Tuesday, September 21 – Another long and dusty drive to Mang’ola and a visit to Mbuga Nyekundu…


The clinic at Mbuga Nyekundu

Our visit to Barazani yesterday had gone well, though we hadn’t seen the same numbers of patients as we had two years ago when we were still living in a pre-pandemic world. I heard later that there was some confusion in the Mang’ola region that patients couldn’t come to see us unless they were vaccinated which certainly wasn’t true, but that certainly would have been an explanation for why we saw about half the number of patients. Very few patients in this region, or in any region for that matter, of Tanzania have been vaccinated at present and it has to do with a number of factors that have occurred here over the last 18 months.

Joel getting the pharmacy ready to dispense medications
Kitashu taking a short breather

To begin, we were here in March 2020 when COVID-19 had hit the US in such a dramatic way with NYC being pretty much ground zero once again. We continued to do our work as it was actually much safer here than it was at home, but when the State Department said to “shelter in place” or return home, we scrambled to rebook flights and made it home to a country that was in the throes of a health disaster unlike any we’ve ever seen in our lifetime. Meanwhile, the pandemic never hit Tanzania in the numbers it did in our country. Remember, this is a country of over 60 million people, one-fifth the size of the US, and the hospitalizations and deaths that have accumulated have in no way approached the numbers that we have seen at home. Though people have attributed that to the fact that there was no testing here would not even come close to a logical explanation as even without testing, hospitals would have been swamped and there would have been bodies in the streets had it even been a small fraction of what we saw at home. And this is a country where you could not find a mask on the street if your life depended on it (and it was just that at home) other than at some health institutions and, even that, was a rarity.

Dr. Anne and Denise working together with a patient
Staffing a patient with Paul

This is not to say that there was no COVID here in Tanzania as there certainly was and it came in three waves that hit in small numbers, but when it did, there were deaths and, tragically, it was the gatherings for funerals that in the end were the downfall for a number of high profile political officials. Hospitals required isolation wards for those patients who presented with symptoms suspicious for COVID so that they wouldn’t infect other patients and caregivers. Since the very first moment of the pandemic, FAME became a leader in the health community of Karatu district, enacting protocols designed after those in the US to prevent the spread of the virus and they did this very successfully. Everyone is masked and all patients are screened for symptoms and fever just as we have been doing in the US since the very beginning. FAME served to educate all of the government health workers in the district and has continued to provide the same services including being the test site for tourists having to get their COVID PCR test prior to traveling back home.

Revo, Cat and Emily evaluating a patient
Akash, Phillip and Leeyan working with a patient

With the death of President Magufuli last March (during our visit, I might add), Tanzania’s vice-president, Samia Suluhu Hassan, succeeded him and quickly realized that she needed to move the country from denial of the virus to acceptance and even more quickly begin to adopt practices that would hopefully protect the country from future waves of the virus. One of her first steps was to accept a shipment of vaccine from COVAX, the international coalition led by the WHO to supply COVID vaccines in an equitable manner internationally and specifically to low-income countries in need of access. At the end of July, Tanzania received the first shipment of their one-million doses. This was certainly an incredible milestone, but unfortunately, this is a country of over sixty-million people and a nation that had denied the existence of COVID until only recently.

Joel discussing a prescription with a patient

The disastrous consequences of the latter of these two facts is that it is my understanding that less than half of those one million doses have even been put into patient’s arms at the present meaning that the percentage of the population that has been vaccinated here is less than 1% compared to the nearly 70% vaccination rate in the US. The difference here, though, is that those who are unvaccinated are not making a political statement, but rather doing it because of lack of knowledge or misunderstanding. I have heard from people here that say they’ve been told that young woman receiving the vaccine will no longer be able to become pregnant. It is on this background that the battle against the pandemic will be fought in Tanzania and many other nations of Africa and, as we have now learned in the most dramatic of fashions, there are no borders when it comes to disease, especially a global pandemic. If the need for increased global health efforts has not been evident to you before, it should be now.

Dr. Anne and Denise with a BPPV patient about to perform a Dix-Hallpike maneuver
The Dix-Hallpike

Our drive to Mang’ola was again an incredibly dusty and bumpy ride. Remember, I am driving a stretch Land Rover that can seat nine passengers meaning that there is a rear row of seats that sit well behind the rear wheels, having the added advantage, or disadvantage, of a tremendous amount of extra bounce when it comes to those extra big bumps. Though it is certainly not anyone’s intention to hit these bumps at high speed, just imagine driving at 80 kph in the dust and on the washboards and trying to slow the vehicle down when you see these at the last moment. I don’t use this as an excuse as much as an explanation for poor Philip who I think sat most often in the back of Turtle on our treks and probably hit his head on the room a time or two. There are certainly disadvantages to being tall.

