The rain fell heavily overnight making a terrible racket on the metal roof of the Raynes House, but all I could think about was the road to the Children’s Village as it would once again be incredibly challenging to get there. We have had to cancel mobile clinics in the past due to the road conditions and I have written before about the time I slid off the road and managed to get my Land Rover stuck axle-deep in the mud on the way to Mbulumbulu, making it not only impossible to get to the planned clinic, but also taking three hours to literally dig ourselves out of the predicament.

I got up extra early to drive Turtle down to Soja’s shop as he had told me to be there at 7:00 am, though I waited for over twenty minutes to no avail and finally walked over to his house to find him. The door was open, so I offered the appropriate response of “hodi,” which essentially means, “may I enter.” Hearing “karibu,” or “welcome,” I entered to find several of Soja’s children in the front room who told me that their father was there and they would let him know that I was outside. After a few minutes, Soja appeared and walked over with me to his shop where I had parked Turtle. To make the repair, it required pulling the floor coverings up and over both of the shift levers and then bending the transfer case lever towards the back so that the throw of the stick shift would now clear the dash. Having finished the work by 8:00 am, I asked him what I owed for the work and he said that there was no charge for the work. Given that I had dragged him out of his house at an ungodly hour, I insisted that I would pay him something for the work, but having no cash on me, that I would return later to make good.

Kitashu texted me regarding the roads suggesting that one of the FAME drivers take us to RVCV in Turtle which I thought was a reasonable suggestion and something we have done in the past. As much as I love to take on a challenge, and especially one that involves driving a Land Rover through tricky and unknown terrain in East Africa, I have come to realize that it is quite unfair for me to risk our ability to get to a clinic for the small bit of machismo I would receive. Unfortunately, it ended up not be a decision that had to make as there were no drivers available given late notice of Kitashu’s request, so it was up to me to get our crew to the Children’s Village come hell or high water, and I had a sneaking suspicion that it would very likely involve both of those.

The road was now a bit worse than yesterday evening, though thankfully I had my full complement of gears with the transfer case now being fully functional, as I could take the downhill portions of the drive in the lower range, thus allowing the engine to brake our descent rather than utilizing the brakes. The lower range was also necessary on the uphill portions of the drive where the maximum amount of torque and maintaining RPM was a necessity. The drive was pretty amazing all in all, and I became totally confident in the abilities of my Land Rover, now with its full complement of gears, as well as to some degree in myself for it was a handful to keep the vehicle on the road and moving in a forward direction until we finally reached the village and prepared to complete our day of patients. As I was approaching the gate of the village, though, a very large squeal began that sounded like it was coming from one of the wheels and I was worried it was a wheel bearing. Thankfully, they have a full-time mechanic at the village and I was later In the morning able to hand over my keys to he and a driver, who determined that the noise was from mud having gotten collected and caked on one of the disc brakes. One cleaned, the squeak disappeared and it was another disaster averted as any major repair would have been difficult, though I’m sure they would have gotten it done for us in a timely fashion to have prevented us from having to overnight there.

Pulling into the village, I had a sense of real accomplishment having tackled what can only be described as a truly gnarly road and, I must admit, I also had a sense of relief as those memories of sliding off that road a decade ago have stuck with me all this time. How the drivers from RVCV do this all the time is quite remarkable and my hat goes off to them. There were many patients waiting for us to see them, of course, and it was now down to the job we had really come to accomplish. Starting clinic was a snap as everyone had already become quite accustomed to their rooms and the routine here.

We did have one very nice addition to clinic this morning and that was Abdulhamid, who had traveled from Dar to work with us for the rest of the month. Abdulhamid is from Karatu and first came to work with us when he was a medical student several years ago. It was actually complete happenstance as had just wanted to volunteer at FAME during one of his school breaks and we happened to be working at the time and in need of a translator. He quickly became interested in neurology (how could one not?) and during his time with us has become a topnotch neurologist whose histories and examinations are as thorough as any trainee I’ve worked with. In 2019, we were able to bring him to Penn for a month with the assistance of the Center for Global Health and he spent his time mostly with the inpatient neurology services. From never having been on a plane to traveling to Philadelphia for the month and even visiting NYC, I am sure that it was a life-changing experience for him.

