of nurses to do the dirty work—not so for
the Malawians. One Malawian intern’s nonmedical friends
teased him about his work, which they imagined as difficult,
poorly paid, and grubby. He could not disagree, he said,
but “even though a job may be dirty, still it has to be done
and it has to be done by somebody. So I think, well, it may
be a difficult thing, but somebody has to do it. It may be a
cross—but somebody has to carry the cross. Maybe that is
me” (interview, July 11, 2003).
Beyond the grubbiness, students noted danger: “We
have a lot of HIV/AIDS and TB here. The chance of con-
tracting disease is high. The working environment is nasty,
unhygienic, not clean” (personal communication, October
4, 2002). Some students contracted cholera on the pedi-
atrics ward during the rainy season outbreak. One died
of multidrug-resistant tuberculosis during the period of
this fieldwork, and an unpublished student research project
showed nursing trainees to have double the expected rate of
TB. The greatest fear for most was HIV: students often suf-
fered needle sticks and scalpel cuts, and the medications that
reduce HIV risks in such circumstances were unavailable.
The gulf between medical imaginary and clinical reality
could make work on Queens’ wards feel darkly surreal.
One late afternoon I followed sounds of commotion to a bay
in the labor ward where a pregnant woman lay convulsing
in a prolonged seizure.16 It was hot, and the air felt thick
with the smells of blood, bleach, and amniotic fluid. In
the ward’s 14 open bays, women in active labor lay on steel
tables. Handwritten notices taped to the walls reminded staff
how to resuscitate newborns, clean equipment, and manage
hemorrhages. On the hallway floor, cardboard boxes made
makeshift containers for “sharps”—the blades and needles
that pose particular dangers in southern African hospitals—
and bright plastic buckets of antiseptic waited for the labor

ward’s midwife to rinse her gloved hands between patients.
In one of the labor bays, the midwife stood holding the seizing
woman’s head to one side, ensuring that she could breathe.
Two sweating Dutch medical students flanked her, struggling
to draw up medication to stop the seizure. The bay was
littered with discarded syringes and medicine vials. When I
examined them, I found the same donated medicine in three
different strengths, labeled in three different languages. The
syringes were donations, too; they featured special “safety”
needles that retracted once used, making reinjection into
the patient all but impossible. Meanwhile laboring women
in the other bays cried out: “Asista, adokotala, thandizani”
[sister, doctor, help me]. One of the students looked up,
met my eye, and said quietly, “Welcome to hell.”
Some Malawian students characterized medical work in
similar terms. “Being a doctor in Malawi is hell,” a student
about to graduate wrote me. “There are limited resources:
manpower, equipment, and drugs. Another thing is poor
salaries (packages). HIV/AIDS is very high, making life really
difficult in patient care because the picture and severity of
disease has changed for the worse” (personal communication,
June 2003). For tourists and Malawians, the wretchedness
of clinical practice in Malawi depended on a contrast with
medicine as practiced elsewhere, remembered or imagined.
This obvious gap between national realities and “interna-
tional” possibilities could prompt doubts about medicine as
a career. In one focus group, Bridget Nyasulu spoke angrily
of foreign experts who had recommended training more
Malawian doctors: Did they understand what they were ask-
ing?
What they have, they are advanced. They have advanced
medicines. All we have are basics. We don’t even have the

basics
sometimes! And maybe they should try to imagine if they were
in this place, where they don’t have many opportunities, many
medications—what would they do? Would they still follow the
same path? . . . If they had to come here and they’d do this,
would
they go through with it? [focus group, February 5, 2003]
A richer and more cosmopolitan world imagined as “out
there” can serve as cruel reminder of one’s abjection—
or forcible disconnection—from modernity’s promises, as
James Ferguson (1999) showed among struggling Zambian
mineworkers. Bridget Nyasulu’s bitter words suggest that a
similar sense of abjection could arise where the (unmarked)
global and (marked) local members of an imagined inter-
national community of doctors met. Abjection was not the
only possible outcome, however.
Better Doctors
One effect of the tourist gaze, for both travelers and locals,
is the opportunity it affords to see one’s own life through
strange eyes: to reconfigure the self in relation to an im-
age of the Other (Stronza 2001). If many Malawian medi-
cal students recognized in the tourist encounter a vision of
Malawian medical practice as hellish, some also fashioned
there an image of themselves as more flexible and creative,
as more committed and empathetic, and sometimes as better
able to see the big picture of health and disease: that is, as
practitioners of a better medicine.
Malawians often compared their clinical skills favorably
with those of visitors from “out there.” Some noticed that

their foreign colleagues could seem helpless in the absence
of high-tech imaging. “This person has a pain in the neck, I
have to order a CT! I have to do this and that,” said intern
Diana Kondowe, gently mocking the rigidity of outsiders.
“But here—well, in our situation you can’t get a CT! . . .
You see what you can do based on the physical exam, based
on the history, maybe an X-ray. But some people just are
not able to do this: they have one way that everything should
be done, only one way” (personal communication, May 14,
2003).
Visiting students could rarely feel an enlarged spleen
with their hands or confirm profound anemia without a
hematocrit by examining a patient’s nail beds and mucous
membranes. Accustomed to following protocols in which
one diagnostic or therapeutic step led to the next, visitors
had little capacity to improvise when the required materials
were not available.
“They may take a lot of things for granted,” commented
student Tuntufye Chihana. “There you have got so many
resources and, you know, so it’s easy to do all these inves-
tigations or maybe even management interventions, treat-
ment. Whereas here you really have to work with, make
the most out of minimal resources. And people do improve!
And you can help people, even with the minimal resources
that we have” (interview, February 7, 2003). The dearth of
equipment that turned a seizure on the labor ward into a
clinical hell could also engender a capacity to “resource” and
repurpose funds, ideas, social networks, and technologies—
an essential and valued skill that I saw Tuntufye and others
demonstrate.17 If sutures ran out, they might sterilize fishing
line. They rewired autoclaves and soldered forceps, repur-
posed IV bags and tubing as urinary catheters, and used
window latches as IV poles. A newly donated ultrasound
from Utrecht was wonderful—but we had none of the gel

that facilitates sound-wave conduction from the transducer
to the patient’s skin. Bridget Nyasulu (who as a student
questioned whether foreign doctors would “follow the same
path” they asked of Malawians) was an intern in 2007, and
she taught me to improvise. A chunk of cheap pink naphtha
soap in a kidney basin half full of water dissolved into a slimy
mush that made a reasonable substitute for gel. It wasn’t per-
fect, it was corrosive to the equipment, and the fumes were
awful, but it worked: gray-scale ultrasound images appeared
on the screen, allowing clinical diagnosis and intervention.
Sometimes even the prevalence of local pathology could
be interpreted positively. Crispin Kamwendo found his text-
books’ emphasis on geriatrics unhelpful for a clinical milieu
without many elderly people. His experience with infectious
disease, on the other hand, outpaced his texts: “We have got
many more conditions in this part of the country, especially
in the village where we have got much infectious disease. I
think we are so, so rich in that!” (interview, February 11,
2003). One student explained foreigners’ inferior anatomi-
cal knowledge: “I hear out there they have plastic cadavers
or something, dolls or something to replace, since they can’t
get [bodies]. . . . Maybe we’re more better off in that way”
(personal communication, February 5, 2003). Another stu-
dent was blunt: “This is the deep end in terms of student
training. Becoming a medical doctor. Some of the things that
you see around here you could not possibly get them or see
them as a student anywhere else in the world” (interview,
March 6, 2003).
Some Malawian trainees also contended that the diffi-
culties they faced gave them both empathetic and intellectual
insight into the larger context of illness—understanding that
eluded outsiders. Empathy sprang in part from endanger-
ment. “If you want to die quickly, you can do medicine,”

