Friday, September 10 – A busy day in clinic and Gibb’s Farm for dinner…

Standard

The weather here has been surprising cool, dropping down into the 50s at night getting only into the upper 70s during the daytime with very brisk mornings on our walk to clinic. I have rarely used any type of sweater here and find now that I’m wearing a fleece vest or else I’m sitting with a chill well until lunchtime. I can’t help thinking that it’s just another worrisome sign of global climate change such as we’ve seen with the storms and fires in the US over the last year. Watching Al Roker cover the recent hurricane Ida coming ashore in Louisiana as a category 4 after she had massively intensified over the warmer than usual gulf waters would have been enough to convince anyone. His comment of, “for those of you who don’t believe in climate change, this is climate change personified,” certainly rang true to me and now with the unseasonably cool weather here, it certainly makes me worry more than I had already been. Climbing to the top of Mt. Kilimanjaro six years ago in an unusual blizzard and viewing the wonderful glaciers that have existed there over millions of years that are now slowly disappearing just as those elsewhere in the world along with the polar ice caps, are also grim reminders of the mess that we are leaving for our children’s children.

Phillip in the morning at the Lilac Cafe – “really, I’m working.”

Despite our world as we know it slowly disappearing (I say that only half sarcastically), we arose for clinic with an extra half hour of time as there was no education lecture this morning and only morning report that begins at a more humane (and not surgical) 8:00 AM. I should have also mentioned earlier that most of the local population here goes by Swahili time which starts at our 6:00 AM and counts up from there. Our 8:00 AM would be 2:00 in Swahili time. There is no AM or PM typically attached to that and it has forever baffled me how one would tell daytime from nighttime, but be that as it may, our clinic runs from 2:30 to 10:30 in Swahili time which is what the sign says at reception and what most of our patients have on their cell phones. That’s another topic for discussion, in case anyone was wondering, but everyone here has cell phones. Most of the Maasai use the older type, non-smartphones, that they carry in a small pouch around their necks as the shukas (plaid cotton blankets) that are wrapped around them in traditional style don’t have pockets and, although the men usually have a belt they wear, that is for their traditional knife they carry. Charging of their phones is typically done via either small solar panels on the roof of their hut as their bomas do not have electricity, or by utilizing a power outlet wherever they find one, such as clinic. For Maasai that live in town, that is obviously less of an issue as they would typically have power in their homes.

Matilda at her best…sleeping

Morning report today included a small child who had hit their head and was having repeated vomiting overnight and into the morning. Though that would be something we would normally deal with here, I was more than happy to turn it over Kerry and Sean since it was much more in their bailiwick than ours and it’s been such a pleasure to have them here for these kinds of things. Over the years, we’ve had neurosurgical cases that I’ve had to deal with, but as long as the time permits, I’ve always utilized Sean for necessary clinic questions. I recall several skull fractures in adolescents that we’ve seen here and he has come through every time in guiding us to the proper decision of whether it’s been something that we can just watch here or would have to refer on to Arusha to see the neurosurgeon there (who’s only been available to us over the last few years). Akash got report on the young baby with the hypoxic ischemic encephalopathy who seemed to be holding their own for the moment and we were otherwise free to start our clinic at 8:30 (2:30 Swahili time) as we had plans for dinner tonight at Gibb’s Farm and wanted to make sure that we were finished in time for sunset which is typically gorgeous there and not to be missed if possible.

Various stages of explosion from the freezer. Oops…

Our clinic began rather slowly, but began to pick up through the day with a smattering of epilepsy patient that were great for Cat and Emily as well as enough pediatric cases to keep Akash in his comfort zone (and the rest in theirs). Denise, our budding neurohospitalist, would have to be happy seeing everything, which is certainly what she’ll be doing in the future, albeit on the inpatient rather than outpatient side of things. The epilepsy cases were all excellent and continued to reinforce the need for our work here for these patients in particular. I’ve spoken about this repeatedly, and it is one of the main focuses of the education we are providing here to both the patients and the doctors. 90% of the world’s epilepsy occurs in low to middle income countries and the reasons are many. The increased incidence of childhood infections including cerebral malaria, traumatic head injuries and perinatal injuries are the main reasons for this increased prevalence of epilepsy.

Experimenting with beer in the freezer overnight. Do not try this at home.

Most worrisome is the fact that epilepsy is also occurring more frequently in exactly the places where there are no neurologists or any expertise to treat it so that it either goes unrecognized, untreated, or treated incorrectly, all of which result in the same thing – poorly controlled seizures that can be life threatening in and of themselves as well as with the risk of injury during the seizures. In the rural communities, as well as the big cities, most Tanzanians cook over open fires or using propane tanks that rest on the floor. Adults and children having seizures and falling into flames sustain horrendous burns that can lead to death or a disfiguring injury. It is not uncommon for us to have several patients, more often children, with severe burns in the ward when we arrive or during our time here. Also, children with recurring seizures are, most often, not allowed to attend school, which is another tragic consequence of this very treatable disorder. Since 2010, we have encountered children, adolescents and adults with epilepsy whose lives have benefited greatly with improved seizure control meaning that the impact of treating this single problem has made perhaps the greatest difference for the patients who we treat.

