March 20, 2017 – Kambi ya Simba….

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This will be our week of mobile clinics for the neurology team and there is always a bit of stress associated with making certain that everything we need has been loaded in the vehicle as we can’t come back for anything once we’re out. When I first arrived in 2010, FAME had been running a big mobile clinic to the Lake Eyasi region one week every month since they hadn’t opened their hospital and the clinic visits were at a low enough volume that it was still doable to split the clinical team and make things work. In 2011, Paula Gremley, who had been working with FAME at the time on the mobile clinics to Lake Eyasi, suggested that she and I travel to several villages in the Mbulumbulu region of the Karatu District where we would see only neurology cases specifically as each of the villages have their own small government dispensaries so we weren’t looking to do general medical care there. Paula, who ran her own non-profit at the time, was interested in providing neurological care to patients in the region and so it worked out perfectly with my trips to FAME and an interest in developing a neurological presence here.

Paula, unfortunately, left to return to the US shortly after our “mini mobile clinics” (in deference to the large mobile clinic to Eyasi) began, but it was a concept that I had felt strongly about as did Susan and Frank here at FAME. When the funding for the Eyasi trips had ended (They were funded by Malaria No More, a Dutch based non-profit), the Neurology Mobile Clinics became the main functioning remote clinic for FAME other than the Rift Valley Children’s Village (RVCV) biweekly clinic that was run at RVCV to care for the patients there as well as the adjoining local village. Since 2012, we have been running a series of mobile clinics in two villages in the Mbulumbulu region as well as at the RVCV accompanying the FAME general clinic there.

Nan examining a patient with Dr. Mary’s assistance

The Mbulumbulu region is a remarkably gorgeous area that follows along on the high side of the rift and forms a triangle bordering the Rift Valley and escarpment to the southeast and the Ngorongoro Conservation Area to the northwest until it reaches it’s apex about half way to Empakai Crater. This region is populated mainly by the Iraqw and is blessed with extremely fertile soil so that it is heavily farmed with many varieties of crops. Driving through this area one is continually reminded of the main occupation here which is farming as there are always people in the fields working, and certainly now as we are nearing harvest time before the big rains of April and May. The road is generally good, though once it is raining it can become quite treacherous and I have learned that the hard way in the past having gotten my Land Rover, a virtual tank of a vehicle, stuck axle deep in the mud after running off the road during the heavy rains of April.

For this year’s mobile clinics, we have chosen to visit two of the original villages in the Mbulumbulu region, Kambi ya Simba and Upper Kitete, though we’ll do only one day in each where we have done two days in each in the past. Kambi ya Simba is the closest of the two villages, about 45 minutes away, while Upper Kitete is almost exactly twice the distance, or about 90 minutes away. For this year, we will be going to another village in a different region, Qaru, in the Endabash region, and spending two days there. Sokoine and Alex had been meeting with villages in this region and chose Qaru over the others for several reasons. We will then finish off the week at Rift Valley Children’s Village on Friday.

Chris examining lower extremity strength with Dr. Mary’s assistance

We had told our patient with HIV and the abnormal CT scan with presumed toxoplasmosis to come at around 8 am on Monday, and sure enough, there he was, having traveled several hours by bus to see us so we could explain his medications to him. Jamie met with him and went over the protocol which wasn’t simple and then explained it to the nurses as well so they could reinforce it with him. He will be coming back to see us next week as well so that we can assess whether he’s had any clinical improvement and after further discussion with everyone, we’ll very likely do a repeat CT scan to gauge if there’s been any improvement in the edema we saw on the first scan, indicating that the medication is working for him. We will have further decisions to make regarding whether we continue him on this course of therapy or not and we’ll cross that bridge later when we’re there and have some more data.

I typically have someone drive us out to the mobile clinics, especially this time of year when a heavy rain can come down without notice and turn the roads into a slip and slide in no time at all. This morning, there was no one available to drive, which meant that I would do all the driving and would also keep my fingers crossed that it didn’t start raining while we were out there. Again, the preparation for these clinics is crucial due to the number of meds we bring, medical tools, and, of course, our lunch which has to be enough for all of us and something that everyone can eat. After filling our fuel tank on the Land Cruiser, we drove a bit further through town to pick up lunch. I sent Nan and Jamie along to make sure what was being acquired would be to their approval as some of the lunch items can be a bit bizarre at times. We ended up with samosas, vitumbua (sp? Fried rice cakes that are delicious, but dripping with grease), donut-like pastries that aren’t very sweet, bananas, and avocados. We also had a huge selection of drinks and addition to the water we bring and which you don’t travel anywhere here without considering any safari (journey) can be an adventure you may get stuck in the bush for hours in the hot sun or torrential downpours as they change that quickly.

