Wednesday, March 11, 2020 – A very slow day, indeed…

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Our volume here has just been very unpredictable so far, and it has not been totally clear to me why that has been. I have been reassured by the FAME staff that is merely a result of the rather early rains and that when they occur, there are many things that need to be done around the house requiring everyone’s participation, making it difficult for them to come to FAME. Regardless of the reason, though, it has left us with more time on our hands than we’d like so that all of us were going a bit stir crazy.

A fair share of our attention, of course, has been on the Covid-19 pandemic that has now caught the world’s attention in a big way with a great deal of craziness and misinformation that has been spread in addition to the real science that is being carried on around the world by many agencies. For better or worse, we had left just advance of the real scare, as had we left a week later, it is unlikely that we would have been allowed to travel, and a question of whether we would have wanted to. We have been monitoring the situation on a constant basis and I have been checking in with those knowledgeable back at Penn to be sure that we are not only making smart decisions here, but also those that will remain in line with what the university has been recommending.

The one thing that has remained quite clear to us all along has been that we are safer here than we would be in the US given the current spread of the disease both globally and in the US. FAME has had meetings with the government here regarding our preparedness in the event someone with symptoms of Covid-19 were to be treated here and we also have a designated isolation room now, but is very unlikely this will be utilized anytime soon and, if it is, it will likely be a due to a tourist coming here with it. We’ve now been here long enough to be pretty certain that none of us are infected and, though that is certainly reassuring, we still have to travel home at some point, which means going through the international hub of Doha, where we’ll spend six hours overnight, and then have to get packed into a large body jet carrying 200+ passengers from around the globe to their final destination during a 12 flight, all breathing the same air. Doesn’t sound like the best of situations when trying not spread a new disease, but I guess there is no other way to take care of things as we have to get home one way or another.

One of the many banana slugs that come out in the rainy season

Amisha had planned to be traveling to Israel after her time here and discovered that they had just announced a mandatory 14 day quarantine for anyone entering the country which meant that she wouldn’t be able to do the things she had wanted to do. Unfortunately, there are so many people in a similar situation trying to the reach the airline and the hotel, that she has been trying to get through to them all day. When she contacted the online agency, who had booked the flight she was asked for a call back number (she gave them mine) and it was going to be 12+ hour wait. I kept joking all night that they had called and I told them she was unavailable. The real joke was, that after all that waiting, they never even called and I guess that wasn’t overly surprising given the circumstances.

Though Covid-19 is, and will continue to be, a major event that seems to be worsening by the day, life here in rural Northern Tanzania seems to be going on as usual and I certainly hope that will continue to the be the case, though I know that it will eventually reach this region in some fashion in the very near future. I know that we’re discussing the shortage of ventilators in the US and number of people that will need them, but imagine living in a place where there are no ventilators to begin with, so that the discussion of their rationing becomes moot. We deal with this on a daily basis here, knowing that a patient, of any age, including neonates, would not have access to this therapy regardless of their need or prognosis. That is life in a limited resource region that includes most of Africa as it is only in a few regions of this continent in which anything else exists. We have been practicing here for a number of years and have learned to care for patients with these barriers to treatment, recognizing that it is not our place to necessarily change their system, but rather to learn to work within it and, hopefully over time, the system will change on its own for the better.

Blood smear from our thrombocytopenia boy we had seen last year that came back to see Dan and Marin

That has been the mission of FAME since its inception over ten years ago; To enhance the quality of medical care in East Africa and to create educational opportunities for individuals who express an interest in contributing back to their communities. FAME is essentially “for Tanzanians and by Tanzanians,” and we are only guests here to assist in providing those educational opportunities that will allow them to improve the quality of medical here in the Karatu district. We have continually kept detailed records of the neurology patients that we have seen here since 2015 along with the assistance of the FAME doctors, and have shown that we have changed the lives of many Tanzanians who we have had the privilege of caring for during that time.

