Funny that it seems my best time for reflection appears to be while high above the clouds and Mother Earth that I love so much. Perhaps it relates to the fact that these are the times of transition for me, often traveling between my two very distinct, but also in many ways quite similar, lives. In the Philadelphia area, where I have now lived for close to the majority of my life, are my family and friends, those that I have grown to know over so many years and that not only include those related by blood, but also my colleagues, my patients and, most importantly, the residents who I work with and who bring me great joy every day to see their amazing enthusiasm, expertise and compassion. They are some of the many lights of my life. In Tanzania, where I have now spent a year of my life with my combined fourteen trips over the last eight years, I have found new family and friends, not only among those who I have worked with so closely and at FAME, but also the many incredible souls who have adopted me as their family and have given so much of themselves along the way. I am forever grateful to have had the opportunities I’ve had in my life and for those many thoughtful and loving individuals who have made it possible for me to have had them. They are too numerous to name here, of course, as there have been so many. You know who you are, though, and you should feel the love and gratitude I have for you not only on this day of thanks, but on every day of the year, for without you I wouldn’t be the person I am today.

I am not traveling to Africa today, of course, having just returned from my fall trip three weeks ago, but rather to Colorado, to visit my son, Daniel, who is living and going to school in Boulder. His journey has truly been an inspiration and for those of you who know him, I need say no more. For those of you who don’t, I could only hope for each of you that you have someone similar in your life. My other inspiration, Anna, who is currently living and working in Los Angeles, not far from where I originally grew up, has found her home and her calling for now on the opposite coast and will have to wait for my visit in the near future as we are now spread across the country. Anna’s life has taken her to such far away places as Turkmenistan, Egypt, Jordan, and Turkey on her own, not to mention that she was the original inspiration for me to have gone to Africa, accompanying her on safari through our mutual love of animals. I have been blessed with two absolutely amazing children and am so thankful on every day of the year to know them for the wonderful individuals that they are.

On this day of thanks, I am also grateful to those who have continued to support me in the work we are doing in Northern Tanzania and at FAME. We have been allowed to enter a world so often very different from ours, where so much of what we take for granted is just not possible, yet with your help we have brought some light to the world of those who are without. As you know from reading my blog, we are now nearing completion of our new volunteer home at FAME, the Raynes House, that will allow us to continue our work into the future. Before it is ready for occupancy, though, it will need furnishings such as beds, sheets, towels, dishes and all the essentials for us to live there while we provide our neurology clinics at FAME and our mobile clinics to the surrounding villages. I would ask for your continued support by visiting our campaign website and considering a contribution to this effort:

https://www.gofundme.com/FAME-A-Place-To-Call-Home

 

For those of you that have already donated, I thank you from the bottom of my heart. And to everyone, I wish you a very wonderful and happy Thanksgiving as we all have so much to be thankful for in our lives.

Asante sana!!

 

Love,

Dr. Mike

I had stayed the extra day to spend time with the Temba children as well as Leonard and Pendo, but it was odd not having Kelley and Laurita with me. We had spent the last month together, every moment of every day, and it was truly a pleasure to have been able to introduce them not only to the world of global health here in East Africa, but also to the Tanzania culture that I have so come to love over the last seven years. The diversity, the resilience, their love of life and their respect for each other is something to be treasured and learned from. In a country whose independence came a mere 55 years ago with 121 different tribes, some still at war until only 30 years ago and one of the poorest countries in the world until only recently, they have achieved great things in such a short time. There were only 11 Tanzanian college graduates in 1961, when they gained their independence and they now have many universities and colleges. As with any highly populated African country there is still much more to do, especially in the health care arena. That will take time, but hopefully we are making a small impact in sharing our expertise with them while learning so much more from them.

Lenox had asked if I had any movies that I could share with him last evening and when I went to look for my external hard drive that I carry with me (I bring no computer, only an iPad on which to blog) I couldn’t find it. The last I knew of it was when Kelley and Laurita were using it to transfer Puerto Rican and Tanzanian music to and from a thumb drive for Sokoine in the back seat of the Land Cruiser as we traveled to Arusha on Friday. I searched all my bags and the Land Cruiser, but Leonard had taken it to get cleaned early Saturday and it wasn’t there. I reached Kelley by email and replying from Doha she told me that she was 99% sure she had put it in the pocket behind the driver’s seat when she was done with it. All of our photos from the trip were on it which would have been a huge loss. As a last ditch effort, Leonard called the owner of the car wash where he had left the vehicle that day to see if they had it. He was still at church, but would call us back when he got to work. Thankfully, he called later in the morning to tell us that it was there and we could come pick it up. Disaster averted!

Leonard used to be a very good football player (soccer, of course) and still plays every Sunday morning with the Arusha All-Star Alumni team. He hadn’t planned to play today since I was still there, but since my flight didn’t leave until 5:30 pm, I thought we had time to go for a bit. I had gone several years ago and had a great visit taking photos of all the players and sending them to Leonard. Besides, both Lenox and Lee were coming so it was a way to spend time with them as well. These players were, in their prime, the best of Northern Tanzania and many of them were probably of Olympic quality. They now play on a community field that is mostly dirt with enough vegetation only to keep it from blowing away. It is rather high on the slopes of Mt. Meru, in the village of Ilburo, and many children come to watch these games which are often against neighboring clubs.

Today, they played amongst themselves, but you wouldn’t have known it based on how hard and, at times, rough they played each other at position. Before playing, they go through a long warm up, running up and down the field doing variously maneuvers to loosen up and prevent injury. I enjoyed taking photos of the players and waited for half-time as we would have to leave early to get me back home and then to the airport. We also had to pick up my hard drive. The game went on as they had decided to play through half time so when I told Leonard the time we prepared to leave. They stopped the game, though, and everyone came to sideline as Leonard wanted me to say something to them since I was again the only mzungu there so presence hadn’t gone unnoticed. The club president introduced me and said a few words after which I thanked them for allowing me to be there and share in their love of football. I donated some money to the club as did Leonard for them to continue and they thanked me profusely. In March on my return, I hope to bring them some supplies that are nearly unobtainable in Tanzania, like good football socks and shin guards. As in everywhere in Tanzania, they make do with what they have which is often not very much.

