Being back at FAME is close to a religious experience for me. This is my twenty-sixth visit to this incredible facility that has become the premier healthcare provider in Northern Tanzania, and a model site for the entire country. Having watched the growth of FAME since its inception the year before my original visit in 2009, it has become clear to me that it is an entirely unique program in Africa, and perhaps even the world. An NGO, non-profit providing healthcare for a segment of the population rather than a specific disease or disorder (e.g., cleft palates, cataracts and the such) is so unlike what any other organizations provide, though I am sure that I will hear about others now. Coming home to FAME, though, means much more to me than the patients who we treat and the providers who we train. Much as having founded FAME is for Frank and Susan, having created a recurring and sustainable program here as we have with neurology has come to define my career and has become the pinnacle of my achievements during my life. I am eternally grateful for having been brought to FAME back in 2009, and to all those who have assisted in making this the successful project it has become.

It has been so long for me that I can only imagine the initial thoughts of the residents, all who are visiting for the first time and not really knowing what to expect, as we drive through the gates of FAME and onto campus. What began as a single outpatient building (the OPD), has now become a true campus, where buildings and services abound, and continues to expand with funding for our bigger and better ED that has just broken ground this last week. FAME is very much “Shangri-La-like” for it fits the entire definition other than the fact that it is not imaginary, but rather exists in such a way that it has changed the lives of countless Tanzanians over the last 15 years.

Everyone slept very well and for more hours than they’re used to back at home for when the sun goes down here shortly after 6 pm, darkness envelops the vast countryside along with our little piece of paradise here at FAME. We are just over 3° south of the equator (i.e., close) and, as such, sunrise and sunset occur at approximately the same time throughout the year with darkness descending quickly and thoroughly other than the light of the stars and moon. When I tell you that it is very, very dark here, I mean just that, and there are times that it can be difficult to see your hand in front of your face. Monday morning report is the most significant of the week as it covers what has happened over the entire weekend as well as what the plans are for the week ahead. In the past, only the doctors attended and presented, but now it is the entire clinical staff at FAME who attends this meeting – doctors, nurses, anesthesia, pharmacy, social work, and any volunteers who are here working. All the cases are discussed, inpatients, maternity, and outpatients, and any issues regarding the management of these patients can be further debated. Even though Tanzanians are perhaps the most polite and gracious people I have run across in all my travels, these “discussions” can become a bit heated at times, though thankfully this is the exception to the rule.

There were neuro cases for us to see in the ward or in maternity, so it was off to begin our clinic at 8:30 that morning. Our clinic space is ideal as it is open air under the sloping roof of the OPD, and perfectly located near registration so our patients can find us easily and sit in our open-air waiting room. We would probably not be able to do something like this in the US from a privacy standpoint and, even though, privacy is very much respected here as it is at home, we do our best to conduct our interviews and examinations in as a respectful manner as possible and will have to say that we have never had an issue with this. I recall working on one of the larger mobile clinics in the Lake Eyasi region many years ago and we had four examination stations in a single room with a packed earth floor and wooden benches on which to work. One makes the best out of the situation that presents itself and does whatever is necessary to complete the job. Frankly, working in the open air under the roof of the OPD exterior has always felt tremendously preferable to working inside. During the pandemic, it also served to lessen the concern for any infectious transmission.

After morning report and storing our bags and tools in our clinic space, it was time for everyone other than me to go for their orientation of FAME Hospital (FAME Medical was the previous designation that has recently been upgraded to Hospital after the Ministry of Health granted it) that has grown from single OPD building in 2010 when I first arrived to now being a huge campus consisting of many buildings including staff and volunteer housing. Getting oriented here is a must considering we would be off and running today, seeing our first patient before lunchtime most likely. We have two coordinators/social workers who help with our clinic during our time here – Kitashu and Angel – both of who I have now known for several years and both who are indispensable to the smooth running of the neurology clinic and our additional mobile clinics that we run. I always make sure to share the daily schedule for our upcoming visit which is often quite complex considering all the other things we do while here Karata to feel a part of the community. Also, having reduced the length of each rotation, down from 4 weeks to 3 weeks, has meant that where we spend our time is more crucial.

Angel and Kitashu make announcements in the community that our clinic will be starting as well as which days we will be at FAME as opposed to being at one of the mobile sites. Today’s clinic was unannounced so as to give the residents a moment to acclimate to the routine here. In the past, everything was on paper charts and scripts for medications were handwritten, though beginning in fall 2020, FAME implemented the use of an EMR (electronic medical record) and now everything is electronic. As any of you in the medical field will be familiar with, the EMR is something that doctors and nurses have a love-hate relationship with and probably more on the hate side than anything else. Most of us have considered it a necessary evil. The residents would have to have a crash course for this EMR before they could begin seeing patients and that was mostly taken care of by Dr. Anne.

