In our previous configuration of having a single team of residents with me for four weeks, it had been convenient for us to schedule our mobile clinics in a single week, though now, with the two groups each for three weeks and trying my best to make the experience similar, we’ve split the mobile clinics up so that each group could participate. I have been doing mobile clinics, in which we bring a team from FAME to a number of the more remote villages within the Karatu district to provide the same neurologic evaluation that we do here on campus, since 2011, the year after I began our neurology program here. We have now provided these services every six months to a number of villages where we will follow patients and see new ones as needed.
This began in Kambi ya Simba in the Mbulumbulu region and we have continued to provide these services there in addition to the Rift Valley Children’s Village. Other villages, such as Upper Kitete and Qaru became less necessary over time for various reasons of either low volume or perhaps patient’s ability to be seen at other clinics. Several years ago, we began attending two clinics in the Mang’ola region on Lake Eyasi which is a fairly remote group of villages inhabited by the Iraqw, Datoga and Hadza, the latter being the last hunter gatherers in Tanzania still hunting with bows and arrows and speaking click language. Barazani, where we will be today, is the largest of the villages in this region, and Mbuga Nyekundu is another village somewhat smaller and further inland from the lake. Medical services are very minimal here and, therefore, our clinics are typically very busy.
Given the time it takes to get to Mang’ola, that being typically over an hour, as well as the size of the clinic, we typically try to leave a bit earlier than we do for the other mobile clinics. We had decided to leave at 8 am which meant missing out on morning report and learning about any new patients that needed to be seen or follow up on patients already in the ward. Heading up to the outpatient looking for the doctor on call to speak with, I discovered that our young rabies patient had passed away around 4:30 am and was, thankfully, comfortable at the end. Ankita and Taha had gone up the night before and were pretty certain that the end was near as he had very agonal respirations despite still being awake and somewhat responsive.
It was an incredibly tragic case for such a young boy to have died of a disease that was potentially preventable on so many levels, the first of which is vaccinating the dogs, while the second is the public awareness campaign to get vaccinated immediately after any exposure to a potentially rabid animal. There was still a need to confirm the boy’s diagnosis, though, and this would require a limited autopsy, something that is not easy to obtain anywhere, but even more so in a country with a tremendous diversity of cultural beliefs. Thankfully, after everything was fully explained to his family, they consented to the procedure such that we would very likely have that information after several days.
Luckily, I have known the road to the Mang’ola region since my very first visits here as this is the area where the larger monthly FAME mobile clinics took place, though a bit further down Lake Eyasi and more into the Hadza, or Hadzabe, community. These were week-long clinics that involved a large number of caregivers and support staff traveling in an all-wheel drive bus outfitted with a lab and solar power along with several Land Rovers as support, one of which would be driven by me. The road to Barazani in those days was a bit treacherous, but nothing like the drive from Barazani to Gitamilanda, the village we were working out of, which was essentially off road for most of way and what roads existed were very often washed away by the rains or impassable due to mud. Needless to say, it was very exciting.
Today, the road to Barazani has been widened and graded, but still presents driving challenge as it is loose rock for the entire way, passing through numerous washes or ravines that become raging rivers in the rainy season. And then there is the dust. Every vehicle puts up a massive cloud of red dust that stays in the air forever and creates an essential smoke screen making it difficult to see for some moments as you pass. To prevent the dust from getting into our vehicle, we are constantly rolling the windows up and down in the front doors and those in the back are sliding their windows closed for the same reason. For the driver, this is all done while driving 60-80 kph, staying hyper focused on the road to look for larger rocks and/or potholes, meanwhile shifting through the gears on the frequent uphill and downhill portions of the road. Needless to say, the drive is not only a challenge for the driver, but also for the passengers.
We arrived at the Health Center in Barazani, a location that I know well from having been there over the last several years and were greeted by their clinical officer and nurses who had most of the rooms already set up for us and our patients were already waiting to be registered and seen. Dr. Anne did her pre-clinic triage speech about what types of disorders and symptoms we see as it is not our interest to provide medical care for things other than neurology. The clinical officer there is fully capable of doing this and it has never been our intention to alienate any other health care provider as that is not the best way to develop and good relationship and be invited back each time. Six months ago, I had also assisted in providing some necessary furniture for the health center and they were very grateful for that – desks, chairs and benches that would allow our clinic to run more smoothly and would be something they would benefit from in between our visits.
The residents worked at a quick pace evaluating patients with the full spectrum of neurologic and psychiatric diseases, both return patients and follow up, but no matter how quickly they were seeing patient, they continued to accumulate. At some point after lunch, I recall going out front to see where things stood as far as patient numbers and remember that we had 28 patients in the register with an additional four patients who had yet to be registered. 32 patients for the day with three residents seemed like a pretty full day to me and I went back to my staffing duties in the back hallway. Sometime thereafter, it became apparent that we had exceeded that total number of patient and were already at 39 with several patients still wishing to be seen. It was now approaching 5 pm when we should have been on the road at least an hour prior to that. There were just that many patients who needed to be seen and we could do very little about. Thankfully, we were able to have the additional several patients come to the clinic the following day that would be in another village, but we would arrange their transport.