We drove home and loaded my luggage as I was mostly packed. We had a quick lunch of meat with vegetables and spaghetti and then left for the drive to the airport. Saying goodbye to the boys and Gabriella is always tough as they will be six months older next time I see them. Gabby is growing like a beanpole and will be talking by then. On our way to the airport we made a stop in USA river to see Leonard’s friend who had had the stroke several months ago. They had obtained his CT scan from KCMC for me to review and it demonstrated a very large hypertensive hemorrhage in the left basal ganglia with intraventricular spread. He was still hemiplegic and mute with good understanding of speech and it is questionable how much of that will return over time. We stayed for only a short time as it was getting late and I needed to check in at the airport. Not counting my driving others to the airport, this is my 14th time flying out of here and the small upgrades are actually noticeable. They now have a small cafe in the waiting area which is a huge addition to what was previously an almost unbearably hot and desolate place with barely a bathroom to speak of. A small bit of progress is everywhere here, some good, and some, like the traffic in Arusha, not so good. Still, it is always tough for me to leave, as I believe it is for everyone who visits this often simple and sometimes complex country that has so very much to offer in so many ways. The people are beautiful and always giving while the land is amazing and often harsh. I look forward to returning in six months time and will be counting down the days.

Having now experienced the Maasai Market once and having perhaps a better sense of strategy, it was Laurita’s and Kelley’s intention to subject themselves once again to this somewhat nerve wracking experience and to so willingly. One might consider this an indication for a psychiatry consultation or to just skip that step and place them on heavy antipsychotic medications, but I did neither and decided to let them run with it. We all slept the night under mosquito netting as is usual for Tanzania, but even more so in Arusha where the mosquitos are bigger, faster and more persistent than in Karatu. They are unrelenting thugs. Though the girls slept well under their netting with no insect incursions, I was not so lucky as I had apparently not tucked my netting in quite so carefully. Trying to describe a night shared with these little beasts trapped in your netting would best be accomplished by referring you to the latest horror flick about being locked in a house with your worst nightmare. And better yet, there is no escape as their little friends are just waiting for you to run outside so they might pounce. Once you’re shield has been penetrated, you can look forward to, at best, an interrupted night of intermittent sleep in between their attacks and there is no clearing your net once the night has begun. That was my Friday night.

The children arose rather early despite having arrived from Nairobi at around 1 am. Pendo later told us that they were stuck in a three hour traffic jam in Nairobi, which has to be one of the very worst cities for traffic I have ever seen. We stayed one night there on our return in 2009, and it had taken us hours to travel a several mile stretch of the main road from the airport with at least four lanes of traffic in each direction. Definitely not for the faint hearted. We had coffee and wonderful African chai with all of its spices before sitting down to a breakfast of pancakes, eggs, toast and fresh fruit. By this time it was well after 10:30 am and we very much needed to get to the Maasai Market for Kelly and Laurita to finish their shopping.

Arusha has become a very congested town for driving with very few traffic signals for a city of well over one million people. The normal route to the market was quite congested and it took us well over twice as long to get there as it should. We finally arrived and thankfully there were far more shoppers than the prior evening so you didn’t feel as much as a target as before. Even with that, though, the vendors from last night remembered and us and their common line was “remember, Baba, you told me last night that you’d look in my shop when you came back today.” Whether they were telling the truth or not, really couldn’t be totally sure so you just believed them for better or worse. We were pushing our luck with time to get to the airport, but I waited patiently for the two of them to finally wrap up their shopping and we drove back to the Tembas to finish their packing and head off to the airport for their flight home. I did take the back way to home this time which was a breeze and made me ask myself why I don’t use the route every time which must clearly indicate that I’m becoming more a local driving here in Arusha these days.

Before I knew it, the girls were packed and they had their bags in the car ready to go. The drive to Kilimanjaro International Airport, or KIA as we refer to it here, is along the Nairobi road that is on the north of town and heads to Moshi at the foot of Mt. Kilimanjaro. The airport is between the two cities (Arusha and Moshi) and sits in a big dusty plain that is just north of the Blue Hills, which is where all the Tanzanite is mined and the only place it exits in the world. Unfortunately, the road is currently being widened and the construction goes on for several kilometers. To say that the roads are poorly marked in Tanzania would be an understatement, and when you put two, two-lane partially finished tarmacs parallel for any distance, it makes for an interesting journey here. Drivers try to take whichever route might be the shortest and quickest, so just when you thought you might have two lanes traveling in the same direction on either side of a median (otherwise known as a divided highway in our country), you probably guessed wrong and you find yourself with oncoming cars or trucks in the lane you thought might be yours. In the daylight it requires quick reflexes and a bit of imagination. In the dark it would be otherwise very treacherous or just as easily referred to as suicidal. We were driving a much smaller car to the airport and, for once, I had wished we were in the big Land Cruiser as it gathers a bit more authority when one is trying to prove his point.

We survived the construction zone intact and were finally on the open road which is still just the original two-lane highway that brings on it own set of nuances when trying to make a flight and being a couple of minutes later than you had planned. The trucks here come in every state of disrepair and when time is not of concern and fuel is the limiting factor, they drive like snails going uphill making it a necessity to pass them or else leave a day early to make it anywhere. That wouldn’t be a huge problem, other than the fact that there are small towns every few kilometers that have speed bumps and 50 kph speed zones. The Tanzanian police who used to only have their random traffic stops to shake you down if you didn’t have all your stickers and safety equipment in your car, now also have the speed traps to generate extra revenue that are set in these speed zones. Leave it to say that travel here is always an adventure whether you’re on a game drive in one of the parks, or just just trying to get from point A to point B. I guess that’s one of the things I like about this place which must sound very crazy to all those who are not familiar with how much I love to drive (which is very, very much).

I dropped them off at the airport and we said our goodbyes with extra hugs even though we’d see each other in several days at work. Now I had to get to Sokoine’s wedding and luckily I was just trying to make the reception and not the church ceremony. I fought the never ending traffic through the construction zone and arrived a bit late, but luckily found that they were still taking photos at another location. The reception was at his in-laws house which was all set up with tents and chairs and the caterers were getting everything prepared. I sat with some relatives who were waiting for them to return as well and we shared some bottles of water sitting in the shade of the tents in the hot midday sun. It was a splendid setting. Finally, a Land Cruiser arrived with the typical decorations that are seen with wedding parties here and eventually Sokoine and Upendo got out to the cheers of all the family and neighbors who had accumulated by this time.

I won’t go into the description of the entire ceremony, but leave it say that it was one of the most beautiful wedding receptions that I have ever been to as everyone participates and says things along the way. It was all in Swahili and at several points, the master of ceremony spoke English for my benefit as I was the only mzungu (stranger or white person) there out of the 75 or so guests. They had a champagne toast (the only alcohol at the wedding as the Maasai don’t typically drink) and a cake cutting ceremony quite similar to ours, but after they gave each other a piece of cake on a toothpick they preceded to call out several other family members to give cake too as well. Imagine my surprise when I was called up to receive my piece of cake on a toothpick from both Sokoine and Upendo. You may recall that this is what I had to do for the entire kitchen and service staff for my 60th birthday party in March. I was so honored over have been not only invited to the wedding, but also included as a family member. Sokoine kept looking over to me to make sure I was being taken care of not neglected, but it was far from that as everyone made totally sure that I was included whether it meant getting a soft drink, in the dinner line (you would have loved it Laurita!) or just knew what was going on.