one student’s secondary-school teachers had warned (inter-
view, January 30, 2003). The constant reminders of death,
an intern said, meant a Malawian doctor could not possibly
forget that “you are still as human as everybody else” (per-
sonal communication, July 11, 2003). Another felt that his
experience on the wards had changed his “whole picture of
life.” “You have to face the realities of life, to say nobody
is actually immortal, everybody is going to die one of these
days. Death actually is the reality—I am going to die.” This
awareness would help make him “somebody who feels the
needs of the people,” a capacity he considered key to good
doctoring (interview, January 24, 2003).
Trainees often reflected on the translation of severe
poverty, inept or corrupt governance, and ill-founded pub-
lic policy into disease: social pathology made corporeal.
One student insisted that the key to improving the country’s
health indicators was educating Malawians on human rights
to health; he studied medical law at night and planned to
become a policy maker. Another hoped to start a health-
education radio show; he has since done so. Two interns
independently attributed high rates of traumatic injury to
poor transport regulation and infrastructure. Such etiolo-
gies, intern Zaithwa Mthindi argued, were invisible to for-
eign doctors who tended to think “that answers are only
drugs. And maybe health education very specifically con-
fined to medical issues—disease and pain and things like
that” (personal communication, July 11, 2003). Malawian
medicine required him to discern a bigger picture.
Real Medicine
Students, interns, and faculty gathered daily in the obstetrics
and gynecology annex for rounds. One morning in 2007,
Dr. Paul Mbanda led a discussion of recent cases. An antena-
tal patient had improved on the antihypertensive nifedipine,
but the nifedipine had run out and her blood pressure sky-

rocketed. Dr. Mbanda proposed two other medications:
one was out of stock; the other had never been available at
Queens. “I’m fed up with this!” he said. “Out of this, out
of that, we’re not going to talk about this this morning”
(field notes, February 26, 2007). An older physician sug-
gested methyldopa, a once-common drug now supplanted by
newer medications. Mbanda rejected it: “We are just giving
things . . . I think we are doing this but I think if medicine
115
has gone to that level it’s not medicine at all.” Dr. Mbanda
was among the earliest College of Medicine graduates, from
a class pushed to get years of advanced training abroad, and
in 2007 he and several colleagues were newly returned to
Queens to teach. Some of them never spoke favorably about
medicine in Malawi. Mbanda proposed more than once at
rounds that Queens should be bulldozed and argued that “the
best thing we can do is to see what they are doing out there
and that is what we should do here” (field notes, February
8, 2007).
In the gap between the global medical imaginary and
Malawi’s clinical reality, alternative imaginaries arose. Some
questioned whether Malawian medicine was “medicine at
all.” Others saw particular strengths. Malawian medicine
was uniquely flexible and creative. It was second rate.
Widespread pathology made medical training there supe-
rior, a deeper immersion. Pathology made it dirty and dan-
gerous. Risks of infectious disease stirred empathy among
medical students and stirred fears for their own lives. In
these struggles, Malawians mapped their work and their
progress—for better and for worse—against imaginaries of

medical worlds “out there.” Clinical tourists helped to fill in
those maps.
CLINICAL TOURISM AND MORAL MAPS
The clinical gaze reads truths from the body. The tourist
gaze reads truths from Other spaces and the inhabitants of
Other worlds. But bodies and spaces reveal different truths
to differently positioned observers, and those truths mark
out different paths to medical progress. The two Malaw-
ians who discussed high trauma rates saw transportation
infrastructure and traffic-law problems requiring structural
reforms. The U.S. student who spoke of “great cases” on the
surgery ward read exotic cultural practices and ignorance in
the pathogenesis of traumatic injury and culture change as
the treatment: the three great cases he described were a psy-
chotic villager whose hands were burned off in an attempted
cure, a man whose eyes and testicles were “harvested” to
be used in witchcraft, and a badly burnt epileptic whose
relatives feared the burns were contagious.
Malawian doctors too could read bodies and spaces vari-
ably, as a discussion on the obstetrics unit shows, and could
base differing prescriptions for progress on those readings.
One night in 2007, a young woman who had been admitted
with a threatened miscarriage in her first pregnancy bled to
death on the ward. The sole nurse overseeing 60 patients did
not notice the hemorrhage or call the intern promptly. The
intern could not get the patient to surgery quickly enough
because her faculty supervisor was in the operating theater
with another emergency. She sent for blood, but the blood
bank—following routine practice—refused to provide any
unless the patient’s family members came in to donate. The
next day, three faculty members, all College of Medicine
graduates who had spent years in specialty training abroad,
interpreted the death.

Paul Mbanda: We have here abnormal situations and we make
them normal. We see them as normal. The whole hospital can-
not afford to have plaster [surgical tape, which had also run out
overnight], and we are still operating? I am really waiting for
the
day Queens Hospital closes down.
Ian Jere: Of course this is far from ideal. It’s a learning process,
and we will get there eventually.
Gray Bwanali: To my mind this is a useful reminder: women
can die of miscarriage here. This woman came in, she was fine.
Now she is dead. Yes, there is scarcity—but much can be done.
When our system is not so strong in terms of supportive
services,
we must rely on our hands and our brains. [field notes, February
21, 2007]
In their postmortem diagnoses, these Malawian doctors drew
various readings from this body, inflected by comparison
of their own medical locations with elsewhere. Dr. Jere
read the death as a moment on a path of gradual progress.
Dr. Bwanali saw evidence that weak systems require doctors
to have greater flexibility and ingenuity. To Dr. Mbanda, this
body was symptomatic of a space so pathological that the only
cure was obliteration.
The discussion above presents more than one affect-
laden vision of the medical future at work in the wards of
Queens. In the space that remains, I outline how the medical
imaginaries of the Malawian trainees—and perhaps, as indi-
rect evidence suggests, those of their expatriate visitors—
layer together time and place to make moral maps that guide
them to where (and when) they might find real medicine
and where (and when) medicine is not what it should
be.18
Spatial terms dotted Malawians’ talk about medicine.