The view out the bathroom window at Gibb’s Farm

In addition to monitoring the basic demographics of the patients seen by us, we have been keeping a separate database of our epilepsy patients in order to drill down on the effect we’ve had providing this care by recording such variables as adherence on medications (compliance) as well as seizure frequency and quality of life issues. We have also looked at the characteristics of those patients who return to see us versus those who are new and seeing us for the first time. In September 2019, Leah Zuroff (medical student then and now second year neurology resident at Penn) crunched the numbers to compare these rates of return vs new by diagnosis and discovered that epilepsy patients were 3X more likely to return for a visit than headache patients. We had truly made a difference for these patients and they were returning to see us. FAME shot a video last fall with an interview of one of my patients who I’ve cared for since 2011, and her mother. She had a perinatal injury with a hemiparesis and was having frequent focal seizures that precluded her from going to school. It was merely a matter of putting her on the right medication and maximizing her dosing regimen such that she has now had no seizures in many years, completed primary school and has advanced to secondary school where she is totally thriving. It is success stories like these that really make all of this worth it and keeps us coming back again and again.

We also saw two patients today with idiopathic Parkinson’s disease, a disorder that is made entirely on a clinical basis and without any testing, which is certainly a blessing considering that we’re very limited on testing here either based on the cost or availability. Though we do have a CT scanner here at FAME, the cost for the patient of doing one can be prohibitive even though it is far less expensive than what one would pay at home. A non-contrast CT scan here may only cost 200,000 TSh, or approximately $90, which would be a bargain in the US, though in a region where the annual income may be only $250/year, that amount is out of the question for most. Thankfully, the culture in East Africa is predominantly communal, meaning that a patient can go back to their family, their village or their community to obtain the funds necessary for something like this. MRI scans are only available in Arusha at one facility and are probably double the price of the CT scan. Something so specialized as a DaTscan which is performed primarily for helpful when evaluating patients in whom Parkinson’s disease is a concern are not even a consideration here. Thankfully, since Parkinson’s disease is primarily a clinical diagnosis and carbidopa/levodopa, or Sinemet, is a medication that is so effective as to be considered a diagnostic test and is available here, we can easily diagnose and treat this common disorder without the need for any expensive or unavailable testing.

The view from the veranda

Some stories, of course, are not so easy to sort out and treat. Histories are quite often very difficult to obtain despite the wonderful assistance we have from the doctors and translators who work with us here. Patients may have been treated at other facilities and have no inkling as to what was done and medical records are rarely available for us to review. Cultural differences that determine just how one relates historical events is often very great, effecting just want facts a patient or family may relate to the condition they’re being seen for. We commonly hear things such as a psychiatric disorder that may begin if a snake crosses in front of the patient or even the name for seizure here which is degedege and that dege means large bird, often linking the superstition that seizures happen because a bird flew over the house. Trying to back up to obtain the necessary information for us to build a good timeline and make a diagnosis can be very difficult in these situations requiring us at times to decide just what the most plausible explanation for a patient’s condition is and go with that. This certainly happens at home as well, but just seems to be that much more prevalent over here.

A walkway at Gibb’s with the night sky in the background

We had hoped to leave for Gibb’s Farm at a decent time, but our clinic turned to be far busier than we had anticipated, seeing, in the end, 28 patients total for the day. Dr. Anne would be coming with us as well which meant that she would need to run home to change and we would pick her up in town where our road met the tarmac. By the time we left FAME, picked up Anne and then drove up the road to Gibb’s Farm, the sun had mostly set, though it was still light enough to enjoy the loveliness and serenity of this place. The view from the veranda is spectacular and no matter how often I return, I never get tired of relaxing atmosphere and tradition that is Gibb’s Farm.

The afterglow of sunset at Gibb’s (photo courtesy of Akash)

The farm was very different when I first visited in 2009 as it was still in its original configuration when owned earlier by the Gibbs family and run as a self-sufficient village where there was a dairy, gardens and a shop for making all of their own furniture. There was also a free-standing clinic, the Osero Clinic, that was run by Dr. Labiki, a Maasai healer, who had his various herbs and natural products that he prescribed for patients, but clearly knew when it was appropriate to send patients to FAME. When I first came, Labiki took me and my kids on a walk through the woods surrounding Gibbs to identify various leaves and bark that were used by traditional healers. He had completed a manuscript along with an ethnobotanist in Nairobi that compared the chemical makeup of the commonly used plants to the medications used in the western world and looking for any similarities. They obviously found many. Labiki remained at Gibb’s and the Osero clinic for several years and I would visit him frequently, but he later left and moved back to Arusha to work with his brother in their own clinic there.

Our dinner table (missing Kerry and me)

Later, there were many renovations done to the farm, all for the best, as it is now a destination resort, but with the old appeal of the original Gibb’s Farm. The main building now has a wonderful dining area that accommodates both inside and outside dining and the veranda and front are wonderful for having drinks while watching the sunset. I have known a number of the staff at Gibb’s for many years and am always greeted with such warm friendship there that it is impossible not to want to remain there for as long as possible. Dinner was once again the incredible affair that it has always been such that Gibb’s remains one of my favorite places to visit here or, for that matter, anywhere in the world. I think we probably spent just short of three hours for dinner, yet the evening seemed timeless as it was spent among friends, both those at the table, as well as those serving.

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