I had scheduled today as a half day as the residents will have just completed working five days straight after a strenuous flight from the US which is rigorous enough for Africa. With the last group, we had planned for a dinner at Gibb’s Farm and an afternoon at the pool relaxing. With this group, I had decided to change things up a bit with a little encouragement from Nish Dodhia, who had suggested that we might want to try the Manor Lodge, which is another of the very fancy, and expensive, lodges in the Karatu region that caters to the wealthier clientele traveling on the Northern Safari Circuit.
Most of these lodges in Karatu are very accommodating to volunteers at FAME, giving us a discount for meals, but also allowing us to use their facilities for the afternoon prior to our dining. Similar to Gibb’s Farm, the Manor Lodge has a nice pool, as well as a stable and horses to ride, and our plan was to head there for the afternoon to relax around the pool and then enjoy an elegant dinner. Unfortunately, we hadn’t quite accounted for the possibility of heavy rains and lightning throughout the morning and, even as it seemed to clear up a bit over Karatu and towards the east, there remained dark and ominous clouds over the crater rim to our north exactly where the Manor Lodge sits. Though it seemed quite unlikely that we’d be going to the Manor to swim, we kept our options open as we began clinic for the morning.
Saturdays are typically a bit slow at FAME in general as well as for our neurology clinic and today proved to be no different. Between the rains and it being Saturday, patients were slow to show up. Our first patient of the day turned out to be a non-neurological case that had somehow slipped through, though I’ll have to admit that our triage procedures have been slacking a bit and could use some revamping. As the neurology clinic is subsidized, meaning that patients pay only 5000 TSh (less than $2 USD) for their visit, any labs and 1-3 months of their medication depending on the circumstances. But this flat fee is for neurology patients only and is not meant to be for the general population of patients. The reason for that has to do specifically with sustainability and funding. We are entirely unable to support providing this type of arrangement for the general population of patients.
Patients, though, have become aware of the how the visit is handled in the neurology clinic, and hoping to benefit from the flat fee will tell reception that they have a neurologic problem or complain of something that is close enough to neurology that they will be triaged to us and it is not until the patient sits down with us that their true complaints become evident. Our first patient of the day was just such a case, and their problem had nothing to do with anything neurologic, though they did have pain in their lower extremities.
The patient had severe swelling and skin changes that were consistent with elephantiasis, or lymphatic filariasis, a mosquito borne parasite causing an infection of the lymphatic system and swelling typically of the lower extremities and genitals. Treatment here is with ivermectin, an antiparasitic medication first used for veterinary applications and subsequently approved for use in humans for the treatment of parasitic infections, though was also at the center of significant disinformation during the COVID-19 pandemic when it was reported to be useful for this treatment, though was never backed by any scientific evidence whatsoever, and finally fell out of favor. The patient that came to see us could only afford the cost of the visit, but not the medication, which would have been a problem in the OPD where patients are charged for their medications. The medication was not expensive at all, though, so I agreed for us to see the patient and not refer them to the general OPD, which seemed far simpler to achieve a positive outcome for the patient.
We finished up in clinic after a smattering of typical patients for us, though one patient, whom we had seen before, returned for additional labs. This was a young man who most likely suffers from Becker Muscular Dystrophy based on his clinical course and current level of disability. He did have a family history of an uncle being non-ambulatory in his middle age and both this and our patients deficits at his age seemed to correlate best with Becker MD as opposed to Duchenne MD which causes tremendously greater disability and death at a much younger age, though Becker also has a reduced life expectancy.
We checked the patient’s CPK (CK) which was still elevated similar to what it had been before, though we didn’t have any further diagnostic testing to provide here at FAME. Patients with muscular dystrophy also have other complications, most notably cardiac abnormalities, and they reported that the patient did have an echocardiogram performed previously, which was helpful.
We had already placed the patient on steroids previously, though had somehow been tapered down to a dose of 5 mg of prednisolone which is fairly homeopathic. Though there are no good randomized, controlled studies in Becker MD, there are in Duchenne MD where it has been shown that fairly high dose steroids can preserve ambulatory function for longer and can also reduce the risks of cardiac involvement over time. Though there are no studies in Becker, the general consensus has been to use steroids, and if there are no complications or significant side effects, to continue them for some time. We recommended this and gave them a prescription for higher dose prednisolone along with something to protect his stomach from the steroid use. He will come back to see us in follow up, though also plans to be seen shortly at KCMC by Dr. Dekker and we’ll do our best to collaborate on a plan of action going forward. Genetic testing would be very helpful to confirm his diagnosis, though this testing is very expensive.
