The Iraqw settled the Mbulumbulu region of Karatu District and today have vast fertile fields that they cultivate here with lots of plants including beans and maize. Though there are some lucky enough to own a tractor, or perhaps rent one from a friend, there are many, if not most, who still plow their fields by hand behind teams of oxen and on our drive to Upper Kitete and back it is the most common sight that we see in the fields. The Iraqw settled this area many, many years ago after having emigrating from Ethiopia, as did the Maasai. They were at odds for many years until their truce in 1986 that settled the feud that had been going on for such a long time. They now live at peace with each other and considering that we are treating mostly Iraqw and Maasai in our FAME clinic, I have never felt or heard of any dispute between them. The Maasai are herders and the majority of them in this region live in the NCA, or Ngorongoro Conservation Area, where there are many, many villages and bomas. This is the area that we had visited on Sunday for a social visit to Sokoine’s father’s boma. In addition to the Mbulumbulu region, the Iraqw have settled much of Karatu and areas south, which is where Qaru is and where we visited yesterday.

The drive to Upper Kitete is about twice as long as to Kambi ya Simba as you travel along the escarpment above The Great Rift Valley. The geography here is such that the area between the ridge demarcating the NCA to our north and the escarpment becomes narrower and narrower until it is no more and you can travel by car no further. Upper Kitete is near the end of the line, though there is one more town, Lostete, that is truly at the end of the road and where we plan to do a clinic in October. The road to Lostete can be very bad in the rainy season and rather than risking getting stuck or unable to make it to a scheduled clinic, we have decided to wait until the dry season for our inaugural neurology mobile clinic there.

Today, the roads were fine and we finally had the Land Cruiser fixed so we didn’t have a borrow a vehicle from FAME and I’m sure was much appreciated since the stretch Land Rover we had used on Monday and Tuesday is one of the primary transport vehicles that is used to shuttle staff from town to FAME in the morning and evening. The seating in the Land Rover is for nine, though someone has to sit on the front console sitting backwards since we had ten of us going the days before. The Land Cruiser seats only eight plus the cooler it the back makes nine, but we again needed it for ten, so had to use a soda crate for someone to sit on to take ten. It wasn’t the worst thing in the world, but it is a very, very bumpy drive so each of took turns on both days sitting on the cooler. I think each of us became fairly nauseated, or at the very least queasy on the drives when having to sit in that seat.

As much as Kambi ya Simba has drastically changed since I began coming to these sites in 2011, Upper Kitete has remained essentially the unchanged other than the addition of one building that has three unfurnished rooms and new outhouses. The main dispensary is entirely unchanged and looks exactly as it did     on my very first visit here seven years ago. There is a nurses office on one side that we have used on occasion and did so last visit I believe, but today we were asked to use one room in the new building and the treatment office, where much of the routine care is given in the dispensary, and a room that I have referred to as the “bat cave.” I have used the treatment office since originally coming here and it is particularly memorable in that it has a square of ceiling missing in one corner of the room that leads into the rafters. There has always been the faint odor of bat urine coming from the hole in the ceiling along with occasional squeaks from the bats as they socialize, but they are mainly silent and have never come out during one of our clinics. The odor has never bothered me, nor does it appear to bother the people of Upper Kitete as no one has ever chosen to change anything about the room, the ceiling or the bats.

Susanna and Johannes were working together in the other building where they had a desk and chairs to use to evaluate patients (always helpful), but no bed or examination table. They were working with Emmanuel, who is Iraqw and can always switch quickly between that language, English and Swahili. Susan and Mindy were working with Dr. Jackie in the bat cave, but after they had seen several patients, they moved to the outside and were seeing patients in the outer walkway of the dispensary to have more fresh air as Mindy complained that she was coughing from being in that room. I’m not sure that I really believed it, though, but had no problem with them working outside as the weather was beautiful and the clinic wasn’t crowded so there was more than enough space to accomplish their work.

