Monday, March 25 – And back to our neurology clinic, though without our pediatricians….

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(Author’s note: though these blogs were written following my return from Karatu, they were written with notes and a fond memory of our visit)

It had been a glorious trip to the Serengeti and perhaps an even more memorable trip to Kitashu’s boma over the weekend, all without incident, and we were now back at FAME to finish out our week. Dan and Marin would be leaving us today, though, to head back to CHOP and to resume their normal schedule there working in the neuro ICU taking care of very sick children with a tremendously greater repertoire of incredibly costly procedures than anyone here could ever imagine. They were scheduled to fly to Dar es Salaam first (a long story that if you’re interested you can ask either Dan or Marin about) around noon and then from there, would be on their way to Doha and then Philadelphia. They had to leave around 6:30 am to make the three hour plus drive to the airport, but both Phoebe and I were both up to see them off. Charles, our “fast Noah” driver was there on time to pick them up and whisk them off, though I know that each of them was already regretting having only come here for 2 weeks, something that they were both planning to rectify in the future, meaning that they would be back again. Of that, I was certain. A “fast Noah,” by the way, merely means one that is direct and doesn’t stop at every little town to pick people up. It is faster by nature of the fact that it doesn’t have to stop rather than how fast it drives.

Meanwhile, still weary from our safari (except for Daniel who had remained at home spending relaxing periods in my hammock), the rest of us prepared ourselves for clinic without the luxury of having our two amazing pediatric neurologists with us who we had become quite accustomed to over the last several weeks. Though I have seen children throughout my career, I will be the first to admit that I am not a pediatric neurologist and the benefit of working with someone like Dan or Marin had not been lost on me for nary a second. Seeing neonates or young infants with congenital, genetic or mitochondrial disorders is not something I, or any adult neurologist for that matter, feel comfortable with and I am not ashamed to admit that. Our adult neurology residents do rotate through the very best children’s hospital probably in the world, but the training is cursory at best, and is certainly not expected to turn them into a card carrying pediatric neurologist when they’re finished. As I’ve mentioned before, probably a third of our patients at FAME are pediatric, and many of them are infants.

We had morning report at 8 am, as usual, and then it was on to our clinic beginning at 8:30 am. I usually try to reserve this last week for us to see the follow up cases who we had asked to return to either monitor a medication’s effect or to just see the patient again and re-examine them if that’s what was needed. Overall, though, it is often a mix of patients that waited until the last minute to come see us, some who have been cared by us before, but hadn’t made it back yet, and still others who just happened to see our announcements very late and decided to come in the last days. I had hoped that at least the majority of the children had been seen previously by Dan with either Marin or one of the other residents, but this wasn’t to be the case today as it seemed that we had a deluge of children brought to us throughout the morning. The residents resorted to texting Dan and Marin throughout the morning and for the rest of the day and, thankfully they were only in the air for a short time on their way to Dar, and so were readily available to provide consultative services for us, at least for today.

Though, luckily, there were very many adolescent children with disorders we all felt comfortable with, there were also those younger children with such things as developmental delay that can be a bit trickier to sort out. Despite all of this, we made it through the day and the residents continued to provide the exemplary care that both I and the patients here have always been so accustomed to over the years.

The Maasai Market occurs in Karatu twice a month, on the 7th and 25th days of the month and so, at the end of the day, there was still enough time for those who wished to check out the market and enjoy the sights. Just to clarify, though, there are several types of Maasai Markets that you can find here in Tanzania. One type of market is comprised of vendors that are in kiosks selling Maasai or Tanzanian handicrafts such as jewelry, wood carvings, baskets and just about anything you can imagine that you would want to bring home to someone as a gift. These markets are for the “mzungu,” which actually means “stranger,” but is actually more widely used these days to mean a white person. It can be used in both a derogatory and a non-derogatory manner and though I’d like to think that it is more commonly used the former, it is sometimes difficult to tell. So, the Maasai Markets with the handicrafts that I’ve described above are designed for the tourist trade and many towns have one or two of these in them where you can find things to bring home as gifts.

