Tuesday, September 24, 2019 – Babies, babies everywhere….

Standard

One of FAME’s main missions from the very beginning has been child and maternal health, though it wasn’t until the fall of 2014 that they opened for routine deliveries here. The reason I remember that date is that Doug Smith was here as the CHOP rotator and was the attending physician for that very first planned delivery here. Since that time, the number of deliveries at FAME has continued to grow as has their reproductive health clinic volume. Considering that woman pay a fee to deliver at FAME as opposed to the government hospital where it’s free, that is a very strong statement in favor of the community’s trust in the care they receive here. The cost at FAME for their antenatal care is very little and the delivery itself is 80,000 TSh, or about $36. At the government hospital, though the delivery is free, the patient must bring their own supplies even down to the sutures if they happened to need a C-section.

Walking past the maternity ward towards clinic in the morning

With the growth of deliveries at FAME, though, there has been a growing need for neonatal care both for babies born here, as well as those who are brought or sent here following birth elsewhere for the exceptional care that is received. During our neurology months, the pediatric neurology residents have also provided pediatric and neonatal care as those who have come are also board eligible pediatricians in addition to child neurologists in training. Hypoxic-Ischemic Encephalopathy (HIE) injury is one that unfortunately occurs all to commonly in Africa for many reasons and having pediatricians, and especially those well versed in this primarily neurological condition, can be extremely important and it is the first hours after birth that can often make the biggest difference in regard to reducing their overall brain injury.

Kyra’s lecture

Though this wasn’t necessarily the purpose of their time here, the residents from CHOP (Children’s Hospital of Philadelphia), recognized as one of the best pediatric hospitals in the world, if not the best, have contributed greatly to this mission of FAME in an exclusively positive manner, and it has been my privilege to have brought them here. They are the most amazing clinicians who, in addition to loving neurology (very dear to my heart), are truly dedicated to children as are all pediatricians. They have always been huge part of this program from its inception given the number of children and adolescents that we see here during our stay.

My first ride in a boda boda

It was Kyra’s turn to give a talk this morning and considering that she’s going into cognitive neurology, it was appropriate for her to talk about evaluating cognition and the various disorders of cognition that we see along with their treatment, or unfortunately, for the most part, their lack of treatment. Regardless, it’s a very important part of the neurologic examination and we have many patients who see us complaining of memory loss, though quite a few of those have primarily issues with focus and attention rather than true memory loss. It is always important to screen for mood disorders or anxiety in those situations as these are very treatable problems that can be treated either with SSRI medications or counseling, though the latter is not readily available here. Perhaps, someday that will change, but for now we’re left with prescribing medications.

Somewhat skeptical in the boda boda

At morning report, the most striking revelation that was discussed was the fact that there were nine, yes NINE, deliveries yesterday, six being spontaneous vaginal deliveries and three being C-sections. That’s an incredible feat when you consider the size of FAME and that we only have a twenty-five bed maternity ward that was now completely full. All the mothers and babies were doing well, another amazing feat in of itself considering the overall higher rate of birth related difficulties in Africa in general along with the fact that not all of the women had received their antenatal care at FAME, but rather came in labor and were appropriately attended to. Hopefully, as the word continues to spread regarding the quality care received at FAME, the deliveries will continue to increase, though that will also require a greater number of doctors, nurses and maternity space over time. As with anything else, this will also require a greater amount of successful fundraising and donors willing to consider supporting these vital services to the Karatu community and beyond.

At the brick quarry

We had another busy day in clinic, but one thing that stood out, actually, was a visit we had from the wife of our patient with the epidural abscess or mass from the week prior and that Ray had initially seen. We had spoken with the patient and his son about the fact that we needed him to see the neurosurgeon in Arusha to probably undergo surgery, but his wife called this morning to ask if she could come speak with us to get more information. Andrea, who had seen him yesterday, agreed to speak with her and we had asked Kitashu to help with the discussion while I sat in to assist if needed. Kitashu, who I have now worked with for about two years, has to be one of the most compassionate individuals I have ever known and his demeanor is so immediately calming regardless of the situation, that I cannot imagine anyone better at speaking with families in these sensitive situations.

