After our exciting weekend in the Serengeti, it was nice be back home at FAME for a full week of seeing neuro patients before our new “group” would be arriving. It was also sad that Julian and Cat were departing today as they had only planned to spend two weeks here, and even though they had huge aspirations for what they wanted to complete while here, they had been incredibly successful in setting up not only the process for obtaining EEGs, but also an entire epilepsy handbook that will serve our neurology patients going forward. I have no doubt that this will not be last we’ll see of both of them here at FAME, and that would be fantastic to have them come again considering the amazing work they’ve already done.

The reason I have the “group” in quotations above is that I have only a single resident coming this weekend who will be replacing Jack and Joe, rather than the typical four residents as there had been coverage issues back at home. Thankfully, our trip in March will be back up to the full complement of residents (two groups of four). For the current trip, though, with the reduced number of residents, it’s been very helpful to have had three junior attendings, all been whom had been here previously, commit to coming to assist in seeing our neuro patients – Cat, who’s departing today and had been here four years ago; Natalie, who will arriving tomorrow and was here three years ago; and LJ, who was here two years ago and will be arriving in a week. Each of them will contribute tremendously, as they had in the past, to the neurologic health of the Karatu community.

Meanwhile, the district OB/Gyn specialist was giving a talk this morning at 7:30 am regarding government recommendations and practices (there are significantly more directives from the ministry of health here in Tanzania then there are at home), which was about as far away from neurology as one could get so we weren’t planning to attend the lecture. As I’ve mentioned in the past, Monday morning report is very crowded as anyone who is clinically oriented comes to these three days a week and getting there early is essential to finding a seat. We arrived a little before 8 am with lots of people waiting to get into the conference room, but the talk, which had been allotted 30 minutes continued on until 8:30 when morning report finally got under way.

It had been a very busy weekend for FAME with several concerning neurology patients that we learned about this morning in report, though I don’t believe we could have contributed any additional recommendations to what was ultimately done for the patients. One was an elderly gentleman with uncontrolled hypertension who had come in with a very large basal ganglia hemorrhage that had intraventricular spread with marked mass effect. There was little that could be done here at FAME other than supportive care and, to be honest, I’m not certain there was much that anyone could do for the patient anywhere, though the family had apparently requested the patient be transferred. They were sent to KCMC for a possible EVD (external ventricular drain) placement, a procedure that could be lifesaving, though, as I had mentioned several weeks ago in a similar case, it would be very unlikely to change the patient’s ultimate functional status.

The other patient who came in yesterday, who was much more of a neurosurgery patient than a neurology patient, was a young man who had suffered a traumatic brain injury secondary to a motor vehicle accident and had a very abnormal CT scan. He clearly had a subdural hematoma, for which they performed a burr hole, though he also had significant subarachnoid and some parenchymal hemorrhage along with marked mass effect that were indicative of the amount of trauma his brain had actually suffered. Despite the burr hole that was placed and maximum supportive care, he succumbed to his injuries in the early morning hours. Traumatic brain injury is a huge issue here in Tanzania and a major contributor not only to morbidity, but also to DALYs, or disability-adjusted life years. DALYs are a measure of the overall burden of disease, injury and/or risk factors on a population and represents not only “years of life lost,” or YLLs, due to premature mortality, but also the “years lived with disability,” or YLDs. Essentially, one DALY represents one year of life lost from full health, whether through disability or death.

Based on a 2021 study published in The Lancet Neurology and contributed to by a WHO analysis of the Global Burden of Disease, Injuries, and Risk Factor Study from the same year, neurologic conditions were the leading cause of ill health and disability worldwide with greater than 1 in 3 people worldwide currently affected by a neurological condition. Over 80% of neurological deaths and health loss occur in low- and middle-income countries (LMIC) where there is far less access to medical care and treatment, having 70 times LESS neurological professionals than in high-income countries. Based on the study published, the top ten neurological conditions contributing to loss of health in 2021 were stroke, neonatal encephalopathy, migraine, dementia, diabetic neuropathy, meningitis, epilepsy, neurologic complications of preterm birth, autism spectrum disorder, and nervous system cancers (Global, regional, and national burden of disorders affecting the nervous system, 1990–2021: a systematic analysis for the Global Burden of Disease Study 2021 Steinmetz, Jaimie D et al.,The Lancet Neurology, Volume 23, Issue 4, 344 – 381). I am always surprised when I am asked the question of “why neurology” in regard to global health as the data regarding the need for improved access to neurological care in LMIC is overwhelming.

On our arrival to clinic this morning, there were a number of teenagers in wheelchairs, none of whom were particularly familiar to me, though I had no doubt where they had come from. For a number of years, a Norwegian gentleman, Ståle Anda, has maintained an orphanage in Mto wa Mbu, Tumaini Home, that has taken in children with neurologic and other medical conditions who could no longer be cared for by their families. For a long time, there were three or four adolescent boys with Duchene muscular dystrophy (two of whom were brothers) that would be brought in to see us. Ståle would drive up from Lake Manyara in his old Land Rover Defender with half a dozen wheelchairs stacked on top and a car full of children to see us in clinic. None of the children were early enough in their disease to treat with steroids (used only in Duchene when children are still ambulatory), so most of what we did was to make physical therapy recommendations and to treat them symptomatically. I haven’t seen Ståle since the beginning of the pandemic, though, and I’m fairly certain that our group of muscular dystrophy boys have passed on by now.

I didn’t see Ståle with this group of children either, though I had no doubt of where they had come from as it would require someone with an incredibly huge heart to have taken these children in, and that would have been at Tumaini Home. Sure enough, I eventually saw someone sitting with the group and introduced myself, only to find that it was Ståle’s sister, and all made sense. The boys in the wheelchairs each had very significant choreoathetoid movements, as well as some contractures, reasonably normal mental status, though obtaining their birth history was virtually impossible as none of their parents were present. Without the birth history, we couldn’t say for certain that we were dealing with hypoxic-ischemic injury (i.e. cerebral palsy), but their histories also didn’t necessarily match with acquired syndromes such as Wilson’s disease, and it was unlikely that we were dealing with a genetic disorder in so many children. We were able to offer possibly symptomatic treatments for their movements and quite possibly their contractures, but we really had little else we could provide for these young men.

In addition to the teenage boys with the abnormal movements, there were numerous children to be seen in clinic, many with epilepsy and, of course, our two epileptologists just departed for home and our pediatric neurologist (Natalie) wouldn’t be arriving until tomorrow morning. The general outpatient clinic was packed which is very typical for a Monday morning here at FAME, and we had a steady flow of patients in addition to the children from Tumaini Home. With only two residents here to see patients (Jack and Joe), we eventually had Dr. Annie see patients on her own to keep things moving and to get all the patients seen by late afternoon. Things went smoothly as they always tend to do here since the pressures to see patients is quite different here than at home and the patients are tremendously more tolerant of waiting to be seen, if needed. The day ended well, and we spend a quite evening in the Raynes House with our beautiful views of sunset and the constant songs of the many birds.