Our Last Clinic Day of the Season…
One of the most difficult things we always have to do deal with at FAME is whether patients and their families have the resources to pay for care that might be necessary if they must be referred to another facility within Tanzania. At the present time, there are no x-ray facilities nor CT scanner at FAME and much of what we do requires the latter and the study is very expensive to obtain. MRI scans within the country are only available in Dar es Salaam, a ten hour bus ride or $1500 medical flight if that is necessary. They are also available in Nairobi and many patients will travel there for their healthcare if they can afford it. So when we refer patients to Arusha for a CT scan or to Kilimanjaro Christian Medical Center in Moshi for care, we must have a conversation with the family regarding their ability to pay for these services and if it beyond their reach then they must decide what to do. Unfortunately, FAME cannot possibly cover the cost of a patient’s care elsewhere within the country. Certainly, we have had special cases where we do everything possible to help a patient and their family, but trying to provide for everyone would quickly drain FAMEs operating funds and it would cease to exist. This dilemma occurs on a daily basis and I am often running to Frank or Susan to discuss a case with them in this regard and it is nearly as often that this discussion will be a reality check for me and much needed as this is not the typical conversation back home in the U.S.
Our last full day in the clinic began with another wonderful lecture by Thu, this time on headache. She utilized case presentations with participation by the doctors to demonstrate the various headache syndromes we see and when one should be concerned about the complaints that may suggest another cause of the headache requiring further evaluation. Headache constitutes a significant group of the patients we see at FAME and as soon as we hear them say “Kichwa” we immediately know that we will be starting our specific list of questions to determine what type of headache they have, what investigations are necessary, if any, and how we will proceed to treat it.
Our first patient of the day, though, was an entirely different story. He was a healthy 30-year-old Maasai who had given a history that he couldn’t walk or urinate for several weeks. We wheeled him into our office to begin our evaluation and were given the history that he had presented to a local hospital in his area (very far from FAME) with the complaint of inability to urinate and leg weakness and that they had merely placed a catheter in him and sent him home. Our examination was quite clear that he had a problem in the thoracic cord and most likely something was compressing his spinal cord at approximately the T10 level. He had no movement in his right leg and little movement in his left leg and his foley catheter that had been placed two weeks prior was still present. This was obviously not a good situation and the first thing he needed was a CT scan of his back at the very least, though an MRI would have been wonderful. The top of our list for diagnosis was Pott’s disease, or tuberculosis of the spine, and though his labs didn’t point to that, we still had great concern for it. We sat the patient and two family members down and recommended that he go to KCMC to be further evaluated and treated. They agreed, but said that they would have to spend the night in Arusha so they could receive the necessary funds from other family before traveling there. Though it’s unlikely he will do well, it wasn’t possible for us to tell a 30-year-old not to make an attempt to find a firm diagnosis and, however slim, treatment.
Another case for us during the day was a older Iraqw Bibi who came in with her daughter as she had been very withdrawn and was not talking much. After a good deal of history taking, during which her daughter, who had been doing most of the talking and had to finally sit outside for us to hear from the patient, it was determined that she had a very difficult home situation in which she was taking of and providing for her five grandchildren. Her daughter’s husband had left him and she was now responsible for the entire family. There are no therapists for us to refer her to or psychiatrists that are available and so after a long discussion with her to make sure she wasn’t suicidal, we placed her on fluoxetine, or Prozac, and asked her to return in one month. We also asked her talk with other family members who are close and may be able to provide some comfort and help for her. This is often the case, that patient’s lives are very difficult here, and they are attempting to provide for multiple family members and, just as often, multiple generations.
Shortly after our arrival to FAME, I had asked about Roza Andrea, who is the young woman we had diagnosed with a somewhat rare condition, Sydenham’s chorea and endocarditis nearly three years ago. I have seen her every six months since then and, due to her condition, she must remain on antibiotics for many years to prevent further damage to her heart that could potentially require surgery, or quite possibly, worse. I’ve shared her story before, but it is one that demonstrates the level of care at FAME along with simple internet ingenuity using cell phone videos. The history was unclear when Roza was brought to FAME after two weeks of abnormal movements, becoming mute and non-communicative. Frank sent a simple video to Danielle Becker and myself and we both immediately replied to him with the diagnosis based on those images, directing them to immediately look at her heart and making the diagnosis before any further damage could occur. A subsequent echocardiogram confirmed her diagnosis and that she had received treatment just in time to prevent her from requiring surgery then and in the future. It took over nine months of on and off treatment with steroids, but the movements eventually subsided and she was able to go back to school.
The problem now was that Roza hadn’t been coming back for the monthly injections of penicillin that she required to prevent a relapse of her condition and hadn’t been seen since last March. Dr. Gabriel had made multiple calls trying to reach the family, but to no avail. I asked him to make some last attempts before we left and, finally, at 4:30pm on our last day in clinic, Roza came in much to my relief and by herself. She told us that the family had moved down the rift to Mto wa Mbu and that the reason she hadn’t returned was due to expense of the treatments. She is now sixteen and in secondary school and doing well and we reinforced the need for her to be on some prophylactic antibiotic to prevent a serious heart problem. During our last visit we had contemplated switching her to daily oral antibiotics rather than the monthly injections, which we had originally started to guarantee compliance, but had not implemented the oral therapy yet. We gave her a new antibiotic script for daily oral medication and I made sure knew that I didn’t want her off medication again and that she should come to us if there were ever any issue again in the future. She is such a special patient for me as she demonstrates the true power we have in collaboration with FAME both during our visits as well as when we are home in the States and only an email away.
On Thursday evening we learned that the official results of the election had been released and that the incumbent party, or CCM, had claimed victory. We didn’t hear of any specific violence in Arusha, and we were all keeping our fingers crossed for our journey the following day to Arusha, a stronghold for the opposition, and eventually to Kilimanjaro International Airport to begin our long safari home. We all gathered in one volunteer house (it was dark and there were too many mosquitos on the veranda) for our last dinner together, some camaraderie, and an episode of Curb Your Enthusiasm to round out the night. I has been a wonderful visit to FAME, accomplishing everything we had planned to do and then some. For me, it was my 11th visit to FAME and though it has become second nature, I never cease to be amazed at how they have grown in the six months since my last visit. For the others who accompanied me on this trip, the largest group to date, I believe it has been rewarding and amazing for them to see what can be done in such a small, rural community as Karatu, where FAME has truly become a mecca of excellent health care in Northern Tanzania through the cooperation of Western volunteers and the Tanzanians. We will continue to provide the neurology services that have now become a standard of care at FAME and for years to come. To continue improving the healthcare of such a lovely people, where we have always been welcomed as family, has become our mission.