We had planned to wrap up clinic sometime after noon and to have lunch at FAME as they serve rice and beans on the weekend, which, of course, we all know is my absolute favorite lunch. Jill had gone for a walk earlier, but then the rains came, and she decided to just eat lunch at home and wait for us. While we were at the cantina for lunch, a thunderous downpour began which pretty much made our decision of not going to the Manor Lodge for an afternoon at the pool given the dark clouds that continued to hang over the Conservation Area where the lodge sat. We had discussed alternative activities given that we had the entire afternoon to ourselves and decided on driving down to the African Galleria to do some shopping and visit with Nish.
As we drove out of Karatu, the skies seemed to open up and we actually had some blue above us, though the dark clouds remained to the west and north. Lake Manyara was fully visible in the distance looking down past Chem Chem into the Rift Valley below as we descended the sharp curves of the highway heading towns the village of Manyara where the Galleria sat. Coming home, we drove past a mangled tractor trailer that had lost its brakes on the descent with its rear trailer having overturned and the cab looking like it had been crushed by Godzilla. It had just occurred and there were lots of bystanders and other vehicles that had either stopped to help or to gawk, it was difficult to tell.
We spent well over an hour shopping at the African Galleria, now called SafariLand, though I much prefer the old name as the new one is just a bit too much “DisneyLandish” for my liking. Everyone found things including some jewelry, which is Nish’s expertise and what he likes best. Tanzanite, a rare gem that is mined just south of the Kilimanjaro International Airport in the Blue Hills is obviously a favorite here, as it should be, though I’m very particular to Tsavorite, or green garnet, a gorgeous sparkly stone that is just a bit harder than Tanzanite, and is significantly rarer, and consequently more expensive. It’s fun looking at their gems, even if the larger stones are way out of our price range.
We left the Galleria to return home, only to change our clothes for dinner at the Manor Lodge but seemed to loosing daylight as we went. The drive to the Manor ascends up through the Shangri La coffee plantation high up on the ridge behind FAME and there is actually an easement through part of the Conservation Area where an electric fence helps keep the elephants inside. As you arrive to the lodge, there are massive gates to let us in and we are immediately transported to the grounds of an estate that would have been what parts of Africa looked like in colonial times.
My plan had been to get there well before sunset, and though we missed that window, there was still plenty of daylight present that allowed everyone time and light enough to meander about their extensive grounds. The Manor Lodge is comprised of the main house where the dining room and lounge is, as well as a large downstairs media room where they can show football matches. There are 9 duplex cottages that are gigantic in size and there is a stable cottage that can also be used for a family. There is a lovely swimming pool for guests as well as others such as us who are volunteers visiting from Karatu.
The three residents spent some time walking the beautiful grounds of the Manor Lodge, though not until we had ordered our drinks. Once our order arrived, they brought appetizers to us outside that were so numerous it almost felt like this was our dinner – cheese samosas, small chicken bites, warmed cashews, potato chips, and taro chips. The staff built a fire for us outside as there was a bit of a chill to the air once the sun went down and it was so relaxing to sit with our drinks under the multitude of stars that were visible to us. It turned out that we were the only guests there that night, so we essentially had the entire place to ourselves.
As the only guests, they had set up a table facing the large fireplace in the lounge where in the past I had only eaten in dining room with other parties or once outside on the veranda. As in the past, there was more silverware than I’ve ever seen on a table, and it was set perfectly for us. It was an entirely spectacular setting for an incredible dinner – we all ordered the five-course tasting menu that was just delicious and were small portions of each course, so we were not stuffed at the end, but had been served a perfectly appropriate amount of food.
Driving home that night was a bit slippery, which is exactly why I drive a Land Rover as the low center of gravity is designed for these kinds of terrain. I’ve definitely driven worse, but the rain and mud here can certainly make driving conditions quite treacherous at moment’s notice. Driving on the FAME road, we followed a boda boda with something I’d never seen before – a driver and a passenger who was holding a calf on his lap. They were driving a bit slowly, but I was nervous to pass them for if the calf somehow wiggled loose and ended up on the road, I would have struck it, something that would clearly have ruined our evening. In the end, we did pass them, though it was sure a sight I wouldn’t forget.