Now, fully armed with their neurology expertise and a one-hour course on the EMR, we were ready to begin seeing patients. I should perhaps be clearer in that the residents would being seeing patients and not me personally, for that is not my role here at FAME. Rather, the residents see the patients along with their Tanzanian counterparts who are also serving as translators, and then bring the cases to me to essentially staff them, much as we do at Penn when they are seeing their own patients at home in clinic. We discuss the cases and then develop a treatment plan based on the resources we have here, which are far different than those we have at home.

For our first clinic, we had a number of children show up first which made Usha very happy, though I’m not sure the others felt quite the same way for examining children can be an incredibly daunting challenge for many adult neurologists. One of our patients today was a gentleman with epilepsy and previously diagnosed abnormal calcification in the brain that was very likely the focus of his seizures given the description of the episodes. When anyone mentions calcified lesions in the brain in this region of Tanzania, we immediately think of neurocysticercosis, a condition that is caused by the pork tapeworm and is the most common cause of epilepsy in the world being very prevalent in South America, but also seen in regions were pigs are raised. This patient, though, had only a single focus of calcification that did not look like neurocysticercosis and was most likely a focus of dystrophic brain that had calcified and had likely been present from birth. He had a CT scan about two years ago and then another one last month and there was no change on the scan which was very reassuring.

Another young child was having headaches and episodes of loss of consciousness. When patients complain of loss of consciousness here, we are completely reliant on the clinical history and description of the episodes to determine whether we’re dealing with epilepsy, cardiac syncope, basilar migraines that can present in children, or psychogenic episodes that are referred to as PNEE, or psychogenic non-epileptic events. The latter are very common at home as well as here in Tanzania and, for those less familiar with this phenomenon, it can be equated to “swooning” (think Scarlet O’Hara in Gone with the Wind). These episodes are not done in any conscious fashion but are rather ways that the brain may deal with stress or anxiety and can often be seen in patients with a history of sexual abuse. In the best of situations, these patients can respond well to psychotherapy and certainly antiseizure medications are not the appropriate course of action. In this given patient, though, there was actually a concern for a specific form of epilepsy given the description of the events and our decision was to place the patient on sodium valproate and to see whether this treatment impacted the episodes or not.

For me, the highlight of the day was lunchtime, for our lunch here at FAME is eaten as a group with all the employees sharing the same meal that consists of a wonderful mix of rice, beans and mchicha (a dark green vegetable similar to spinach) that we are served 5 days a week. When I leave FAME to head home, I dream of this meal. What makes it even more special is Samwell’s hot sauce, referred to here as pili pili, that is a blend of local peppers and spices and is to die for. His pili pili makes everything taste even better than it already is. Teatime, which occurs in the morning at around 10:30 am, is a leftover from British colony days, but well enjoyed by all when we are served a delicious tea masala and white bread, the latter which we choose typically to pass on, though I will have to admit that Mark has seemed to enjoy the bread.

As for Turtle, she was now at the Black Rhino Academy where Soja, FAME’s mechanic and someone who I have used for many years for the various vehicles that I’ve had, some borrowed and some my own. I had contact Soja early in the day and had Turtle brought over the Black Rhino where he was working at the time and after he began to work on the vehicle, it was very clear that there was a major issue with the cooling system and it appeared to be at least the cylinder head gasket, if not the cylinder head itself. After conferring with Leonard, he was going to have a fundi (specialist) come from Arusha to look at the vehicle and hopefully fix it here rather than having to bring it back to Arusha. The fundi would also bring our other vehicle, Myrtle, a more standard (i.e., not safari) Land Rover that Leonard and I had rebuilt last year and had planned to use as a second vehicle for our mobile clinics so that we would not have to rent vehicles any longer.

We spent a rather quiet evening in the Raynes House, partially because we still had no shillings or vehicle with which to get to town. The weather was beautiful all day, though it did heat up throughout the afternoon. Jill had spent the day at the Black Rhino and had a wonderful time there with the children and the teachers and was looking forward to returning each day. Jill and I walked over to the Lilac Café to pick up some necessary tonic water (medicinal, mind you) for our gin and tonics with a splash of mango juice. We sipped on our drinks, sitting on our veranda as the sun slowly set to the west, each of us thinking about just how lucky we were to be here right now. Life is good fails to fully express how we felt knowing that we each had many more weeks to spend in paradise.