Mission Not Impossible For Ohio Psychiatrist

Each summer, Mary Kay Smith, M.D., boards a plane in Toledo, Ohio, and arrives at her destination many hours later on the other side of the world. She spends the following month or so living, working, and teaching in sub-Saharan Africa. Her students are eager for information she passes on to them, not because they must remember it for a test, but because they will use it to save the lives of the men, women, and children they encounter daily.

Anna Davies

Since 2001, Smith, who is an assistant professor and director of public and community psychiatry at the University of Toledo College of Medicine, has been traveling to Zambia to teach about HIV/AIDS and its prevention at the Kafakumba Training Center near Ndola to hundreds of United Methodist pastors-in-training. Pastors are often the first people contacted by those experiencing health problems, including AIDS and psychiatric illness.

Smith’s path to Africa began with her work in Ohio in education and publicsector psychiatry. And oddly enough, it all leads back to sports-related injuries she sustained in her youth.

“I went to medical school to be an orthopedic surgeon,” she explained in an interview with Psychiatric News. “I was athletic in my youth and had undergone four knee surgeries by the time I was in high school.”

In her mid-teens, Smith was inspired by her orthopedic surgeon to learn more about the surgeries that healed her and many others. “Whenever I had days off from school, I’d find a ride to a hospital in Toledo. . . .I’d hang out and watch total knee and hip replacement surgeries,” she said.

Bridging Academia and Public Psychiatry

As an undergraduate at the University of Toledo, Smith majored in biology, chemistry, and psychology. “Psychology classes were fun for me, and I found the subject matter to be incredibly interesting,” she noted.

Smith described her educational evolution as a classic example of bait and switch. “The bait for me was orthopedic surgery. The switch was when I got to medical school and realized that orthopedic surgery was not what I wanted to do on a longterm basis.” It struck her one day while driving on I-75 in Ohio that psychiatry was what she loved.

Smith did her psychiatry residency at the Medical College of Ohio and embarked on a fifth year of training in a program that exposes psychiatry residents around Ohio to public mental health in different regions in the state through the Ohio Department of Mental Health.

Today, she is director of that program in Northwest Ohio. Residents are exposed to different settings encountered in public-sector psychiatry, including correctional institutions, homeless shelters, clinics, courtrooms, and various community services. In addition, university faculty members present two series of community conferences each year so that mental health professionals in rural Ohio can expand their knowledge.

“I think it’s important to expose residents to public-sector psychiatry not only with the hope that they will consider practicing in those settings, but also so that they can learn about the recovery of people with serious mental illnesses,” she noted.

Along with the two residency training directors in her department, Smith designs the public-sector and community-based curriculum for psychiatry residents, which is “spectacular,” according to Dale Svendson, M.D., director of the Ohio Department of Mental Health, and includes courses on spirituality, administrative psychiatry, recovery, and the integration of child and adolescent psychiatry with pediatrics.

“Mary Kay has a great deal of energy and has been quite successful at getting residents who finish her program to enter public psychiatry,” Svendson said.

Smith is also a member of the Psychiatric News editorial board.

Fighting the AIDS Pandemic

Smith, through her role as chair of missions at a local United Methodist church and her work in psychiatry, participated in a treatment team meeting in 2000 for a young man from Africa who had been studying in Toledo to take part in a mission to provide medical care to people in Africa. He’d been diagnosed with bipolar disorder and was hospitalized for more than a month after a psychotic episode, Smith noted.

In the meeting, Smith met a relative of the young man, who told her that if the hospitalized family member had experienced a psychotic episode in Congo, he would likely have been suspected of possession by evil spirits and would not have a chance at recovery. The relative was the Rev. Kasongo Munza, and he happened to run a school for Methodist pastors in Africa, he told Smith. “He wanted me to visit Zambia in order to teach our approach to dealing with psychiatric illness” to the pastors at the training center, she remarked. Munza also believed that her status as a woman physician would be important to the pastors who came to Kafakumba from five countries in sub-Saharan Africa.

Smith began teaching at the Kafakumba Training Center the following summer— not just about the causes and treatments of members in the news mental illness, but also about prevention of HIV/AIDS.

According to the HIV/AIDS information Web site Avert.org, an estimated 24.5 million adults and children were living with HIV in sub-Saharan Africa at the end of 2005. During that year, an estimated 2 million people died from AIDS in the area.