The brick quarry

We explained to the wife why he needed to see the neurosurgeon and very soon as time was of the essence in situations like these. She explained that they didn’t have all the money necessary for the surgery and that he didn’t have the government insurance (which most people don’t have) that would have covered the major cost of the surgery. It is always so difficult to sit there, knowing that the amount of money we were discussing was not that significant to us, but could ultimately be life changing to this family, yet we are unable to step forward to help in these situations as it would not be appropriate if we can’t do it for everyone. One of the biggest lessons you must learn here is that what sometimes seems like the right thing to do, isn’t, and you must resist reaching into your pocket as those actions are not sustainable nor do they solve anything but for one individual. These are very hard lessons, and sitting in a room explaining to a spouse why her husband needs surgery that they may not be able to afford to possibly prevent him from being a paraplegic, isn’t an easy task by anyone’s standards. Yet Andrea was stellar in this most difficult and delicate of situations that required a tremendous amount of empathy and strength of character.

Walking through Tloma village near the lodges

At some point during the day, I needed to bring Turtle down to the mechanic as the driver’s door was still out of commission and entering through the passenger side or climbing through the driver’s window, though possible, was not an ideal situation for someone with a history of both back and neck surgery. At the right moment, I told everyone that I’d be gone for 30 minutes and I zipped down to the tarmac to have the vehicle looked at, originally thinking that they could fix it quickly, but realizing once I was there that was highly unlikely. I left Turtle at the shop and decided to take a bijaji back to FAME as that would be the least expensive option short of taking a boda boda (motorcycle taxi) back which I didn’t even consider given the number of accidents I’ve seen here on them and not wanting to end up in the ED at FAME. So, I hailed a bijaji, never having ridden one before, and began my short ride back to FAME in style. Well, if climbing into Turtle wasn’t a good idea for me given my past orthopedic issues, then riding in a bijaji definitely wasn’t a good idea either. These three-wheeled motorcycles with a body have absolutely no suspension or shock absorbers and you feel every bump, which, had it been on the tarmac, wouldn’t have been a problem, but on the horribly rutted FAME road it was quite uncomfortable and something I will not experience again. Suddenly, I now realized that taking placing my life in danger on a boda boda may have actually been the smarter option here. I made it safely and didn’t suffer any new injuries that would have been difficult to explain to the others if I had.

Finding some friends during our walk

We finished early enough today to consider taking a nice walk for both exercise and exploration after clinic. It was a beautiful afternoon/evening as the temperature was very mild even though the sun was out and strong. I took Kyra, Andrea, Leah and Marissa for a walk down through the brick quarry that is adjacent to FAME across the road and then up the opposite side of the valley to the road that leads to Tloma village, one of the main Iraqw communities nearby and where Gibb’s Farm sits just above. The brick quarry is very interesting as this is where they dig the clay to form the bricks, dry them and then stack them into tall oven-like structures that are hollow inside where they stack wood to eventually ignite and fire the bricks to finish the process. How this all works as far as who owns the quarry or the bricks once they are made, I’m not sure, but they are eventually purchased and made into structures that are often left incomplete and may take years to finish. There is a long explanation for this behavior, but essentially it has to do with community and the fact that if you have money in your pocket, or in the bank, and someone you know is in need then it is considered an obligation to help them. Therefore, if you have your money tied up in bricks and half built buildings, you can’t give it to someone who may be in need and you won’t be effectively shunned for not sharing.

We walked through the brick quarry where there many men working at all phases of making bricks and eventually walked all the way to the Tloma village past several nice lodges and eventually intersected the Gibb’s road where we turned to walk uphill towards one of the shops where ebony and acacia woodcarvings are made in the Makonde style of southern Tanzania. These beautiful works of art and there are carvings of most animals, bowls and the “tree of life,” which is a tradition carving typically of people stacked on top of each other, but hollow inside and well-polished. We didn’t end up buying anything, but the owner of the shop remember me from a number of years ago as I had purchased a very large tree of life carving that is now in my office at Penn.

A Makonde tree of life

We walked back along the road through the Tloma community where we encountered many children, some young and some school age walking home from school in their uniforms. The greetings were nearly unanimous with a frequent “jambo” and a wave to us. The lighting was wonderful as the sun was low in the sky and would be setting very soon. We reached home just before sunset and were all happy to be back in our comfortable house to enjoy our dinners and a later movie. I had suggested “The Eagle Huntress,” a delightful documentary about the Mongolian practice of eagle hunting a young girl who is determined to become the first female to compete in the previously all-male competition to be the best eagle hunter in the region. For anyone interested in determination, wildlife, gender barriers and gorgeous cinemaphotography, this is the movie for you.

Arriving back at FAME

 

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