Monday, September 13 – A new week at FAME, Akash in Dar, the team hits the market and the ants go marching on…


Patients waiting in our outdoor clinic

I had failed previously to mention that we were missing one member of team for our Tarangire trip yesterday as Akash traveled to Dar es Salaam for a visit to the US Embassy that was scheduled this morning at 9:15 AM. The reason for this unexpected visit to the coast is that Akash is an Indian citizen currently on a J-1 Exchange Visitor visa for his training at CHOP. With this type of visa, leaving the US means that you must visit a US embassy to have your visa renewed prior to re-entering the States. In normal, non-pandemic, times, this would not be a significant issue and was pretty much standard practice, but given the situation in the world, all of the US Embassies have been working with a reduced work force meaning that merely scheduling an interview was virtually impossible, not only here in Tanzania, but also in India. Originally, Akash had planned to travel home following our work, get his visa renewed and then travel back to Philadelphia. When he went online to schedule the interview in India, it was impossible to do so and became readily apparent that this was going to be a major problem.

Cat and Revo examining a patient with Emily documenting
Cat and Revo examining their patient

Thankfully, I was able to make a few inquiries regarding him getting an interview given the service he was providing to Tanzania by coming here as the only pediatric neurologist in the country and providing care to countless children. Though this did allow him to eventually schedule an interview, it remained touch and go along the way and we weren’t fully comfortable with him traveling until the very last minute as any hang up along the way would have meant that he would not have been able to return to the US after this visit. Trying to figure out how we would pay for the application process when the two methods were either to wire the money (there was no time) or to pay with M-pesa, their telephone payment system which could only be done in-country, was a major obstacle that required me sending money a friend that then paid it for us. That certainly would not have boded well for our program considering CHOP would have been down a senior resident. So, considering that his interview was scheduled first thing Monday morning, that meant that he had to travel to Dar on Sunday afternoon and could not travel with us to Tarangire. In the end, Akash made it to Dar as planned and even though his Airbnb he had rented had power issues causing him to relocate, he was able to make it to the interview, which was successful, and get his visa renewed. Of course, there was still the two day wait for his passport to be returned, meaning he had to remain in Dar until Wednesday, when he could pick up his passport and then fly back to Kilimanjaro and catch a shuttle back to FAME. There were still many moving pieces, but the first major hurdle was now over with and the focus was getting him back here to FAME.

Dr. Anne with the residents
Dr. Anne and Denise taking a history of a patient
Chatting with Dr. Anne

So, our Monday morning, most often the busiest day of the week, began with one less resident and the only one who couldn’t be replaced. Not having a dedicated pediatric neurologist with us is a major limitation as probably 1/3 of the patients we see here are children and their neurological assessments are often very difficult. Not only do we have lots of childhood epilepsy and cerebral palsy, but also developmental issues and muscular dystrophies. Even though I’ve taken care of children my entire career, I do not feel comfortable evaluating the youngest of children when one has to consider all of the genetic and metabolic disorders that can occur. I was probably the most relieved of all that he had completed and passed his interview, otherwise I would not have had his input on the multitude of children that we see here.

Revo, Emily and Phillip evaluating a Maasai patient
Revo, Emily and Phillip evaluating a Maasai patient with his son
Dr. Anne and Denise evaluating a young girl with a static encephalopathy from birth injury

The patients seen today were, I will have to say, all pretty basic as I can’t say that anything really stuck out to me. There did seem to be a large preponderance of musculoskeletal patients today, meaning those with back or neck pain, joint or muscle pain. These are really not neurologic problems, something the residents hear me say time and again in the clinic at home. The fact that pain is mediated by nerves does not make pain a neurologic condition. A ruptured appendix, a very painful condition, is not a neurologic problem just because it is manifested by pain. Regardless, since we’re here and these patients need to be seen by someone, we tend to be a bit more relaxed about our triage, unless, of course, we become overwhelmed and need to be more selective so we can get through the day. In addition to the MSK (musculoskeletal) pain we saw, most often treated with ibuprofen and exercise or physical therapy, there were the normal smattering of neuropathy and epilepsy patients, some who had seen us before and many who had not.

