FAME’s success over the last 15 years has been predicated on a number of key elements, though there are two that I have always found to be the most important from my perspective. There are also those that are clearly mandatory when undertaking a project such as this – the trust that’s built with the community and the sense of family that I have spoken of previously which has been created by FAME and its employees who come to work each and every day to make this a better world. Of the two key elements that are not so obvious, though, first is our volunteer program and emphasis on education, and the second is the fact that FAME is run by an all-Tanzanian clinical staff and can operate completely independent of the volunteer program as we demonstrated so clearly during the pandemic when there were essentially no volunteers save for our neurology program for a span of two years.

The volunteer program has been an essential component of FAME’s character from its very inception and has continued to attract doctors, nurses, and others from the US and many European countries who come for both long and short-term visits to work with FAME’s clinical staff and provide addition training in their various areas of expertise. It is certainly a bidirectional transfer of information, though, as the volunteers also learn a great deal of information, such as how to practice in a low resource setting, by working with FAME’s dedicated doctors and nurses. At last count, FAME is averaging in excess of 60 volunteers a year in all specialties that continue to provide current practices, though with the continued sensitivity that is always necessary when you are a guest in someone else’s culture and a long, long way from home. That requires an open mind and a willingness to see things through other lenses than our own, as well as the realization that you are not the center of the universe (being humble).

When speaking with anyone about global health, the conversation will always lead to single concept that is often the most important thing to consider and cannot be overlooked – Sustainability. For without sustainability, all is for naught. The fact that FAME has an all-Tanzanian clinical staff was by no means an afterthought, nor has it ever been something that has been reconsidered as FAME developed through the years. If anything, the philosophy has been increasingly reinforced along the way, and its importance has been continuously demonstrated. When the pandemic hit in March 2020 (while I was here at FAME with my team, by the way) and it became readily apparent that the volunteer program would at least be temporarily shutting down as were the borders and flight patterns throughout the world, having a self-contained medical and nursing staff without the need for outside help became a necessity and a God-send.

Even more apparent, though, was the fact that the training and education that had been provided to our clinical staff over the preceding years had now proven to be key to the success of FAME in the coming years, allowing for the long-term sustainability of a rural based healthcare center (hospital) dedicated to providing patient-centered care for a population where access to healthcare had previously been very limited. Over the ensuing months, as it became increasingly clear that the pandemic was here to stay and would change our lives forever, FAME by was called upon by the government (don’t forget that we are an NGO) to provide the necessary training and education to the other healthcare facilities and workers in the region concerning proper practices, providing further proof that the careful planning and sustainability were essential to our success.

This morning’s lecture was provided by Dr. Anil, an emergency medicine physician now volunteering at FAME. Anil is from New Zealand and had learned about FAME as these things always go from a friend of a friend of a friend. Ultimately, it involved Dr. Pete and Dr. Amanda, who had just finished a two-year volunteer stint here at FAME earlier this year. Pete and Amanda were from Tasmania and were being funded by an Australian non-profit, NGO that provides support for volunteer physicians. Amanda, an emergency medicine physician, was here following the completion of our new emergency department, so spent her time developing protocols and teaching just about every aspect of emergency care to the clinicians and nurses at FAME. Pete, a pediatrician, spent his time working with our neonatal intensive care unit and inpatient pediatric population. It was sad to see them go, though they had been here for a full two years. Our lecture today had to do with traumatic head injury, a topic near and dear to our hearts.

Following the lecture, we received report on several interesting patients, though unfortunately, we had very little to offer them. One was a young 45-year-old woman who had presented with a severe headache and was found to have fairly massive intraventricular blood on her CT scan. She subsequently decompensated and passed away, though I am doubtful that anything would have changed the eventual outcome – had someone placed an extra ventricular drain (EVD), she may have survived a bit longer, but her quality of life would have been non-existent, and she would not have survived long, regardless.

The other patient presented at morning report was a bit more troubling as it was a child who had bilateral subdural hygromas and severe atrophy (collections of fluid, not blood) on CT scan. Problematically, though, the imaging also demonstrated severe global atrophy and as expected, the child had severe developmental delay and hadn’t met any of their normal milestones since birth. What had been described to me as chronic bilateral subdural hygromas (which, after reviewing their scan I would have agreed with) are essentially spaces between the brain and inner surface of the skull that become filled with cerebrospinal fluid as something must occupy the space in the absence of brain due to atrophy. The key is that it’s not acute and not under pressure in most circumstances. The child underwent bilateral burr holes, which had been recommended, but what normally happens in these situations, and happened here, is that the fluid just reaccumulates as there is nothing else to fill the space (the brain doesn’t bounce back since it’s a chronic compression).

Inpatient consults for the day included someone who had been advertised as a patient with a basal ganglia hemorrhage, though after looking at the image, both Joe and I were equally concerned that this could represent a lobar hemorrhage, something that would have a broader differential and a different workup. Clinically, the patient was hemiplegic, but this did not add anything to our differential, unfortunately. Jack also evaluated one of the patients (an 8-year-old child) in the ward with suspected TB meningitis who had been receiving his anti-TB meds for several weeks, but still looked very, very sick. It would be fair to say that this child’s prognosis was guarded at best.

Perhaps the most interesting patient in clinic today was a young 4-month-old child who had a very significant perinatal history, had seized shortly after birth and was noted to have a large head circumference concerning for congenital hydrocephalus. They had received a VP (ventriculoperitoneal) shunt for the hydrocephalus at 2-months of age, and it was unclear whether they had improved at all following the procedure. They had brought the child in for us to evaluate because the child was not improving after the shunt and continued to have seizures despite a very high dose of phenobarb. We did not have the previous imaging as it had been done elsewhere along with the shunt, and we were concerned as to whether the shunt was fully functional.

On examination, the child could do very little – they were moving their extremities, but they did not otherwise respond. Our recommendation, in addition to decreasing the phenobarb and adding levetiracetam, was to bring the child back to the other institution to make sure their shunt was functioning, but they told us they had done that already and were told it was. The family requested that we obtain another CT scan here at FAME, and we were all quite happy that we did, for it revealed the fact that the child was missing the vast majority of both of their hemispheres, which was the reason for their failure to reach their milestones and had little to do with hydrocephalus. Ultimately, we had a long discussion with the family regarding the child’s very poor prognosis, and that other than trying to help with the seizures, there was nothing that could be done to improve the child’s devastating neurologic functional status or their prognosis. Though we had little to offer the child, we could certainly explain this to the family and try to prevent them from going to another healthcare facility looking for answers.

We finished clinic early enough to head out on a hike through the fields behind FAME before sunset. The region here is gorgeous with rolling foothills bumping up to the edge of the Ngorongoro Conservation Area that rises more abruptly and eventually meets the crater rim. There are lots of animals in the conservation area, and they will on occasion come down from the slopes, so it is important to be alert. Cape buffalo are very aggressive, but would rarely chase a human here, though not the same for the occasional leopard that comes down from the hills. There have been sporadic leopard attacks in the area over the years, but walking in numbers would drastically reduce the likelihood of any unwanted encounters. Our walk was lovely as is always the case here. The weather over the last few days has been beautiful – cloudy and cool in the mornings, strong equatorial sunshine by midmorning, and a high in the afternoon in the upper 70’s with low humidity. You really can’t beat it.