Thursday, March 11 – FAME Neurology clinic is open for business….

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To say that it had been an interesting journey for me to get here would be a bit of an understatement, though we were all finally here in Karatu and together, ready for another month of neurology clinic. Due to the uncertainties of the pandemic, we had made the decision not to fully announce our clinic to the district, but would rather see return patients who needed to be seen for their continuity of care or new patients who were being referred by other clinicians at FAME and had been seen in the recent months. In addition, we would not be traveling to the villages where we normally hold our mobile clinics, again because of pandemic concerns and not knowing fully what the situation would be at all of the locations. That part would be unfortunate, as the mobile clinics have become a significant part of our program here, not only for the communities that we serve, but also for the residents as it enables them to see more of the culture here as we are usually visiting rather remote areas that have fewer and fewer resources. For this trip, though, we will be restricting our clinics to FAME proper save for two days at Rift Valley Children’s Village (more on that later).

The vast majority of patients we see in the Karatu district, as well as those from surrounding districts, are members of two tribes, the Maasai and the Iraqw. These are not the largest tribes, that honor is held by the Sukuma tribe of Northwestern Tanzania on Lake Victoria, but they are both very prominent in Northcentral Tanzania. The famed Maasai also live throughout Kenya and this region of East Africa is often referred to as Maasai-land given the colorful heritage of these pastoral people, well-known for their large herds of cattle, goats and sheep. As I have mentioned before, they mostly live in small enclaves, or bomas, that consist of a number of small mud and dung, thatched huts, each built by one of the number of wives of the husband/father who lives there. Children remain in the boma until they are old enough to be married and move on, sons or brothers often building a boma nearby. In addition to each of the wives huts, the boma is often enclosed by a short loose shrubbery fence along with another small corral inside for their cattle. Younger animals will often be housed in the huts along with the children of each wife. Each hut has a small cooking fire inside and separate elevated beds for children and adults to sleep.

The Iraqw on the other hand, are very organized agriculturalists and have been for many years. They also keep cattle and farm animals necessary for their existence, though this has been a point of contention with the Maasai for many years as it has often by said that cattle are God’s gift to the Maasai, or at least that is how they have felt. The Maasai and Iraqw have been at odds for many years leading to many small conflicts, typically over ownership of cattle, and it was not until 1986 that a treaty was finally signed between the two tribes to preserve the peace. The Iraqw have many small villages and farming regions in the district of Karatu and through the Great Rift Valley. The villages that we have visited in the Mbulumbulu region to hold our clinics are all in the heavily Iraqw-populated regions and are typically the most common patient that we see there. Our clinics in the Mang’ola region on the shores of Lake Eyasi is also almost exclusively Iraqw. Unfortunately, these clinics will not be occurring this trip and it is sad to think of the patients who we see there going without our care for any period of time as I have also visited them for the last ten years. The pandemic has created unforeseen issues that will affect the health of this community in unanticipated ways.

We knew, though, that our clinic was going to be far smaller than it has been in recent years when we have seen 300-400 patients on each trip, many coming from distant regions of Northern Tanzania through our announcements and word of mouth. We would only be seeing those patients we contact for follow up visits or those who may have heard that we’re here. As in September and October, when I was here alone, FAME has taken steps to lessen the concerns of COVID similar to what we have done in States. Everyone wears masks on campus and anyone coming to be seen is screened prior to entering the clinical areas. Hand washing stations have been set up at every possible location and antiseptic lotion is on every table in every room. Our cantina, typically bustling and bursting at the seams during chai time and lunchtime, has now been emptied out of its picnic tables to promote social distancing and everyone is eating outside under the trees. I’ll have to say, though, that it has been incredibly pleasant given the wonderful weather we’ve been having here.

Having arrived rather late last evening, there was no time for Phoebe, FAME’s volunteer coordinator, to have given her usual tour of the campus with any light, so we had planned to do it in the morning instead. We decided to delay the start of clinic until later that morning and, since everyone here goes for chai midmorning, Phoebe took everyone around to familiarize them with the campus here which has grown quite large over the last years. While everyone else was on tour, chose to circulate to a number of offices to get things in place for our clinic. Space for our clinic has always been an issue and, now with the pandemic issue, it was even more of an issue as Ward 2, that had served us well over the last two visits, had subsequently been dedicated for use as a COVID-19 isolation ward and was no longer available to us. The good news, though, is that Kitashu, our amazing outreach coordinator, and others had worked to set up a more than adequate space for us to use that was actually outdoors on the backside of the outpatient clinic. They had hospital beds, room dividers, desks, chairs and computers set up for us that gave us more room than we’ve ever had before and, best of all, it was outside and covered, with loads of fresh air and cool breezes.

Despite the fact that there were far fewer patients than normal today, mostly due to the fact that we were running rather incognito given the lack of announcements, we did have the opportunity to evaluate a truly unusual patient that had not been previously diagnosed. Though I have always seen children throughout my career, those who know me are quite aware of the fact that I draw the line on the numerous metabolic disorders that affect children as I much prefer to treat problems such as epilepsy, headache and Tourette syndrome. Jess S. had just finished seeing a child with epilepsy I believe when I spotted a young boy sitting out in the waiting area that I knew she would be excited to see as he clearly had one of those genetic disorders that I have chosen not to focus on in my practice.

Our young boy with scaphocephaly

He was six years old with reportedly normal cognitive development, though this was not entirely clear. He had a very large head that was greatest in the AP dimension (front to back) and which we often refer to as scaphocephalic. His facial features were extremely coarse and he had significant frontal bossing, or a very wide and tall frontal bone. He was of very short stature and on further review, he had a very large ventral abdominal hernia that was, in fact, the largest Jess had ever seen. His parents also reported that he had a nasal polyp, which, upon further inspection, was definitely present. There was little question in our minds that he had one of the disorders seen in children that are often referred to as the genetic storage disorders of which there are many and they are usually diagnosed with genetic testing that would certainly not be available to us here in Tanzania. Not certain of exactly how we should proceed and given the fact that the boy lived in Karatu, we decided to email Dan Licht at CHOP and would then bring them back for testing once we had a definite plan moving forward. He will most likely return next week once we’re able to organize the visit to ensure that everything will be available on the day that he is here.

It was slow first day, of course, which was much appreciated as I think we were all still a bit jet lagged from the long travels and even more so for Margo and I, who had spent two extra days sitting on egg shells in Chicago, not knowing for sure whether we were going to be able to meet up with the residents or now. Despite this, we had all made it here in one piece and with all of our luggage which is not always the case. With the change in equipment to the smaller plane in Doha, I was definitely worried that they would have just decided to send our bags with the next flight, but thankfully that had not occurred. Settled comfortably in the Raynes House, I was home again and looking forward to the coming month, even with the fewer patients and slower clinics. We would see whatever patients come and continue our training of the staff at FAME. One other silver lining is that with the current somewhat slower pace at FAME, we would be given two doctors to work with, Dr. Anne and Dr. Adam, while Revo, who has worked with me over the last two years and is now an intern in Moshi, would also be joining us. This would mean that the residents would have lots of opportunities to teach, and learn, and there was no question that their experience would be great. Satisfied with the day, we took the short walk home after clinic and readied ourselves for a relaxing evening.

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