It was supposed to have been a small affair, but here in Tanzania, a wedding is a community event so not only family, but also neighbors are welcome to attend and have something to eat. I hadn’t counted on being there the entire night which I could have easily done and would have loved to, but I needed to get back to the Temba’s at some point as I had their car and also wanted to spend some time with them. The dinner was to be at 6 pm, but it was well after 7 when we all got in line for the buffet. It was white rice, pilau, banana stew, beef stew, salad, fresh fruit and several other dishes I didn’t recognize, but just ate anyway. Tanzanians pile their food quite high on their plates, but I did take smaller portions even though I was starving as we hadn’t eaten lunch before heading to the airport. Everything was delicious and when I went to sit at my chair, Upendo’s father grabbed me and had me sit with them at their table. I couldn’t believe how much everyone was attending to me. Earlier the master of ceremony had asked me if I would mind giving a toast at some point, but they hadn’t yet called me up to do so and it was getting quite late. Sokoine asked me on several occasions if I needed to leave as he knew of all my obligations so at 7:30 pm (I had told my Pendo that I’d be home around 4 pm) I told him I had probably better get on the road home.

If I had had the opportunity to give the toast (I had already thought in my mind what I was going to say) I would have told everyone how much Sokoine meant to me in the time we’ve worked together over the last several years as he is perhaps the most capable and trustworthy friend I have here other than Leonard and Pendo. What we accomplish during our time at FAME would not be possible without him and the preparation he does to make things happen here. He is truly an amazing individual who has not wasted an opportunity to better himself with his education, his work and his family, and I very much respect him for that. I’m pretty sure he knows how I feel and I also know that he is meant for far bigger things than working with me and at some point he will have to move on. I will be very sad on that day, but sincerely very, very happy for him and his family of which I am now a part.

It is never easy to leave FAME, both emotionally and logistically. I should have learned this long ago. The times we’ve planned a safari on the way to Arusha seem to work the best, as we leave before sunrise and there are no goodbyes or late packing to deal with. As we had done our major safari last weekend and I had promised the girls that I’d take them to the Maasai market in Arusha to buy gifts, we decided instead to leave mid morning and would pick up Sokoine in town around 10am. Best laid plans as I’ve said before.

Kelley and Laurita still had one more talk to give at 7:30am (their third this week) and so we all headed up to the conference room at the early hour to talk about headache. Of course the talk went great as both of them are incredible educators and once again, Dr. Lisso held his tongue at the witching hour of 8am and let them continue. As it was our last morning report, we each said a few words and then headed off to get things done. We still had three patients in the ward – our young boy with meningoencephalitis, our girl with Sydenham’s chorea and a the gentlemen with Wernicke’s encephalopathy that I think I had mentioned before. If I didn’t though, it was a great pickup on Laurita’s part and he was now receiving his thiamine. We had to write final plans on them for our departure so the staff would know what to do going forward with each of them. Amazingly, all of the charting had been completed by Kelley and Laurita so there was nothing left to do there. We headed back to the house to get packed as neither of us had done any of that yet. Of course, we had to have a snack first of the left over rice from last nights dinner that Kelley fried for us with some egg while we watched segments of Samantha Bee that we all love with her commentaries on the current election. Thankfully, we are all exceedingly of the same political persuasion which makes things a little easier.

Packing for me does take a bit of logistics as I have things that I leave there each time such as our ophthalmoscope kits and I have to remove all the batteries from them as I found this out the hard way on one occasion and spent a day scraping out battery acid from their holders after the batteries corroded inside. I have a large duffel filled with my clothes that I leave, an extra pair of shoes, crocs, rain boots and all of my medical tools and references. Soon, after the new house is built, I’ll have a locked closet to leave everything in that will make things much easier for me. Once packed and the Land Cruiser loaded, I wanted all of us to walk over to the Raynes House for a quick inspection of where things were. The house is really taking shape and now has all the window frames in. The roof is complete and they are finishing the outside surface of the walls with concrete about the exposed brick. It really looks amazing. I think we’re in good shape for a finish prior to our return in March.

Now it was time to drive down and say our goodbyes. Since I’m always returning in six months, it’s never really that difficult for me to do this. Kelley and Laurita, on the other hand, had become quite attached to everyone here and I could see it was difficult for them. We made our way through the outpatient clinic, the administration building, the lab and the ward. Selina was somehow nowhere to be found when they initially went through, but I bumped into her on her way back to the clinic and sent the girls to find her. When I found the two of them they were pretty choked up as Selina had cried saying goodbye and that was about all they could take. We realized that we almost forgot to say our goodbyes to Mama Susan so we went to her office and found her. It was obvious I think at how emotional the two of them were. Susan was her amazing self as usual and we headed for the Land Cruiser to drive downtown. I did mention that we had told Sokoine to meet us at 10am, but by now it was 11:30 am and we still had more errands to do in town. First was to pick up our final gifts from the tailors shop that required me to get some shillings and both Kelley and Laurita to visit the ATM both for this and their plans at the Maasai Market.

Then it was a visit to Daniel Tewa’s home to say goodbye. That is never easy and, of course, Daniel had African coffee ready for us so we all sat down in his living room (the center room of his Bantu-style house) to enjoy the noontime coffee boiled with milk. Both Laurita and Kelley had wanted to look at some things that Daniel had for sale in his house as he has safari groups often come by to see him original Iraqw home and to give a presentation of Iraqw culture. We all enjoyed the coffee which can’t be chugged given how hot their thermoses keep liquids here, so we just relaxed and enjoyed the friendship while the girls did some shopping . Sokoine had never met Daniel before, so it was fun for the two of them to banter back and forth since the Maasai and Iraqw were enemies for so many years mainly over the fact that the Maasai believe all cows belonged to them and taking them from the Iraqw was merely returning them to their rightful owners. We left Daniel’s to hit the road for Arusha, about 1-1/2 hour drive, all on tarmac.

