Given it was a Thursday, this morning’s lecture was on the examination of the newborn, being given by Mary Ann, a volunteer pediatrician and fellow FAME Board member. There was little question that Gina, our pediatric neurologist, and Megan, our soon to be pediatric neurologist, would be attending the lecture, though I would have to skip it as I had thought Jill would need a ride to the Black Rhino this morning with Pete and Amanda’s car still in the shop. Luckily, it had been fixed in a day with parts being shipped by bus from Arusha and, at the last minute, I was replaced as a chauffeur and Jill caught a lift with Amanda and her son, Ollie. The school is certainly walkable, though not well-advised to do so on your own given the chance that running into a stray buffalo, or even worse, leopard, is not insignificant. Given the fact that I was very interested in keeping Jill around for some time, she took the Amanda option rather than hoofing it on her own.
It had been intended this morning for the residents and Joe Berger to have had a meeting with Susan (I would also attend) so that she could give them a bit of the FAME mission and philosophy, but as so likely happens here, our schedule was very quickly derailed as morning report went nearly thirty minutes over and there were patients waiting for us in clinic. The purpose of the meeting with Susan was really to just hear from her exactly what FAME was doing here and what we hoped to accomplish. As I had mentioned previously, FAME is current seeing 30,000 patients a year and is providing medical services to a vast population of Northern Tanzania in the Karatu district as well as more remote sites that may be more than a day’s drive and tremendously longer on foot.
Again, our role here is to assist the Tanzanian caregivers and staff at FAME and not to be the sole provider interacting with the patient. Seeing a patient without a Tanzanian colleague is an opportunity lost for we would leave very little behind. The other issue that is quite significant here, as it is no matter where one is participating in global health, are the unintended consequences that are the result of actions that may seem like the right thing to do, but, in actuality, are not and often create a cascade of events that only complicate matters in the long run. I have numerous examples that I could give, but the one that I usually use to illustrate this exercise is the patient one sees in clinic who cannot afford their medication or treatment. The actual cost of these things in Western terms is very, very small and there is every temptation to reach into one’s pocket and either hand them the necessary money or pay for them at the cashier’s office.
Though helping this one patient may seem like the right thing to do, you have actually created something of an international event as, despite helping that single patient, they will now go back to their village and tell everyone that if you go to FAME and see the mzungu (meaning stranger, though mostly used in reference to a white person) doctor, they will pay for your care, whether you need that or not. That would certainly be a problem as we are not here as the primary caregiver but are partnered with the Tanzanians to share (often bidirectional) in the care of these patients. And, what’s worse yet, is that by the single act of paying such a small amount for a patient’s care, you’ve just completely alienated the entire Tanzanian staff as they do not have the same ability to reach in their pockets. With a single act of what was thought to be kindness, and certainly the well-meaning intention was there, you have created a situation that will now require a significant amount of finesse to undo, and, in doing so, may limit your effectiveness in the future.
That is not to say that patients here who are unable to pay for their care are not treated, but rather we have well-trained social workers (Kitashu and Angel) who will assess the situation and determine what the best option is going forward. It is inherent that they are involved before any decisions are made or before any unintended consequences might occur. There are creative ways for us to be certain that those in need are cared for and it must seemingly come from anonymous sources that do not involve the volunteers at FAME. It is not enough to be well-intentioned in this world and acts of kindness must be well-thought out and planned, or inevitably things can go awry.
In the end, our meeting with Susan had to be cancelled given how late it was after morning report. We will meet sometime next week after our mobile clinics so that she can hear from the residents. Perhaps, with more time under their belts, they will have more insight and opinions to share with her. Either way, postponing the meeting will not deter our work in any way.
As for patients today, it seemed as though someone had advertised that there was a blue light special on psychiatric disease. Seeing psychiatry for us is not at all unusual, as there are few psychiatrists just as there are few neurologists, but it was the volume that we saw today that was perhaps a bit surprising. In the population of patients that we are seeing on a regular basis, that is, they are returning every six months to see us, we have many with various psychiatric illness including bipolar disease, schizophrenia, and depression. Most of these are doing incredibly well on the medications we have prescribed and, except for periods of non-compliance, often from running out of medication due to cost, they are well-controlled and very functional. To be honest, I’ve been a bit surprised over time at the number of schizophrenic patients that we’ve seen and followed here, but I have little to compare it to as this isn’t something that we treat at home.
One of the more interesting patients for today was a young woman who had been struck by a motorcycle (or a boda boda as it is referred to here) about a week ago. She had lost consciousness and by report had been out for about two days but had gone to the local hospital in town (Karatu Lutheran Hospital) and was transferred to Mt. Meru Hospital, which is the government hospital outside of Arusha. There, she underwent a CT scan of the brain which she did bring with her today and which we were able to review.
