For a land that is so often thought of as dry and dusty, the heavy rains that come in April and May are a welcome thing, as are the often earlier rains that may pop up in March and even February. Lives depend on the rains coming on time, for without them, the spring planting season would be bust and fields would go unintentionally fallow and the harvest would suffer. I’ve been here in the heavy rains before and they are sight to see as everything turns to a sea of soupy mud where all transportation is brought to a standstill. The roads become so slippery that making it to our mobile clinics becomes impossible and patients also have a hard time even making it to FAME. In the Southern Serengeti, where the great migration gently pauses momentarily with all of its new wildebeest calves, much to the pleasure of the predators that depend on this, the level lands, that are for the majority of the year as dry as one can imagine, become like a shallow sea trapping anything that dares to challenge it. Having your Land Rover stuck in this mess is not what one envisions for their game drive, though having been there on several occasions, it can generate its own excitement, if not fear of being swallowed up by the complete emptiness of the landscape here.
It rained heavily last night with lots of lightning and thunder, much to my pleasure for those who know me well, and we could not help but stand on the back veranda looking off into the blackness that was briefly shattered by sudden displays of nature’s fury. There is nothing quite like the sound of heavy rain on a metal roof and ours was no exception as it’s almost impossible to even think at times. Sitting in our house at those times, the rain is all that one can focus on for it is that loud and that intense, occupying your entire focus. Conversations come to a standstill and reading is even difficult. These are the opposite of the soft rains one often thinks of when trying to relax or meditate as these rains are all consuming. They are life preserving, though, and are a reminder that the steady rains will soon be here next month, if not sooner, and that the circle of life that is nature will continue as it has done for millions of years.
Walking to clinic in the morning, the ground was wet, but we knew that it would quickly try given the completely clear skies and the intense rays of the sun that were already pouring down upon us in the early hours. During the dry season, Karatu becomes a dust bowl with the fine red clay seeming to be equal parts aerosolized and on the ground. Everything within several meters of any nearby road dons a lovely coat of red-orange ocher dust that remains until the next rainy season. We are thankfully spared that pleasure during this season as the light rains of January have managed to wash it all away. Our walk this morning, other than the dew on the grass, was unimpeded as the wetness from the rains last night had already evaporated into the warm rays of the sun and, thankfully, there was no mud to impede anyone’s travel.
We again had a hybrid patient population for clinic with the group from Food for His Children coming again to see us. Once again, we had many challenging patients mostly from the treatment side and mostly from the standpoint of cost of medications. A young teenage girl came to see us today who had a history of epilepsy that had been poorly controlled, though quite infrequent, in the past, but she was unable to attend school as the teachers had said that she could not return until her seizures were completely controlled. This is often the case here concerning epilepsy as there are a great many children who are unable to attend school for their most formative years for this reason. One such patient I had originally seen in 2011 as she was continuing to have seizures secondary to a perinatal stroke and had been repeatedly send home from school. We were able to place her on a simple treatment regiment, maximizing her medication and she has remained seizure free now for many years. More importantly, she was able to not only attend school, but graduated from primary school high in her class and has gone on to secondary school where she continues to excel. Neither her hemiparesis nor her seizures have ever been a problem since her first visit with us over ten years ago.
More significantly, though, was the young woman we saw today who continued to have seizures and was not on medication at the present due to the fact that her family felt as though they were not helping her. Additionally, she was now 15 years of age and we had to consider the fact that we could not use valproic acid for her given the issue of teratogenicity, and specifically neural tube defects, which are disastrous when they occur. Because we wanted to make sure to control her seizures while also not causing any harm, it would be best to place her on lamotrigine, our anti-seizure medication of preference when it comes to women of childbearing age.
The issue, though, becomes complex when we look at the cost of the medication and its availability here outside of FAME. It is a drug that one can obtain in many pharmacies (a duka la dawa), but access is not universal and starting and stopping this medication is not something that is good for reasons beyond being unprotected for seizures. Lamotrigine must be titrated upward slowly due its propensity to cause a rash and, in extreme cases, a Stevens-Johnson reaction that can be life-threatening at its most extreme. Therefore, patients much have ready access to the medication even if they can afford it. A target dose of 100 mg twice daily, therapeutic in the majority of patients, would cost 1000 TSh per day, or 30,000 TSh per month, the equivalent of $13 USD per month, is typically out the question for many patients here. As I have mentioned previously, though we cover the cost of medication for a month, or maybe two, the patient must still cover the cost of the majority of their medication in between our visits here. She had been on phenobarbital previously with inadequate control and was unable to attend school, so hence the conundrum that exists here.