The drive went quickly with a stop in Makyuni for fuel and before we knew it we were in the outskirts of Arusha. I had wanted to stop at the Arusha Coffee Lodge as the Shanga Shop is now there and it is a great place to shop for gifts. They employee people with physical disabilities who make things out of recycled glass and other materials. After this, we were off to drop Sokoine at his in-laws house where his wife had come yesterday from Karatu and where his son lives to go to school. They live in Mianzini, a small suburb of Arusha on the north side of town on the slopes of Mt. Mere. Most importantly, Sokoine had informed us on the ride into town that he was getting married tomorrow!! They had never really had a formal ceremony and the affair was going to be the following day and he asked me to come. He would have love for Laurita and Kelley to come also, but unfortunately they were flying out just after noontime and that wouldn’t work. As I had to drive them to the airport, I would be back just in time for the ceremony.

As with any visit to a Tanzanian household, one can never escape some type of a meal (we were only able to leave Daniel’s with just coffee as I told him that we were running late getting out of town) as it would be considered rude to have a guest and not offer them something. They had prepared us Pilau, which is meat flavored with chunks of beef in it, and soft drinks. We were actually quite hungry as we hadn’t had lunch so it was very much appreciated. Sokoine’s wife, Upendo, is lovely, and his 3-year-old son, who looks just like him, is amazing. We left their house to head to the Maasai market, but before we could leave, I had to back an incredibly large stretch Land Cruiser out of their gate that opened onto a less than one car alleyway with shops directly across. After almost completely collapsing a row of shops as I couldn’t see the post behind my vehicle with the side mirrors and it wasn’t until Sokoine and Kelley got out to tell me that we were finally on our way.

The Maasai Market in Arusha is an experience to say the least. And arriving in evening when there are far fewer mzungu around can be dangerous and give one the feeling of being fresh meat. There are at least 100 stalls that are under cover, kind of, and all carry mostly the very same thing – beadwork, paintings, carvings, knick knacks, wall hangings and ever other imaginable tribal piece of art or craftwork. All the vendors stand immediately outside of their stall and try every which way to get you to enter their little shop to possibly buy something however small. It is mind boggling and mind numbing at the very same time. I’m not sure that Kelley and Laurita were quite certain exactly what they were walking into, but they quickly discovered the real ambience of the place. You end up loving it, though it does take some time getting used to it. We bought a few things that evening with the intention of going back the following morning as neither of them had completed all of their shopping and we were all pretty pooped from the day. We left the market when it was pretty much dark and getting a bit scary to be walking around.

We drove home to Leonard and Pendo’s house where we’d be spending the night. Leonard was our safari guide who introduced me to FAME and who I owe everything I now have in Tanzania to. I have had residents stay with the Tembas for virtually every trip I have brought them and they remain as gracious as ever, making sure everyone has a bed for the night and serving whatever meals are needed. They are truly amazing. Pendo had driven to Nairobi for the day to pick up the their two boys, Lenox (11) and Lee (7), who are going to school in Nairobi and were getting out for November and December. Leonard was working in town when we arrived to their home, but we were able to enjoy the company of Gabriella, their youngest, and Pendo’s sister who cares for her when they’re gone. Leonard arrive a little bit later and we all had dinner together as Pendo had been delayed in leaving Nairobi and wouldn’t be getting home until very late with the boys. We all went to bed before 11pm and were quite exhausted from the day between the emotions of leaving FAME, the drive, and shopping.

Both Kelley and Laurita had agreed to do two more lectures for the medical staff. The first was to finish the talk on evaluating an unresponsive patient that had been started on Tuesday, but they had run out of time. Dr. Msuya also wanted them to do the talk on headache that they had originally planned for last Tuesday, but had been preempted by the unresponsive patient talk which has been in response to the patient last week who had not survived his code. Since the nurses were using the conference room for their regular morning education lecture, we decided to use the education room in the admin building that doesn’t have the big screen TV like the conference room, but does have a small LCD projector for PowerPoint presentations that can be shown on the whiteboard that works quite well. Laurita finished the lecture in about 30 minutes which meant that we were on schedule for morning report.

We hadn’t planned on seeing any patients today, but as we’ve come to expect, there is almost no way that we can be here and not have patients to see as it seems that patients show up looking for us no matter what. We were working in the volunteer office, me composing my blogs and Kelley and Laurita working on data entry, when Sokoine came looking for me to tell that there were a few patients to be seen. As usual, it is often those who most need to be seen that are the ones who straggle in at the end of our visit here. It would be unthinkable for us not to see them given the difficulty to find any specialty care here and the fact that we won’t be back until March of next year.

I watched them wheel the first patient in for Laurita and it was a young boy in a wheelchair. I decided to follow him in since I had some suspicion about his diagnosis and wanted to be there since it is not something seen by our residents often and certainly not as a new diagnosis as I didn’t recognize him as having seen us before. He was an 8-year-old Maasai boy who had been brought in by his uncle who he was living with as his mother could no longer care for him. His main complaint was that he was having pain in his legs and was unable to walk any longer. His symptoms had been present for several, but he hadn’t walked in four months. Weakness was only his secondary complaint, but I knew from being here so long that this was a bit misleading.

One of the tough parts about taking a history here is that patients often create complaints to explain their deficits which requires a bit of practice to tease out the real problem. A young boy who can no longer walk doesn’t necessarily complain of weakness, but rather will explain that it “hurts” for him to walk, meaning merely that he can’t do it. When Laurita began to ask questions about his pain, I subtly told her not to worry about it and to ask more questions about why he couldn’t walk. What came out was that he actually had weakness in the legs and arms that had been getting progressively worse over the last several years to the point that he couldn’t walk. His complaint of leg pain was what we call a “red herring” and wasn’t his primary problem. When still walking earlier in the year, he had been seen at FAME and diagnosed with a polyarthralgia for which he was given ibuprofen. His history was further bolstered when the uncle said that he had an older brother with the same problem. His examination was quite classic with proximal greater than distal weakness in his upper and lower extremities, pseudohypertropy of his calves and a very classic Gower sign when he tried to get up from sitting on the floor. Laurita originally wanted to spare him from having to do this, but I felt it was important enough for her to see this finding in person as that is the real way we remember things.

We had a discussion with the uncle, initially through Selina and then through Sokoine, who speaks Maa since he’s Maasai, as we wanted to make certain that the uncle fully understood the prognosis for his nephew. It is often very hard to tell situations as the Maasai like many tribes here are very stoic and often don’t volunteer their emotions quite the same as we do in the west. We did institute steroid therapy as that is one thing that has been shown to help maintain ambulation, but it is not in any way disease altering and certainly does not extend life expectancy. Since the boy had stopped walking in the recent past, I thought it was worth a shot to see if perhaps he could regain some function, though it would only be on a limited basis. He will need to watched closely on the steroids to make sure he doesn’t have any side effects and there is a small increase in his risk of infection which is always a concern here in rural Tanzania. We also asked that he come back once Dr. Reed is here next month as he will need to have a cardiac evaluation with an echocardiogram as these children have cardiac complications as part of their muscle disease. As unfortunate as this diagnosis is, it is always rewarding to be able to diagnose a condition with certainty so that a family will hopefully not have to go on searching which is quite often the case here as families typically don’t get answers and then travel from facility to facility looking for them. At least we can give them the answers they seek and spare them from the unknown, or at least that is our intention and we do the best we can at it.

