Odyssey of a Homesick Healer

At 58, Dr. John Karefa-Smart wonders where he will be a year from now. The tall, trim visiting professor of International Health may still be at the Medical School, lecturing on preventive medicine and world health. Or he might be back in West Africa, helping fellow Africans survive the unending five-year drought. But, if he had his way, he would be home in what he calls "my little country," in Sierra Leone, where re-arrest and imprisonment may await him now.

"I would go back tomorrow if I could," he says with a wistful smile. "I never will adjust myself to living out of Africa. Every time I have left it has been a temporary sojourn." But then he laughs, and nods toward the large, base-relief map of Africa above his desk, and adds, "In some ways, I never really leave."

If Sierra Leone were to suspend tomorrow the four-year-old state of emergency--declared the last time Karefa-Smart came home--and the government withdrew its warning to him to stay out of the country, he could probably be packed in time for an afternoon flight. His office at 641 Huntington Ave. is clearly a temporary measure, dominated not by a massive oaken desk, but by a few filing cabinets and bulletin boards. There is another map of Africa, perforated by colored push-pins, and an exhortation, carefully written in magic marker on lined yellow paper, to remember that "I" is the least important word and "we" is the most. His inspirational message is obscured when the office door is open. Karefa-Smart maintains a more substantial address out in Weston with his wife, but, from all appearances, he is only hanging his hat here for a while.

A sudden departure would not be too traumatic. By now, Karefa-Smart must be used to drastic changes in his life--once, he was taken from his dinner table in Sierra Leone, imprisoned, and released just as unexpectedly 141 days later. Having witnessed the confusion and coups of Sierra Leone's birth and growing pains, he realizes that he cannot enjoy a peaceful retirement after a long, lucrative practice like that of most of his McGill classmates. His open-end appointment at Harvard is as secure a job as he has had.

Despite the instability that has characterized his career, he bounces from continent to continent, confident that he will always be wanted, that he will always be useful. "There is so much to do," he says frequently when discussing the world's health, and he seems uncomfortable with suggestions that much of it cannot be done.

Karefa-Smart traces his determined optimism and sense of community to his childhood among the indigenous tribes of Sierra Leone. His grandfather was Paramount Chief of the area, and concern for all of the Chief's subjects naturally flowed to others in the ruling family.

Karefa-Smart was a third son, and not in line for his grandfather's post. "So I had to look for other fields," he says. An American missionary encouraged him to attend the American Missionary Society's local grade school and the high school at the capitol, Freetown.

The westernized schools gave him a piously western education: "We learned about all the capitol cities of Europe, the rivers of Europe and America, the mountains of those places, and very little about our own," he recalls. "Even the songs we learned in school--we sang about ice and snow. At that time, I never dreamed I would ever really know what ice and snow were."

Karefa-Smart's understanding of his own people was based on his parallel education that began when his grandfather decided that, at the age of six, he was ready for initiation into the secret Poro Society. Seventy-five years ago, that society gaimed fame for its resistance of British domination. But by the 1920s, it was actually an indigenous community school, and becoming a member was like making a social debut.

"It was secret just in that there were passwords that only members knew," Karefa-Smart explains, stripping away the mystery. "We learned tribal history, tribal customs, tribal traditions. At the end, we had a big ceremony in which we were introduced to the tribe as new members.

"All the stories you hear of Tarzan in the jungle and so on just aren't true. What is true is that we have our own system of life, our own culture."

Intent on helping the missionaries at the local hospital, Karefa-Smart decided to become a doctor--an almost unreachable goal for an African then. He was the first member of his community to go to college, and only the second from an indigenous tribe in the entire country to go to professional school. The first was Sir Albert Margai, Sierra Leone's first Prime Minister; Karefa-Smart became Margai's top aid and the country's first Foreign Minister.

At 23, a mature Karefa-Smart left Africa for the first time to study premed courses at Otterbein in Ohio. American medical schools were practically closed to all blacks, so he enrolled at McGill. As a British subject, he was drafted by the Canadian government during World War II, served his time in the Bahamas, and immediately after V-J Day, returned to his home village of Rotifunk.

He saw his community in a new light. "I was shocked to find what the real health status of my people was," he recalls. "When I went away, I knew nothing about nutritional diseases; I regarded it as normal that everyone should have worms. Every year at the beginning of the rainy season, we all took the indigenous medicine for expelling the worms, but for us it was natural.

"I remembered children often having high fevers, and sometimes, dying. But when I came back after being trained as a doctor, I couldn't believe what I saw."

Karefa-Smart went right to work at the missionary hospital in Rotifunk with the American missionary who had originally inspired him to go on to college. And when she returned to America on furlough, he continued alone. Twelve to fourteen hours a day, he treated the Africans who came to him with every tropical disease imaginable.

"It occurred to me what I was really making no progress at all," he says. "The same type of people from the same village communities along the river would come with diarrhea, with infections, with malaria--the whole range.

"Then it occurred to me that perhaps the right approach was preventive, since I didn't have the missionary attitude to this. I had the interests of my people at heart, and wanted to do something about community health."

By "missionary attitude," Karefa-Smart means the spirit of self-serving forays into the jungle by westerners in the footsteps of Livingston and Schweitzer. Their attempts at curative medicine had little impact on total community health; they were better at healing their own spiritual woes.

"They are always coming back to report to their country," Karefa-Smart says. "They tell how the people are suffering; they speak of the great need. In this way, they get support, but there is no real progress for the Africans. It is only a career to the missionary: getting support and treating a few people. I want to see my people's health improved."

So Karefa-Smart came to Harvard in 1947 to study public health, and, after a year, returned to his village to apply community health measures he was sure would cut down the number of patients needing treatment for contagious diseases. But, before he could begin, the University of Ibadan, Nigeria, asked him to train other Africans in preventive medicine. He lectured there until 1951.

