October 27, 2017 – Saying kwaheri, (or baadaye for me), to FAME and on our way to Arusha and the airport……

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NOTE: I do apologize for the length of this post and the lack of photos. It was a very harrowing day (no spoiler alert) and there just wasn’t an opportunity to take pictures. I thank you for your patience.

We were all packed and just had some loose ends to take care of at FAME, one of which was to go to our final morning report. We are there everyday at 8am sharp to hear about the patients in the ward and anything new that may have come in overnight. Presentations are always in English, even when we are not there, so it is easy for us to follow what is going on with patients we have seen, as well as those that we are going to see for neurologic problems. We are treated as fellow clinicians rather than guests. I have never felt like an outsider and I try my best to foster that same feeling by the residents. It’s not easy to practice in a completely different system than we do in the US, but it is also important to remember that it is the same medicine that we practice, so the basic premise if always the same. We help patients to the very best of our ability and we relieve suffering.

We are not here necessarily to practice “Western Medicine,” as that would not only be unrealistic, but also impossible. We are here to teach the clinicians how to evaluate neurological patients, which is the same anywhere one cares for patients, and to help develop a treatment plan in cooperation that fits within the paradigm of care available here while also considering other options that also fit within that paradigm. Teaching care that would be impossible to provide here, such as doing an MRI for every patient presenting with a headache, which is often the case, unfortunately, in the US (and can no longer be sustained for very long), would do a tremendous disservice to FAME, the Karatu community, and the people of Tanzania. There is only one MRI currently available in Northern Tanzania, and that is when it is operational, which is not all the time. The medical school at Kilimanjaro Christian Medical Center, the only one in Northern Tanzania, only has a partially operational CT scan and no MRI.

Our role is to enlighten, and to be enlightened. That is the beauty of FAME and its mission, which is often lost in so many other institutions and programs. For it is only by providing this two-way learning experience and the opportunity to work side-by-side with the Tanzanian caregivers that one can really appreciate and implement to improve health care here in Tanzania and elsewhere. We had all felt truly welcomed for the entire month, and, most importantly, the residents, who have not been here the fifteen times that I have, were welcomed and appreciated. That was clear not only from the comments of Dr. Gabriel at morning report when he offered his and everyone’s thanks for our being there, but also from how everyone worked together during the month. It was a cooperative effort.

We had one last patient to see after morning report that we had known about in advance so it wasn’t a burden. We took care of our 325th patient of the month and closed the books on another incredible visit, having seen the more patients than ever before. Each of the residents had seen well over 100 patients (I had seen only one patient by myself this visit, someone I had seen in the past and had asked to see me personally) during the month and had seen pathology they had never seen before, but had quickly recognized it. They had never appeared stressed from the volume nor did they ever shy away from volunteering to see that last patient in clinic, all despite the fact that they had seen far more patients than they would have ever seen in the same time period at home.

We packed the Land Cruiser with everyone’s duffels and drove it up the parking lot to say goodbye to everyone we could find. As I’ve said so many times, it’s much easier for me to leave than it is for the residents, as I will be back in six months and the likelihood of their return is less certain, though it always remains a possibility. We headed down the FAME road towards town, having only to throw some fuel into the vehicle, buy some airtime, change some cash and then stop by Daniel Tewa’s to pick some extra coffee beans to bring home for friends, before departing Karatu on our way to Arusha.

There was one last chore to take care of and that was to meet up with Ståle Anda, the Norwegian gentleman who so selflessly takes care of the children with neurologic impairments in Mto wa Mbu, so we could pass on some donations that I had received to be directed to him to assist with his children. I had texted him yesterday to let him know we would be passing through, but when I called him this morning, he was just leaving Arusha having to make an unexpected trip there. We decided to meet up in Makuyuni, a junction on the highway half way in-between Karatu and Arusha.

As I pulled into Makuyuni and waited at the agreed upon spot for well over 15 minutes, we were bombarded by Maasai women selling their beaded jewelry at our windows, but there was no sign of Ståle. I had finally decided that we would have to leave, as we were already running a good hour behind schedule, and I would get the money to him another way, when, as I was turning back up on to the tarmac, who was just making his turn at the junction but Ståle. We both pulled to the side of the road and I ran across to give him the money we had for him, and then he came across to our vehicle to thank each of the residents, each of who inquired about the children he had brought and who they had seen. Father Bill from the Caron Foundation, a very good friend of mine and someone who I owe a tremendous amount to, calls these “God-incidents” rather than “coincidences.” I truly believe this to be the case.

Our drive to Arusha was otherwise uneventful, though as I had mentioned, we were well behind schedule for the airport. We stopped briefly at the Shanga Shop, and then traveled to the Maasai Market, a permanent market here in Arusha that is comprised of probably over 100 stalls, most of which carry the same merchandise and all of which are manned by shopkeepers who can be very aggressive in trying to persuade you to step into their shop. It can be a bit nerve wracking and I warn each and every resident of this long before we arrive. We didn’t have much time, but everyone wanted to find just a few more gifts before they left, so I waited while the three of them shopped.

We were finally able to break free from the allure of the market and head to my the Temba’s house so they could say goodbye to Pendo and little Gabby, while also meet the boys. Pendo, of course, had prepared a small lunch for everyone so it was not until probably 3:00 pm that we were able to hit the road. I knew that things would be rather tight as I usually leave much before that, but at least we were on our way. The new four-lane highway had finally been finished in our absence over the last month but there was still an occasional vehicle traveling on the wrong side in the wrong direction and I was thankful that it wasn’t dark yet.