We arrived at Kambi ya Simba without incident and found no patients waiting there for us, but it was around 11 am and Sokoine informed us that many people here were still finishing their morning chores so would likely begin showing after noontime. Sure enough, a few patients began to show, but not the volume that we had hoped for. There were a few children for Nan, one of whom was a very cute little two year-old child whose mom brought her in because she wasn’t able to run and play like the other children. It was clear that she had a mild right hemiparesis on her exam that had been present since birth so in the end she was another child with mild CP, though she was functioning very well cognitively with only mild delays. Nan felt she would do very well long term and she instructed mom on some simple exercises she could do that would help with her physical issues. Mom had also described two episodes of seizure in her life so Nan decided to treat her for these as it would be difficult to tell if she were having additional seizures and, if she were having more, they would also negatively impact her development that was already delayed. We stressed the need for her to follow up at FAME for refills of her medication and to see us back in October to re-evaluate her when we’re back.

Nan evaluating our little patient with CP and seizures with Angel’s help

The other patients were a smattering of typical complaints here – headache, neuropathy, back pain – but at the end of the day before our departure we were asked to see a 17 year-old schoolgirl who had been brought in with a severe headache and was in their small ward there. It turned out that her headache was only a minor problem and the more significant issue was the recurrent episodes of prolonged unresponsiveness she was having which would last up to 11 (!) hours and without any clinic story suggestive of seizure. What she had was a conversion disorder (psychogenic) and further investigation by Nan and Jamie it was discovered that she had significant traumatic issues in the past that were contributing to this and was also clinically depressed. After we discussed the case further, it was decided to place her on fluoxetine (Prozac) as she would clearly benefit from a course of antidepressants. Unfortunately, what she really needs is counseling and psychotherapy, but these really don’t exist here in any reliable fashion so we would have to rely on the medications and letting the clinical officer there know what our thoughts and recommendations were so they wouldn’t treat her with anything else for these episodes.

Psychiatric disease is very prevalent here as it is elsewhere, but often presents very differently than it does back home due to cultural variations. Prolonged episodes of unresponsiveness lasting hours and hours is quite common which we don’t see quite as much at home. I have my suspicions as to why that is, but I’ll not bore anyone here with my hypothesis at this time. “Swooning” is quite common as I have seen many a patient brought in by their co-workers from the fields or from their schoolmates from school where they were basically not responding, are carried in, and miraculously wake up within a short time of being here and are back to their normal selves immediately. An unresponsive patient obviously creates lots of excitement and angst among the family and medical staff, which is perhaps the point, but is something that we have dealt with fairly frequently and is most often readily clear to us.

Our lovely child with CP and seizures

We departed Kambi ya Simba seeing perhaps fewer patients than we had hoped, but it still serves a purpose to visit these villages so they are aware of the neurologic disorders we can treat here. For the little girl with CP and developmental delay it will make a huge difference in her life having seen us at age 2 as opposed to at age 10 after she’s developed contractures or has been seizing intermittently for 10 years. Hopefully, we were able to also help the school girl with her depression, but that’s a tougher problem. We arrived home after dropping all of the FAME employees off in town and Nan went to the peds ward to check on her patients here. After relaxing for a short bit, we met up with Alex as we had plans for dinner at the Manor Lodge which is a lovely resort that sits high up on one of the hills overlooking FAME and town. The drive there is through the Shangi-La plantation (coffee) which is massive and then through a short easement that cuts through the Conservation Area where you can occasionally spot some wildlife.

You then cross the gate into the lodge grounds were you enter another world of closely kept lawns and landscaping with gorgeous white washed cottages interspersed looking out over the coffee plantations that adjoin the grounds. The Manor House is a large lodge building with fireplaces and sitting chairs and perhaps the finest dining room in all of Tanzania. I had thought there was lots of silverware at Gibb’s Farm, but there was at least an extra setting here for an additional course so they had them beat. We sat outside on the veranda looking out across the rows of coffee plants in the distance with the hills dropping off to Karatu even further in the distance. Nan was enjoying the grounds taking more photos of flowers and eventually joined us as we relaxed under the clear sky to watch the stars begin to surface as there was no moon. The soft hues of the sunset faded away slowly to an amazing gradient of blues that began at the horizon and darkened to the night sky above.

We eventually moved inside to our dinner table where we enjoyed luxurious service and food to match. Glen selected a few nice wines to go along with dinner and it was a marvelous time with good friends and colleagues as we all share now in our love of Africa and of serving the people here where it makes such a difference. I know that I will be back as will Glen, and I’m hopeful that Chris, Nan and Jamie will consider it in the future, whether it be here at FAME or elsewhere, whether it be Africa or at home, it it is all the same. The lessons learned here will last a lifetime as will the memories, and they will carry it all with them for as long as they live. That is the beauty of it all.

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