Karefa-Smart's political awakening came shortly after that, during a tour of East Africa. He was stunned by the exploitation of Africans in the mining industry throughout the copper belt, and, looking around, saw far more rigid repression than relatively liberal Sierra Leone had known.

He was surprised to find one young man who was already fighting this discrimination, and they became friends. That early organizer was Kenneth Kaunda, now the president of Zambia. Kaunda's courage forced Karefa-Smart to re-evaluate his own career and the fruits of all his education.

"I said to myself, look: Here you are, you have a university education, a professional education, and you are not doing as much for the political situation of your people as this person here," he recalls.

Karefa-Smith returned to Sierra Leone and resigned all of his other posts to go into political life. With Sir Albert Margai, he organized the Sierra Leone People's Party, which eventually won Sierra Leone's independence from Britain in 1961. Over the next three years, he served in a variety of key positions: Foreign Minister, Minister of Defense, and Acting Prime Minister during Margai's frequent illnesses.

When Margai finally died in 1964, his brother, Sir Michael, took over the government by military force to avoid an election with Karefa-Smart. This placed Karefa-Smart in a delicate position. "When this brother pulled this fast one on us, I found I could not stay under those conditions," he says. "So I left the country. I remained a member of Parliment, but took a post at Columbia University because it would be safer."

Karefa-Smart commuted from New York to sessions of Parliament four times a year until 1965, when new coups forced him to cut off all political contact with Sierra Leone. For the next five years, he served in Geneva as assistant director general of the World Health Organization, but continued to watch the political situation in Sierra Leone. In 1970, with power in the hands of an old political ally, Dr. Siaka Stevens, he reasoned that the time was right for him to return to Sierra Leone for good. Karefa-Smart smiles at his own innocence now when he says," I thought I was getting to the age when you could retire."

There was no peace waiting for him in Sierra Leone. Stevens saw his return as a political threat--the people might sweep this old but not aging hero, who had negotiated Sierra Leone's independence, back into office. He declared a state of emergency, and, in October, 1970, ordered his former friend's arrest.

"It was all quite unceremonious," Karega-Smart recalls. His house was surrounded by soldiers, and one interrupted his family's dinner, and said, "Dr. Karefa-Smart, I have orders to take you."

Karefa-Smart began to protest, but another soldier put a hand on his soldier, and said, "Please don't argue, Doctor. We have orders to shoot you if you do." He went quietly.

Karefa-Smart was placed in the maximum security section of an old British prison, along with supporters from Steven's own cabinet. He spent the first three weeks in solitary confinement, and the remaining 17 weeks in a tiny cell with a small window near the high ceiling. He could not see out, even by jumping and trying to grab the window bars, and he was not permitted visits, letters, or any pasttimes.

So he just sat, marking the days with a piece of charcoal smuggled from the kitchen by a sympathetic trustee. He suspects now that Stevens hoped he would go insane. If so, Stevens gave up. Karefa-Smart was released, again without ceremony. He only had time to count the number of marks on the wall. There were 141.

As he was freed, Karefa-Smart was warned that while there were no charges against him, he should leave the country, that anything could happen during a state of emergency. At first, he tried to see Stevens to ask why he could not remain in peace. But a minor coup sent Stevens to neighboring Guineau for troops. Karefa-Smart envisioned possible retribution for instigating the spirit of rebellion, and took Stevens' advice. He left again for America.

Karefa-Smart and his family went to New England, where his wife was raised. A friend at the Medical School, Dr. Alonzo Yerby, persuaded him to come back to Harvard to teach public health.

He accepted Harvard's offer of a visiting professorship, and, with a handful of others, has been trying since 1971 to elevate preventive medicine from its marginal importance at the Medical School. But his success has been limited. After a steady diet of Dr. Kildaire and Marcus Welby, Americans are conditioned to curative medicine. "It's natural," says Dr. Dieter Koch Weser, associative dean of the Faculty of Medicine and a close friend of Karefa-Smart. "Someone comes to you with a high fever, you give him antibiotics, and two days later, you have accomplished a minor miracle. It's dramatic. But if you walk into a village, line up 200 children, and shoot them with a vaccine, you're no hero."

Saving a few lives continues to be more attractive to medical students than protecting against losses that can only be measured statistically. Emphasis on curative medicine also decreases the probability that patients in Third World countries will die of an easily curable disease while the physician stands by helpless without modern equipment.

"Sometimes, this will have to happen," Karefa-Smart says. "It will not be easy for the doctor, but you have to think of how many lives can be saved with the money that might buy one kidney dialysis machine. You have to set priorities, think of the community. Sometimes you will appear a villain."

Americans, Karefa-Smart has found, would usually rather be the hero. "The American success story has always been that of the individual," he explains. "Supposedly, an individual can by his own efforts rise from lowly cabin boy to president. So the individual tends to look after himself. True community health and capitalism may well be antagonistic."

While his years in the west have taught him the techniques of modern medicine, the workings of power, and the comfort one man may occasionally achieve, Karefa-Smart has resisted the indivudal-oriented outlook--he says he still thinks like an African.

"My approach to life is still very much the same way," he says, surveying his own development. "I'm still very much community conscious. This is why I have never sought a career outside of Sierra Leone. The values I have are essentially African values."

So Karefa-Smart continues to look toward his homeland, writing to friends there, sure that he must return, determined that he will. But he says he is afraid that should he return people might say, "Ah, Karefa-Smart is back. Perhaps better days are at hand." And the political turmoil will begin again.

What if he finds that he will never be able to return to Sierra Leona? "In that sad case," he says, "I will adopt another African country. I would go there, and do what I could in health and politics. There certainly is much to be done."