Foreign medicine was outside, out there, a place to which
one might find a path or door. Local medicine was the deep
end or, as Dr. Gray Bwanali once called the antenatal ward,
“the forest”—a term invested in Malawi with notions of
wildness, fecundity, and danger. Malawian clinicians, ef-
fectively collapsing spatial and temporal images of progress,
often posed the rhetorical question: “How shall we know the
way forward?” Their language plotted Malawi’s medicine on
a developmental path on which the today of clinical tourists’
home countries was Malawi’s anticipated tomorrow. When
Dr. Jere promised that “we will get there eventually,” he
evoked a Malawian future in which women would not reg-
ularly die of miscarriage, a future already present “there”—
elsewhere. Medical student Joe Phoya, who had previously
worked as a clinical officer in a decrepit district hospital,
spoke in similar terms: “The world out there should recog-
nize us and give us help, you know? We are a developing
country, especially in the medical field . . . If you guys out
there cannot assist us, then progress cannot be ours. It may
be there, but it will be so sluggish. We want things to move
fast! We want at least to be closer to other places out there”
(interview, March 3, 2003).
But the people to whom Joe appealed—“you guys out
there”—may have been following other moral maps to a
different kind of medical progress.
Pilgrimages to Far Away and Long Ago
Tourism is in some ways an imperfect rubric under which
to consider the journeys of students who seek “global health
experiences.” If tourism is conceptualized as leisure activity,
much clinical tourism is a poor fit. Furthermore, tourist can

be used pejoratively, and in the medical literature it usually
is (Bezruchka 2000; Wall et al. 2006). Plenty of student
travelers would indignantly reject a label that can suggest
inauthenticity or exploitation of an exoticized Other, pre-
ferring to consider themselves medical humanitarians. Are
some the “ego-tourists” or “middle-class leeches” against
whom Ian Munt (1994:59) inveighs, their hospital stints
little more than adventure travel “in its new wafer-thin dis-
guise as a more ethical and moral pastime of the new bour-
geoisie”? Perhaps. Perhaps clinical tourism is in part a fad,
a strategy for students from wealthier countries to accrue
cultural capital and academic credit alongside the thrill of
the exotic—and of virtue. Some clinicians involved in global
health suspect as much of themselves; one Canadian doctor
confesses disarmingly that “my motivations for involvement
with global health have surely been mixed with a desire for
professional intrigue and escapades to punctuate what may
be an otherwise dreary career” (Philpott 2010:281).
For me to denounce clinical tourists who go to Malawi
to learn on the bodies of the poor—or, more generously,
to volunteer their services to people in great need—would
be both hypocritical and inadequately complex. Hypocriti-
cal, because I first went there myself in exactly that capacity
in 1990 during my last year of medical school and because
the line between their travels and the journeys of ethnogra-
phers is blurry. And inadequately complex because depicting
clinical tourism as invariably extractive, neocolonial, or ex-
ploitative would disregard many cases in which students’
travels lead to long-lasting connections among Malawians
and expatriates that appear to enrich all concerned.
Although the rubric of tourism is imperfect, it serves
two useful purposes. First, it helps us to recognize similari-
ties with other kinds of tourism on which a richer literature
exists. The most obvious connections are with volunteer,

educational, or science tourism (West 2008). When medi-
cal tourists seek out especially poor or HIV-affected areas,
we may also note echoes of the “dark tourism” of travelers
who chase dangerous thrills in war zones (Lisle 2000), safely
view threatening others in prisons (Schrift 2004), or ponder
mortality at sites of genocide (Stone and Sharpley 2008).
These connections can alert us to possible motivations for,
and effects of, short-term clinical travel. Second, and more
important to my argument, the lens of tourism intensifies
focus on the layering of place, time, and value. That layering
underlies global health electives’ function as moral pilgrim-
ages: searches for a better medicine to be found somewhere
else out there.
Anthropologists sometimes interpret tourism as a rite
of passage, a ritual journey through which travelers leave a
mundane world for a strange and disorienting one to find the
sacred (Graburn 1989; Stronza 2001). Medical educators
echo this language of moral transformation, claiming that
global health experiences “capture student idealism” (Smith
and Weaver 2006). No other part of training “transforms stu-
dents so rapidly and so profoundly,” claims a Lancet editorial
(Lancet 1993:754). Even a short-term stint in global health
helps students and doctors “awaken Hippocrates,” a book
published by the American Medical Association promises;
they will “[tap] into the ethical, faith-based roots of our pro-
fession, where the art of medicine intersects with the highest
aspirations of man . . . reconnect with the ideals that first
drew them to a career in health care” (O’Neil 2006:xvii).
The language of roots and reconnection alerts us to a curious
feature of clinical tourists’ moral pilgrimages: they entail
travel across both place and time—not just to far away but
to long ago.
Paige West (2009; see also 2008) suggests that inter-

national adventure tourists look for a “past beyond”: an
imagined purer, more authentic time unpolluted by cap-
italist modernity. The Australian surfers she studied saw
themselves as a diasporic community and imagined in Papua
New Guinea’s waves an unknown, unspoiled primitive.
(This imagination required the erasure of local signs of
modernity, along with erasure of the New Guinean surfers
and commercial fishermen who were already there.) West’s
concept of the past beyond illuminates clinical tourism, too,
because physicians from wealthier parts who write about
African medicine often characterize geographical journeys
as temporal ones to a simultaneously primitive and romantic
past. The Lancet editorial that characterizes electives in poor
countries as transformative also promises students “19th-
century” panoramas of disease. In the American Journal of
Medicine, two educators claim that global health opportuni-
ties “provide Western physicians with the opportunity not
only to work towards a critically important goal, but also
to regain our center and our focus, and in the process re-
mind ourselves of the fundamental values that define our
profession” (Shaywitz and Ausiello 2002:355). This empha-
sis on regaining and reminding conjures a past in which
medicine was more meaningful—and perhaps higher status,
as the later promise of “renewing the dignity of our calling”
(Shaywitz and Ausiello 2002:357) hints. Physicians and stu-
dents who go to the world’s poorest nations become good
doctors not just by providing good care, then, but by recap-
turing an imagined history in which doctors were humani-
tarian figures, not well-paid technocrats.
Two centuries ago, a U.S. medical education could best
be capped by a stint in the hospitals of Paris. Returnees from
“the Paris School,” as John Warner (1998) has shown, used
the social capital accrued through their journeys to advo-
cate for medical reforms that some characterized as returns
to Hippocratic tradition: corrections to a wrong path taken

by the U.S. medical profession. In the early-19th-century
United States, reformers urged a return to empiricism and
a move away from overly theoretical “systems” of medical
thought. In the early-21st-century United States, the medi-
cal transformation also characterized as a Hippocratic return
117
is a move toward idealism, not empiricism. Although both
movements appear to draw moral maps in which a better
medicine can be found elsewhere, the parallels should not be
overdrawn. The simultaneous location of a better medicine
in poor countries and relative inattention to domestic med-
ical reform are distinctive to contemporary times. So is the
scale of today’s global health phenomenon. True, earlier
generations of medical students admired medical missionar-
ies like Albert Schweitzer and Tom Dooley, but few actively
followed in their footsteps. Current students are more likely
to take secular missionaries like Paul Farmer as role models
and to seek direct experience of what their forebears mostly
imagined.19
The U.S. student who worked on the Queens pedi-
atric nutritional rehabilitation ward described her work
repeatedly, with self-conscious irony, as “feeding starving
children,” simultaneously evoking a humanitarian imaginary
(and the images of African desperation it often deploys) and
an ethos of medicine as caretaking. Contemporary clini-
cal tourism, however variable the underlying motivations,
is surely also part of a wider struggle to convert knowl-
edge into useful action, and even—for a generation of stu-
dents bombarded since childhood with reminders of global
suffering—to orient one’s professional self meaningfully to

