Our Last Day and some final thoughts…

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Preface: As you may have noticed, this post is a bit overdue and I will have to admit that I am typing it while sitting comfortably on a train traveling through the suburbs of Philadelphia into Center City. You would have thought that over 24 hours flying would have afforded me enough time to have taken care of this last responsibility, but alas, the movies on board were too enticing and with a bit of busy work for those who know me well.

Following our failed attempt at a wonderful Sunday safari in the Crater we were able to completely pack that day which made for an unhurried and more relaxing last morning than usual. Our Land Rover had miraculously been repaired the day before and all we had left to do was load it up with all of our half-packed duffels (not only were we leaving our hearts in East Africa, but also over 150 lbs of medical supplies), say our goodbyes and hit the road. Or so we thought.

I had scheduled a meeting with Susan, Caroline and William (the FAME brain trust, so to speak, with the noticeable absence of Frank as we had work to do) to discuss the future of the neurology program in Northern Tanzania. It was essentially a debriefing along with setting our short and long term goals for upcoming trips. FAME has grown tremendously over the last several years which requires constant vigilance to maintain focus on their mission and purpose. Christyn and Payal attended the first part to provide their valuable insight following their first visit to this remarkable oasis of healthcare.

Our meeting lasted a little longer than I had planned, but we were still reasonably on time for our departure. Frank constantly uses an expression here, “TIA,” which to most is well recognized as a transient ischemic attack, and especially to us nerdy neurologists. Here, though, it refers to “This is Africa.” It is often quite frustrating for us westerners, but time here is different. It is not measured in minutes or hours or even days. It is not the time, but the task that is important and the fact that things get done, not when they are done. And that is because most everything here just takes longer and one can never anticipate what will happen between now and then. Expectations have to be different here for obvious reasons. Hence our previous day’s adventure. We all just said, “TIA!”

We had many, many individuals to say goodbye to and thank here at FAME. For me it’s become an easier task since I’ll be back in six months. As I was walking to the meeting earlier, though, Dr. Gabriel had caught me and asked if we wouldn’t mind seeing one last patient in the ward who had come in the day before with some odd story of a very likely neurologic basis. Knowing that once we leave there would be no neurologist in the region until our return it would be very difficult to say no in this situation. Knowing Gabriel as well, and the fact that he is a remarkably competent Tanzanian MD who I’ve worked with closely over the last several years, it was clear that this was very likely to be something in our bailiwick.

So with our expected time of departure fast approaching (or had it passed already?), Christyn offered to start evaluating the patient on the ward while I took care a last minute detail with Will. When I arrived to the bedside a few minutes later, Christyn was surrounded by the team of doctors and nurses and well into her evaluation. The patient was a 50-year-old Maasai women who was complaining of pain and weakness on one side of her body. She had been seen weeks earlier and sent for a plain x-ray and her working diagnosis was ankylosing spondylitis, an arthritic condition of her spine. It was readily apparent to me on arrival to the bedside and quite clear to Christyn after only a moment that she was far from normal neurologically. Without going into details so as to bore all the non-medical readers and even the non-neurologists, she had a clear problem with misalignment of her eye movements and her exam was grossly abnormal suggesting a problem either in her cervical spinal cord or a bit higher in her brainstem. After brief deliberation, Christyn and I were both convinced it was the latter and she was in need of a CT scan above anything else to make a diagnosis. Problem is, we don’t have one, nor was her family likely to be able to afford one.

Such are the inequities that we face every day in Tanzania and at FAME. Despite our clinical skills and our ability to bring this to such a remote region of the world, without some access to technology we are ultimately unable to provide the care necessary. The team there wanted to know what they could do to further evaluate the woman and the sad truth is there was nothing else until we had a scan. I don’t have follow up yet, but I’m hopeful that somehow she received the scan and, if it showed anything potentially treatable, that she was sent to the neurosurgeons in Dar es Salaam for treatment. But this was just one patient in a country of 47+ million last count. How do we solve this issue of access to health care and the technology gap?

We had planned to hit the road by 10 a.m. and by the time we said goodbye to everyone, stopped in town for a few errands and got cold drinks for the road, it was now noon! The weather was as gorgeous as it had been our entire trip and we made the drive to Arusha through the Great Rift Valley, through the towns of Mto wa Mbu (Mosquito River) and Makuyuni, past the Maasai bomas and to the slopes of Mt. Meru where our adventure had begun three weeks prior. Pendo had lunch waiting for us and we visited with baby Gabrielle before the boys got home from school to play soccer and do our final packing before heading off to the airport. The boys are growing like beanpoles into fine young men and now we get to watch Gabrielle do the same.

The KLM flight doesn’t leave until 9:50 p.m., but you have to get to the airport a few hours early given the often chaotic scene there, but tonight it’s very quiet and we get to spend plenty of time in the Tanzanite Club – they have WiFi and the first air conditioning we’ve encountered in country. The drive to the Kilimanjaro International Airport was uneventful, other than the fact that the top of Mt. Kilimanjaro, which is almost always shrouded by the clouds, was perfectly visible to the north. It was majestic with its long vertical snowfields and it was clearly beckoning me with open arms. It was unusual to see it so clearly and there was no doubt that it was an omen for our return trip in October when we are planning to climb to its summit before our time at FAME. That will be another adventure and another trip. For now, we were more than satisfied with the work we had accomplished at FAME. We had seen over 240 patients in the twelve clinic days there and all but perhaps a dozen by Payal and Christyn. The two of them were stellar clinicians and I couldn’t have been more proud of them. They had an experience that they will never forget and saw things they may never see again, but if they do, they will recognize them immediately. Such is the way medical education and the practice of medicine should be. Technology will never replace the history and the physical examination. It will always be the clinician and the patient….

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