Kelley’s first patient of the day was a gentleman in his 40s who had been seen by Dr. Frank in the past and was from Arusha. Frank had shown me a CT scan on Wednesday and had asked what I thought about the story so I told him if there was any way possible for the patient to come on our last day it would certainly be helpful to examine him which was the interesting of the case. The patient had been previously well until earlier this year when he was walking with his wife and suddenly collapsed to the ground without any loss of consciousness, but was quadriplegic. I had told Frank that from the sounds of it he had a vascular event in the spinal cord and if his arms were involved that it localized to the cervical spine, but the CT scan had been done of the thoracic cord only. He did indeed have an asymmetric quadraparesis that had improved somewhat from the onset of the event and a sensory exam that demonstrated a level at the low cervical region. He also had crossed motor and sensory findings confirming the location was in the spinal cord. There was very little else that could have done this and even though we suspected a low cervical cord process, we found very little reason to obtain a CT scan as it would not change his management at this time. We did offer him some medications for neuropathic pain and for his spasticity which might help make him more comfortable overall. He may continue to regain some function, but unfortunately he will never be independent or be able to lead a normal life and at a very young age.

So we had actually planned not to see patients today, but ended up working until around 2pm or so and still needed to hand out blankets to mothers with newborns. A patient of mine at home, Mildred Staten, and a group of her friends crochet (I’m hope I’m correct on the process) blankets for newborn babies that they distribute in hospitals back home in Philadelphia and a year or so ago she had asked whether I thought they would like them at FAME. We brought them last October and it was a huge hit on the maternity ward, so we had brought them again and hadn’t yet had a chance to hand them out as we had been so busy seeing patients every day. We went to Ward 2, the maternity ward, with Sokoine as our interpreter and photographer, and each had a small stack of baby blankets for the mothers to choose from. It is so enjoyable to see the mother’s faces light up as we offer them a blanket and each mother eyes the blankets to find the one she likes the best for her baby. There are several premises in the ward right now, one of whom is in an incubator and ways a mere 0.76 Kg, or 1.67 lbs. The baby is just so very tiny, but has been holding their own since we’ve been here and seems to be thriving despite everything. It is a miracle to see these babies fight so hard to stay alive and it is this resilience that exists among all those we meet here. It is clearly something born in each and every Tanzanian and part of why we are so privileged to work and live with them. The blankets from Mildred and her group of women were very much appreciated by every mother we presented them to and I am sure by each little newborn, big or small.

It has been a tradition it seems for Frank and Susan to have a get together for our team the last night or two of our departure. This trip was no exception and we were all meeting this evening at their lovely home that sits just above the volunteer houses as if to keep an eye on everyone though from an appropriate distance. Alex, our new volunteer coordinator as of two months ago with Pauline’s departure, had taken it upon himself to personally prepare the menu for tonight. The party of typically catered with pizza or similar, but tonight we were having a feast of Mexican food with homemade tortillas, corn salad, homemade salsa fresca, lettuce and rice. Most of the vegetables were from FAME’s garden. Oh, and I forgot to mention that Alex was unable to find good group beef in Karatu so went instead with some unreal sliced filet that was out of this world. Frank had forgotten that he had a talk to give on animal borne pathogens in Africa to some visiting doctors that he does annually so was running a bit late. We all gathered at their house just after sunset – there were about ten of us without Frank – and just sat and relaxed before dinner with popcorn, beers, soft drinks and wine while Alex and Laurita worked in the kitchen. Kelley was told there were too many cooks in the kitchen, but she and I were fairly certain that it was excuse for Laurita to sample the cuisine as it was well after her dinner time. She swears she didn’t, but neither of us really believed her. As we sat on the veranda with their three dogs – Molly, Nickie, and Oscar (their new mostly Rhodesian ridgeback puppy) – and Charlie, FAME’s mascot (Popie, who is now very aged, no longer partakes in parties) roaming around getting lots of love from everyone. Elvis, their fairly rare Kenyan or Ethiopian cat (I can’t recall which and what the name of the breed is), also showed his face from time to time.

Frank arrived finally after his talk just in time for dinner and couldn’t believe that were than just scraps left, so he was very excited to join in the food line as it really was amazing. Somehow, though, Frank never left the food line as I didn’t see him on the veranda again and noticed that he stayed in the kitchen munching until it was after his usual bedtime of 8pm. I’ve been at these enough to know that Frank usually just slips off to his bedroom without saying goodnight and those that aren’t familiar with this ritual will look around and wonder where he went. Given his work schedule, he needn’t make any excuses and I know that he’d agree with that.

The party continued for a while longer as we just relaxed and told lots of great stories of FAME, past and present, of how it’s changed over the years, and where it’s going. Stories of travel and aspirations which is always amazing when you consider the diversity of the group sitting around the table. A Swiss pediatrician who has worked in Africa for a number of years, a cardiology physician assistant who has been here for long stints in the past and worked with me before, a Swiss emergency room nurse here for her first time, a retired professor of laboratory sciences who built the lab here and spends nines of the year here, two neurology residents working in Africa for the first time and trying to decide where their careers will take them, our volunteer coordinator who just finished with several years working at a primate rescue in Ecuador, and then me and Susan. Susan has committed her life to FAME along with Frank and they have successfully built a health care facility out of nothing that now rivals any institution in Northern Tanzania and employs well over 100 Tanzanians. They have truly changed the lives of countless patients as well as the residents of Karatu whose families benefit from their employment by FAME. And then me.

Global health had never been on my radar screen until very late in my career, but it was the education aspect that had always been the most important part of my work and that led me to FAME on that fateful trip in 2009. Still, it was not a given that I would return and there was something that drove me to do so and it is so hard to explain. We all look for purpose in our lives and providing the care for my patients and teaching residents had obviously been totally fulfilling for me through many years. There must have been some unknown void, though, that lead me here, to return again and again, and to bring those individuals who I knew would equally appreciate the significance of what we are achieving here. And in doing so, I hoped to impart in them the same enthusiasm I have not only in practicing neurology and teaching, but also to see the World as a smaller place without borders where we all speak the same language of love and deep down, we all have the very same values. The residents that have accompanied me here have all found this very same message on their own, and even more so, have managed to teach me more than I could have ever hoped for. This is my legacy.