This has been most evident among patients with epilepsy, many of who have never seen a doctor or have never been on an anti-epileptic medication, or if they were, it wasn’t the correct medication. I have mentioned numerous times in the past of how epilepsy patients are stigmatized here in very severe ways and children with seizures are typically restricted from going to school because of them. We see many young adults who were not allowed to attend school from an early age because of their seizures when, in fact, they had a very treatable condition that merely required a medication to completely control their epilepsy. These patients respond incredibly well to placing them on simple medications that they have here and our data shows that there are very adherent to their medication schedule and also have a very high rate of either being completely controlled or marked better in regard to frequency.

Blood smear from our thrombocytopenia boy we had seen last year that came back to see Dan and Marin

In monitoring the cost of our program in regard to the total cost of medications that we supply for a month, along with the future cost of medications over the year, it would require only a small amount of resources to completely control this population of patients.  Providing continued care would truly make a difference in their lives and that of the community where they would return as productive members as opposed to a burden to the community and their families.

As you might expect, there are plenty of insects here in Tanzania, as there are everywhere, but given how exotic it here, they can sometimes be a bit more intimidating with the consequences of an encounter more significant than it is back home. The same goes for snakes here where there are no rattlesnakes, which like to warn you ahead of time, but rather tremendously more deadly reptiles such as the many pit vipers, the boomslang, cobras, and the black and green mambas. Despite my incredible love for reptiles, which comes from my childhood growing up in the pet industry and having many, many reptiles at home over the years, which has led me to search for them here in Africa, I have actually seen very few during my adventures into the bush. I have seen one large king cobra in Manyara and numerous Nile monitors, but overall, snakes have eluded me much to my disappointment.

Insects on the other hand, have been quite numerous and I have mentioned the tsetse fly on many occasions as a real issue here in some of the parks, and, in particular, Tarangire National Park, where they can be terribly numerous and bothersome. I have seen residents with the most incredibly strong demeanor, who could stand strong regardless of what was thrown at them, melt when threatened with a swarm of these flies, only slightly larger than our house flies. Tsetse flies are blood sucking and have a bite that is difficult to feel initially, but then develops into such a significant pain that it is difficult to ignore and will eventually become a large itchy welt that last for days. It is far more severe than a mosquito bite, which is no different than those at home other than the fact that they can carry malaria here which is why all of us are taking our Malarone. If you’d like to see something truly disgusting, watch a video of a tsetse fly engorging itself and enlarging to twice it’s normal size with blood. They also have a nasty habit of flying up your pants leg when sitting in the vehicle on a game drive, especially mine as I’m driving, and I will suddenly notice the sensation of something crawling up my leg, reach down and crush it inside my pants. On several occasions, this has left me with blood oozing down my leg and on the inside of my pants, that hasn’t been my own as I hadn’t been bitten by anyone and I could only assume that it was that of a nearby Cape buffalo or wildebeest.

A Nairobi fly on the wall outside of clinic

Another bug that has been here in the past, but in limited numbers, has been the Nairobi fly and it seems to be much more prevalent on this trip. This small insect (1 cm in length) is actually not a fly, but rather a beetle and, more specifically, a paederus eximius beetle whose hemolymph contains the toxin pederin which is a very potent toxin and can cause a severe burn of the skin by just touching it, or worse, if it is crushed against the skin. The burn may not declare itself for 12-24 hours so it not always obvious where it came from and even more problematic, is rubbing your eye if you’ve happened to touch one of these little creatures as you will develop “Nairobi eye,” a severe irritative conjunctivitis caused by the toxin.

I have seen these before, but never as many as I have this time, and there are many of these on the walls of the main corridor where we staff our patients. I typically lean against the wall when residents are presenting to me, so this has become an occupational hazard for me if I happen to forget to inspect the wall in advance. Several nights ago, when readying my bed for sleep, I pulled back the covers, only to discover a single Nairobi fly smack in the middle of my sheets where I was just about to lay down. Dan informed us this morning that while using the bathroom last night, he looked up at the roll of toilet paper to see one of these nasty insects on the top sheet. Had the light not been on or had he not looked first, he could have been in for at least several days of some very uncomfortable sitting. To date, none of us have been impacted by the Nairobi fly, but given the number of these little devils that we’ve seen, it would not be surprising for one of us to encounter them while we’re here.

 

 

 

 

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