Tuesday, September 17, 2019 – A new clinic in Mang’ola….

Standard

The normal way we start our day….shoeing Andrea out of the house

As I’ve mentioned before, the neurology mobile clinics began in 2011, initially at the suggestion of Paula Gremely, a social worker who, with her partner, Amiri Barkari, were doing outreach in area and had been working with FAME on their week-long mobile clinics the Lake Eyasi region to provide medical care to the Datoga and Hadzabe in this very remote region of Northern Tanzania. I had been able to go on several of those clinics that had been funded by a Dutch non-profit, Malaria No More, to provide monthly clinics to this region for a period of three years. Paula had suggested that it might be worthwhile if she took me to some of the villages in the Mbulumbulu region of Karatu district to provide neurological care specifically. The first was in April 2011, to Kambi ya Simba and was very successful. We have continued to provide that clinic to Kambi ya Simba, which is where we were yesterday, though decided this year to forego our visit to Upper Kitete as patients from there can easily get to Kambi if they need to be seen.

The road to Mang’ola

Roadside scenery

We have continually looked for other sites to do our neurology mobile clinics, but it is not always as easy as it sounds as it must be done with the approval of not only the local health ministry officials, but also with the blessing of the local community. It is complicated and what may seem like a wonderful idea to us isn’t always how it seen by others and we must always be respectful of that so we can continue to work the way we do with the confidence of those we are trying to help. Our mission is not to provide what we feel a community needs, but rather to work with the community and to provide what they see as essential while applying our principles of practicing medicine. We must always remember that we are guests here and that it is essential that we are always welcomed, for without that, there can be no partnership.

The road to Barazani

The ditch blocking our entrance

This trip, the team at FAME had arranged for us to go to the region of Mang’ola which is east of Karatu near Lake Eyasi. The town of Barazani is the settlement there where we would be holding our clinic and I was really looking forward to this as we used to pass through this town on our way to the Lake Eyasi village of Gitamilanda, which is where we used to set up camp for the larger FAME mobile clinic several years ago. This is a region very much different than the areas surrounding Karatutown. As much as Karatu is like the frontier, Barazani is that and more. It is an outpost of civilization and an incredibly harsh environment where the principle produce is onions (acres and acres of them) that grow in the areas adjacent to Lake Eyasi which is a seasonal lake and mostly dry, but is very large. The Hadzabe, the last hunter gatherers in Tanzania, live in this region, still hunting with their bows and arrows, though the large game they have historically hunted is going away, leaving them to hunt only small birds, dik dik and baboons these days. They are a dying tribe with only 1500 members left and will likely not be around much longer. They are also one of the few remaining tribes who speak click language, a unique language used by a very small number of groups that are culturally diverse with little connection that anthropologists have found to explain the similar use of the unique language.

The Mang’ola/Barazani dispensary

The neuro team at the Mang’ola/Barazani dispensary

I had spent some time the Hadzabe in the past and they are an amazing group of people living off what is left of their original lands that they now share with the Datoga, who are herders, hence the issue with their game. The Hadza are bushmen and very culturally diverse than any other tribe in Tanzania. They are resilient, though only to a point, and once their game is gone, they will be left with nothing to hunt. It is a very sad thought to think of a dying culture in terms of extinction as it is not only their gene pool that will be lost, but their language and their way of being. I feel so incredibly fortunate to have spent time with them during my life, something very few people have gotten to do, and though it is unlikely that they will be gone during my lifetime, the knowledge of their trajectory still saddens me very much. I could not help to think about this with the loss of the Hadzabe woman that occurred the very first weekend we were here as they cannot afford to lose even a single individual without it affecting their tribe.

The clinic at Mang’ola

Dr. Annie making our morning announcement about what we see

So, today we were off to Mang’ola and Barazani to begin a new chapter in our neurology mobile clinic and to see what our reception would be there. But first, we had to make it there! I remember the road to Mang’ola being legendarily rough and treacherous with continuous washboards on the road (the rippling on the road caused by water running over it) and sometimes treacherous culverts where raging rivers would form and rip apart whatever semblance of a bridge or surface to cross had been there previously. I have several great stories about traveling this road in the past where we had to all pitch in and do road repairs in order for us to make it through some of these drainage areas. We had two vehicle again, which was very good as having to cram extra people in the Land Rover, some sitting on soda crates would have been even more uncomfortable for this long and bumpy ride.

A primary mode of transportation

The customary baby scale

I drove my group plus Dr. Annie and Angel, the latter knowing the directions as it had been so long since I’ve driven here. Describing what it is like to drive these roads would be difficult, but suffice it to say that it was 1-1/2 hours of pure concentration where you really couldn’t take your eye off the road even for a split second. The washboards were brutal and it is essential that you maintain your speed (usually about 50 kph, or 30 mph), otherwise they become bouncier and you just have to get up to speed again. Often, there will be a desired track that will be less rough, but it is not always obvious, so you are continually driving to either side of the road to see if you can find a smoother route. The roads are heavily crowned to prevent erosion, often with large drainage ditches on either side that would be catastrophic to run into. It also means that driving on either side of the road leaves the vehicle at a fairly steep angle that doesn’t bother me, but the others have to hold onto their seats to keep from falling off.

