We had finished a strong week of neurology at FAME, and it was time for our only Saturday clinic of this three-week block as we will be in the Serengeti next Saturday and the following one will be our changeover weekend with this group departing and the following group arriving. That’s good, as Saturdays tend to be slower on the whole. There is also no morning report on Saturday, or Sunday, for that matter, so we had an extra 30 minutes in the morning with clinic not starting until 8:30 – that gave plenty of time for Jenn and Leah to get to the Lilac for their morning coffee and for Gina to complete her run. I don’t recall for certain if Megan had gone with her or not, but regardless, it was an extra few minutes in which to get things done. With an invitation from Amanda, Jill had amazingly found a yoga class for the morning, instructed by the Black Rhino headmaster’s wife. So, everyone had someplace to be for the day and something very much to look forward to in the evening.

With our normal complement of residents and translators, but now with Marissa to also assist with the pediatric patients, and Joe was still here for the adult patients, there seemed to less for me to deal with throughout the day. It had also rained a bit throughout the night, which makes it more difficult for patients to travel to FAME on the muddy roads until they dry, often delaying everyone’s arrival. The red clay that is so ubiquitous here quickly turns to a sticky mud and coats virtually everything in sight, turning your shoes into 5 lbs. weights on your feet. Driving can be equally tenuous in the big rains of April into May where the red clay becomes more a slip and slide, though there was not enough rain last night as that situation takes at least several days of constant rainfall, and we haven’t had that yet. How the workers at FAME keep their shoes and clothes so clean as they show for work each day remains a mystery to me for it has not been my experience. I will routinely wear my mud boots from the house each morning when it’s raining, and bring a second pair of shoes to switch to once I am there.

Though the morning started slow, it was soon enough that we had patients showing up to be seen. With Marissa now here and her strong interest in headaches, she was very interested in gathering some data on those patients who might benefit from an occipital, or other types, of nerve block or trigger point injections. We have traditionally used bilateral greater and lesser occipital nerve blocks in patient who are felt to have occipital neuralgia, but it has become clear over the recent years that the occipital nerve blocks are often very effective for other types of headache such as chronic intractable migraine, especially when they are interspersed with Botox, as they definitely “cool” things off and provide at least some short term benefit. For several years now, I have brought along the necessary supplies for us to provide these injections and I have a suspicion that they may be perhaps even more effective here given how often women carry things on their head and how heavy the loads are. In building our maternity ward at FAME, I watched the workers carrying 5-gallon buckets of concrete on their heads.

It wasn’t long at all for Marissa to begin assisting with this procedure for patients to be evaluated for headache. As in the US, we frequently use tricyclic antidepressants for chronic headaches, whether migrainous or not, and have very good success with these older and very inexpensive medications such as amitriptyline and nortriptyline. When we’re seeing patients in the US for headache, in addition to deciding what our treatment options are, we are always trying to decide what “red flag” symptoms or signs the patient may have as a way of determining whether or not the patient needs to have an imaging study of their brain, either an MRI or a CT of the brain. The threshold, though, must be much higher here for several reasons, not the least of which is that virtually all our patients do not have insurance and are paying out of pocket for their care. Additionally, practicing in a low resource setting means that access to imaging for most patients is very limited. The closest MRI scanner is two hours away and is also very expensive for most. Though we have a CT scanner at FAME, providing these services not only has a cost associated, but must also be priced similarly to other facilities in the local region to prevent patients not under our care from traveling to FAME just to obtain their CT scan.

So, deciding whether to recommend a CT scan to a patient can have significant ramifications. Labs and medications are bundled into their neurology visit, along with the cost of the visit itself, though they are subsidized by FAME, so there is a cost to someone. Radiology studies, including CT scans, are not covered, and are therefore borne by the patient and family. In the same fashion as my earlier discussion about unintended consequences, if we feel strongly that a patient requires a scan and they are unable to afford it even after a discussion with our social worked, then, and only then, will we have a more lengthy internal discussion regarding what type of resources we have that might be used to help with the cost of the scan. Never once will the patient be told that their mzungu doctor is helping with the cost of the scan.

This situation arises on a regular basis and though it certainly places greater pressure on the clinician regarding determining what studies to obtain or not, it is appropriate and something that has long been called for in the United States, where the cost of healthcare at its present state is unsustainable. Though I am certainly not in support of patients being unable to obtain studies due their cost to them privately, having some form of a nationalized base health insurance for all those in the US is an absolute must going forward, coupled with the option for those with the ability to pay additionally to have further benefits (a two-tiered system). IMHO.

I had hoped we’d get home very early from clinic so we could leave for shopping at the African Galleria as we had planned, but unfortunately, we had several more complicated patients show up at the end, so we were pushing our window to leave. I arrived back to the house with the others and went into my room to change. On stepping out the door, it turned out that they had planned to wish me a happy birthday (it was my 68^th today) and present me not only with a very nice cake, but also, Mary Ann had made some banana bread that was delicious. As we were heading to the Galleria for dinner, we decided to forgo eating the cake, but did sample the banana bread (one of my favorites, though I have many). I was finally able to corral everyone into our vehicle and we began our short journey to the Galleria.

We had planned to have dinner at the African Galleria tonight as we are on our own for dinners on the weekend nights and, besides, it was my birthday today! The African Galleria is difficult to describe as a souvenir shop as it also has lots of artwork, antiques, and gems in addition to the items one would normally pick up on a trip to another country. It is a pretty amazing place that I’ve seen grow from very little since I’ve been coming to Tanzania and, several years ago (4 to be entirely accurate as it was just at the beginning of the pandemic), they built an incredible open-air restaurant that serves some of the most delicious food here in Tanzania. The founders, Nish Dodhia and his brother, Punit, were raised in Mombasa, Kenya, but have lived in Tanzania for a number of years, so the food at Ol’ Mesera restaurant is a blend of East African Cuisine.

The menu for the Ol’ Mesera also includes several very yummy drinks, though my favorite is the Dawa, which means medicine in Swahili, and they make it with local gin, honey, tonic water, lime, and diced cucumber, served with a muddling stick. One of my favorite foods is the Zanzibar Mboga Mboga soup, which is an amazing pumpkin, coconut, ginger soup that I just love. Two other favorites are the cheese samosas and the grilled paneer and beetroot skewers. Putting this together with their chicken mishkaki (grilled skewers), nyama choma (barbecued short rib), mchicha (spinach), pilau, grilled corn, and many, many other amazing dishes, it is always a wonderful culinary adventure going there.

We traveled home early enough for the residents to make our lunches for our safari in the Ngorongoro Crater tomorrow while I took care of getting our camera equipment together. We had picked up our safari guide, Joram, in town so he could drive us home and then take the stretch Land Rover back into town to fix an ignition problem we were having with it. It was starting only intermittently and, when it didn’t, it required a push to pop the clutch which, thankfully, worked quite well.