It seems like it was only yesterday that we were returning from our mobile clinic in Mang’ola and, having received the news from our State Department that we must either shelter in place (not really an option for either I or the residents, though it was quite tempting) or return home immediately, quickly scrambled to find new flights home safely and together. Shortly after returning, the discussion began of how each of us in the global health world had made the decisions we had and, for the global neurology community, the AAN Global Health Section became a forum for not only these discussions, but also how the structure of global health education would go forward into a future where travel was now heavily restricted. Here is the post that I submitted on the forum on April 4, 2020:
From: Michael Rubenstein
Subject: Torn between two homes
As many of you know, I have been traveling to a clinic in rural Northern Tanzania for the last 10 years and have developed a neurology program there training the Tanzanian doctors in the art of evaluating and treating neurological disorders in the community as well as bringing residents from both Penn and CHOP to help with the training and to experience working in a resource limited setting themselves. We have traveled there twice a year (March and September) for a month each time with residents accompanying me since 2013. The experience has been incredibly rewarding on both sides and we now see well over 700 patients a year. The impact on the epilepsy community has been the greatest as you might expect.
We left for our March trip on February 28, in advance of the full force of the pandemic, with plans to spend the month there. As our trips are supported by Penn and CHOP, we had registered with ISOS and had conferred with our global health resources prior to leaving with the expectation that we would be in constant contact and would monitor the situation on a daily basis. As you can imagine, once in Tanzania, we were far safer there than we were in the US in regard to exposure, though that situation changed very quickly at the end of our visit. Once it was apparent that the Covid-19 was going to become a pandemic, and certainly after the WHO declared it, we had to make decisions on a daily basis of whether to return to the US.
I have spent 10 years developing the trust of not only the Tanzanian community, but also the Tanzanian caregivers and clinic that we work with and our clinics are announced well in advance such that neurology patients travels for days to see us and from as far away as Dar es Salaam. In addition to our clinic that we have at FAME (Foundation for African Medicine and Education), we also do a week of mobile clinics in surrounding villages to see patients who are unable to travel to FAME or are unaware that they may have a treatable neurological condition. The mobile clinics are always equally busy our clinics at FAME and I knew that they would be expecting us.
It was with the worsening worldwide pandemic that we had to make decisions not only about our own health, but also those patients that had expected to see us during our clinics, many of who had waited six months to see us in follow up or for the first time. Every day, I checked with our global health center back home to ensure that we were still making the appropriate decision to stay and continue our work rather than come home before it was completed. As the group leader, these decisions were obviously mine to make, though I met daily with the group to make sure that no one was uncomfortable with what we were planning. For the residents and our one medical student, there was the obvious disappointment of possibly having to go home early, and I needed to make certain that disappointment didn’t cloud their decision making in any way.
In the end, we were able to complete our week of mobile clinics from March 16-19, though it became increasingly clear that we were not going to be able to finish our last week there which is usually to see follow up patients and any stragglers who hadn’t come the first two weeks at FAME. The good news was, that I have doctor there who I have now worked with for five years and who we have trained as our “community neurologist” who could see patients for us that last week and communicate back with me for any questions she had regarding their management. Ultimately, when we received word that there was the plan to announce that US citizens either needed to return home or “shelter in place,” it became clear that we needed to return home not necessarily for our own safety, but because the airlines were in the process of cancelling flights to the US and it would eventually become difficult to get home. We were never under the disillusion that being in Tanzania, a country with essentially no available ventilators or ICU level care outside of a very few hospitals, was necessarily a good place to be during a respiratory pandemic, but there was little Covid-19 there at the time, nor is there now, though we knew it would be coming.
Getting home became a bit of a difficulty only from a logistical standpoint as the airlines were impossible to reach by phone from where we were and the websites were all useless in trying to change flights. Thanks to our wonderful Global Health Center, they were able to change our flights for after speaking with the airline, though I did have to purchase a grossly overpriced ticket for one of our members as she had originally planned to fly on a different airline at a later date and there was no way that we were flying home without her being on the same flight with us. Our flights to Philadelphia were ultimately cancelled and the airline flew everyone through JFK, where we rented a car and drove home as none of us was interested in getting on another plane at that point.
Ultimately, we completed the most important three weeks of our work in the face of growing concern for everyone’s safety, but we did so successfully and, I believe, made the correct decisions at the time. There is no question, though, that having remained in Tanzania, or South Africa or Zambia, was not an option given the limited resources there in regard to respiratory support in the event of its need. When I left, it was incredibly sad for me given that I was leaving a medical community and friends that I have worked with for 10 years in the time of crisis and felt as though I was abandoning them, I am sure much as Omar and others have felt in having to return “home” to the US. It once again only underscores the need for health equity in the world when those of us who spend our careers for this purpose have to make these tough decisions for our own health and leave those we love behind in a resource limited setting. My heart breaks for my other family in Tanzania and I am communicating with them on a daily basis, though I know that I can now only my thoughts and prayers.
Michael Rubenstein, M.D., FAAN
It was quite clear to me at the time, full well knowing that travel for residents and medical students would be heavily restricted for the foreseeable future, that I must return to FAME if at all possible in the fall. Our neurology clinics have become a fixture at FAME and in Northern Tanzania over the last ten years and, although perhaps varying by a month here and there, have occurred every wet and dry (for us it is spring and fall) season so that our patients have come to expect our return as have the doctors at FAME. It was truly difficult for me to imagine traveling back in the fall to my other home and the patients, families and friends that have become such a part of my life. It won’t be the same without my wonderful residents, who have so masterfully become a fixture there both seeing patients and teaching at the same time as only residents can do so skillfully as they are the ultimate educators in my mind. I merely supervise them and make sure that things keep running smoothly.
It has been seven years since I was there on my own, back when the neurology clinic at FAME and our mobile clinics were first taking form and were a dream of mine. Since then, I have brought countless residents, a handful of medical students, and a few colleagues with me to this amazing place that is a Mecca of healthcare and Shangri La all mixed into one. In their absence, I will make do as I have in the past, though, on a much smaller scale than we have in the past years where we have topped on average 700 patient visits each year. Still, I feel that the trust this visit will instill, not only in the community, but also in the clinicians at FAME, will go a long way towards the continuation of a program that I could have never dreamed would come of my first visits there.
So, it is on this background that I am now traveling back to FAME during the middle of this historic pandemic, facemask in place and loads of sanitizer in my bags, to pick up where I had left off in March, at the very beginning of this monumental crisis. The world has changed forever, as have we, and though we must find new ways to provide global healthcare and global health training both here and abroad, the basic premise remains the same. To develop a system of education in country, whether in person or remote, to train local doctors to work within their health systems to better the health of their communities. This has been FAME’s mission from their conception.