Another, much simpler, case for us was seen by Natalie later in the day and consisted of a lovely young 15-month-old child with a mild left hemiparesis since birth. She was very alert and attentive and clearly had normal cognition while she had a mild increase in tone on the left that was also mildly weak. Her condition was most consistent with a perinatal stroke or injury that was static. We spent a great deal of time explaining to her grandmother, who had brought her, that she was a gorgeous child who would most likely overcome these deficits and begin to use her left side much more over time, but would need to receive physical therapy to maximize her functional status. Her grandmother suddenly began to cry, at which point I took the child from her so that she could be comforted, but her tears were those of joy as she explained to us, for she had been told that the child would likely never walk by others who had evaluated her in the past. One could not help to have been overcome by gratitude over witnessing this scene and, though it was such an incredibly simple thing for us at the time, having required no imaging or other testing, yet had we not been there to reassure this grandmother, she would have continued with her concern for who knows how long. The impact and significance of one’s care is often not measured by the sleuth-like detective work we do or the number of tests that are ordered or even the severity of one’s condition, but rather by the amount of reassurance and comfort we can give. I have little doubt that the grandmother of this little girl now believes Natalie to be one of the greatest people on earth, which, of course, she is, but measured by her compassion and not solely by her clinical acumen.
At the end of the day, we were summoned to the maternity ward to evaluate a 10-day old baby that had been born at home with an encephalocele. Natalie went to evaluate the baby, who was neurologically intact as far as the exam was concerned, though we did not have any imaging to fully evaluate the nature of her encephalocele. These are an outpouching of the back part of the head that are covered in skin and may contain various other components such as the meninges and even parts of the brain. The trick is to determine exactly what is inside as the ones that contain brain are obviously tremendously more complex and trickier to deal with, though regardless of whether they do or not, the encephalocele itself serves as an incredible nidus for infection with a very short distance to the brain. Whether we did an ultrasound here or not, the baby would ultimately need to be referred to the only neurosurgeon in Northern Tanzania at KCMC in Moshi.
As our plan had been to finish early with the idea of cool drinks on the veranda at Gibb’s Farm firmly in our minds, we left clinic and all headed back to the house to get ready – that is everyone but Alex and Meredith who were planning on visiting one of the inpatients who we had seen two days ago and had been vacillating clinically, but never really turning completely around. He had come in agitated and combative with a significant alcohol history and a CT scan that looked mostly like diffuse edema with loss of sulci bilaterally. He was covered with antibiotics and we were concerned about doing a spinal tap given the likelihood of increased intracranial pressure. We were unable to give him thiamine as all that was available was PO and he wasn’t taking anything orally with consistency. Alex, Meredith and Shama thought about his case long and hard, at least until I tore them away as there was little that we could do that required our presence and we would just be a phone call or text away if they came up with additional recommendations. It was not the best of starts to an evening at Gibb’s, but unfortunately, puzzling cases like this are all too common here.
Our evening at Gibb’s Farm was, as expected, a lovely affair. Gibb’s Farm is an old coffee plantation that has transitioned through multiple owners since its original German founding at the beginning of this century, then followed by the Gibbs family who later purchased the working farm, owning it for many years until the last decade when it has been transitioned to a destination resort by the owners of Thomson Safaris. Completely independent of its history, though, is the magical place that the Gibb’s Farm holds in the memory of those who visit. I had first come in 2009, when I believe it was still owned and operated by the Gibbs family and prior to the extensive renovations that make it the resort it is today with a world class restaurant a view looking out from the Ngorongoro Highlands that is beyond description. Sitting on their veranda in the late afternoon and early evening breeze looking out across what seems like all that is important in the world at that moment, one cannot help but forget every ill they arrived with.
We sat for quite a long time on the veranda sampling the many delicious drinks that I am sure were made that much tastier by the incredible surroundings and eventually made our way into their amazing dining room and table that was set so beautifully with more glasses and silverware than I thought existed in the Karatu district. Dinner is a fixed price affair with several choices of dishes that are either farm fresh or come from local regions and all were presented in most lovely manner. Edible flowers covered everything and complemented each dish appropriately. Needless to say, everyone was very happy with their selections and dessert was an equally delicious affair. We finally left after 10 pm, a very late night here in Africa and were all thankful that morning report doesn’t occur on the weekends, though we would have a full day of clinic and the last of our Food for His Children contingent.
Author’s note: When preparing to post this blog with its photos, the contradiction in terms between my discussion of the financial hardships of our patients here who cannot afford their medications and our dinner out at Gibb’s Farm did not escape me. These are conflicts that are self-evident each and every day that we are here. Though the solutions are complex, it does not go without recognition by each and everyone of us.