The third week of our clinics here in the Karatu District have traditionally been reserved for our outreach clinics, or mobile clinics, to some of the local villages around Karatutown. The neurology mobile clinics began back in 2011, with clinics primarily to the Mbulumbulu region of the district, but have grown now to include other villages. We have managed to continue them despite limited funding and it has only been through the help of FAME as far as staffing. The clinics are announced in the villages where they will be held, similar to what we do for our clinics on campus, and the outreach coordinator/social worker will usually return again to the village weeks prior to our arrival to remind them of the disorders that we treat. The clinics are limited to only neurology patients as that is our primary purpose here and we are not interested in alienating the clinical officers and nurses who are staffing these dispensaries on the daily basis when we’re not there.
The team that we bring is large and over the last several years, we have required two vehicles for each of the clinics. We bring our entire group (myself, the residents and medical student, as well as Ray today), one clinician from FAME (Dr. Annie), our two Tanzanian medical students who have been acting as interpreters (Abdulhamid and Reivo), a social worker (either Angel or Kitashu), a nurse/pharmacist (Patricia or Yona), and a registrar (Yohan) to take care of registering the patients. We bring a large Rubbermaid container of medications with us for most neurological disorders including antihypertensives. In additional to the announcements made in advance regarding what types of symptoms we are willing to see, Dr. Annie will address the group of patients to let them know what we do and what we will see. The cost of being seen is identical to that at FAME, 5000 TSh, or just over 2 dollars, and includes the visit with us and medications. We are unable to do lab tests on site, but give the patients a prescription for the labs so that they could travel to FAME to get them and would not be charged an additional amount.
Kambi ya Simba, or Lion’s camp, was the first site of our mobile neurology clinic and, back in the beginning, it was only me with a clinical officer, a nurse/pharmacist, Paula Gremley (who had her own non-profit for provided these services), and Amiri Bakari (Paula’s business partner) who drove us everywhere. We also went to the village of Upper Kitete which was further out on the escarpment, though still in the Karatu District. The Mbulumbulu region is inhabited primarily by the Iraqw tribe and the area is quite fertile and good for planting. For the last eight years, we have done various combinations of clinics at these two villages in addition to some others, but the numbers had been dwindling at Upper Kitete, and so it was decided that we would only go to Kambi ya Simba for this trip and patients would have to travel there if they wished to be seen by us.
The dispensary/health center at Kambi ya Simba has had an interesting evolution in that the very first clinics here were held outdoors in a field where we would set up a desk for me to sit at and write while the “pharmacy” was another desk set some distance away. This was not at all an issue and it seemed to work quite well for both us and the patients. Several years ago, though, the health district decided to begin building a much more expansive health center at Kambi ya Simba that eventually warranted a visit from the Tanzanian Prime Minister. The health center today comprises numerous buildings and wards and is still expanding. Most of the facilities have not yet been fully utilized, but I am sure they will in the near future. There is a very large population in this area that would certainly benefit from a greater access to closer health care, though it is not difficult to get to Karatu from this region if needed.
So, we began our week of mobile clinics by setting off to Kambi ya Simba with our two vehicles, medications, and support staff for the 45 minute drive to their health center where our clinic would be held. This will be my 17th or 18th visit to this village for neurology mobile clinic so that I know the road very well at this point. When we arrive, it is usually customary for either Kitashu or Angel to speak with the clinical officer in charge to make sure that we are still welcome and the find out what the arrangements will be in regard to the number of rooms that we’re given. It usually depends on whether they are having their own clinic there that day, which they were today, and therefore we were only able to utilize two rooms as opposed to our hopeful three or four. With two rooms, the day would go a bit slower and we had enough patients that we weren’t able to finish and depart until later than we had hoped for.
Ray was able to accompany us today and since it was his last day working with us, he opted to staff most of the patients that were seen, though I was able to snag a few. The bulk of our patients here had headaches of various types, but none that were concerning enough to warrant further evaluation with other testing. Depending on other symptoms and comorbidities, many of the patients were placed on amitriptyline which is our main chronic headache medication here. Those who work with me are well aware of my being very partial to nortriptyline rather than amitriptyline due to its far less anticholinergic side effects, but unfortunately, the former is more expensive here in Tanzania for some inexplicable reason.
As is often the case with patients coming to see us for what are felt to be neurologic symptoms, their underlying problem turns out to be of a more psychiatric nature. The same is true for our patients at home. Anxiety most commonly presents with symptoms that are felt to be of a neurologic basis and then there are the psychosomatic illnesses such somatic symptom disorder and conversion disorder, both illnesses in which symptoms that are believed to be physical, are actually of a non-organic cause. Probably one of the most consistent conditions in this realm that we see both at home as well as here, are the non-epileptic events, or what used to be called pseudo seizures. We see these frequently here as we do in the US, and they can often be very difficult to treat in the long run, though they can frequently resolve over time. These disorders seem to be very difficult for non-neurologists to diagnose and manage and Ray is actually planning to do a lecture on the topic tomorrow morning for the FAME staff. The biggest issue in making the diagnosis, as Ray so deftly noted when we were discussing is lecture, is that you must first feel totally comfortable with your ability to make a neurologic diagnosis before you are able to rule out one.
So, several of our patients had symptoms of either depression or anxiety that we wished to use either an SSRI or SNRI medication for, but unfortunately, we discovered that FAME had actually run out of fluoxetine, which we were unaware of, and that we actually hadn’t brought the venlafaxine with us. This was a significant problem for us as we had wanted to put two women on fluoxetine for their anxiety during our morning clinic, but did not have the medications with us to give them. Luckily, there was a patient from Rift Valley Children’s Village who had been sent to FAME to see us, and when it was discovered that we weren’t there, they sent the patient over to Kambi ya Simba to see us instead. We asked if the vehicle from Rift Valley could possibly bring the two women to FAME when they left as it was on their way back home and, that way, the women could pick up their fluoxetine that we had prescribed them since we’d found out that it had been delivered that morning and was now in supply. Things often happen this way in Africa, and it is all a matter of taking advantage of the situations that you’re presented with rather than restricting yourself to those that have been planned. If you sit around waiting for those moments exclusively, you’ll miss tremendous opportunities in life. The two women traveled to FAME for their medications and would return later on the bus, but would otherwise not have been treated which would have been a shame.
The rest of the clinic went smoothly, other than the fact that we ran later than we had anticipated given the fact that we only had two rooms in which to work and, though we weren’t necessarily swamped, it was still a long clinic. We finally departed around 4:30 or so which would put us in Karatu at bit after 5 PM and we had hoped to pick up the clothes that everyone had made by Teddy, a seamstress that we’ve used on the last two trips and everyone has been exceptionally happy with her work. I texted her to let her know that we’d be a bit late getting into town and, of course, she said that she’d be happy to have us stop by whenever.
Knowing that the visit would not be quick as everyone would want to try on their new clothes, I prepared Ray for the extended visit. As expected everyone was incredibly happy with the work that Teddy and her other seamstresses had completed and the most impressive work was the short sleeved jumpsuit that Mike had made for himself. It’s certainly a unique piece of clothing to be sure, but I’ll have to admit that I was incredibly impressed with the style and fit. By the time we got home that evening, I think everyone was exhausted following the busy day and upon returning home, it seemed that everyone was appropriately exhausted and ready to hit the sack. Tomorrow morning, we would be traveling to a clinic that was much further and would have to leave much earlier than we had today, It was off to bed to make sure that we all had enough rest before hitting the road once again tomorrow for a very early departure time of 7 am.