In Zambia, where the training center is located, 1 in 6 adults is living with HIV, and 98,000 people died of AIDS in 2005, according to the site. In addition, life expectancy at birth has fallen below 40 years, and 710,000 children have been orphaned because parents have died of AIDS.

Smith called the need for education about HIV/AIDS and its prevention in Africa “staggering.” It is not uncommon, she noted, for the pastors attending the 16-month program at Kafakumba to preside over multiple funerals each day for people who have died of AIDS in their communities.

For Smith, arriving in Zambia and teaching a group of about 100 pastors-intraining about HIV/AIDS prevention was not as easy as, say, educating medical students in Ohio.

In Zambia, Smith would be challenged by deeply rooted traditions and beliefs in presenting a Western perspective of disease and treatment. Her job when she first arrived at the training center was to listen and learn—Smith recalls hours spent talking with Munza on his porch as he described the cultures and traditions of the Luba people.

Illness Attributed to Evil Spirits

She explained that since many native Africans attribute illness to evil spirits, those who are stricken with disease often seek the assistance of traditional healers and pastors, “who sit at the interface of the physical and spiritual worlds.”

Though they use the Bible as the basis of their teachings and sermons, it is not uncommon for pastors to refer people who are ill or have lost their “life force” to prophets or diviners for help. People who are not healthy or have no children are also considered devoid of life force, said Smith.

The prophets and diviners then contact the spirits of the ill person’s ancestors and ask them to remove the evil spirits, spell, or curse, thereby removing the person’s illness and restoring the life force.

Strict adherence to traditional beliefs often leads communities to pursue only spiritual solutions to stem the increasing rate of new HIV infections. Unfortunately, Smith said, many of those same traditions promote the rapid spread of HIV.

“That’s where I come in,” Smith said, who teaches the pastors about the immune system, science, and HIV prevention. But she is cautious about her approach. “I never tell them that their beliefs are wrong.”

Instead, she begins by reviewing traditional African beliefs and traditions and then describes the Western approach to illness and disease management. She presents information in line with the United Nations AIDS Comprehensive Prevention Program, which is translated into Swahili and French for those who don’t speak English.

The pastors accept her instruction and have told her more than once, “Mama Mary Kay, our tribal traditions are failing us. Your explanation makes sense,” Smith said.

Immune System Takes the Stage

To help the pastors understand the immune system, Smith engages them in role-playing exercises. The pastors wear different colored shirts to distinguish themselves as B-lymphocytes, different types of T-lymphocytes, antibodies, phagocytes, and bacteria, for instance, and each person interacts with the others based on what their cellular function is. Together, they make up the human immune system. Smith’s pupils take various instructional methods and information and teach in their communities in Zambia and other countries in sub-Saharan Africa. Some even become politically active by pushing legislatures to implement HIV prevention, screening, and testing in different settings.

Smith also teaches her students about the causes and treatments of major psychiatric disorders—the symptoms of which are also believed to be caused by evil spirits in many of these African regions.

“Mary Kay has been an extremely valuable colleague who has come into this environment and against all odds has done a very good job,” Rev. John Enright told Psychiatric News. Enright’s parents founded the pastor’s school a half century ago, and he now oversees Kafakumba Training Center. “She was eager to learn about the cultures of the African people and to understand their traditions, and rather than disparaging them, valued and respected them,” he said.

This enabled her to take inherently Western concepts that were once foreign to her students and integrate them into the various educational approaches she uses, including “drama” or roleplaying exercises of the human immune system.

“As the play unfolds,” Enright explained, “people are able to understand what the virus is doing to the body. Combined with the scientific knowledge she shares, this drama is then taken to the villages and reenacted, and people are made to understand HIV and AIDS.”

“What she does is miraculous, and we are deeply grateful,” he said.

On the basis of pastors’ reports that have been submitted to Smith detailing their efforts to teach others in their own countries, she estimates that her HIV/AIDS prevention instruction has reached more than 40,000 people in six African countries. Still, she noted, this is not enough.

“I have a really hard time getting to sleep at night after being asked by villagers and pastors, ‘Do Americans know what is going on with us in Africa, with thousands dying every day?’ ” and pondering the seemingly endless need for medical help and prevention training, Smith noted.

“I know that what I’m doing is helping to meet a grossly unmet need in some small way,” she said. “But in the end, I am only one person. The developing world deserves more.” #9632;