The four-lane extends for perhaps 1/3 of the way to the airport perhaps, and after that, it’s back to the two-lane highway with trucks that inch, at best, up steep hills and practically stop at every speed bump. I finally decided that I had to pass and am fairly certain that I did so on a broken line as I had been fined for this in the past, but apparently I had finished the pass on a solid line. The traffic police, of course standing at just the right spot up ahead, waved me over in a flash.

She asked for my license and when I tried to explain to her that I was certain the line was broken when I started the pass, she didn’t want to listen whatsoever and kept repeating, “Mr. Michael, you were overtaking where you can not,” or something to that effect. Despite my continuing to vigorously make my claim, she would have none of it and wanted me to pay the 30,000 TSh (less than $14) on the spot at which point she’d give me a receipt to ensure she wasn’t pocketing the money for herself, but that it would instead go to the government. This had been a problem in the past; fines going into pockets rather than the government, i.e. bribes, and the new president of Tanzania has cracked down significantly on this. We were already so late that I couldn’t really argue any further, nor do I think it would have mattered at all, so I paid the fine, collected my receipt and we were soon on our way, albeit a bit lighter in the wallet.

We finally made it to the airport at around 4pm for a 5:40pm flight time and, though I knew it was pretty tight, I didn’t think there would be any issue getting everyone checked in. That was until I went to open the boot (back door) of the Land Cruiser and found that it didn’t want to open. I had put all of their luggage in the back so it would be together and easily accessible when we reached the airport. This is not a locked door mind you, but the back compartment is completely separated from the inside of the vehicle by very strong bars making it virtually impossible to get anything through by reaching into it. Likewise, there is no handle on the inside. I tugged and tugged on the handle to no avail and finally resorted to some very strong flat footed kicks that I am told completely impressed the residents as they didn’t think I had it in me.

Finally, a few of the workers at the airport pitched in to try, but were also still unsuccessful in getting it open. Neena finally suggested that perhaps they should just fly without their big duffels and I would bring them with me when I flew home, which was an excellent alternative, but would likely be very costly. Fifteen minutes had gone by during which the clock was continuing to tick as they really needed to check in and we would soon be risking them missing their flight. At the very last minute and why, I am still not sure, the door popped open as if it were a test of will and had finally decided that it had enough fun with us. I quickly removed the bags and got them on their way to the front door of the terminal, which was as far as I could go. We bid farewell with hugs and shouts of “safari njema” (safe travels) and they were finally on their way. I watched through the glass as they each approached the ticket counter to make sure there wasn’t an issue and watched as they went off towards immigration. Not the type of send off that I had planned and I must admit that my nerves were just a tad frayed from the drive and the boot door sticking, but in the end, it all worked out.

I decided to take my time driving home considering the harrowing time I had had getting everyone to the airport. I grabbed a Fanta Passion (our favorite drink here along with the Stoney Tangawizi – strong ginger ale) for the drive home and headed back out onto the highway. Nearing Arusha, on the four-lane highway and just about to take my turn off onto the road to Njiro, I was once again pulled over along with a number of other vehicles. An officer walked up to my window and again asked for my license. I was still a bit baffled as to what I possibly could have done when he told me that I had exceeded the speed limit and was traveling 55kph when the limit on the four-lane highway was 50kph.

Now mind you, there are no posted speed limits on the new four-lane and the speed limit traveling through a village on the two-lane highway is 50kph (i.e. pedestrians crossing the road in front of you) while the remainder of the road is in excess of 80kph. Also, remember that 50kph is only 30mph and pretty much a snail’s pace. Basically, I had no defense and he told me that I’d have to pay the same 30,000 TSh fine as before. I went through my wallet and found that I had only 23,000 TSh there along with a $50 bill that wouldn’t do me much good in this situation as I certainly wasn’t going to hand that over as I’d rather have them haul me off to jail. I kept telling the officer that I only had the smaller amount and he kept telling me that he wanted the full amount which I didn’t have and wasn’t possible. We were at this standstill for a bit and I wasn’t in a rush this time so I just sat there smiling at him. He apparently became frustrated with me and finally called over a senior officer who came up to my window smiling, telling me that the fine was 30,000 TSh. When I explained the situation to him, he had a bigger smile and said, “10,000 shillings and no receipt.” Having no good alternative to the situation, I was more than happy to hand over the 10,000 TSh (slight more then $4), even though it was promoting the old style of doing business here, namely bribery, which everyone detests, but still exists.

So much for my civics lessons as I drove home very slowly, staying on the right side of the white line at all times regardless of how slow anyone was traveling in front of me, with the hope of avoiding a trifecta for the day. Such is life here. I did make it home and had absolutely no intention of going out on the road again that evening. I spent time with the Temba boys and little Gabby, counting my blessings that I was safe and sound, and that the residents were safely on their way home to the US after such an amazing adventure that we all shared together. Four weeks of seeing patients at FAME and in the bush, traveling to three parks and seeing the great migration in all it’s glory, enjoying dinners and lunches together and learning another way to live if only for a short time, we have each become that much better of a neurologist for it and that much better of a person. It is these experiences that will last a lifetime.

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