With the internet still out and my life somehow spared from having been murdered in my sleep by one of the residents, everyone was up bright and early for our first neuro educational lecture for the staff of this trip. In the past, we have always given at least one lecture a week, and sometimes two, but much of the schedule had already been made prior to our arriving. We always offer to lecture on whatever neurologic topic might interest the group of physicians here at FAME and over the years, we have collected a vast library of lectures that remain available for reference should anyone wish to look back at them. With only two slots for us to use, and Whitley and Meredith now having already gone home, the residents had decided to divide and conquer with Peter and Natalie covering seizure disorders this morning and Alex and Savannah deciding to something more neuromuscular related since the two of them are both pursuing that for their careers.

This morning’s lecture was held in the education room in the administration building which, being tremendously smaller than the normal conference room, allows for a much more cozy and somewhat cramped time among the FAME medical staff. Unfortunately, the room has far fewer chairs than are needed given the growth of the staff over the last several years and when adding in the often difficult transportation to FAME in the morning, with many individuals arriving late not because of tardiness, but just because their ride was delayed, it gets pretty congested at the door with others pointing out a sliver of room on one of the cushions to those who are entering. Be that as it may, once the lecture got going, everyone was paying close attention given the high prevalence of epilepsy in Tanzania and the need for each of the caregivers to be aware of how to treat it.

What Peter and Natalie didn’t discuss this morning, as there was little need to do so, was the fact that 90% of the world’s epilepsy occurs in low to middle income countries and that is exactly the place where there are no neurologists. The reason for this, the high prevalence rather than the lack of neurologists, is due to the number of childhood infections, head trauma and birth injuries that occur here compared to the high income regions of the world. The lack of neurologists is a bit more complex, but in Africa in general, there are very few specialty trained physicians as most of the care here is delivered by generalists who have not done residencies following their internships, but rather have gone out into practice. Our postgraduate medical system (i.e. residencies) are wholly funded by Medicare in our country, a government program that doesn’t exist in most African countries and, at least in Tanzania, nor does a solid government health plan that everyone pays into. So, in a region of the world where by far the majority of epilepsy exists, there are no specialists to treat it.

There are only a handful, and I mean literally, of neurologists in Tanzania and none in the regions of the country most needy such as the area around Karatu and the Ngorongoro Conservation Area, where I have been working for the past twelve years. Though we have gotten the word out to the communities, it is common for us to see patients in early adulthood who have been seizing their entire life because they either didn’t know it was treatable or had seen someone once who put them on an anti-seizure medication at a sub-therapeutic dose, or the wrong one, and since it didn’t work, they stopped it and never saw someone again. We also have patients who tell us they took the medication and it worked, but when they ran out of it, the seizures came back, clearly not understanding that the medication, very often, must be taken for life, or at least for several years. It is an issue of education both for the caregiver, as Peter and Natalie were doing this morning, but also of the patient and family.

Our efforts here at FAME in treating neurologic conditions and, specifically, epilepsy have seemed to make a difference in the health of the population here in the Karatu district. Patients with epilepsy come back to see us in follow up at a tremendously greater rate than any other population of patients and we have a great many patients who have remained seizure-free or their seizure burden has been greatly reduced. Through the data we have collected at FAME, we’ve shown that our efforts have made a significant impact, but the problem is more complex than just a matter of simply educating the patient and the caregivers here as placing patients on the proper (and that term can obviously have very different connotations) anti-seizure medication may not be possible due to the cost of treatment, and that means primarily the medication. Sustainability is the buzzword that you cannot help but think of nearly every moment of every day. How to make this all work is the million dollar, or billion Shilling, question that everyone thinks of every moment of every day.