Returning home, he has graduated medical school and now completed his internship. Most physicians in Tanzania, after finishing their internships, will go to work as generalists rather than starting residencies for the sole reason that one has to pay for residency here as there is no government health system like Medicare, which is what pays for our training programs in the US and allows residents to receive income. Here, one must be sponsored in some fashion or have the means to pay for their residency education. Until recently, all of the MDs at FAME have been generalists and we only recently hired a residency trained general surgeon to head the surgery program here.

Then there is the problem that there are very few neurology training programs in Africa and, until recently, there were none in Tanzania. Even the program that currently exists at Muhimbili University, which now has two neurology fellows (neurology is a two-year fellowship here after one completes their internal medicine residency) only recently came into being and though the fellows that I met last fall were very good, they are lacking a faculty neurologist currently, making it very difficult to entertain a full program similar to our residency training at home. How do you create a neurology department and training program in a country that has fewer than a handful of neurologists  or a continent where many countries still have no neurologists?

In Zambia, a country that was in a similar situation only several years ago, two neurologists from the US have now helped create a bona fide neurology training program that rivals many in the US and they have now graduated fully trained neurologists in a country where there were few previously. Omar Saddiqi, who is on faculty at Harvard Medical School and is a neurovirologist, has been living in Zambia with his family for probably ten years now, has been working in the capital city and providing incredible research on HIV, TB and epilepsy. Deana Saylor, a Johns Hopkins neuroinfectious disease specialist moved to Zambia with her family just prior to the pandemic to create the neurology residency program and maintained it single handedly during the height of COVID as there was little in the way of international travel during that time. It is programs like these that will create the future neurologists for Africa and in low resource settings.

Meanwhile, our visit today went smoothly and we had a good number of patients to see, but with the four rooms going and help from both Meredith and Whitley, we were able to get everything completed. Of course, we made certain that we enjoyed another wonderful lunch with the RVCV volunteers and, at the end of the day, visited the duka, or shop, where all of the items made by the Rift Valley Women’s Group are on sale. In addition to the Children’s Village, the other activities of the Tanzanian Children’s Fund focus community empowerment and include microfinance programs and the women’s group, which in the latter, women are trained in making various crafts such as clothing, computer cases, bags, pouches and other useful things using cloth as well as jewelry. Similar to what many organizations have learned in the past, empowering women is tremendously more effective in supporting families as the income will go exclusively home where the same cannot be said for the alternative, empowering men. Nothing sexist there, just reality.

The visit to the duka is one of the other highlights of a visit to the RVCV and this group of residents were no different than any of the last that I have brought. The items to purchase are either incredibly useful or incredibly beautiful or both and everything is priced very reasonable. In the US, these items would go for multiples of what is charged in the duka. After completely their shopping, we all walked over to one of the houses where the children live, each managed by a house mama. The houses are grouped by the age of the children and by sex. The youngest child they now have is a local 9-month old baby who was recently orphaned when her mother was killed by a cape buffalo and the family couldn’t care for the child. As we were in the house, it began to rain heavily meaning the drive home was going to be another challenge for us. In fact, just making it to the vehicle can, at times, be a challenge.

There is another way home from RVCV that I had never driven before and that was through the village of Odeani, where I had never been in the past. The road is supposedly better graded and there are none of the steep ascents or descents to content with. It is a bit longer, though, but knowing that we had a better chance of making it home was enough to sway the decision and it was off we went once we finished our tours. Anne and Eliza who had intended to ride home with the others and despite the fact that Anne told Kitashu that she’d kill him if he left, they were abandoned and had to drive home with us. The road was truly better which was apparent by the numerous vehicles from RVCV that we passed who were heading home after we had left. Navigating a tight one lane road in the mud with ditches on both sides can be a challenge in those situations, but all worked out well. When we reached the road to Mang’ola that we had taken days earlier and turned to head home to Karatu, the skies opened up and an intense downpour began that made it difficult to even see the road. The numerous culverts that cross the road repeatedly became raging torrents of water throwing a muddy bath entirely over the top of Turtle and our windshield, temporarily blinding us as we hit each of the crossings. Thankfully, though, the road was gravel and not the slippery mud of the other smaller roads, so I was confident by now that we were assured of making it home. We dropped Anne and Eliza in town and as we passed Frank and Susan’s house to get to ours, I received a text from Susan as she had been worried about us with all the rain. I was quite happy to home once again and tomorrow we would be heading to Lake Manyara National Park for a game drive as Meredith and Whitley were leaving on Saturday.