the world.
Suffering Strangers and Unintended Consequences
Margaret Lock and Vinh-Kim Nguyen remind us that “the
promise of and the actual effects of biomedical technologies
are embedded in the social relations and moral landscapes
in which they are applied” and call for ethnography in which
“the views of local actors provide insights into the ways in
which the global dissemination of biomedicine and its spe-
cific local forms transform not only human bodies, but also
people’s hopes and aspirations in ways that may well have
broader repercussions for society at large” (Lock and Nguyen
2010:5–6). Both transformed aspirations and broader reper-
cussions can be seen in the moral maps of Malawian students
and the would-be humanitarians they meet.
Medical humanitarianism, like other forms of humani-
tarianism, “offers a seductive simplicity, suggests no grand
commitment, allows a new generation to find solidarity not
in ideas of progress but rather in projects of moral urgency
and caretaking” (Barnett and Weiss 2008:6). Such projects
entice many medics: MSF volunteers often hope initially for
“the opportunity to experience the essence of a medical ca-
reer, ‘to feel like a real doctor’ by providing basic health care
in response to a clear need irrespective of political or social
considerations,” as Peter Redfield (2005:335) notes. Long-
term clinical volunteers ultimately must grapple with some
of the considerations they sought to leave behind, struggling
over the ethical complexity of responding to social rupture
and political abandonment with medical aid in a postcolo-
nial world (Hunt 2008; Redfield 2005). In short-term tours,
those ambiguities may be less apparent.
The dazzling light of moral clarity can blind clinical
tourists to both complexity and complicity. The “suffering
stranger” depicted in many humanitarian appeals and some

anthropological work is “a discursive construction that re-
duces global entanglements, and potentially rich human sto-
ries, to a moral model that allows for a sustained dependency
between one group of people (i.e., those coded as needy)
and another group of people (i.e., those coded as expert),” as
Leslie Butt (2002:17) cautions. It may be hard to argue with
experts, or would-be experts, who envision the most “real”
medicine as ministry to the most needy. But such visions
risk reducing “global health” work to a technical gift from
donor to recipient rather than seeing it as either the mutual
struggle of equals that Malawians like Joe Phoya imagined or
the ambiguous social process that anthropologists often see
at work (Crane 2010).
WHERE PATHS CROSS: WHY MAPS MATTER
FOR THOSE IN THE MIDDLE
Student doctors, both tourists and Malawians, are middle
figures on the wards of Queens: not quite laypeople, not yet
experts. Their paths cross at a liminal moment, when their
medical imaginaries and professional identities are in flux.
They also cross in a place where possible professional lives—
like therapeutic options—are dictated by the unevenness
of medical globalization. Technologies and pharmaceuticals
flow fitfully across this difficult terrain, people a bit more
freely, if for now mostly in one direction. Ideas travel fastest
of all. These middle figures’ mapping of ideals, technologies,
riches, and heartfelt work onto places—a specific here and
a generic “out there”—illuminates their struggles over what
it means to be real doctors.
If you want to be a doctor in Malawi, and you want to live the
way real doctors live, then this is not the place! Because as a
real
doctor, you are supposed to be rich. But for sure, I might finish
my
school, and I might work two or three years without even a car.

Your expectation [is] to say as a doctor you are supposed to
have
this. But here in Malawi, no. [interview, Arthur Kamkwamba,
medical student, March 6, 2003]
One part of society [says] “this person has been to America,
UK,
western countries, and they are very good,” but you find that the
true doctors—the real doctors—they’re out here. They are really
doing their job. They’re putting their hearts out . . . If it was in
that part of the world [points away], I think these people would
be getting a Nobel prize every year. Every single year.
[interview,
Gift Mkango, medical student, May 8, 2003]
As these brief interview excerpts show, students compare
their own anticipated futures with their imaginations of the
lives of doctors elsewhere, as they work out what, whom,
and where “real doctors” should be. Is the real doctor the
visitor, who travels from afar, owns a car, has wielded the
technologies of the textbook, and represents a humanitar-
ian international? Or is it the Malawian, who understands
how to work in scarcity, speaks patients’ languages, and
sees deeply the causes of illness? In these struggles, we can
see that the Malawians are also middle figures in a second
sense, simultaneously representatives of medical modernity
to their African patients and of Africa to the medical moderns
who visit their wards.20 Like the Indonesian conservation
biologists studied by Celia Lowe (2006) or the Nepalese
community-development workers studied by Stacy Pigg
(1997), they are transnational subalterns and aspiring na-

tional elites.
In this middle, tourist and clinical gazes both shape
moral imaginations. Both gazes use the eye and the mind’s
eye; both interpret the sensory through the imaginary. Med-
ical students learn to look on the bodies of others using “a
gaze equipped with a whole logical armature” of medical ra-
tionality (Foucault 1975:107). But the Malawians who learn
to gaze on Other bodies simultaneously understand them-
selves as Others in others’ regards. Like the visiting students,
they are subjects deploying the clinical gaze. Like their pa-
tients, they are objects of a tourist gaze. This dual position
as subject and object is an unstable one that allows for shift-
ing alliances and for different ways of understanding their
work. Now they imagine themselves as tourists, learning to
be “international doctors” in Zambia or Tanzania; now they
recognize themselves as sacrificial objects of pity: “some-
body has to carry the cross.” At times they ally themselves
with their own patients: endangered, mortal, “as human as
everybody else.” At other times they identify strongly with
their clinical-tourist “brothers.”
In this vulnerable moment, where paths cross and gazes
meet, students plot the same people and places onto very
different maps of good (or bad) work. One medical stu-
dent’s short-term humanitarian intervention site and space
of “global” need is another medical student’s long-term
home and national development project. One’s morally clear
past beyond is another’s grubby, dangerous, and ill-paying
workspace. One student’s starving Africans are another stu-
dent’s fellow citizens. Textual evidence suggests that tourists
whose trust in medical modernity has been shaken may seek
in Africa a return to an imagined past in which medicine was
an unambiguous good. Their geographical journey becomes
a temporal and moral one: from present to past in search
of a more authentic medicine and a better professional self.

Ethnographic evidence shows some Malawians meanwhile
seeking out that medical modernity; their moral maps chart
courses from present to future in search of real medicine and
a better professional self. On these maps, times have places
and places times: for some clinical tourists the past is an
elsewhere, and for some Malawian trainees the future is an
elsewhere. That is not all that is happening, however. Some
Malawian trainees are also rethinking their medical present,
casting their own version of medicine as superior—not else-
where or sometime, but here and now.
Their imagined moral maps matter, analytically and
practically. Practically, moral maps chart for student doctors
actual routes to coherent professional lives. Malawians were
alert to the privileges of medicine “outside,” and to their
exclusions from it, yet some mapped the best medicine at
home. Others did not. Those who imagined real medicine
to be “out there,” where doctors have specialty training
opportunities and CD4 counts, will likely envision their own
futures “out there” as well. Conversely, if real medicine re-
quires starving children and suffering strangers, the moral
clarity allowed by brief encounters across huge social and
geographical distances, then clinical tourists risk disenchant-
ment with the obese children of their domestic poor and the
suffering of those all too familiar.
Analytically, mapping forces us to attend to place and
direction and, therefore, to the actual processes of globaliza-
tion when we consider medical imaginaries. The examples
given here show how people (real doctors and witchcraft
victims), things (reflex hammers, cars, cadavers, and ul-
trasound gel), diseases (parasitic infections and geriatric
disorders), and medically relevant values (selflessness and
technical adeptness) take positions on students’ moral maps.
Unequal processes of global exchange shape the actual distri-