Now back to Peter and Natalie’s lecture. Simply put, it was great. They went through the basics of epilepsy, what it is and why we need to treat it and then, using a case based discussion with several of the cases we had already seen here, covered all of the information necessary to effectively treat the epilepsy patients we were seeing at FAME on a regular basis. It is usually a bit difficult to get group participation here, especially at 7:30 in the morning, but they did manage to get some involvement by the group and there were some excellent questions which is always a good sign that people were listening. I should also tell you that it has been an absolute rule enforced by Dr. Frank since I came here on day 1, that we use no brand names, which is totally appropriate as those brands are only in the US and are not used in most other parts of the world. Using generic names like levetiracetam (Keppra), lamotrigine (Lamictal), sodium valproate (Depakote) and carbamazepine (Tegretol) can be very difficult at times if not only to spell them correctly and certainly gives you a sense as to why drug companies like you to use their more simpler brand names. I will typically go through their presentations ahead of time to make sure there are no digressions to Frank’s rule. Another good sign as to the veracity of their lecture was the fact that when it came to the 45 minute mark, I didn’t see Dr. Ken getting fidgety and he allowed the questions to continue on.

The start of clinic was a bit slow and most everyone decided to run up to the Lilac to get coffees before things got out of hand, which typically happens once we get rolling. Alex, when checking on her patient with the leg weakness who had presented earlier in the week, found that she was vastly improved and, although she didn’t have all of her strength back, she was able to stand and walk with a walker after several days of steroids which was a good sign that she would continue improving. Her examination had also evolved and she was clearly looking more like a patient with transverse myelitis rather than one with Guillain-Barre syndrome. Without going into too much details, these exams are vastly different as one is an upper motor neuron problem and the other is a lower motor neuron problem. Alex’s patient had come in with a somewhat confounding examination as she initially had spinal shock and it required days for her exam to declare itself. I’ll apologize in advance to those of you who would rather not have heard that explanation.

Clinic did end a bit early for us and we were all able to head out by 4:00 pm which was good as we had scheduled with our seamstress, Teddy, to go over to her place for the residents to get fitted for some clothes they wanted to have made. Peter had decided to excuse himself and remained home to relax and do some reading, while Alex, Savannah, and Natalie hopped in Turtle along with Anne and myself to head to the other side of town and visit Teddy’s. I am sure that most of you are aware that the fabrics here in Central Africa, both East and West, are incredibly gorgeous with their vibrant colors and patterns. When I first came to Tanzania, I couldn’t help myself and would just bring the folded fabrics home to give as gifts or keep for myself. Several years ago, though, and probably under the influence of Anne, it became clear that we could buy the fabric and then have it made into all sorts of clothes. I know that this sounds pretty obvious, but with Anne’s help, none of that would have been possible as you can imagine walking up to a small shop where no one speaks English and trying to navigate the intricacies of having a piece of clothing made to your specifications. Having an interpreter along to help with that process is not only crucial, it is a necessity, and Anne has served in that role for us for at least six years that I can remember, ever since Kelley Humbert and Laurita Minardi accompanied me here in October 2016.

Several years ago, though, I was introduced to Teddy, a seamstress who can do amazing work and can do it quickly if needed as there are times that we can’t get to her early in our trip and may need things done over a weekend. She is the most incredibly pleasant person you could possibly wish for and she can create most anything including sport coats out of Kitenge cloth, men’s pants, shorts, shirts, not to mention the standard dresses and skirts. Even though I have long lost the idea that I could ever find a piece of clothing here that would fit comfortably on me (no need to go into detail on that matter here), I still love my visits to Teddy’s shop and look forward to taking the residents there. And despite the fact that everyone was getting something made, and I won’t tell you who had the most (don’t worry, Alex, I won’t rat you out), I think we were there for only a bit over an hour, which in Africa is a quick visit. I had brought my computer to catch up on work and emails and it was a relaxing time for me.

After Teddy’s, it was home for everyone as tomorrow we would be heading to Tarangire National Park in the middle of the day and we had no clinic in the morning. Normally, we fit in a trip to the Serengeti, leaving early in the morning, but with three of the four residents heading to the Serengeti (and Zanzibar, I might add) at the completion of the rotation, I had decided to switch things up and go to Tarangire for two nights instead as it was a much less expensive proposition owing to the high cost to travel through the NCA and to enter the Serengeti compared to Tarangire National Park. As we were taking the day off and not going to morning report early, it was a perfect night for a movie and popcorn, so we set up the projector and watched the Borne Identity.