As first days go, yesterday was pretty brutal for everyone considering we were all still a bit jet lagged from our long journey here. Despite that, I think it had been a very exiting day with lots of good patients needing neurologic care and opportunities to teach the FAME staff about neurologic illnesses, the entire reason that we’re here in the first place. I should also mention that there are other volunteers here with us, for FAME is not just a neurology center, but rather provides full medical care to the entire community of Karatu and for miles around. Our catchment area is roughly 2.9 million individuals, and patients may often travel for days to reach us here.

The volunteer program has been one of the central tenants of FAME (only one aspect of the education piece with the other being sponsoring nurses and doctors going back to school) since its inception, and the infrastructure to support volunteers have included not only a volunteer coordinator, who takes care of necessary medical licensing and other paperwork, but also housing. When I first arrived here in 2010, we had two houses, each of which had two bedrooms with two beds each, and over the years, there have been two additional houses built along with a small duplex that is used for long-term volunteers, those staying for six months or more. One of the newer houses was funded by a donor who has followed our neurology work here from the beginning and wanted to build a place where we could all stay together, so it has four rooms and houses 8 people.

The other volunteers currently here at FAME include two fellow board members, Mary Ann Zetes and Barbara Dehn. Mary Ann is a recently retired Stanford pediatrician who first came to volunteer several years ago and now returns at least annually to assist with our pediatric programs here at FAME that are quite robust. Barb, who is a close friend of Mary Ann’s and has traveled here with her to volunteer also for several years, is a nurse practitioner who specializes in woman’s health issues and spends most of her time in our maternity ward and with the RCH (reproductive and child health) program. A close friend of their, Sari Levine, is also here for several weeks and was first here last year to volunteer. She is a urologist and not only assists with patients and surgeries in her area of specialty, but also works closely with the surgeons.

Two other volunteers, who are long-term and here with their young children, are Pete and Amanda. They are Australian and have been funded by an Australian non-profit to spend a full year here at FAME. Amanda is an ER physician who has been tasked with bringing our new emergency room here at FAME up to speed, and Pete is a pediatrician who has assisted in general pediatrics while here. They have been here since last August with plans to spend the year, though are already looking into the possibility of staying on longer, especially given the significant need here for both an emergency medicine physician and a pediatrician.

And last, but by no means the least, we have Elissa Zirinsky here, who is a pediatric infectious disease specialist, and is now halfway into her second year at FAME this time around. She has a long history with FAME as she was originally connected with Rift Valley Children’s Village through her aunt who is on the board. Having spent time at RVCV as a volunteer, she was eventually introduced to Frank and Susan and the work they were doing which was a huge factor in her eventual decision to go into medicine. Coming back to Tanzania to practice at FAME has always been a dream of hers and has now become a reality.

Working at FAME is completely a shared experience, and as much as we are bit secluded seeing neurology patients all day, it is often very important for us to be involved with other aspects of patient care here. Seeing babies with hypoxic-ischemic encephalopathy (HIE) or women with pre-eclampsia in the maternity ward are easy examples of the overlap of specialties, but it’s also necessary for us to be involved in morning report, where all the ward patients are discussed, and morning rounds, where the inpatient team will go over patients’ clinical history and course in further detail. During our last visit here in October, while rounding with the medical team on a patient that hadn’t been billed as a neurology patient, LJ heard something that had raised her concern for something neurologic going on and, sure enough, it turned out the patient had suffered a stroke which greatly affected the necessary care to be provided.

Having someone from our team round with the inpatient doctors not only gives the residents a better appreciation of what the doctors and nurses are dealing with on a daily basis here and also allows a contribution to even non-neurologic cases in the ward. It was decided that Joe and Leah would round on the ward service today and there were several patients for them to see, one of which was an unfortunate young boy who had been admitted for the last 6+ weeks with a history of Tb meningitis that had been diagnosed based on response to therapy as opposed to the normal CSF analysis. They had obtained CT scans back in January that were available for our review and, based on those images, they were certainly consistent with that diagnosis and the child looked very, very ill.