One of the significant issues we had today was that we had agreed to go out into the bush to visit a young patient, Pendo (which means “love” in Swahili), that Dan Licht and Marin Jacobwitz had seen back in June while here and were working on sponsoring her in school as she had been disabled for over a year with bilateral lower extremity paralysis and had been unable to attend school. She lived somewhere far beyond Barazani in an area that I had driven through years ago on our other mobile clinics, but the landscape is every changing due to the rains. Kitashu knew where she lived apparently and had it not been for him directing us, there would have been no way whatsoever that we would have found her home.
We drove along minor roads and/or trails, through tiny villages and in between homes with the residents wondering what a Land Rover filled with mostly mzungu, and, even more so, a mzungu driving, was doing way out in the middle of nowhere. There were massive river beds that were dry, thankfully, and needed to be crossed at just the right place so as not to high center Turtle, which has a very long wheelbase and can be prone to this. For me, it was incredibly exciting and there could be nothing more than I would rather be doing than this, but I suspect for the others in the vehicle, it was all a bit questionable to them. One of the funniest things, though, and I kick myself for not getting a photo of this, was the fact that there were street signs out in the middle of nowhere indicating the names of what appeared to be livestock trails. The country just decided to put up street signs in over the last six months as they were not here during my last trip. I did like in the past when people asked me what street someone lived on here and I would say I have absolutely no idea since there are no street signs. I can’t say that any longer.
We were essentially driving through perhaps the most remote landscape one could imagine, with home which were very small structures of one or two rooms made out of clay and branches and surrounded by brush fences to form enclosures for their livestock. These were the Datoga, who are pastoralists similar to the Maasai, and had no fields or agriculture to speak of. The homes were in small groups that formed more of an enclave than a village as there no structures other than these living units. We stopped at several and asked people we would come across where the family of this young girl were located and, thankfully, were able to finally find her home. Pendo lived in the village of Majiyamoto (which means “hot water” and named for the hot springs nearby), though calling it a village is really a misnomer as the distance between homes was incredibly vast.
Once we found the correct home, Pendo’s brother, who was home at the time as her mother was not, directed us to the front door where we found young Pendo sitting on the ground on a cloth, with her legs folded underneath here. After speaking with Marin, who had evaluated Pendo at the last clinic in Barazani, she had lost the use of her legs about a year earlier and on examination had a T12 spinal level. There had been no x-rays taken or any other tests as it was unclear how that would have changed her management, though at some point, I suspect we will try to obtain more information so as to know exactly was caused her condition. Her legs are severely contracted and unable to be extended in any fashion and the only means for her to move around at present is to scoot along the ground using her arms and to carry her body forward with her legs remaining folded beneath her. She briefly demonstrated this to us and it was very tragic to see.
The reason for our visit was that Marin found Pendo to a bright young child with absolutely no future unless she could get to school and then some type of vocation rehabilitation. Unfortunately, she is too young to go to the vocational rehab center we had sent the two Maasai Down syndrome boys to a year or so ago, but Kitashu miraculously found a school for children with disabilities that she could go to until she is old enough to go to the vocational rehab center. Marin is in the process of raising money for this to occur and Pendo will be going to the school in Moshi shortly for a visit to see if it is the right fit for her. We can only hope that this will work out as it would be life changing for her to get to school and later, vocational rehab.
Meanwhile, it was now sunset and we were in the middle of essentially nowhere with the light quickly fading. Kitashu felt that it would be best for us to take a different route, or really just a different direction, to get back to main road that would take us home, but the problem was there were really no roads to speak of and we would have to cross several deep river beds along the way. We made several tries to find a route to cross the dry rivers with no success as they were rather steep banks that were completely unpassable to us. We eventually made it across one, but were still somewhat lost in regard to finding anything that resembled a road or even a viable trail. We spotted a Datoga man walking some distance in front of us and eventually caught up with him to ask for directions. He spoke with Kitashu for some time and, the next thing I knew, the man was climbing into our vehicle to show us the way himself which I was glad he did as it was not an easy path, either to find or to drive. We eventually came upon a major graded road that was clearly our way home and the man hoped out of the car with a tremendous debt of gratitude from us and countless thank yous in Swahili.
By now it was dark and time for headlights which is never a thrilling idea as the headlights on vehicles here are not well leveled and driving in the dark is treacherous. Any oncoming vehicle is blinding and then there is the dust cloud that follows. With my bright lights on, I could just about see my way, but with all of the oncoming motorcycles, whose headlights were worse than the cars, along with the cars and trucks, I was constantly turning my bright lights on and off throughout the drive. Maintaining one’s focus on these roads is essential in the daylight and, in the dark, is a matter of making it home safely or not. Thankfully, we arrived home in one piece, though all a bit frazzled. It had been an epic adventure and, coming from me, that’s saying a lot considering some of the crazy travel incidents I’ve had in the past here in Africa. After arriving home, I made my special gin and tonics with mango juice for everyone and they were more than well deserved. Not only had it been an epic adventure, but it was day that none of us will soon forget.