The rainy weather seemed to be continuing making it either difficult for patients to get to clinic or they were choosing to go to their fields to till – regardless, the number of patients who were showing up continued to be exceedingly small. One might think that perhaps we had stamped out all the neurologic disease in Karatu district, but I know well from past experience that this has never been the case as there has always been more than enough work for us to do as long as we can get the patients to clinic. We’ve definitely seen spells of decreased volume for us before, and it has always been related to other events occurring in the country – whether it be the rain or a presidential election, in which patients tend to remain home, or harvest time, when they are in the fields, either way, they are not here for us to see them. Presidential elections in Tanzania (I have been here for four as the term in five years) have always been heavily contested here with regions either leaning towards the ruling party or towards the opposition, and the recommendations for us has always been to avoid political demonstrations at all costs, though that also seems to hold for the local villagers who tend not to want to travel during this time.

One of the patients seen by Shannon today was an eleven-month-old child who was brought in for concern of developmental delay as well as for frequent infections and appeared to have a diffuse rash consistent with varicella zoster, or chicken pox. The vast majority of children that we see in clinic with developmental delay is the result of birth injuries such as HIE (hypoxic ischemic encephalopathy) or perhaps other genetic disorders that we have no way of diagnosing here as we are far from getting genetic testing for these patients when it wouldn’t be changing their prognosis or treatment. This child, though, had clear dysmorphic features, which hadn’t been brought to the mother’s attention previously, that were consistent with Down syndrome, or trisomy-21.

This was clearly the reason for their delay to date in milestones and, perhaps more importantly, it was necessary to make the diagnosis to provide the necessary medical care such as following thyroid levels annually, as they have a much higher prevalence of hypothyroidism that increases with age, and make plans for rehab. Unfortunately, the government rehab center in Monduli, which is free for the patient therapy, but can be costly as their family must accompany them and find housing, doesn’t see patients until they’re two years of age which is starting late for these children. There is another rehab center in Moshi that we have recently contacted that is not a government hospital and will see younger children, though we just at the beginning of any collaboration. Hopefully, that will work out as these children with developmental delay from HIE, Down syndrome, or any similar condition, would benefit from starting therapy at around four months old.

I’ve mentioned in the past that we have seen Down syndrome patients not uncommonly at FAME, and Marissa Anto, one of our child neurology superstars who visited here as both a resident and attending, wrote a small blurb for the FAME website about her experience with a mother with a Down syndrome baby that was quite touching (There’s no word for Down syndrome in my language). The history of children with severe developmental delay in this country, with its incredibly harsh environment, extreme poverty, and complete lack of any social safety nets, has not been one of extreme compassion or altruism, but rather one of harsh reality. In the not-so-distant past, these children were set aside and not provided adequate sustenance, or perhaps even worse, and would rarely, if ever, survive past infancy as a matter of practicality.

As an example of how things are managed differently here as opposed to at home, Shannon also saw a young two-year-old Maasai boy who had a normal birth history and was developmentally normal but presented with recurrent, prolonged generalized febrile seizures that were consistent with complex febrile seizures based primarily on their duration. Febrile convulsions in children are benign, and we usually don’t treat them unless there are extenuating circumstances that would indicate an increased risk for harm or that the child actually had epilepsy that was being provoked by fevers. This child had been started on levetiracetam 125 mg bid previously based on the fact that they live quite far from any medical facility or hospital should the child have a prolonged convulsive and need medical care. After discussing the situation with his parents, it was clear that they felt more comfortable continuing his medication and the decision was made to continue his antiseizure medication for another six months and then discuss discontinuation when he returns for follow up.

That night, the rain fell as hard and fast as I’ve ever seen it here, and then the lightening with its tremendous thunder began and continued through the late-night hours and into the morning. As many of my friends and family know, I have always had an attraction to thunderstorms that dates all the way back to childhood but was further honed when I began working as a Forest Service firefighter immediately after receiving my undergraduate degree. I spent four seasons working for the Inyo National Forest and was stationed in the Mammoth Lakes Ranger District, which is in the heart of the eastern High Sierra and just below Yosemite, where I began working on the fire line as a grunt, but eventually worked my way up to TTO, or tanker truck operator.

For anyone who has spent time in the High Sierra, you would be familiar with the frequent thunderstorms that roll through the mountains on a regular basis, most often with magnificent lightning strikes and thunderous booms, that would, on occasion, strike a tree and ignite a forest fire. Whenever thunderstorms were forecast, we would be sent out on lightening patrol – which meant sitting in our fire trucks at the top of some peak with our binoculars watching the lightning strikes hit the ground and looking for “smokes,” or the beginning of a wildfire. We would then call the coordinates of the strike into the fire tower, who would locate the potential fire and, if big enough, would dispatch a crew to that location to prevent it from spreading. Now, some would ask whether sitting on the top of a high peak during a thunderstorm was actually a smart thing to do, but as the invincible twenty-somethings we were, we never really questioned that, and just did our jobs and somehow survived.

This morning’s educational lecture had been cancelled as the doctors were having a meeting that didn’t require our attendance, so we rolled up to report at around 8:15 am after they were finished with the doctor’s meeting. There was lots of discussion going on in Swahili, which none of us understood of course, but we were soon aware that there was a significant undertone of sadness in the room only to discover that a young fifteen-year-old boy had died the night before from a cobra bite. The area where he was bitten was in the Qaru region, a place where we had previously gone for one of our mobile clinics, and he had been brought initially to the local government hospital, where he was observed for several hours before being transferred to FAME. The local hospital did not have any antivenom, where FAME had a full complement of the polyvalent antivenom that could have been used. Unfortunately, by the time the boy arrived here, it was far too late for even the antivenom to work, though he was given one vial of it before determining that it would no longer be of benefit to him.

The most common cobra species in Tanzania are the Naja species whose venom is composed primarily of postsynaptic neurotoxins, cytotoxins, and cardiotoxins that cause rapid paralysis, severe tissue necrosis, and respiratory failure. There are both spitting and non-spitting species of cobra that are found in Northern Tanzania, with the former having the ability to accurately project their venom into the eyes of their attackers up to several meters away, immediately incapacitating the victim. The polyvalent antivenom available here has done away with the necessity to identify the exact species of snake or to have the correct antivenom available, though it’s essential they receive treatment as soon as possible after the bite as the toxins delivered immediately begin to cause remote effects that can be irreversible after only few hours, leading to death.

As if almost on cue, a good-sized scorpion decided to show up in clinic that morning only a few feet from where we were seeing patients. When someone spotted it and said something, I thought for sure it was one of the harmless whip scorpions that are found here, but, in fact, it was the real deal and looked like it was ready to cause some trouble. It had captured a large cricket that it had attached to its back in some fashion, though I removed it, there was little question that this scorpion was not pleased at all to be played with. I grabbed a teacup that was sitting on my desk and corralled it without causing it any harm to either me or the arachnid. I didn’t have the heart to kill it, so walked it some distance from the clinic and freed it to go about its own devices and hopefully not travel underfoot.

We had only three patients for the day, so it was a good that we had a few diversions to keep us occupied. We finished relatively early and I had been invited for dinner at the Plantation Lodge with Susan as there was a tour group staying there that one of my fellow board members, Barb Dehn, had organized, and she thought it would be nice if we could share information about FAME and answer questions they might have for us. There was great conversation and it was a lovely evening. The Plantation Lodge is pretty far off the beaten path, and I was thrilled that they had offered to have one of their safari guides come pick us up given the state of the roads. Though it would have been fun to have taken on the challenge, it was more important that we made it there safely, as the last thing I would have wanted to have happen would have been to miss such a fine dinner.