She was now having headaches (not surprisingly), but more importantly, she had a complete left ptosis (her eyelid was completely drooped) and her left eye was “down and out,” meaning that it was fully abducted and depressed. The meaning of this was she appeared to have a third-nerve palsy (less likely entrapment of the muscles given the ptosis), and, with her history of head injury, this was concerning for either a direct injury of the third nerve or for some compression of the nerve due to bleeding or swelling. In reviewing her CT scan, it was very clear she had orbital fractures involving her left orbit with near-complete opacification of her left maxillary sinus as well as some opacification of her ethmoid sinus suggesting a basilar skull component.
We could certainly treat her symptomatically, but what she really needed was to see an ENT specialist for the orbital fractures and the third nerve palsy to see if she needed any procedure or stabilization of the injury. The closest ENT would be at Kilimanjaro Christian Medical Center (KCMC) which was unfortunate as it is very close to Mt. Meru Hospital where she had the CT scan to begin with and could have simply been referred directly to them, rather than having to be sent back from Karatu. She was also complaining of hip pain, so we did get an X-ray of her hip that looked normal to us and certainly did not show any significant fracture or deformity. We made the recommendation for her to be seen at KCMC, which they did seem to indicate they could do, and hopefully she will go.
There is a phenomenon here in Northern Tanzania that has to do with the large population of Maasai in the region and that is the Maasai Market. This is not the Maasai Market that exists in Arusha or other locations for the purpose of selling things to tourists, but rather a market for the Maasai, or any other locals who wish to buy virtually anything that you can thing of. Every village will have a market day either once or twice a month, and the Maasai Market in Karatu is one of the largest around, occurring twice a month, on the 7th and 25th of each month. I have experienced the market on several occasions and fondly recall shopping with Jess Weinstein and Jacci Herold back in the spring of 2016, when I watched the two of them happily shopping among the vast piles of second-hand clothes, most of which have come from the US. That was the last time that I enjoyed visiting the market.
Since then, I have driven many groups to the large fairgrounds just outside of Karatu where the market is located twice a month, but I have not gone in myself. Rather, I have sat in my vehicle while the others have spent varying amounts of time sifting through the many vendor’s wares. You can buy vegetables and cooked foods, bulk grains, hemp ropes, livestock, personal items, baskets, pots, or virtually anything else you could possibly imagine. The market is huge, and it is filled with shoppers and vendors, each hoping for a bargain. As I mentioned, though, the market is for locals and there are no mzungu to be found there, other than us, making easy marks for anyone interested in making a good sale of some local piece of handicraft to bring home.
As we drove up, all the while preparing the others for what they soon be experiencing as Jill and I had no plans to stray from our vehicle, a few of the local “entrepreneurs,” one of whom I have known for several years from the streets of Karatu, ambled up hoping that we would be interested in buying something. They quickly suggested acting as guides for our group, which actually seemed like a reasonable thing given the mass of people who were milling through the marketplace, as well as the immensity of the market itself. It would not be difficult to become disoriented and the last thing I wanted was to lose one of the residents in the market and be putting out an APB later for them. All was well, though, and seeing the entire group coming back after less than thirty minutes with everyone accounted for was an excellent sign and a good indication.
After leaving the market, we still had plenty of daylight left and decided that we would visit Phillipo and his wife, Fausta, our coffee source. We stumbled upon Phillipo and his family about two years ago while walking towards Gibb’s Farm. His neighbor, the wood carver, who I have also known for several years, suggested that I meet his neighbor, and we’ve been friends ever since. Phillipo is a second-generation coffee grower who has a small farm that he runs with his family and caters mainly to locals and other guests lucky enough to know him. He is the loveliest person and each time we visit, we are treated to small cups of coffee to taste as well as spoons of honey from his small stingless bees that inhabit his numerous hives hanging in his yard and around his house.
It wasn’t the right season, but he demonstrated how he processes the coffee beans, first by removing the outer shell in a manual hulling machine, then drying out the beans and pounding them in a pestle with large mortars to remove the inner shells. Once they are winnowed to remove the chaff, the beans are then ready for roasting which is done by hand over hot coals, constantly turning for 45 minutes to prevent any burning of the beans. They are then placed in a cooling bin where the beans are left for about 30 minutes after which they are ready to bag into half kilo portions, either whole or ground, or to enjoy immediately. Though we typically bring only whole beans back with us (we’re purists, of course), we don’t have a grinder here, so buy the ground beans for the house.
It was a wonderful evening and a gorgeous sunset. We departed Phillipo’s home for our home away from home as our dinners were waiting for us. Life is good in Karatu.