It was our third day of clinic, and everyone had hoped for a more reasonable workday, given that we had finished late on both previous days. We were still having plenty of patients show and the reception area for FAME was equally swamped once again. Given the number of staff that show up for Morning report on Monday, Wednesday, and Friday, only Leah and I were planning to go as representatives for the group. Walking up to the main conference room, we quickly found that there was a management meeting happening this morning (first Wednesday of the month) and were redirected to the administrative building where there is yet a smaller conference room, but it utilized when there are multiple meetings taking place. Thankfully, there was a seat for me as my back has been bothering me and I wasn’t looking forward to standing for the meeting.

I had forgot to mention that we have educational lectures every Tuesday and Thursday at 7:30 am that are most often given by visiting volunteers, and that yesterday’s lecture had been given by our visiting urologist, Dr. Levine, and was on male sexual dysfunction. Though certainly a fascinating and important topic, it was fairly far afield from being of use for the neurology residents, so they all excused themselves to get some extra sleep or more time for breakfast. On the other hand, I had decided to show up more from a standpoint of courtesy to the presenter than anything else, though I must admit that I have dealt with this topic among my patients for a number of years and was reassured to learn that very little had changed since the advent of Viagra. Still, Sari has a wonderful way of presenting the topic, and I’m sure much was learned by all those who attended.

I’ve typically had the residents give presentations while they are here, but over the last years, as the volunteer numbers have steadily risen, it has become more and more difficult to secure enough slots for the residents and we have inevitably had them combine their efforts for each lecture. With the TB meningitis patient in the ward, Joe has volunteered to give the talk upcoming on Tuesday on just this subject given his background in HIV and neuroinfectious diseases. I’ve warned him that he will be speaking to general practitioners and not a roomful of neurologists, so will have to be sure to speak more slowly and be certain that everyone is understanding him.

Over the years, our neurology talks have obviously repeated themselves – as amazing and interesting neurology is, there is a limited number of talks that can be given to primary care practitioners in rather rural Africa. We have covered epilepsy, headache, stroke, the neurologic examination, reading CT scans, neuromuscular, tremor, Parkinson’s disease, pediatric neurology, and the neurologic examination, each on multiple occasions for giving several lectures a visit twice annually over the last 14 years adds up to quite a few lectures over that period of time. They have all been well received and though much of the staff here at FAME has been here for multiple years, hearing them several times over has never been an issue both as a reinforcement of the material and having it presented in a different manner each time.

From my very first visit to FAME in 2010, I have also maintained an open line of communications with the staff here to help them with new neurology cases or follow up cases in between my visits. Often, the patients can be quite complex and, in addition to the history, I will be sent videos of the patient’s appearance or examination but trying to make a diagnosis based on someone else’s examination can be difficult, especially if they are a novice. Early on, I may be given a very simple history such as a new patient presenting with weakness, and I would be given nothing else. Weakness in neurology is something that could be related to a great many sources and, because of this, it requires more information to even begin an evaluation. We divide the nervous system into two big buckets – the central and the peripheral nervous system, and weakness from each of these will act very differently and have very different exam findings. So, after a year or two of coming to FAME and teaching everyone how to take a history and examine a patient, I would receive the information necessary to begin investigations and to develop a differential diagnosis for the patient. This was such a major turning point and has only continued to improve so that I will now receive information enabling me to develop a working diagnosis with them and a plan for investigations.

In previous blogs, I have spoken of a patient with multiple sclerosis who we had diagnosed about two years ago and had started on a medication that was unavailable here in Tanzania (in fact, there are no MS drugs available here) and which we have been able to bring from home to provide her with treatment. We had once again brought a supply of the medication for her that would last another six months and I had contacted after arriving to make sure she came during our first week here as I had hoped that she could see Joe and, for that matter, either Leah or Gina as well, both of whom are also MS neurologists. She was able to come today and was already on her way here.

Though the risk of developing multiple sclerosis is multifactorial, one of the more significant factors playing a role in one’s likelihood of developing this autoimmune disorder has to do with the latitude of where you live and, more specifically, where you spent the first 15 years of your life. The incidence of MS is the lowest along the equator (strongly felt to be the result of high vitamin D levels) and essentially increases the further away from the equator you are raised, whether it be the northern or the southern hemisphere. Once you reach the age of 15, though, that risk is essentially fixed and will not change regardless of where you may immigrate. That is why the incidence of MS is very low here in Tanzania, as well as other equatorial African countries, though just how low that is may be very difficult to tell. Having very few neurologists to make the diagnosis and very few MRI scanners to help confirm it when it’s considered, the numbers seem very small, but it’s unclear just how accurate that may be.