I have been here now for nearly a month and between us, this is our 16th day of neurology clinic and the patients continue to come. We had planned for today to be a day to catch up at the end and complete our data entry for the patients that we’ve seen and a chance to take the “neuro team” all out to dinner for an evening on the town. It’s been an incredible visit so far and both Kelley and Laurita have easily managed to become a part of the family here such that it will be very hard for them to leave. The work here is like that. It’s so easy to get caught up in your own life at home and your own work schedule, but here that doesn’t happen. Everyone is working together for the same goal and the pace is much different. There are none of the pressures that we always seem to be under and which occupy so much of our energy to deal with. Here it is pure and simple. We wake up, we walk to work, we see a large number of patients, most of who have very little in the world, but have done what they could to get here to see us because they are concerned. We practice medicine as it has been practiced for centuries, listening to the patient and examining them, making an assessment and offering a treatment plan. Sometimes we have something to offer and other times we don’t, but we take our time explaining to them what we believe is going on. It is this time honored tradition that has brought each of us to medicine and has brought each of us here to Tanzania. This is what we have been seeking.

Each day was truly “unadvertised” this week, but yet we have patients seeking our care that have often traveled far and cannot be sent home. And they are all patients in need of our services. Today was Kelley’s day for pediatric neurology and she was very happy to have me sit in on her cases as they were all complicated. First was a young child who had been seen by Dr. Jackie in March and diagnosed with infantile spasms and developmental delay. Infantile spasms are typically associated with a very poor prognosis and we had seen them two weeks ago and the child had been off of their antiepileptic medication for about a month and had had no return of the spasms. We wanted to leave the child off the medication if possible so asked them to return and that we would contact Jackie in the meantime, which we did and she suggested leaving the child off medication unless either the seizures returned or she regressed in functional status. Neither had occurred so we opted to leave her off the medication, but to return if she had more events or had any functional regression. The family was quite happy with those plans and we sent them on their way.

The next patient she saw was an 18 month old boy who had been having a number of febrile convulsions, perhaps monthly, but with an episode of complex febrile convulsion in July as the event had included focality with the child shaking on one side only. We always worry with that type of seizure as there could be something structural intracranially, but the baby had been seizing for some time and his exam was entirely non-focal. He was very well advanced developmentally and was bright and interactive in every aspect. We told his parents that the seizures were febrile, but there was an increased risk of epilepsy due to the complex nature of the one seizure. Unfortunately, there really is no good data on the subject and the jury is still out. It is still felt, though, that daily treatment with a prophylactic medication may have to greater risks than benefits. We did not prescribe an antiepileptic medication for the child, but did decide to send an email home to Jackie to see what she would do in the situation. I believe we’re not far from starting medication, but we’d love to have her thoughts first and can easily bring the child back in if she feels otherwise. Meanwhile, he had to be one of the cutest babies we had seen while here and he definitely entertained us during the visit. I have a little frog with a light that I had found at CHOP and he loved playing with it, but was not very happy when he found out that I was not giving it to him to keep.

The very next patient for Kelley was another baby with a much different story. She was 14 months old and her mother’s pregnancy with her had been normal and she was normal at birth by report. But then, at 3 weeks of age, she began to have multiple seizures per day and her parents didn’t bring her to a hospital to be seen for at least a month. At that point, she was placed on phenobarbital which she remained on, but continued to have seizures, though perhaps a bit less frequently. She was having them perhaps several times a month, but then began having more seizures again most likely as was now underdosed on the phenobarbital because of her growth. The child was developmentally very abnormal doing very little on her own and was not crawling. Though she was initially sleeping when Kelley went to examine her, it was readily apparent that she was quite abnormal with nystagmus and a right gaze preference, failed to attend whatsoever once awake and couldn’t hold her head up. She was spastic throughout all of her extremities. It was pretty heartbreaking as I don’t think her parents really understood how grave the situation was at the beginning. I will have to admit that these are the children I chose not to see in practice ( I always said that I didn’t see floppy babies!) and so we also emailed Jackie about this child to her input. We of course adjusted her dose of phenobarbital which was the obvious thing to that even we were capable of as big people neurologists. I should mention to you here that on my first trip to FAME in 2010 and when arriving to clinic one morning with a long line of patients, half of them being children, I lamented to Frank that I’m not really a pediatric neurologist, at which point he quickly replied to me, quite seriously, “right now, you’re the closest thing that Tanzania has to a pediatric neurologist.” I learned my lesson then that we have to make do with what we have and do our very best for each and every patient.

Laurita had a very interesting elderly patient whose problem was that she had episodes where she would begin singing and praying, but would still be responsive during the episode. This had been going on for many years and, of course, occurred during the visit when she began chanting and rocking in her chair. Laurita came out to get me so I could observe the episode which was clearly a conversion disorder and not a seizure or, as often they are considered here, demon possession. She was very responsive during the episode and could answer simple questions, but continued for some time with her singing. We later got the history that these episodes had started when she had killed a snake and some blood had gotten on her face during the event. When she went to wipe the blood from her face, some of it got into her mouth and this is what precipitated the behavior. We recommended using an antipsychotic medication to see if it could decrease the episodes, but what she really needed was psychotherapy which just isn’t available here in any shape or form. One might think that she could get some help from her church, but unfortunately it is often the pastors at the churches who propagate the demon possession explanation for them which only worsens the stigma to the patient and family.

Sometime after lunch we were called to the ward to evaluate a patient with weakness and numbness in her legs. She was a 65-year-old woman with a 9 month history of progressive weakness and sensory loss and hadn’t been able to walk for over two months. She also had significant weight loss and during her examination was found to have a very large supraclavicular lymph node quite worrisome for a malignancy. We sent off all of her lab work which returned with an extremely high platelet count and an erythrocyte sedimentation rate of greater than 120, both also very worrisome indicators for malignancy. Neurologically, she had brisk reflexes in the legs and poor rectal tone, both suggestive of a spinal cord process. Top on our differential was a primary malignancy with a metastatic lesion to her lower spine and compression of her spinal cord. Unfortunately, none of this bode well for her prognosis and now it was time to make decisions about her care. If we obtained a CT scan, which would cost her family a significant amount, it would not likely change her management as the very best we could hope for would be sending her to Dar es Salaam to the only neurosurgeons in Tanzania to remove a tumor that would not improve her neurologically and then they would have to deal with the primary malignancy. We had no evidence that she had tuberculosis and given the large lymph node which was painless and hard making it more likely to be malignant rather than reactive from an infection. A discussion would have to be had with the patient and her family about her prognosis and whether they had the resources and/or the desire to know what was going on given the most likely scenario that she wouldn’t improve neurologically and would eventually succumb to this process. I will try to post the outcome of that conversation when it occurs. Regardless, it was a very good educational experience for both Laurita and Kelley not only as far as the evaluation of the patient was concerned, but also the discussion over treatment recommendations.