A patient who presented with seizures and concern for COVID getting CT scans of the brain and chest
Dr. Anne and Denise waiting on the CT scan
Onaely (CT tech) preforming a scan on the patient with seizures.

The day ended at a fairly decent time, though, allowing everyone, including Dr. Kerry, to head downtown in the company of Dr. Anne, to purchase some groceries (really Konyagi, the local spirit here) and cloth so everyone could have clothes made by Teddy, the tailor who we’ve worked with for several years now and who does an absolutely amazing job of creating just about anything you can show her a picture of or draw for her. The fabrics here are out of this world beautiful and very fairly priced so that between the fabric and Teddy’s cost to make a skirt, dress or shirt, each piece probably comes in at only $10 to $15. There are absolutely no large stores here in Karatu and all shopping is done in small little shopfronts or kiosks depending on what you are looking for.

Shopping for fabrics
A street in Karatu

There used to be a huge, poorly constructed vegetable market where you could find anything grown here, but with the dirt floors and leaky roof, it was always a muddy mess. You’d walk through the market, constantly hopping between the large puddles of mud that always dominated the aisles, hoping not to slip or fall along the way, while managing to find just the right vegetable or fruit you were looking. They have been building a new vegetable market over the last year that is now finally open and much less challenging to navigate with an intact roof and gravel on the ground. Though I will absolutely miss the incredible character of the old market that had provided many an amazing photo, I will certainly not miss the muddy shoes or the poorly selected vegetables or that occurred as a result of the horrible lighting of the place. Progress is not always a photographers friend.

The new vegetable market
The old vegetable market
Vendors outside of the vegetable market

I drove the entire group, less Sean, down to the market area and dropped them all off with the instruction to Anne to make sure they arrived home safely and each in one piece. I sat at home working as the sun slowly set and it quickly became pitch black outside. Though I still wasn’t worried in the least as I knew they’d eventually show up, I was getting pretty hungry and was therefore quite pleased to finally hear everyone outside. They had all taken a couple of bijajis home from town along with all their prizes and importantly including the Konyagi so we could enjoy some cocktails with dinner. We found that it mixed quite well with tonic water, mango juice and a lime. We all migrated over to the veranda at Joyce’s house to meet with Sean and Kerry for dinner as they are staying in one of the other volunteer houses and Joyce’s veranda is the best place for dinner given the seating. It is under a pitched roof that works well so the bats flying through in search of the insects attracted by our lights are high enough over our heads so as not to be too intimidating. When we built the Raynes House with its small veranda, I promised Joyce that we would always gather on her veranda for dinner and I was keeping true to my work even though she’s back in the States at the moment.

Sunset in Karatu
A street in Karatu at sunset

Meanwhile, I have to mention the incredible ant migration that has been going on just outside the gate to the volunteer housing that we walk past every day on our way to clinic. This truly represents a migration that far exceeds by number the Great Migration of the wildebeest that involves millions, but given their tiny size, go unnoticed. But not by us. We have watched their diurnal progress, coming out at night and still being present in the morning while completely vanishing during the daytime other than the faint trail they leave in the grass. On the third or fourth day, they began to form archways or tunnels made up of the perfectly still bodies of both the workers and the soldiers. There are worker ants going in both directions, or coming and going, while the soldier ants continuously guard their procession that is presumably serving some ultimate purpose, though it’s not so readily apparent to us at the moment. Regardless, it seems like it must be some monumental task given the sheer numbers that are involved and remains very impressive just the same. It is equally enthralling to me as a Nat Geo, Discovery or Animal Planet special and is occurring in our own back yard.

The Great Ant Migration
A tunnel of ants
Close-up of the ant migration

And finally, as if to add insult to injury, Akash checked in with us from Dar just to let us know how he was doing. After his first experience with the Airbnb and a second experience with an equally dumpy place, he elected to move to a hotel just north of the city that also happened to be on the beach. He sent us photos of the beach and, even though we were all still sad that he had to travel to Dar for his visa on his own, we did feel just a bit less sorry for him, and perhaps a little jealous, after seeing his photos. He would have to remain there for two days waiting for the return of his passport, but it now seemed to be that much more tolerable.

A view from Akash’s hotel. So sad, but someone had to do it.
A view from Akash’s hotel

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