Wednesday, September 15 – More neurology clinic, a hike and a wonderful surprise…

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An afternoon at the Lilac Cafe – Denise, Emily, Annie, Revo, Leeyan, and Kerry

Thankfully, it was a morning to sleep in by an extra 30 minutes and I think everyone in our group took advantage of the extra minutes of slumber. It only takes five minutes to walk up to FAME from the volunteer housing and it’s always interesting to see what the normal morning schedule is for each of the travelers with me. I’m typically an early riser (which doesn’t work well considering I get my best work done late at night), but others seem to roll out of bed with just enough time to pour a cup of tea or coffee, often though unable to finish it. Regardless, we all seem to make it in time. Phillip has had the luxury of taking most mornings to do his work on the database at the Lilac Café where he can order breakfast and a coffee or cappuccino for the morning while working on the internet to enter data and take care of his emails. Sitting out in front of the Lilac with a nice cup of Joe is probably one of the most relaxing things I could ever imagine doing. I dream of this when I’m back home in the US.

Cat and Revo evaluating a patient
Emily and Leeyan evaluating a patient

We learned at morning report that our seizure inpatient had done well overnight with no further seizures on the increased dose of valproic acid 1000 mg twice daily. He was awake and seemed better than before so the decision was to send him home on the higher dose of medication and have him come back to see us in clinic the last week that we’d be here with the hope that he would remain seizure-free and that his exam would be non-focal. Our hope was to hold off making any long term decisions as long as he remained seizure free and regained his prior functional status. The decision of whether or when to reimage him would really depend on his clinical status going forward and whether his exam changed or whether he begins to have more seizures. For now, though, we would simply maintain him on his current medications.

Dr. Anne, Emily and Denise evaluating a patient

Our Sydenham’s patient returned for his echocardiogram that demonstrated evidence of inflammation and would determine the length of antibiotic prophylaxis that we would recommend. Based on the current recommendations, given the evidence of carditis, or inflammation seen on echo, he would require IM or PO penicillin for 10 years! I can’t recall whether I had mentioned it yesterday or not, but we would also place him on a fairly long course of oral steroids as an immunosuppressant to decrease the movements over time and hopefully hasten their resolution. Most often, the movements will completely resolve over time, but it can take many months or even years and having them resolve just a bit sooner I am sure would be very much appreciated. After initiating his medications and giving the family all of the necessary information, he was sent out with instructions to return in several months to see Dr. Anne and then in March to see us on our return. Again, Sydenham’s chorea is such a classic illness and so rarely seen in the US, it was great to have all of the residents, Phillip and even Sean and Kerry see him. Once you’ve seen an adolescent present with these movements, you will never forget the diagnosis.

Hiking down to the brick quarry

Another young boy who we saw today was brought for evaluation of two months of mid back pain that had been bothering him significantly. These types of complaints wouldn’t normally be seen by us as a neurologic problem, but the family had come from Arusha to see us specifically. Our neurology clinics are subsidized for several reasons, but the most important perhaps is to allow patients to come see us without worry about the cost of medications or diagnostic labs. We charge patients a flat rate of 5000 Tanzanian shillings (slightly over two dollars) for a visit that includes at least a month’s worth of medication (I am often asked to approve a two or even three month supply of medications due the distance a patient may live or their ability to pay for refills) and it may be often that patients are not even able to pay that amount. Because of the flat rate, though, many patients may come to our clinic to seek care for other conditions (most often muscle or joint pain) and, despite our best efforts to make it clear on our announcements to the community and to triage patients in clinic, we have routinely had to categorize some patients as “non-neurologic” or “MSK pain” for our clinics.

The brick quarry

Given that back pain in a twelve-year-old is that unusual, though, we felt it reasonable to have Akash evaluate him and make some recommendations. In the end, we were quite thankful that we did so, as it was not only the back pain that worried us, but also his abnormal neurologic findings that revealed some mild weakness present in his lower extremities. This combination of history and abnormal examination required that we refer him for advanced imagining (which would have to be done in Arusha or further away) and would need to be done sooner than later so that we could also review the studies before our departure.

Phillip in the brick quarry

We finished our clinic a bit early this afternoon and everyone had been wanting to take a hike around the area since we’d arrived. The red clay in the Karatu district is remarkably perfect for brick making and there are community brick quarries located throughout the region, but one of the larger ones just happens to be down below FAME. Walking through the quarry and up the other side of the ravine takes you onto a small road that leads to the town of Tloma, an Iraqw community where many of our patients come from and a stone’s throw from the entrance to Gibb’s Farm. Everyone chose to tag along so it was the neuro team along with Kerry, Sean and Revo. Leaving from the main gate of FAME, it’s just a short distance across the main road to reach the trail that descends into the ravine where we’d find the quarry and the trail up the other side. The trail that descends is also used for cow and goat herds, so one must do their very best to avoid  these booby traps, though they’re fairly obvious. As we got the very bottom of  the ravine, there was a small stream that hadn’t been there in the past, or at least I couldn’t recall. The braver half crossed as we first encountered the stream, though those of who were a bit more interested in remaining dry chose to scout out a better crossing point and found one close by.