bution of these entities. The travels of clinical tourists, like
those of other trainees and experts, are made possible or
impossible by those same processes. To consider the specific
effects of global exchanges on imaginaries is to move beyond
assumptions that moral worlds are largely local (Kleinman
and Kleinman 1991) and beyond analyses that seem to see
globalization as transporting an essentially similar imaginary
into vastly different places (Good 2007). Instead, we find
that the specifics of one-way travels and unequal exchanges
are consequential for people’s pictures of the world and
of their own places in it—a longstanding anthropological
concern.
In the course of our work, many anthropologists en-
counter humanitarians, migrants, tourists, trainees, and ex-
perts of various sorts following their own moral maps to
better lives, worthwhile work, or places of “real need.” We
create and follow such maps ourselves. Our discipline too
has staked claims to discursive, scientific, and (sometimes)
moral authority on experience in an “out there” conjured as
different, sometimes in both time and space (Fabian 1983).
As Redfield (2005:349) notes, we too can be included in “the
greater industry of transnational virtue.” Moral maps layer
pathologies onto places, and progress onto time and direc-
tion, in the imaginaries of the mobile experts and would-be
experts (including clinical tourists and Malawian medical
students) who people that transnational industry. Attend-
ing to those maps gives us the binocular vision we need
to discern the complex motivations involved and the com-
plex consequences of mapping virtuous work onto faraway
places.
Claire L. Wendland Department of Anthropology, University of
Wisconsin-Madison, Madison, WI 53711; [email protected]
NOTES

Acknowledgments. The original field research for this article
was supported by awards from the Social Science Research
Coun-
cil, the University of Massachusetts at Amherst Graduate
School,
and the University of Wisconsin-Madison Graduate School.
Years of
119
conversations with Drs. Chiwoza Bandawe and Terrie Taylor,
other
colleagues, and the many medical students and interns whom I
may
not name at the University of Malawi’s College of Medicine
have
shaped my thinking on the issue of clinical tourism—as well as
on
other peculiarities of “global health.” Warwick Anderson,
Elizabeth
Bintrim, Maria Lepowsky, Mary Moore, Alex Nading, Natalie
Porter,
and Noelle Sullivan all provided thoughtful critiques of this
article in
various earlier drafts. American Anthropologist’s editor Tom
Boellstorff
and a series of anonymous reviewers gave me extensive,
sometimes
conflicting, and often extremely valuable criticism. This article
is
much stronger for their efforts. Remaining infelicities,
misinterpre-
tations, or errors are mine.

1. All individuals’ names are pseudonyms, as is required by the
Uni-
versity of Malawi College of Medicine Research Ethics
Commit-
tee, which approved this study. Names are matched for gender
but not for ethnicity. Neither Queens nor the College can be
anonymized: at the time of this project Malawi had only one
medical school.
2. In 2003, interns earned $2,148 yearly, including all
allowances.
Starting salary for a civil service doctor licensed postinternship
as a general practitioner was $2,904.
3. After eight years as a general practitioner in Malawi, Dr.
Kamwendo secured a position in a specialty program (not in
internal medicine) elsewhere in Africa. When I last spoke with
him, in January of 2011, he was to begin training there later that
year.
4. The yearlong limit on “tourism” is arbitrary: most stints are
much
shorter, typically a week at the least and two or three months
at the most. These brief clinical tourism experiences sometimes
pave the way for later mid- or long-term journeys.
5. Readers can find the larger study, with details of research
meth-
ods, in Wendland 2010. Students’ participation was voluntary
and uncompensated. I obtained formal consent for interviews
and focus groups. Before training in anthropology, I practiced
for years as an obstetrician-gynecologist. Colleagues at the Col-
lege of Medicine felt strongly that my active participation in
the wards, clinics, and operating theaters at Queens would be
important to this project. I am grateful for their insistence on

this point.
6. Julie Livingston built on the concept of moral imagination
pro-
posed by T. O. Beidelman in 1980. Beidelman, in turn, drew
from Clifford Geertz (1977). Because neither Beidelman nor
Geertz provided a definition of the term, I have used Liv-
ingston’s. In addition to anthropologists, ethicists, epidemiol-
ogists, and others have also used the term, sometimes in relation
to global health (see, e.g., Benatar 2005); in that literature, it
often simply connotes empathy.
7. Such tracks vary among nations even within southern Africa.
In
Zambia, for instance, also once under British rule but eastward-
leaning during the Cold War, many short-term expatriate doc-
tors are Cuban, Russian, or Chinese. Tanzania’s long-term ex-
changes with China, as Stacey Langwick (2010) demonstrates,
mean that biomedicine there differs from its Malawian equiva-
lent in many respects (including practitioners’ greater openness
to herbal medicines).
8. All data is from World Health Organization n.d.
9. Clinical officers are mid-level clinicians who remain crucial
to
Malawi’s medical system, performing most surgical operations
and treating all but the most complex medical cases.
10. The College of Medicine also used a secondary teaching
hospital
in the nation’s capital, where conditions were even worse—
famously so. An image of patients in Lilongwe Central Hospital
dying three to a cot has circulated widely, showing up in talks
by Bono, writings by Jeffrey Sachs, and other venues (Richey
and Ponte 2008). Such images, accessible to white experts—

including me—who show up on the wards at Malawi’s hos-
pitals, contribute to the country’s status as what Lisa Bintrim
[personal communication, January 2010] calls “the poster nation
for poverty.”
11. Numbers peaked during malaria season, when a U.S. malaria
research team provided housing for visiting students from its
home institution. Queens keeps no central registry of visiting
trainees; these totals are based on observation.
12. Medical technologies cause iatrogenic damage in Malawi
too, but
toxicity was less obvious against a background of high
morbidity
and mortality.
13. I owe the image of the virtual pressing on the actual to a
comment
from Adriana Petryna.
14. Research, mission, and humanitarian aid groups bring into
Malawi much of what medical technology, pharmaceuticals, and
specialist-level expertise exists there. With only rare
exceptions,
these groups are not involved in medical students’ training.
James
Ferguson (2005:380) notes that in Africa international capital
and
national governance work not on standardized national grids but
“spread across a patchwork of transnationally networked bits”
or enclaves, with the rest of an Africa deemed “unusable” left
to its own devices. Ferguson did not discuss biomedical care or
research, but the metaphor fits both well (see Sullivan 2011).
15. Television was unavailable in Malawi until 1995, and even
af-

terward access remained limited. The medical television dramas
watched by people in the United States and Europe (and Indone-
sia and China, as Good [2007:366] notes) were not in
circulation.
16. Eclamptic seizures are complications of a pregnancy-related
hy-
pertensive disorder.
17. Elise Andaya (2009: cf. Brotherton 2008) finds a similar
emphasis
on abilities to resource (there the term is resolver or “resolve”)
among Cuban physicians who use social networks to access
what
cannot be obtained through formal state mechanisms.
18. The term moral geographies, which might also be
considered here,
refers to ideas about who (and what) belongs where: which
people, objects, or animals are in or out of place (Cresswell
1996). The moral maps of medical trainees seem to me to
function less as atlases of belonging and exclusion than as route
guides: where to go—and when—to find good or bad medicine.
19. Here I am concerned with Paul Farmer’s role as medical cul-
ture hero (Kidder 2003) rather than with his anthropological
scholarship.
20. The term middle figure is Nancy Rose Hunt’s (1999). Her
study of the introduction of colonial obstetrics to the Congo
paid close attention to Congolese mediators (nurses, mid-
wives, medical assistants) who reworked the missionaries’

therapeutic practices as they learned and then practiced mission
medicine.
REFERENCES CITED
Andaya, Elise
2009 The Gift of Health: Socialist Medical Practice
and Shifting Material and Moral Economies in Post-
Soviet Cuba. Medical Anthropology Quarterly 23(4):357–
374.
Appadurai, Arjun
1996 Modernity at Large: Cultural Dimensions of Globalization.
Minneapolis: University of Minnesota Press.
Barnett, Michael, and Thomas G. Weiss
2008 Humanitarianism: A Brief History of the Present. In Hu-
manitarianism in Question: Politics, Power, Ethics. Michael
Barnett and Thomas G. Weiss, eds. Pp. 1–48. Ithaca, NY:
Cornell University Press.
Beidelman, T. O.
1980 The Moral Imagination of the Kaguru: Some Thoughts on
Tricksters, Translation and Comparative Analysis. American
Ethnologist 7(1):27–42.
Benatar, Solomon R.
2005 Moral Imagination: The Missing Component in Global
Health. PLoS Medicine 2(12):1207–1210.
Bezruchka, Stephen
2000 Medical Tourism as Medical Harm to the Third World:

Why? For Whom? Wilderness and Environmental Medicine
11:77–78.
Brotherton, P. Sean
2008 “We Have to Think Like Capitalists but Continue Being
Socialists”: Medicalized Subjectivities, Emergent Capital, and
Socialist Entrepreneurs in Post-Soviet Cuba. American Eth-
nologist 35(2):259–274.
Butt, Leslie
2002 The Suffering Stranger: Medical Anthropology and
Interna-
tional Morality. Medical Anthropology 21:1–24.
Crane, Johanna T.
2010 Unequal “Partners”: AIDS, Academia, and the Rise of
Global
Health. Behemoth 3(3):78–97.
Cresswell, Tim
1996 In Place/Out of Place: Geography, Ideology, and Trans-
gression. Minneapolis: University of Minnesota Press.
Fabian, Johannes
1983 Time and the Other: How Anthropology Makes Its Object.
New York: Columbia University Press.
Ferguson, James
1999 Expectations of Modernity: Myths and Meanings of Ur-
ban Life on the Zambian Copperbelt. Berkeley: University of
California Press.

2005 Seeing Like an Oil Company: Space, Security, and
Global Capital in Neoliberal Africa. American Anthropologist
107(3):377–382.
Foucault, Michel
1975 The Birth of the Clinic: An Archaeology of Medical
Percep-
tion. New York: Vintage.
Geertz, Clifford
1977 Found in Translation: On the Social History of
the Moral Imagination. Georgia Review 31(4):788–
810.
Good, Byron J.
1994 Medicine, Rationality, and Experience: An
Anthropological
Perspective. Cambridge: Cambridge University Press.
Good, Mary-Jo Delvecchio
2007 The Medical Imaginary and the Biotechnical Embrace:
Sub-
jective Experiences of Clinical Scientists and Patients. In Sub-
jectivity: Ethnographic Investigations. João Biehl, Byron Good,
and Arthur Kleinman, eds. Pp. 362–380. Berkeley: University
of California Press.
Graburn, Nelson
1989 Tourism: The Sacred Journey. In Hosts and Guests: The
An-
thropology of Tourism. Valene Smith, ed. Pp. 21–36. Philadel-
phia: University of Pennsylvania Press.

Hunt, Matthew R.
2008 Ethics beyond Borders: How Health Professionals Ex-
perience Ethics in Humanitarian Assistance and Devel-
opment Work. Developing World Bioethics 8(2):59–
69.
Hunt, Nancy Rose
1999 A Colonial Lexicon of Birth Ritual, Medicalization, and
Mobility in the Congo. Durham, NC: Duke University Press.
Ingold, Tim
2007 Lines: A Brief History. New York: Routledge.
Kidder, Tracy
2003 Mountains Beyond Mountains: The Quest of Dr. Paul
Farmer, a Man Who Would Cure the World. New York:
Random House.
King, Michael, and Elspeth King
1992 The Story of Medicine and Disease in Malawi: The 150
Years
Since Livingstone. Blantyre, Malawi: Montfort Press.
Kleinman, Arthur, and Joan Kleinman
1991 Suffering and Its Professional Transformation: Toward an
Ethnography of Interpersonal Experience. Culture, Medicine,
and Psychiatry 15(3):275–301.
Lancet
1993 The Overseas Elective: Purpose or Picnic? Lancet
342(8874):753–754.

Langwick, Stacey
2010 From Non-Aligned Medicines to Market-Based Herbals:
China’s Relationship to the Shifting Politics of Traditional
Medicine in Tanzania. Medical Anthropology 29(1):15–43.
Levi, Amy
2009 The Ethics of Nursing Student International Clinical Ex-
periences. JOGNN: Journal of Obstetric, Gynecological, and
Neonatal Nursing 38(1):94–99.
Lisle, Debbie
2000 Consuming Danger: Reimagining the War/Tourism Divide.
Alternatives-Social Transformation and Humane Governance
25:91–116.
Livingston, Julie
2005 Debility and the Moral Imagination in Botswana.
Blooming-
ton: Indiana University Press.
121
Lock, Margaret, and Vinh-Kim Nguyen
2010 An Anthropology of Biomedicine. Oxford: Wiley-
Blackwell.
Lowe, Celia
2006 Wild Profusion: Biodiversity Conservation in an

Indonesian
Archipelago. Princeton: Princeton University Press.
Munt, Ian
1994 Eco-Tourism or Ego-Tourism? Race and Class 36(1):49–
60.
Muula, Adamson S., and Robert L. Broadhead
2001 The First Decade of the Malawi College of Medicine: A
Critical Appraisal. Tropical Medicine and International Health
6(2):155–159.
O’Neil, Edward, Jr.
2006 Awakening Hippocrates: A Primer on Health, Poverty, and
Global Service. Chicago: American Medical Association.
Philpott, Jane
2010 Training for a Global State of Mind. Virtual Mentor
12(3):231–236.
Pigg, Stacy Leigh
1997 Found in Most Traditional Societies: Traditional Medical
Practitioners Between Culture and Development. In Interna-
tional Development and the Social Sciences: Essays on the His-
tory and Politics of Knowledge. Frederick Cooper and Randall
Packard, eds. Pp. 259–290. Berkeley: University of California
Press.
Redfield, Peter
2005 Doctors, Borders, and Life in Crisis. Cultural
Anthropology
20(3):328–361.

Richey, Lisa Ann, and Stefano Ponte
2008 Better (Red)TM than Dead? Celebrities, Consumption and
International Aid. Third World Quarterly 29(4):711–729.
Schrift, Melissa
2004 The Angola Prison Rodeo: Inmate Cowboys and
Institutional
Tourism. Ethnology 43(4):331–344.
Shaywitz, D. A., and D. A. Ausiello
2002 Global Health: A Chance for Western Physicians to
Give—
and Receive. American Journal of Medicine 113(4):354–357.
Shweder, Richard A.
2000 Moral Maps, “First World” Conceits, and the New Evange-
lists. In Culture Matters: How Values Shape Human Progress.
Lawrence E. Harrison and Samuel P. Huntington, eds. Pp.
158–172. New York: Basic.
Sinclair, Simon
1997 Making Doctors: An Institutional Apprenticeship. Oxford,
UK: Berg.
Smith, Janice K., and Donna B. Weaver
2006 Capturing Medical Students’ Idealism. Annals of Family
Medicine 4(suppl. 1):32–37.
Sparke, Matthew
2009 Unpacking Economism and Remapping the Terrain of
Global Health. In Global Health Governance: Crisis, Insti-

