Friday, September 9 – Yes, it’s still cold here and we’re looking for patients…

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Given the relatively late night at the Golden Sparrow (affectionately known just as “The Sparrow”), there were no early risers this morning, but thankfully everyone felt remarkably well and there were no causalities from our night out dancing. I did have a good video to post, but was vetoed by the group so it will have to go simply imagined. “What happens at the Sparrow, remains at the Sparrow” will remain intact and honored going forward, though I will have to say that we are, in general, very well behaved as a group and that holds for everyone who has come over the years.

Meanwhile, all news of the day is overshadowed by the death of Queen Elizabeth, and perhaps even more so given that we are currently residing in a former British colony and current member of the Commonwealth. I will have to admit that I have held a fascination with the British monarchy and Winston Churchill for some time and even though it has been rather peripheral and a part of my interest in all things historical, I was convinced to watch the series, The Crown, which followed the rise of Queen Elizabeth and was, from I understand, pretty factual. In addition, I had recently finished Erik Larson’s new book, The Splendid and the Vile, which is the account of Winston Churchill’s struggles during the London Blitz of WWII. Maintaining the monarchy and Britain’s parliamentary processes through this turbulent time and then subsequent to WWII was a fascinating study in the strength in one’s character and political intrigue.

The day a princess became a queen

As many may know, and certainly if you had watched The Crown, Elizabeth became the queen of England while on vacation in Kenya, just to north of where I sit now, following her father’s death from lung cancer. For several hours after his death, they had been unable to reach her because of her remote location and at that exact moment she was out watching rhinos from a perch in a tree. In very short order, she became the queen of all Britain and the leader of the Commonwealth Countries. At the time, Kenya remained an English colony, as did Tanganyika, or present day Tanzania.

Our horrible walk to work in the morning

Tanzania’s history of colonization, similar to all of Africa, is one of having been under changing rulers as the winds of fate would have it but mainly the politics of the rest of the world and the results of wars in distant lands. In the mid 1800s, having a colony in Africa became the high fashion for any European country of significance and this was no more evident than in the case of Belgium and King Leopold, where perhaps the world’s greatest genocide occurred in the Congo under the guise of bettering their fellow man. For an amazing read on this subject and a history of colonization in Africa, King Leopold’s Ghost is a must. It is a book that can’t be put down once it’s started and an untold story of absolute unadulterated greed that will shock even the most hardened of skeptics with tales of absolute inhumanity that goes far beyond slavery and our treatment of the First Nations, but only in numbers and not in brutality.

Partners in crime

The region of East Africa that is now Tanzania first fell under the rule of Germany and was known German East Africa (Deutsch-Ostafrika) and also included present day Rwanda and Burundi. Germany enforced its strict rule over much of the coast and inland regions throughout the end of the 19th century and by the early part of the 20th, began to suppress numerous rebellions, none of which were successful, by the inhabitants of the areas they suppressed with extreme consequences for those fighting on the other side as well as the general population with hundreds of thousands dying of starvation, a common practice in putting down these insurrections. At the outbreak of WWI, the Germans had control over much of the coast with their major stronghold in the city of Tanga, not far from the border with Kenya, which, by way of geography, created an issue for the British and Allied forces looking to maintain control of the valuable coast. Significant battles took place along the coast throughout the war until the Germans were finally defeated and fled south to Portuguese Mozambique.

Cara with one of her tiny patients

Following WWI, though, Tanganyika Territory, as it then became known, fell under British rule and through an agreement between Britain and Belgium, Rwanda and Burundi went to the latter. It remained under the same British rule during the years prior to WWII, but following the great war became designated as a UN Trust Territory with significant pressure bearing on Britain to move towards independence for the East African country. Finally, in 1961, Tanganyika gained its independence with Julius Nyerere serving as the first prime minister and later president, though with Elizabeth remaining as the Queen of Tanganyika. Zanzibar, which had remained as a Sultanate and British Protectorate throughout this entire time, finally gained its independence from Great Britain in 1963, but remained under control of a sultan who was then overthrown in a revolt, opening the door for the union of Zanzibar and Tanganyika in 1964 to create the United republic of Tanzania. Though it is obvious that the name Tanzania came from the first three letters of both states, I am told by Daniel Tewa, my dear old friend and historian of most everything, that there was a contest to come up with the new name in 1964 and that the winner’s initials were “ia.” I have not found independent confirmation of this, but considering that Daniel lived through these transition of state and is an authority on all things Tanzania, I have no reason believe otherwise.

The finer things of Africa

How Julius Nyerere, the father of this nation and referred to passionately as “mwalimu,” or teacher, served as first prime minister and then president of Tanzania from 1964 through 1985. How he took a country that had only 11 African college graduates at the time of their independence and 128 separate ethnic tribes into the modern era is a story for another time. Leave it say that although he remains a controversial figure, there is no question that he was also an incredibly great leader and man of unmatched vision.