We finished a bit earlier which was good as we all had plans to go out for dinner with the entire neuro team and were heading to Carnivore for grilled chicken, chipsees (French fries), grilled plantains and beer. We had Dr. Badyano, Sokoine, Angel and Alex along with the three of us. The chicken here is the most tasty around we always look forward to this visit. Best of all, they play wonderful African dance music and have a small dance floor that we all monopolized until the wee hours after dinner (here that means 11pm). We all returned safely home after dropping off Angel and Badyano at their homes and went to bed for some sleep looking forward to our final clinical day here at FAME on the morrow. Each of us, though, knew that we would be missing FAME in very short order and would be leaving with heavy hearts.

Tuesday morning was once again time for our educational talks and there was a special request for Kelley and Laurita to cover the causes and evaluation of patients with altered mental status, a very broad topic that was quite a challenge for them to prepare. Like the pros they are, though, they tackled it with enthusiasm and came up with an excellent presentation that fully covered the topic. Once again, they had the full attention of the entire medical staff and when it was clear that they weren’t going to be able to finish the presentation in the time allotted (Dr. Lisso again did not cut them off which is always an excellent sign that they’re doing a good job) they were asked to finish the lecture on Thursday morning which is not a typical morning for educational lectures. Not only that, but the lecture that had gotten bumped for the altered mental status evaluation, headaches, was now being move to Friday morning, the morning we’re leaving for Arusha, but both Kelly and Laurita were more than willing to give the lecture before we leave that day. So, all in all, there will three educational lectures this week when there is normally only one.

At morning rounds, we discovered that our young boy with meningoencephalitis was actually somewhat improved as he responded slightly. The night before, on our way home, Kelley had brought up the thought of covering him for listeria, which causes a brainstem encephalitis, as he did have some of these features on presentation. We stopped by the ward and wrote orders for ampicillin to cover him for Listeria. He continued to have fevers and had also had a few more seizures so we were keeping him on his anticonvulsant medication, but were considering adding another if he continued.

Our young woman with Sydenham’s chorea was actually doing better after receiving the steroids, antibiotics and more diazepam to help her sleep the night. She was still having some confusion, though, and we knew it would take some time for everything to clear. Frank and I had a long discussion with her mother who was now also staying at FAME and tried to explain the nature of this disease to her. They are rural Maasai so it is very difficult to explain the nature of an infectious and Neuro-immunological disorder that isn’t contagious and wasn’t caused by anything her daughter or she did wrong, but just happens to some people when they develop a strep infection. She would be going home at some point and would probably still have some of her movements and confusion and we wanted to make certain that her family wouldn’t take her to a traditional healer or shaman where they might try to exorcise her. We frequently see patients here at FAME after they’ve been to a healer and they have lots of marks and burns on their bodies from attempted treatments or they’ve ingested local herbs that have unknown toxicities or effects. We also explained to her mother that this wouldn’t get better immediately, but would take at least several weeks to notice any possible benefits and that she would have to come back to be followed.

Laurita had a very interesting patient with the largest gouty tophi any of us had ever seen. Gabriel told us that this wasn’t as uncommon here as both of us thought as many patients are unfortunately non-compliant with their medications and many can have tophi such as this patient had. The reason he was seeing us, though, was because of his symptoms of neuropathy which were undoubtedly related to his gout. His examination confirmed his neuropathy and he was treatment with medication for symptomatic relief and hopefully he will be compliant with it.

No other patients stood out for the afternoon, but we were able to finish in a reasonable time today. I had driven downtown to pick up some things from one of the fabric stores after lunch, but they hadn’t given me everything for some reason, most likely because I was by myself and I’m not sure how clearly I had gotten the message across to them. So Kelley and I decided to run back down there before they closed for the evening and brought Selina along with us to help with any interpretation. It turned out that they had really failed to give me several things and it was unclear if they just weren’t sure if I was supposed to be picking up stuff for everyone or what. We had all ordered a number of things from them and given them quite a bit of business they wouldn’t have otherwise gotten so it seemed reasonable to us that they would want our business. We were never entirely sure, though, and that is something that is often the result of the cultural spread.

We returned home before sunset and once again sat on he veranda overlooking the beautiful hills that opened up in front of us. Dr. Liz, another volunteer from the US who has been here several times with me, arrived yesterday afternoon and joined us on the veranda to reminisce as well as to catch up on each other’s lives and the events of the day. We had the last of our prepared dinners as we’d be going out for the next two nights before we leave. What seemed like such a long time for us to be here now seems like it has slipped away so quickly and we are all becoming very sad at the thought of leaving soon.

I think we were all quite exhausted on Monday morning after our weekend safari and despite a good night’s rest we were all dragging a bit. We had already spent nine full days seeing neurology patients at FAME and four days of mobile clinic yet it seemed that our patients were still coming in droves. When clinic opened at 8:30am (in Swahili time that’s 2:30 as the day begins at 6am with the sunrise) we immediately had over twenty neurology patients to see us and they were still coming.

Meanwhile, there had been an admission last Friday of a young boy who presented with seizures and altered mental status who they wanted us to see. They had done a lumbar puncture on Friday, but not all studies had been run on the fluid and all we were told was that the fluid had been cloudy and there too many white blood cells per HPF (high powered field on the microscope) meaning that he very like had a meningoencephalitis and probably viral given some of his other labs such as elevated liver function tests. He had been put on antibiotics, but when we asked about acyclovir they hadn’t considered it. When I tracked down our pharmacist to ask about obtaining the medication we always put these patients on in case of herpes encephalitis, I discovered that it is virtually unobtainable here having to purchase it from Nairobi at a cost well beyond FAME’s means as it would have cost $500 dollars a day for fourteen days to treat this child. Luckily, it didn’t appear that he needed it though he continued to have some seizures and did remain intermittently febrile. We wracked our brains throughout the day to make sure we weren’t missing anything with this child as he was very ill and we certainly wanted to give him the best chance to improve. We did add one other antibiotic on our way home that evening to cover one other possible infection, but otherwise we had no new thoughts.