Yohan registering patients

Leah and the building that we saw patients in

Some portions of the road are incredibly rocky, most often the descents into and ascents out of the very deep culverts that essentially dry river beds which we continually cross during our journey. I’m frequently downshifting for the steep incline into and out of these culverts and to slow down over the rocks or just in trying to avoid the many huge holes that pockmark the road throughout. With all of this, though, the drive is strikingly beautiful during its entirely and the scene as we come over each and every rise seems more so than the one before it. As we arrive to Barazani, the entire upper valley containing Lake Eyasi comes into view and is stunning. There are lots of people here, perhaps more than you’d imagine given the remoteness of the area and the drive we’ve just taken, and they are all walking about taking care of their normal daily business.

A hallway in our clinic

One of our exam rooms

As we drive up to the dispensary, there are workers digging a ditch that we can cross at only a single point just wide enough for my Land Rover, thankfully. The clinical officer and nurses at the dispensary are waiting for us and were incredibly happy to see us which is always a good sign given that we had never been there before. They were welcoming and gracious and immediately asked how they could make us most comfortable in setting up our exam room and brought desks and chairs into each room for us. We had three rooms to start plus a vitals room, the latter later being used as another exam room once everyone was “vitaled” and registered. It was very clear from the outset that we had many patients waiting to be seen which required that we would come up with a maximum number of patients for the day and see what there was left over. We did have options for the overflow, though, in that our clinic the following day at Mto wa Mbu had been cancelled, allowing us to come back if we chose to and if that would be OK with the dispensary. The other option would be for patients to come to FAME, but that would be a hardship for most. In the end, we decided to return on Wednesday, meaning that everyone would be subjected to that lovely (a bit facetiously) drive again the following day.

Marissa and Revo seeing a young man and his mother

Andrea and Annie evaluating a patient

Dr. Annie and Angel again addressed all of the patients at the beginning of the clinic regarding the fact that we were neurologists and went on to describe exactly what it is that neurologists treat. The set up would essentially be the same as it was at Kambi ya Simba in that we triaged the patients who then had to wait to see us, sometime most of the day. The patients were, for the most part, excellent neurology cases with the standard fare of kichwa (headache) and dege dege (epilepsy), while there was also the smattering of sensory loss and then there were a few puzzling cases that took much more thought.

Leah scribing for Kyra and Abdulhamid

Definitely a closet pediatrician

Meanwhile, we had left Ray back at FAME as he was flying home this day, but didn’t need to leave for the journey to the airport until about. 3pm. Ray was giving the. Morning educational talk, which he chose to do on somatic disorders as they are just not recognized and treated well her for reasons I mentioned early. After that, though, they had him see a patient in the ward who had weakness in his legs for about a week or so. Ray felt the exam was most concerning for a cauda equina syndrome (where there is compression of the spinal roots in the lumbar region) and did have them do a CT scan, but didn’t see anything obvious and the diagnosis wasn’t entirely clear. They then found two outpatients for him to see, as well, which was fine keeping him busy, though knowing Ray, I think he was very anxious to get to the many other tasks he had that included reviewing medical student applications for residency that were just becoming available. He saw the patients happily (he was in his element here as the master diagnostician that he is) and had no problem making his departure for the airport.

A zen listening the residents

Of patients that we had in Barazani, there were two that stood out perhaps, and one was a patient in his 20s with epilepsy who also had what appeared to be significant cerebellar dysfunction. It had a been a progressive course such that he was mostly disabled at this point and there was little question that he probably had a metabolic or mitochondrial disorder that we would be unable to test for here nor would we be able to treat other than symptomatically and make sure that his epilepsy was under good control. The other patient was a gentleman who had a patient of sensory changes involving his upper extremities that most likely represented a somewhat asymmetric syrinx as this was the only way we could put him together. I believe that he had suffered some trauma in the past, but regardless, this wasn’t entirely a necessary component as a syrinx can certainly occur spontaneously in some patients.

Dr. Mike with a new friend

We finished our day here rather late which meant that some of the drive would occur in the looming dusk and darkness, a very difficult time to drive here and especially on that road. We had ended up seeing 42 patients, a record I believe for a neurology mobile clinic. I made sure that I repeated told the clinical officer and the nurses how much we had appreciated their assistance and how thankful we were for them allowing us to see their patients. We would be back first thing in the morning to see the remaining patients that at the time were in the low 20s.

Leah’s birthday cake from Happy Day

Making the best of no candles – with lit match

The drive home seemingly went much quicker to everyone’s delight, though it was already dark when we arrived back to Karatu. We dropped the other team members off in town and drove up to FAME, all of us incredibly weary from the long day in Barazani. It was Leah’s birthday, though, and I had called Katherine earlier in the day to have her order a cake at Happy Day, which she did, and brought it over. Everyone was showering at the time so Leah didn’t see it delivered and was genuinely surprised when we brought it out later for her and sang Happy. Birthday to her. It has been a great day in clinic, though exhausting, and after cake and celebration, I think everyone, including me, went to bed a bit early.

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