The other type of Maasai Market, and the one that everyone was going to visit today, is a market where the locals come together to buy and sell just about anything that you can imagine. The Maasai men will travel from the surrounding areas to sell their goats and cattle and local farmers will bring their vegetables to market. There are braided ropes and chicken cages, plastic containers of oil and bottles of honey, bags of rice and other grains. And then there are clothes. Sure, you can find clothes made out of Kitenge cloth here, but what you really find are the clothes that have been discarded and collected in our country, and then shipped to Africa in huge bales that are compressed and tied into 4’x4’x6’ blocks of solid cloth, until they are cut free and released, exploding into a literal rainbow of colors and textures that are then madly sorted through until one finds the right size and style and color they’re looking for. Some are new clothes, but most are used and you can find virtually every school in our country represented here in some way, shape or form. You can also find the Championship Superbowl T-shirts for the losing team if you are so inclined as they are printed in advance and then shipped over here immediately after the game so as not to cause any confusion at home. Sifting through the clothes can also be an adventure, as Jess and Jackie learned here several years ago in the company of Paula, our volunteer coordinator back then.

The practice of our hand-me-downs being donated (really discarded), bundled and shipped to Africa has always been a controversial area for a number of reasons (stunting development of local economies for one) and there has always been a little sense of incredulousness over the fact that you can spy every institution from home represented here on the streets of Arusha, and even more impressively, Karatu, can be a bit unsettling even to the most seasoned of travelers. The argument that these clothes would have ended up in the landfills if they weren’t here just doesn’t hold water in the long run, though, as that’s good for us perhaps, but not for the receiving countries. It is perhaps more of a commentary on our practice of massively over producing so that we can make sure to overstock the shelves of dozens of shops and department stores that all carry the same thing with merchandise that is duplicated over and over again just to prevent the possibility that one may not find what he wants at that very moment and may have to look elsewhere. Though the clothes are donated and probably shipped here by some nonprofit for little or no cost, there is no question that they are then sold on the docks in Dar to the vendors who load them into their trucks and cart them off to the market where they are then sold for what may be pennies to us, but not to those buying them. Seeing your alma mater worn in a remote village in bush, though, can be just a little bit disorienting at times.

This was of course the premise of a wonderful book called “The Blue Sweater,” the true story of a woman whose unsettling career amid the financial giants of Wall Street eventually leads her to Rwanda where she actually sees a young boy unmistakably wearing the same homely (read ugly) sweater that had been given to her as a gift when a child and which she had, with tremendous gilt, given to Good Will, or someone similar years before. This was, of course, only a very peripheral commentary in the story, which really revolves around the concept that throwing money into third world countries, like those in East Africa, is pointless, without first providing the means of a sustainable economy. In a true “teach a man to fish” manner, she teaches a group of women in Rwanda how to create a bakery that becomes incredibly successfully to the level that they are now supporting their families and all is well. But then comes the horrifically ugly genocide when she is back home for a few years and everything she has built for these women, who are both of Hutu and Tutsi descent, has crumbled as the result of a senseless conflict. She returns and interviews the women, many of who are now in prison, accused of otiosities and awaiting trial. Regardless of knowing the full story of the genocide or having watched or read “Hotel Rwanda,” “The Blue Sweater” in an engrossing story of one women’s discoveries in her quest to change the lives of those she is able to touch. I highly recommend it.

The Foundation for African Medicine Education, is the same sense, a “teach a man to fish” story as the mission here is not really to swoop in and provide care to patients without leaving behind the knowledge and expertise we bring to continue providing this care to patients in our absence and into the future. Though we are not training neurologists, per se, what we are doing is providing a basic understanding to those clinicians at FAME who will go on continue providing this care and, hopefully, teaching others as well. In this manner, we can continue to improve the lives of those individuals with neurological disease in the Karatu District along with their families and fellow villagers.

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