There was the regular smattering of patients that we see at most locations here, those being headache, generalized body pain or numbness and epilepsy, but one young woman who had seen us was a particularly sad case who had been seen by us previously and was developmentally delayed in addition to having seizures. We had wanted to titrate up her carbamazepine in the interim since our last visit, but unfortunately the patient had not followed up with FAME. The family felt strongly that the medication had not helped her and had perhaps even made her worse. What was striking about the case is that she is moderately delayed and non-verbal, but yet had a three-year-old child that her mother was caring for.

This rather tragic situation is something that I have seen on several occasions in the past and it is even more unfortunate given the fact that birth control here is free, including the implantable long acting progesterone, the Implanon implant device. Thankfully, her family had already taken care of the family planning aspect and had had the implant placed which actually made our job just a bit easier since we wanted to switch her to a medication, valproic acid, that can cause very serious birth defects and so is not used in women of childbearing age unless we can be assured they won’t become pregnant. Her Implanon device was good for five years and had been placed within the last year, so we were safe from that standpoint. The other issue, the fact that she had become pregnant and now has a young child that her family is raising, is unfortunate and thankfully her family has taken the initial steps so that it will not happen again.

 

We had finished our list of patients and were ready to leave when another patient came late to be seen and it was a child with possible epilepsy, so there was no way that we were going to leave as far as Susan was concerned. Though we could have instructed the patient to come to FAME and see us, there was no way to know that that would actually happen so we added the patient to our list and Susan proceeded to see him. Within moments of hearing the story, and I was listening in with the hope of expediting the visit, it was clear that the child was not having seizures, but rather non-epileptic events as they were clearly situational. What was a bit concerning to Susan, Mindy and Jackie, though, was that the child had burns on the back of his hands and they were told that he had fallen into an open fire which didn’t make much sense as to where the burns were. They were worried the child was possibly being mistreated so they spent extra time explaining to the family that the episodes, though not epileptic and not requiring medications, were also not something that he was doing intentionally. There are no social safety nets here in this situation and all we could hope for was that we they were able to get the point across to the family. Hopefully we did.

We had finished up seeing patients in time for us to briefly drive to the Overlook, a spot on the top of the 2000-foot escarpment that overlooks the Rift Valley and allows a vantage point so you can see Lake Manyara far to the south and up the valley far to the north towards Lake Natron. As you approach the Overlook, it appears that you driving into oblivion as the road merely ends at the edge of a dramatic cliff, but is really the incredibly steep embankment that was formed millions of years ago. This region, and nearby Oldupai Gorge, were the birthplace of mankind over five million years ago and everyone on this planet has descended from those individuals who migrated from here to populate the rest of our planet over the centuries and centuries that have followed. We all stood at the edge of this amazing precipice, as I am sure our ancestors did millions of years ago, in wonderment at was laid out in front of us. Huge birds of prey could often be seen soaring high above the ground, but far below our feet, looking for prey as they have always done since the beginning of time. One can easily imagine prehistoric birds having flown these same updrafts, perhaps looking for different prey along the evolutionary line, but prey just the same.

It is impressive how remote this site is and how little know it is. Most in Karatu have never heard of the area as the drive here is one you wouldn’t take unless you needed to, as there is nothing beyond us other than the small village of Lostete. We are lucky to have been invited to continue here to Upper Kitete over the last seven years and I’m thankful to Paula and Amiri for having introduced me to these sites. And I am lucky enough to bring my residents back here twice a year and share it with them for each individual has a different reaction to the grandeur of this place. To me, it is always a highly spiritual moment when walking to the edge of this precipice as I know countless other generations of our ancestors have done in the millions of years that this has existed.

The drive back to Karatu is always breathtaking and today the weather was particularly cooperative so the views were again breathtaking. The escarpment remains immediately to our left as we travel with Lake Manyara and Mto wa Mbu, or Mosquito River, the village at the close end of the lake, laid out before us at the bottom of the valley. We returned home with plans for dinner and then heading out to Happy Day as it was once again Wednesday night, when all the expats meet at the pub to socialize and share stories. I hung out with the other directors of programs here while all of the younger volunteers shared stories or did what those half my age do these days. It is a wonderful community of volunteers here that come from different countries on different continents, yet all have so many things in common. There is such camaraderie of purpose here that can’t go unnoticed.