It had been a rough night with my cold, though digging through my cabinet I had managed to find some cough suppressant/expectorant in my bag of those “just in case medications” that also includes those for any traveler’s diarrhea or stomach upset of any kind which is not to uncommon here. I will admit that the cough suppressant was outdated by about a year, but those kinds of things have never stopped me in the past, nor would they now, and the very worst would be that it wouldn’t work for me. I will have to admit that I felt a bit better in the morning, even with the rough night, and I was off for another day of clinic as the patients would be expecting me and not showing was really an option that I did not wish to consider at the moment. Having no lecture this morning, I did know that I could sleep in a bit as we wouldn’t be starting and the few extra minutes of sleep were quite welcome to say the least.
I made my way up to clinic as ready as I could be for the day and, thankfully, there was not a mob waiting to see me. It was a smattering of follow up patients as well as few new patients for the day. Again, as I was going to be by myself this trip, we had made the decision not to do our normal outreach to the community, or any outreach for that matter, and to just have patients contacted for follow up or those new patients that were being referred from the other providers at FAME. There were several very interesting epilepsy patient as is usually the case, one of whom was being referred from Dr. Caren and was a young woman with new onset seizures. Dr. Caren has had the opportunity to work with us on only a few occasions in the past, but the assessment she had provided for this patient several days earlier was one that would have easily belied that fact, for it contained all the necessary information for a detailed evaluation of a seizure patient and it was only for my having been here that she did not initiate treatment at the time. To be honest, there was very little for me to ask or add to her assessment and her preliminary diagnosis was spot on so that all that was necessary was for me to choose the proper medication to place her on. As she was planning to have a family soon, we chose lamotrigine as it has the best pregnancy data of all the antiepileptic medications and is reasonably available here. I can’t tell you how rewarding it was for me to have read Caren’s note from the earlier visit as it was a clear indication of the impact we have been able to make here and why we need to continue our work.
As I am sure everyone has realized in this time of the pandemic, supply chain issues have been a problem on all fronts and in all regions. I had planned on my return in March to do some work on my 13-year-old Audi that, for those who know me, is a possession that I am very attached to and am very protective of. It has been the most incredibly dependable vehicle that has served me well and, with its manual transmission, can no longer be replaced even if I wished to do so. With now over 165,000 miles, I decided to replace some of its suspension with upgraded aftermarket parts and found that ordering them would be a chore as most of the manufacturers in the US had a very limited stock on hand with reduced manufacturing schedules. In the end, it took over three months for all of the parts to arrive and the project could not be started until everything had arrived.
With the impact that coronavirus has had manufacturing, employment and the economy, it is not surprising that the availability of many common items have become very limited since this all began. Now, consider what effect that same process might have on an already fragile limited supply chain economy that already exists in most low income countries and you can already guess that necessary items such as medications might become difficult to obtain despite the lesser impact the pandemic seems to have had outside the US. This problem has already come up on several occasions with fairly common medications that we use here for our neurological patients. On one such occasion, a patient with epilepsy who has finally been very well controlled on levetiracetam (Keppra) was unable to have his medication refilled by us due to the fact that we have been unable to obtain it, but hopefully will soon. I received a call from our pharmacy regarding another patient with an essential tremor for who I had prescribed propranolol to tell me that they were out of it. Being their typical incredibly helpful selves, they had suggested perhaps choosing another antihypertensive medication that they had in stock though I informed them that we were using the medication for an entirely different purpose. They would check on Monday morning and hopefully it would be available soon.
The supply chain for medications has always been a bit tenuous here and a problem that we have encountered over the years, but is even more significant now. This has been most apparent in some of the medications we use to treat the neurological disorders that we identify here like epilepsy, Parkinson’s disease and other related movement disorders. Between this not too infrequent lack of availability of these medications and their often high prices, maintaining our patients on long term, otherwise effective therapies can often be quite difficult and none of this has anything to do with patient compliance which can be an entirely different matter altogether.
Taking medications on a regular basis for chronic illness is not a fact of life here in regard to societal or cultural norms. Patients are quite familiar with taking medications for a problem such as malaria, worms or a transient GI issues, but when it comes to taking medications for diabetes, hypertension or epilepsy, the understanding that these are chronic disorders that are not cured by their treatment, but rather controlled, is not a general concept here and, therefore, the amount of education that goes into explaining to, and quite possibly convincing, a patient that they will need to quite possibly take their medication for a long period of time can often be immense. FAME has created a recurring clinic for chronic illness that manages many of these patients and education is a huge component of their success in maintaining a patient’s compliance on a therapy.