Kelley gets into the trenches
Paul now confirming

The road to Mbuga Nyekundu leaves the main road to Barazani as you enter the region of Mang’ola and it sits in a valley that is more distant from Lake Eyasi. The district dispensary there is rather large and, though there was amble space for us, there were no desks or chairs in the building we had used in the past, which meant that they all had to be carried from the other building. Kitashu once again took care of the organization and with everyone’s help, we soon had three examination rooms set up to get through the patients that had already accumulated for us to see. Dr. Anne once did her announcements to the patients regarding what types of conditions that we see so as to triage out patients with non-neurologic conditions who would be better seen by the clinical officer stationed here and who delivers care to the community on a regular basis.

Kelley staffing a patient with Cat and Emily

The weather was incredibly dry and dusty and there was a strong wind that blew through the community reminding me of my days exploring through the inland deserts of California as the landscape was also quite similar. It was not hot at all, but the dry wind felt as though it sucked all of the moisture out of your body and for someone like me, who drinks very little water to begin with, it was a firm reminder to hydrate. It was decided that we would eat our lunch inside the building, not only to avoid the wind and dust, but also because we want to be sensitive to the patients and community by not eating out of lunchboxes in front of them. We’ve also done this from day one on our mobile clinics as it very often the case that we’re enjoying a meal when the patients and villages may get only one meal a day and are most frequently underfed and malnourished. The number of nutritional anemias here is quite large, but you must also remember about deworming younger patients at least one a year as it has been shown not only to help the anemia, but also to improve academic performance.

Emily, Revo and Cat staffing a patient with Kelley and Paul

Akash had both of the more interesting patients today. The first was a young man who came in with patchy sensory complaints that had been going on for some time and, though they were certainly neuropathic sounding, the patchy nature of them argued against the more typical length dependent process, such as what we seen commonly in Diabetes, and he had to give some more thought to this patient. His examination failed to yield any additional clues other than confirming the he indeed had something other than a common neuropathy. There were some additional clues that can’t recall at the moment, but with further questioning, it turned out that the man’s father actually had leprosy, but had passed away previously. After discussion with Paul, it was felt that this patient actually leprosy and would require further treatment in a center that deals with this diagnosis and does exist here in Tanzania for this and other diagnoses such as tuberculosis and anthrax due to their specialized nature of treatments.

Revo, Cat and Emily evaluating a patient

The other patient was a child with a much simpler diagnosis of cleft palate, something that is actually treated for free by the government and so there should be no barrier to the child getting surgical correction for this condition. Although the treatment is free, there is still a cost for the family as it requires that they travel to a government center that deals with this and that usually means the parents and other siblings would have to travel somewhere, find a place to live during the procedure and take care of whatever other expenses there might be other than just the surgery. Things are not always as simple as they sound here and “free” treatment may not always come without a cost. This is not unlike home in many ways and is why we have the Ronald McDonald house at CHOP so that families can have somewhere to stay for extended periods if necessary.

Staffing resident clinic

Our clinic wound down and it was eventually time for our departure from Mbuga Nyekundu. Thankfully, now knowing the way home, we would not have to drive with the other vehicle making the dust more manageable, though not entirely as there were certainly lots of trucks and other vehicles on the road that we would either overtake or were driving in the other direction to turn up enough dust to still make it miserable. We arrived home before sunset, though, and had time enough to run to Teddy’s as Kelley and Paul had wished to have some clothes made, as well, and the others needed to try on a few things. Amazingly, having never had anything made during a visit here, the group talked me into making a pair of shorts with some of Emily’s left over fabric. The cost to make the shorts was 10,000 TSh or slightly more than $4.00, so it wasn’t like I was taking a big risk regardless if I never ended up wearing them.

Trying on their new clothes

We finished at Teddy’s and drove home for the evening, having had a very full day of work and driving and it was now time for rest and relaxation. We still had two days of mobile clinic left in the week, though they were much shorter drives to the idyllic site of the Rift Valley Children’s Village, a place that is always wonderful to visit for so many reasons. Friday, we would be heading to the Serengeti for two nights and everyone was clearly looking forward to that, including me. We would have drivers and two vehicles and, even though driving on a game drive is one of my favorite things in the whole world, it is nice to be driven once in a while and I would be free to take photos as well.

Cat, Denise, Emily and Phillip in their new clothes with Teddy

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