tutions, and Political Economy. Adrian Kay and Owain David
Williams, eds. Pp. 131–159. New York: Palgrave Macmillan.
Stone, Philip, and Richard Sharpley
2008 Consuming Dark Tourism: A Thanatological Perspective.
Annals of Tourism Research 35(2):574–595.
Stronza, Amanda
2001 Anthropology of Tourism: Forging New Ground for Eco-
tourism and Other Alternatives. Annual Review of Anthro-
pology 30:261–283.
Sullivan, Noelle C.
2011 Mediating Abundance and Scarcity: Implementing an
HIV/AIDS-Targeted Project within a Government Hospital
in Tanzania. Medical Anthropology 30(2):202–221.
Thompson, Matthew J., Mark K. Huntington, Dan Hunt, Linda
E.
Pinsky, and Jonathon J. Brodie
2003 Educational Effects of International Health Electives on
U. S. and Canadian Medical Students and Residents: A Litera-
ture Review. Academic Medicine 78(3):342–347.
Turner, Leigh
2007 “First World Health Care at Third World Prices”: Glob-
alization, Bioethics and Medical Tourism. BioSocieties 2(3):
303–325.
Urry, John
2002 The Tourist Gaze. 2nd edition. London: Sage.

Wall, L. Lewis, Steven D. Arrowsmith, Anyetei T. Lassey, and
Kwabena Danso
2006 Humanitarian Ventures or “Fistula Tourism?”: The Ethical
Perils of Pelvic Surgery in the Developing World. International
Urogynecology Journal 17(6):559–562.
Warner, John
1998 Against the Spirit of System: The French Impulse in
Nineteenth-Century American Medicine. Baltimore: Johns
Hopkins University Press.
Wendland, Claire
2010 A Heart for the Work: Journeys through an African
Medical
School. Chicago: University of Chicago Press.
West, Paige
2008 Tourism as Science and Science as Tourism: Environment,
Society, Self, and Other in Papua New Guinea. Current An-
thropology 49(4):597–626.
2009 Such a Site for Play, This Edge: Surfing in Papua New
Guinea. Paper presented at the University of Wisconsin-
Madison Culture, Health and the Environment Colloquium,
Madison, March 4.
Whiteford, Linda M., and Lenore Manderson, eds.
2000 Global Health Policy, Local Realities: The Fallacy of the
Level Playing Field. Boulder: Lynne Rienner.
World Health Organization

N.d. Malawi. http://www.who.int/countries/mwi/en/, ac-
cessed August 17, 2010.
FOR FURTHER READING
(These selections were made by the American Anthropologist
editorial
interns as examples of research related in some way to this
article. They do
not necessarily reflect the views of the author.)
Feldman, Ilana
2007 The Quaker Way: Ethical Labor and Humanitarian Relief.
American Ethnologist 34(4):689–705.
Mindry, Deborah
2001 Nongovernmental Organizations, “Grassroots,” and the
Pol-
itics of Virtue. Signs 26(4):1187–1211.
Nguyen, Vinh-Kim and Karine Peschard
2003 Anthropology, Inequality, and Disease: A Review. Annual
Review of Anthropology 32:447–474.
Redfield, Peter
2006 A Less Modest Witness: Collective Advocacy and Moti-
vated Truth in a Medical Humanitarian Movement. American
Ethnologist 33(1):3–26.
Speier, Amy

2008 Czech Balneotherapy Border Medicine and Health
Tourism.
Anthropological Journal of European Cultures 17(2):145–159.
Zhan, Mei
2001 Does It Take a Miracle? Negotiating Knowledges,
Identities,
and Communities of Traditional Chinese Medicine. Cultural
Anthropology 16(4):453–480.
Tropical Medicine and International Health
volume 2 no 9 pp 903–911 september 1997
© 1997 Blackwell Science Ltd903
Is there a role for traditional medicine in basic health
services in Africa? A plea for a community perspective
Sjaak van der Geest
Medical Anthropology Unit, University of Amsterdam, The
Netherlands
Summary Traditional medicine in Africa is contrasted with
biomedicine. Most traditional medical theories
have a social and religious character and emphasize prevention
and holistic features. Traditional
medical practices are usually characterized by the healer’s
personal involvement, by secrecy and a

reward system. Biomedical theory and practice show an almost
opposite picture: asocial,
irreligious, curative and organ-directed; professional
detachment, public knowledge and – until
recently – ‘free of charge’. It is suggested that local
communities do not expect that basic health
care will improve when traditional healers become integrated
into the service. They ask instead for
improvement of basic health care itself: more services with
better access, more dedication and
respect from doctors and nurses, more medicines and personnel.
Fieldwork needs to be done at the
community level to arrive at a better understanding and
assessment of the community’s opinion
concerning a possible role of traditional medicine in basic
health care.
keywords traditional medicine, basic health care, primary health
care, cooperation, quality of
care, community perspective, Africa
correspondence Sjaak van der Geest, Medical Anthropology
Unit, University of Amsterdam,
Oudezijds Achterburgwal 185, 1012 DK Amsterdam, The
Netherlands
Introduction
The quality of modern health care services in Africa is

increasingly being criticized in recent literature (Hours
1985; Van der Geest et al. 1990; Gilson 1992; Gilson
et al. 1994; Booth et al. 1995). The consequences of
structural adjustment are strongly felt in the diminishing
budgets for health care. At the microlevel, the attitude
and behaviour of health personnel towards patients have
been singled out as problematic. Compared to local
traditional healers, health workers in the basic health
services are often found to show little concern and
respect for patients. The question could be raised
whether integration of traditional healers in basic health
care would help to improve its quality.
Since 1978 the WHO has been calling for more
cooperation, even integration, of traditional medicine
and biomedicine. The role of traditional medicine was
viewed as an integral part of primary health care with its
basic philosophy of self-reliance. Obviously, traditional
healers and traditional self-care were considered a form

of self-reliance.
The idea was inspiring and breathed the spirit of
optimism of those days. However, national governments
and their ministries of health, controlled by biomedical
practitioners, were less enthusiastic. They did pay lip
service to the WHO suggestion, created token
departments of traditional medicine, but did not give the
idea much chance to materialize. Green (1996) provides
a useful overview of government policies, ranging from
banning traditional medicine to programs for
integrating it into the regular national health service, but
most policies existed merely on paper to please
international donors. I shall return to this intentional
misunderstanding later on when discussing the
multilevel perspective. In the meantime the WHO itself
has – almost silently – changed its position and placed
traditional medicine in the Division of Drug