Though I believe I have seen one or two patients over the last 14 years who I believe may have MS, it was difficult to make the diagnosis due to the lack of accurate history (as I discussed yesterday), the lack of follow up and the inability to obtain an MRI due to availability and cost. This patient, whose history was suggestive, had already obtained an MRI scan that she brought with her to her first visit and very clearly demonstrated abnormalities that were consistent with the diagnosis. After some doing, we were eventually able to bring her medication and she has been stable since that time without progression of her disease or any MS flares. Having the ability to provide treatment for her was crucial and with continued treatment, the hope is that she will remain symptom and episode free going forward.

The infant who had been in clinic yesterday with her mother, who was the patient, and raised concerns for hydrocephalus, underwent an ultrasound of her head this morning as she had an open fontanelle that allowed for this. Thankfully, she did not have any evidence for hydrocephalus on the study and would not have to be referred for a shunt.

As for the young boy with TB meningitis who has been extremely ill for the last two months and remains unresponsive, he is not being ventilated (no one is ventilated here) and only continues to receive his TB treatment such that his family wants to take him home and continue to treat him there. This is a common theme here (much different than at home) as families are paying directly for their medical care and, even though it is very little from our standpoint, the amount adds up quickly and is often difficult to pay. When patients are here only receiving medication, families very often want to take them home for financial reasons. I remember an 88-year-old woman who had suffered a large hemispheric stroke a number of years ago and, despite the fact that she was hemiplegic, she could swallow, and within three days, her family wanted to know whether they could take her home or not. This would never have occurred at home.

We had decided that since he hadn’t had a CT scan in some time, it would be good to get one given the nature of his meningitis and the risk of hydrocephalus, as well as the fact that his ventricles were rather large when looked at previously. Unfortunately, the CT scan demonstrated that his ventricles were enlarging and that he needed to have a shunt placed to allow the fluid to drain or another procedure that works similarly. Thankfully, Kerry Vaughn, a pediatric neurosurgeon who visited here at FAME for two weeks a few years ago with Sean Grady, both of whom were teaching the staff here to do burr holes for subdural hematomas, is currently doing a one-year global health fellowship at KCMC in Moshi and would be able to weigh in on the case.

Arranging these types of transfer for care is always a difficult situation as it is almost never based on bed availability as it is in the US, but rather on the financial issues that are at play. Very few people here have health insurance, and though there is a national plan, very few people participate in it, meaning that nearly all individuals are paying for care out of pocket. Though it is often a matter of speaking with their family and their community to raise the funds, it is not something that we are used to dealing with at home. Before a patient can be transferred, there must be some type of guarantee of payment, often delaying the process. As for this boy, he has been accepted to KCMC, and though the financial aspects still need to be worked out, it appears very likely that a solution will be found, and he will be transferred.

Interestingly, just yesterday, Joe was speaking with me about a colleague he knows, Ben Warf, who’s a neurosurgeon that spent time in Uganda, and during that time, despite having placed many VP shunts, continually wanted to find a procedure that would provide similar results for children with hydrocephalus without having the risk of subsequent shunt failure that were an emergent event. He went on to develop the endoscopic third ventriculostomy and choroid plexus cauterization (ETV-CPC) that was found to prevent developmental and brain growth delay in a randomized trial that included 100 children. When this boy is transferred to KCMC, it is very likely that he will undergo an ETV-CPC as will the other child that we referred, also with hydrocephalus.

Our day ended much earlier today, allowing us to finally head into town and visit the exchange bureau so that everyone could get some Shillings to use. Several years ago, there were exchange bureaus practically on every street corner here, but when it was found that they were essentially laundering money, they were all shut down overnight, and exchanges could only be done in banks with your passport. Thankfully, that situation has become less strict and, once again, there are exchange bureaus, though they are more closely monitored now and still require your passport. The exchange rate currently is 2650 Shillings to the dollar (I think it was around 1400 to the dollar when I first came in 2010) and their largest bill here is a 10,000 note – less than $4.

Once they had Shillings, the first request I had from the residents was to take them to a liquor store where they could buy more wine. Luckily, the liquor store was right next door, and they were all happy.

Meanwhile, we had been told that we must visit the Lilac Oasis on the other side of town as it was a new place to visit for dinner, drinks, and dancing. The last time that I was there six months ago, it consisted of a food truck, a bonfire, and music, all outside, but it is now a magnificent facility with a lovely restaurant and bar, a swimming pool, a spa, and the loveliest of landscaping. It’s still under construction, but open for some of the activities. We’ll report more once we visit it for real.