I saw a patient the other day with panhypopituitarism that Dr. Gabriel had diagnosed and had on thyroid replacement and was feeling completely back to normal and very well. The issue came when he told me that he wanted to stop his medication because it had worked and he was now better. I spent the vast majority of our visit with him trying to explain that the reason he felt better was because he was taking the medication and that if he stopped it, he was quite likely to return to the state he had been in previously when he had originally sought our care. I used every analogy I could conceive of and am not sure I had ever truly convinced him, finally instructing him to see Dr. Gabriel in follow up to discuss the issue further, hoping that Gabriel might have more success than me in keeping him on his medication. Meanwhile, we checked his thyroid studies which were improved from those that had been earlier which was quite reassuring.
Our clinic ended early in the afternoon and given the nice day out and the fact that I was feeling a tad better, I decided to go for a ride on my new mountain bike. As many who know me, I have become nearly religious about riding my road bike, often alone and sometimes with friends, along the Schuylkill River Trail as long as the weather would permit it and there was still light to be had. During the pandemic, without the opportunity to engage in other social activities with friends, riding has occupied much of my spare time and, in doing so, I have noticed an obvious and expected improvement overall in my riding times as I track my progress on every ride. Prior to leaving on this trip, I was averaging 100-150 miles per week, and the thought of not riding for an entire month was something I did not wish to consider, necessitating the purchase of a bike here in Tanzania. Having only a road bike here would be rather difficult given the lack of paved roads, so a mountain bike made tremendously more sense to me and eventually led to the acquisition of a very nice bike that I would have been thrilled to find in the US.
Not having completely recovered from my cold, I decided to take a gentle ride to town down the dirt road I’ve become so familiar with over the last ten years driving to and from FAME countless times during each visit. Knowing that I was planning to ride here, I did bring some equipment with me, most important of which was a spare helmet that I had at home and would work perfectly for me here. I also brought some riding gloves, tools, a mountable pump (I use CO2 containers at home, but were worried they would allow them on the plane) and riding gear (a few extra bibs and jerseys). So, I suited up, hopped on my new bike and started down the road to Karatutown. It was so nice to finally be riding here and I was thrilled to be seeing the road from a completely different perspective than what I normally do driving Turtle up and down these hills.
I did come to realize several things on that first ride, though. First, it is just incredibly hilly over here and despite the fact that my new bike has 30 speeds and could probably climb a tree in the lowest gear, it was a struggle for me to get up a few of these hills. Second, it is the dry season right now meaning that the roads are terrible dusty and any passing car will leave a cloud of this thick red clay dust for me to inhale into my lungs as I rode along. And third, not having brought a bottle of water with me was a serious error and, had I been riding further this day, could have easily have been a disaster. It was for lack of planning, mind you, as I had a water bottle set aside to bring with me, but was unable to fit it into either of the duffels and had planned to look for one here at some point. So, I continued my ride to town, constantly taking my hands off the handlebar to wave back to children and murmur “jambo” as I passed, struggling up the few hills I encountered heading to town, but knowing full well that the ride home would contain much more of the up than down. I made it to the tarmac, or the main road through Karatu, and continued on towards the center of town, pedaling away often faster than the bijajis, and finally reached the Tanganyika Farmers Association gas station, a common meeting place as it sits right in the center of all the hustle and bustle of this frontier town.
The ride home was uneventful, other than the massive thirst that I had acquired after conquering the many hills climbing up to FAME, but I had the feeling of achievement. Hopefully it was the first of many bike rides that I would be taking here in Tanzania and both my bike and I had met the challenge, though the latter barely so, and I had immediately discovered that this mountain bike riding was tremendously more intense than my rather flat road cycling at home, meaning that I would need work up this more slowly. Oh yes, did I happen to mention that our elevation here in Karatu is nearly a mile high compared to sea level at home. I guess that could also have something to do with at least some of the difficulty I encountered along my way, though perhaps that’s more of a rationalization than a reality. Time will tell.