Tropical Medicine and International Health volume 2 no 9 pp
903–911 september 1997
S. van der Geest Traditional medicine in basic health services in
Africa
Management and Policies where it is dying a slow death
(Ventevogel 1996).
By now we have a library of publications advocating
or rejecting the idea of integrating traditional and
biomedical services. Most authors who have contributed
to that discussion base their argument on their own
assessment of the complementarity or incompatibility of
the two – or more – medical traditions (for overviews
see Bichmann 1995; Green 1996; Ventevogel 1996). Some
have interviewed local healers and/or biomedical
practitioners about their views on a possible
cooperation. Overall, however, their conclusions reflect
their own logic. Amazingly, the question whether local
communities favour an integration of traditional and

modern medicine has hardly been raised, let alone
investigated by medical anthropologists. This article is a
plea for such research and at the same time carries the
cautious suggestion that local communities may be less
enthusiastic about the idea of integration than some of
its advocators assume.
African medical traditions
It has become a tradition in Africa to refer to medical
practitioners outside the realm of biomedicine as
‘traditional healers’. In the same vein, their practice and
knowledge is called traditional medicine. The term is
misleading, embarrassing and naive. It is misleading
because it suggests that there is a more or less
homogeneous body of medical thought and practice
which can be put together under one name. Such a body
does not exist, however. If one examines the type of
medical practitioners who are designated traditional,
one will find an extreme diversity both in theories and

practices. The only thing these practitioners have in
common – like alternative practitioners in Europe and
North America – is that they are non-biomedical. That
is why the term is embarrassing. Lumping together
everything which is not ‘ours’ and treating it as if it
were one type is a school example of ethnocentric
ignorance. Finally, the term is naive because it suggests
that ‘our’ medical system is not traditional, meaning
handed over, from generation to generation. Clearly,
biomedicine is being handed over all the time, in
medical schools, in hospitals, in books and articles,
through conferences and the media. Biomedicine
therefore is as traditional as any other medical
tradition.
Another misunderstanding is brought about by the
term ‘medical system’, which suggests a coherent whole
of beliefs and practices. Anthropologists, however, have
shown that medical ideas and practices do not always

harmoniously fit together. There is often confusion,
ignorance and contradiction in what people think and
do around health and illness. To a Western-trained
scientist the statements and activities of traditional
healers and their clients may seem outright illogical and
unsystematic.
Having said this, I will nevertheless – with some
embarrassment – try to make a few general observations
about African traditional medicine. African medicine
consists primarily of self-help. For various reasons, self-
care and self-medication are far more widely practised
in African families than, for example, in my own
society, the Netherlands. Self-care is not only something
of people’s own choice, it often is bare necessity due to
poverty or lack of good medical facilities (Van der Geest
& Hardon 1990). Home remedies and popular
knowledge of herbs and other therapeutic substances
take up the greater – and perhaps the better – part of

African medicine. Its efficacy is publicly discussed and,
for that reason, open to critique and adjustment.
Popular knowledge therefore is a most valuable part of
the medical tradition. It needs to be safeguarded and
strengthened if we want to enhance people’s ability to
cope with health problems and to improve the quality of
health care.
It is more difficult to speak in such general terms
about the specialists in African medicine, the traditional
healers. To risk overlooking their cultural diversity and
to simplify the complexity of their medical practice, I
shall discuss four more or less characteristic features of
their medical theories and three features of their style of
practice.
Most African medical theories have a social character.
The description and explanation of illness is often
phrased in terms of social interaction, in particular
between members of one kinship group. The origin of

illness, its treatment and prevention is linked to the
quality of human relationships. Jealousy, hatred and
moral wrong-doing are associated with physical and
mental dysphoria. Ancestors and witches are believed to
play a crucial role in bringing about illness and other
misfortune. Disorder in the community leads to disorder
in the health condition of its members. An illness of one
family member therefore is seen as an illness of the
Africa
entire family. Finding a solution to the problem is the
responsibility of the group to which the sick person
belongs.
The second feature is the religious dimension of
medical reasoning. Religion permeates every aspect of

human existence, including health and disease. Medical
problems are often interpreted in religious terms and,
conversely, religious rituals are nearly always linked to
the maintenance or restoration of well-being in the
community. Many medical practitioners are also
religious specialists. Healing the body while neglecting
the deeper religious grounds of the problem is senseless.
African medicine’s third characteristic will be a
surprise to most readers: its orientation to prevention.
There is a popular western prejudice that Africans do
not worry about the future and are little interested in
preventive medicine. It is one of the most stubborn
misconceptions about Africa circulating in the rest of
the world. Prevention, however, is central in people’s
everyday life and follows logically from their
preoccupation with religious and social values. As we
have seen, traditional healers concentrate on the deeper
origins of illness and insist that something should be

done about them to avoid a repetition of the misfortune.
They provide their patients with moral and social
guidelines to prevent them from catching the same
illness again. The preventive character of traditional
medicine is, however, hardly recognized by outsiders
who do not believe in the social and religious roots of
illness and consider the healers’ suggestions irrelevant to
health and illness.
The fourth characteristic of medical theories in the
African tradition is that health and illness are more
comprehensive concepts than in the Western tradition.
As a matter of fact, ‘health’ cannot be adequately
translated in many African languages. Indigenous terms
closest to it comprise a much wider semantic field. They
refer to the general quality of life including the
conditions of animals and plants, the entire physical and
social environment. ‘Well-being’ or even ‘happiness’
seem better English terms to capture the meaning of

traditional African medical concepts. As a consequence,
the English term ‘medicine’ is also a misnomer, but
interestingly the term has been indigenised in many
African languages and now entails much more than
restoring bodily health. Medicine is any substance that
can bring about a change, anywhere, anyhow.
Medicines heal a sickness, catch a thief, help someone to
pass an exam, make a business prosper, kill an enemy
and win someone’s love (Keller 1978; Whyte 1988). In
the explanatory model of many African healers there is
no neatly demarcated field of physical health. Their
medical perspective is holistic in the most holistic sense
of the word. Interestingly, their vision is not so different
from the idealistic and much criticized WHO definition
of health: a state of physical, mental and social well-
being.
Three prominent, more or less general features of the
practice of traditional medicine in Africa are the healers’

emotional commitment in the therapeutic process, the
secrecy surrounding their practice and the healers’
reward.
Several students of traditional medicine have
described the deep personal involvement of African
healers in the treatment of patients. Therapeutic sessions
lasting more than an hour, and continuing over a period
of several months are common. The style of treatment
also indicates the healer’s concern. Patients are
frequently touched and their social and mental problems
extensively discussed, often in the presence of their
relatives.
Many traditional healers consider their medical
knowledge as personal property which they protect by
keeping it secret. Only a few select people are allowed to
know their secret, for example an apprentice who has
paid for his training or a relative who is destined to
succeed the healer in the future. The secrecy may be

medically legitimized: if the secrecy around a treatment
is broken, the treatment loses its efficacy (Cohen 1969;
Buckley 1985; Pearce 1986, 1989; Van Sargent 1986,
Wall 1988). The secrecy also has consequences for the
healer-patient relationship. The patient knows nothing
and must totally surrender to the healer (Buckley 1985;
Wall 1988).
A final characteristic, contrary to some popular
beliefs, is that traditional healers are rewarded for their
service. Their personal involvement does not imply that
their work remains unrewarded. The social context of
the therapeutic act requires reciprocity. In most cases
the positive outcome of a treatment needs a response
from the patient or his relatives. Paying for received
treatment is a sign of respect and appreciation. No
payment implies no obligation, no appreciation, no
relationship (Van der Geest 1992). If no reward is given,
the patient runs the risk of falling sick again. Like the

concept of secrecy, the reward too has been built into
Africa
medical theory. The payment contributes to the efficacy
of the treatment.
The imported tradition
The imported biomedical system is in many respects the
opposite of the above described indigenous tradition.
The religious dimension is totally absent and the social
dimension only plays a marginal role. In European
history, biomedicine made its great advances after it had
isolated the human body from its wider context and was
able to concentrate on technical failures of the body-
machine. Its great achievements were in the field of
curative medicine while prevention received far less

AMERICAN ANTHROPOLOGISTMoral Maps and Medical Imaginaries.docx

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