As can be seen by the CT scans, there is a significant inflammatory response and diffuse meningitis filling all the sulci and the basal cisterns, with enlargement of the ventricles concerning for hydrocephalus. Though the child was on therapy for their TB, whether they improve from a neurologic standpoint remains unclear at this time. TB meningitis is a basilar meningitis that is often associated with increased intracranial pressure and a high risk of hydrocephalus. It is most often associated with immunosuppression and patients with HIV have a much higher risk of having TB meningitis in the setting of TB than do patients without HIV. This child was not HIV positive.

Later in the day, Gina was evaluating a 10-month-old child with developmental delay and no clear history of HIE or anything else that would suggest a cause for the delay. Given that, we had decided to obtain a CT scan of the brain and quickly discovered the reason for the child’s delay. Her ventricles were huge, and it was clear that she had a communicating hydrocephalus that was significant enough to require placement of a VP shunt, and better sooner than later. At home, VP shunts in children are placed by pediatric neurosurgeons, though that’s not possible here and they are typically placed in Arusha by pediatric general surgeons. There is a single neurosurgeon who is now in Moshi at Kilimanjaro Christian Medical Center (KCMC), and I suspect that she now places many of these as well, but it really depends on availability.

Obtaining an accurate history from patients here can often be quite challenging and it is not only because of the language barrier, though that is also challenging in its own right even with our interpreters. There are over 120 tribes in Tanzania, all of which speak their own language and there can be little similarity between them as many of the tribes, such as the Maasai and the Iraqw, both of which migrated to this region from different areas. Older patients will often have never left their villages and may speak only their native tongue. Even the younger Maasai women may not speak Swahili as they have never left their families boma to travel to the Market where Swahili is spoken. In these situations, it’s required that we have a translator from the local language to Swahili and then from Swahili to English. Kitashu, our social worker who is also Maasai will often serve as a translator for Maa (Maasai means speakers of Maa), and since he knows English well, it removes the need for another translator.

The other reason it’s often difficult to obtain an accurate history, though, is much more of a cultural nature. Most often, when questioning a patient and trying to determine what specific disease process is occurring, it requires a meticulous recounting of the timing of events, often over a course of years. Unfortunately, time in Africa doesn’t carry the same significance as it does in the Western World and the ability for a patient here to give a good timeline of events is often virtually nil. They can recall specific events, but often not in what specific order they may have occurred and rarely exactly how long they have occurred. Though health literacy here is clearly less than it is at home, and health literacy at home varies significantly on its own, the difficulty with obtaining a history is not related to this in any manner. It merely relates to how time is perceived in one’s culture to what importance we place on it.

One of our last patients of the day was a middle-aged woman who came to see us for headache, but it was also noted that she had weakness and atrophy of her right leg as well as some abnormal posturing of her right foot. The initial history that was obtained was that her leg problems had all occurred over the course of the last year and made us most concerned for some process involving her motor neurons. She had no other signs to suggest ALS, though this was in the differential, of course. After she was presented and Joe had a chance to examine her, it was decided that she would go for an MRI scan in Arusha as a CT scan would not be very helpful. After some time, though, and more questioning as to the onset of the leg symptoms, it finally came out that her leg had been like that since she was two years of age, easily clarifying her diagnosis for the withered leg as being polio, which made absolute sense. It had just taken asking her numerous times about the history and mainly about the time course and when the symptoms had begun. Thankfully for her, she did not have a recent motor neuron issue, nor did she require any additional testing for her leg. We offered her treatment for headache and called it a day.

It was another late evening seeing patient, though we had time enough before sunset to have a round of my special gin and tonics made by adding a splash of mango juice. They were absolutely delicious, though of course their main purpose was solely medicinal to further prevent malaria with the tonic water. Or at least that was our excuse.