Philippo explaining the process of making coffee beans

Having now all successfully navigated the stream, we walked through the quarry where there were several workers processing bricks and a number of children working on piles of broken bricks turning them into gravel with clubs, a very labor intensive job for certain. The bricks are first formed and then stacked into very large, perhaps 10 feet tall, towers with cavities in the bottom where wood is placed and eventually lit to fire the bricks. The finished product is used for building all of the structures in the region that are not otherwise built of wood branches and mud. Once out of the quarry and onto the road above we encountered lots of children who were playing on the many properties that we passed on our way to Tloma Village. There are also a number of nice lodges here that are older and have high walls that surround them. We finally intersected the Gibb’s Farm road which is the center of Tloma Village and begins the countless rows of coffee bushes that form the Gibb’s Farm coffee plantation.

Philippo and Mbuga pounding the coffee

As we were walking past one of the remaining shops of wood carvers, we heard a “hey Dr. Mike.” Though I hadn’t been up there in several years, an old friend, Mbuga, had recognized as we were walking past. He is one of the remaining Makonde wood carvers in the village where before there had been dozens and had entertained residents in the past by demonstrating and then instructing them in the fine art of wood carving. In addition to the wood carvings that were more than plentiful in his shop, he also had many pieces of art that were mostly in the Maasai or Tinga tradition. Several of our group spent a good amount of time shopping there and when we were almost all finished, Mbuga told me that he wanted to bring me next door to meet a friend of his who was serving coffee. Our little impromptu visit to the house next door turned into the most amazing and pleasant of experiences.

Young coffee bushes before planting

Next door to Mbuga’s wood carving shop lived a family of coffee farmers who had been in the area for at least two generations and not only grew their own coffee beans on the five acres of land they owned, but also processed and roasted their beans for sale to the public. There resided Philippo, his wife, Fausta, and their four children, all of whom helped with harvesting and processing the coffee beans. There were no other visitors when we arrived, so we had he place to ourselves and Philippo proceeded to not only give us a guided tour of the farm, but he also delivered an incredibly detailed explanation of each of the various steps in bringing the coffee from plant to bean to cup. The beans are shelled with a grinder and then pounded by hand before they are then winnowed to remove all of the chaff. Philippo and Mbuga gave us a demonstration of pounding the beans, singing “Twanga, Twanga….Twanga, Kahawa, Twanga” as the did. Then they Cat and Denise a turn at the pounding that was pretty impressive. Once the beans are dried, they are then put into a canister and roasted over coals while turning by hand for approximately 40 minutes to achieve a perfect medium roast.

Sampling the coffee while Philippo has ground our coffee for home

Philippo was one of the most patient and warm individuals, answering all of our questions along the way and then some, and after all was done, we sat down for a cup of his freshly brewed coffee that was truly amazing and served by his wife. In addition to his coffee, he also had many bee hives as the bees were necessary for pollinating his coffee plants. He told us that he had recently harvested his honey and didn’t have any left over for sale at the moment. When I asked about purchasing some of the honey from him, he did promise to save his next batch for me as soon as he had more to sell. Both Phillip and Sean turned out to be closet bee keepers and were enthralled by Philippo’s hives there were the home to a species of small stingless bees. He opened one of the hives for them that was handy so we could all look inside and actually scooped out some of the existing honey for us to taste. It was a very thin, sweet, coffee-tasking honey that was really out of this world. I sure hoped that he would come up with some extra bottles before I left.

Philippo showing the inside of one of his hives
Close up of the hive and honeycomb. Not the standard honeycomb seen with larger bees

After our tour was through, everyone put their orders in for bags of coffee as we didn’t want to have to carry them back with us on the walk home. We had a half day of work on Saturday and planned to return on that day after our work was done. Before we left, though, we did make sure to pick up a 500 gram bag of ground coffee, which Philippo proceeded to freshly grind for us with his mechanical disk hand crank grinder. We all said our good byes to Philippo and his wonderful family. Their home, their lifestyle and their hospitality were all idyllic and, as a group, we all agreed that our visit was incredible and that none of us could wait until we visited with Philippo and his family once again. We trekked home into the setting sun, down into the quarry and back up the other side until we reached FAME once again. We all met on the veranda for dinner in the gentle darkness that is Africa, lit only by the waxing moon and our little solar powered blow up lantern.

Philippo and Fausta’s home with bee hives hanging in front

Later that night, I did run up to the clinic as I was asked to check in on a tourist of one of the tour companies who had been admitted for the night, though she had been put in the isolation ward due to some low oxygen levels and concern over COVID. I wasn’t able to see them as they were isolation, but did follow up the next day. It was not a neurologic case, so I had little to offer medically over the doctors here at FAME, but I was happy to help out with communications. On my way back to the house, I marveled at our migrating ants who had creating quite a sight and worthy of a photo.

A mass of ants while walking home from the clinic late at night

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