More importantly, buying gin for our mango gin and tonics

In the midst of this story of Tanzania, African colonialism, and eventual independence, I would be remiss not to mention the wonderful recognition recently given Abdulrazak Gurnah who won the 2021 Nobel Prize in literature for his amazingly colorful stories of colonialism and both personal and cultural conflicts in East Africa. Gurnah was born in 1948 in the then Sultanate of Zanzibar and fled to England in the early 1960s during the Zanzibar revolution as the ruling Arab government was overthrown in the pre-independence days and just prior to its union with Tanganyika. Having not known of Gurnah prior to his winning the Nobel, I was immediately intrigued and wanted to find his books to read, though despite my very savvy ability to search the internet for anything book related, I had a hard time turning up copies of his many novels as they had originally been published in England in small numbers and were now in high demand. I was able to locate a few of them, though, and now, a year after having received his recognition, they are much more available through the normal means and no longer require a “Sherlockian” effort in finding them. Having now read several, I can highly recommend them as being beautifully written stories of personal struggle and, for anyone who is familiar with Tanzania as well as those who are not, they will ring true in almost any culture. They should not be missed.

I hate to be a bit of a broken record, but once again, with the weather cold and cloudy at the start of our day, there were few patients for us to see and likewise for the general clinic. At morning report, there was discussion regarding a women whose copper IUD had apparently perforated her uterus and was now residing in her abdomen and causing significant belly pain. The IUD had originally been missed on ultrasound, but easily be seen on an abdominal plain film and the plan by Dr. Alicia was to make a tiny incision through which she would try to fish-out the device and save the patient from a full open procedure. Not being surgeons and not knowing the technical aspects of the planned procedures other than knowing the difference between laparoscopy, a min lap, and a full laparotomy (one’s smallest, one’s smaller and one’s bigger – spoken like a true medicine person), I didn’t feel it was our place to contribute much to the discussion, though it was interesting. In the end, Alicia managed to remove the errant IUD with a tiny several centimeter incision and no need for any repair of the uterus as there was no bleeding from the perforation.

Probably the most interesting patient of the day was one that Moira saw who was a young gentleman with a 16 year history of left sided headaches that would occur in clusters (over a period of weeks typically) and would be exacerbated by leaning forward or performing a Valsalva maneuver – something that raises intracranial pressure hence raising some concern on our part. All of this would certainly raise our level of interest in the patient’s headaches, but the clincher was the video she took demonstrating a small area over the left forehead that would balloon outward when he bore down (the Valsalva maneuver) and then resolve as soon as he stopped. Now this was fascinating for all we could imagine was that there must be some sort of vascular structure externally on the forehead that would engorge upon reducing venous return (which happens with a Valsalva), but we had little information on whether there existed a matching lesion intracranially which was our concern. We obtained a CT scan of the head with and without contrast that did demonstrate soft tissue enhancement extracranially at the site of the lesion as well as a subtle depression underlying it, but no evidence of any intracranial lesion connecting. The next step would be to figure out what other tests would be helpful in determining the nature of the lesion and whether these tests could even be done here or whether they would make any changes to our overall plan, for, it now, we would likely not proceed.

Alex also saw an interesting young woman who can in for what was described as intermittent weakness prompting some concern for the possibility of periodic paralysis, a neurologic condition that results in transient episodes of weakness and is typically the result of an error in ion transport within the muscle cells. It is a rare genetic disorder and there was no family history here. The patient, though, was of very small stature with a round ovoid face and somewhat almond shaped eyes that were very suggestive of some developmental syndrome and quite possibly trisomy-21, or Down syndrome. On examination, she had mild weakness of her extremities. With further questioning, the patient had previously been on thyroid replacement and the family felt that she had developed a rash related to the medication, stopping it. Her TSH was found to be sky high and her T4 was almost non-existent. Given this scenario, the likelihood was that all of her symptomatology and examination were related to profound hypothyroidism and a myopathy as opposed a rare disorder – as we say in medicine, “common things are common” and “if you hoofbeats, don’t think of zebras (unless of course you’re in Africa 🤣).” We decided to treat her thyroid disorder first as this was clearly the most likely cause of her complaints and hypothyroidism is commonly seen in trisomy-21.

Cara got to see two interesting, though, unfortunate patients – one young child suffering with the sequalae of kernicterus who was profoundly impaired and another young woman who had been hospitalized at the beginning of the year with cerebral malaria and was not suffering from severe seizures. Alana had the pleasure of seeing Dorthea, a young 19-year-old woman who I had seen first in 2011 suffering from uncontrolled seizures as the result of a perinatal stroke and right hemiparesis. She was unable to go to school at the time as that is what happens here and after placing her on the correct medications, she has been seizure-free for many years. She was able to complete school and attend secondary school as well. She is a wonderful testament of how someone’s life can be changed forever with a minimal amount of effort and support.

Today was the day to visit Teddy, our amazing seamstress, who would be taking all of the fabric purchased the other day and turn it into a wonderful wardrobe for everyone. Dr. Anne had sent lots of patterns and examples for them to choose from which made things much easier when we met. Anne always comes along to help out with translation as though Teddy speaks a few words of English, there are technical aspects that just don’t cross over in the translation. I bring my computer with me so that I can sit and work during the visit as though I’ve always wanted to like the clothing made here, it has never felt comfortable on me for various reasons despite numerous tries and I’ve given up that cause a long time ago. No worries, as I love making this possible for the residents and they are always so excited at the prospect. With the new three-week rotation, it will be more important to get this done during the first week of their visit so that the clothing is ready before they leave. Teddy works incredibly fast and this has never been an issue for us in the past.

Leaving Teddy’s house

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