We had our usual compliment of patients that included one Maasai woman who I have seen for several years with seizures. She has remained well controlled on lamotrigine which is the best drug for her given her age and likelihood that she’ll become pregnant in the coming years. She did have a baby last January who I had seen in March as her husband brings her back for follow up religiously every time that I am here. He had invited me to his boma for a goat roast last time I was here and wanted us to come this time, but I explained to him that we were leaving in several times and unfortunately didn’t have time to make it there. We both agreed that we would do it for certain in March and Sokoine now has his phone number and location so we’ll visit earlier in the trip next March. I haven’t yet had someone cook me a goat so that should be very exciting indeed.

Sometime in the mid morning ( I can’t recall if it was before or after chai), Frank called me over to his office to see a patient who had been brought from a fair distance to see him. It has been billed as a psychiatric patient, but he wasn’t certain and as I walked through the door of his office I immediately recognized what the patient had. She was a fifteen-year-old Maasai girl brought by someone from her school and she had been having strange behaviors and movements for several days. Her family thought that she was possessed, but thankfully she hadn’t yet been touched by any local healers. As soon as I saw her movements I recognized that she had Sydenham’s chorea, a very rare disorder in the States that is caused by an untreated Strep infection. It causes neuropsychiatric manifestations in patients in addition to the infection which is very dangerous as it can cause a bacterial endocarditis that has a predilection for the mitral valve, often destroying it and causing a serious problem if left untreated. I asked Frank to check and he said that she did indeed have a murmur. I explained to the situation to the American teacher who had brought her here and we suggested that she stay here at FAME for several days while we initiated both the antibiotic treatment as well as treatment for her uncontrolled movements. Her mother was called and agreed to travel to FAME from the Arusha area as she wanted to be here if she was going to be admitted. Her movements were very impressive and it took 30 mg of diazepam to get her some rest that night and that dose was repeated again during the night amazingly.

We had diagnosed a young girl with the same disorder back in December 2012, and after over a year of treatment she was finally without any movement or issues, though the last time I saw her was in March of this year. We had impressed upon her family that she would need continuous prophylactic antibiotics for many years to ensure that she didn’t develop another episode of endocarditis, but they moved to Mto wa Mbu and it become more difficult for her to come back here for her checkups. I am hopeful that she’s still receiving the antibiotics to protect her heart. This young woman I saw today will also require the same treatment with immediate antibiotics for the acute infection, long term prophylactic antibiotics (until the age of 40!) and a long course of steroids to control her movements which are the result of an immune-mediated response. It is very rare to see these patients here and extremely rare to see them in the States, so I was quite happy that both Kelley and Laurita would be able to see this patient with such a classic and now rare neurological disorder. It is something that will remain with them forever.

Laurita also had a very complicated patient that came to see us from Arusha and required well over an hour of her time. She was a young woman who had developed eclampsia following a delivery around the first of the year and had suffered two intracranial hemorrhages. She underwent surgery to evacuate them with an excellent recovery initially, but then developed an intracranial abscess requiring additional surgery, suffered seizures, then hydrocephalus needing a shunt placed. She underwent an immediate replacement of her shunt and subsequent to that lost her ability to speak. We had most of her CT scans to review and an MRI that she had obtained in Dar es Salaam as well as her examination. Unfortunately, it appeared that she had suffered some damage from the placement of her first shunt that explained her difficulty speaking and there was very little that we had to offer her as far as treatment or therapy. She was extremely abulic as a result of the frontal lobe damage she had from the initial hemorrhages and with all the deficits, she was extremely disabled. It was a very sad case as even with rehabilitation she will likely recover very little.

Given the complexity of cases today, things were moving a bit slow in the afternoon making it necessary for us to work well into the evening which also meant that Sokoine and Selina would miss the staff bus to town at 4:30 and had to find an alternative means of getting home. Luckily that was taken care of by one of the other FAME staff vehicles as I had work to do this evening along with Laurita and Kelley. We ended up staying in the volunteer office until 8:30pm as they both had to work on their talk for tomorrow morning and needed the use of the Internet, which if you remember, runs incredibly slow if it runs at all. Starvation finally got the better of us, and especially Laurita, so we all went home to eat our prepared dinners of roasted chicken, potatoes and green beans. Somehow, Kelley managed to go back up to the volunteer office to complete her talk, but I’ll have to admit that I was far too exhausted to do any more work and chose rather to go to bed and set my alarm for well before sunrise. We had all worked very hard today and I sensed a bit of frustration in everyone with the late hour that we finished so decided to make sure we wouldn’t run into the same situation tomorrow and planned to speak with Sokoine regarding this in the morning. Regardless, we had seen some very interesting patients once again and fulfilled our purpose for being here, not only in regard to educating the doctors here as well as my residents, but also myself included.

Spending the night on the African savannah in a tent, even with a hard floor and plumbing, is a very unique experience. Soft breezes continually buffet the fabric in a pleasant and relaxing fashion throughout the night while the nearby nocturnal wildlife make their presence known. Depending on the location, we commonly hear hyenas or lions that sound as though they may be right outside the tent. We were so tired from our safari the day before that we all slept quite soundly and were ready for the new day. I had planned to use the outdoor shower, but reconsidered as it was a bit chilly so I enjoyed my shower inside instead. Before breakfast, I readied my cameras for the day ahead and headed off to the dining tent for another wonderful meal.

We ate outside with the soft rays of sunrise beginning to cover the plains in front of us with the start of a new day. Breakfast was a buffet this morning as there were a few more guests at the lodge and we enjoyed eggs, mushrooms, bacon, sausage, potatoes and homemade granola again. Oh yes, the wonderful pancakes or crepes with syrup. All of this was preceded, of course, by the requisite cup(s) of freshly brewed local coffee. As we would not be returning to the lodge after our safari today, we thanked all the staff for their amazing service and picked up our lunch boxes for later in the day. When staying in the tented camps, it is the common practice to give the camp manager a tip to divide among his staff thanking them for their fine service. When we gave the manager our tips, I am not sure that it was totally expected and they were all very thankful for our generosity. This really was an amazing stay for us and it was probably one of the nicest places I have visited in my time here. I will definitely return to the Tarangire Simba Lodge in the future and may well make it part of the resident’s “cultural experience” here.

Having battled the tsetse flies yesterday, we were all a bit weary of encountering them again this morning so began our trip with the top down on our vehicle and the windows mostly closed. Yusef had his cracked slightly and Laurita was a bit more daring having her window open about half way much to Kelley’s dismay. We went through the gate again and began our drive through the acacia woodland, or home to the notorious tsetse. A few flies got into the vehicle through Laurita’s window and we were able to dispose of them rather quickly. We didn’t kid ourselves, though, as we knew we would run into them again during the day and only hoped that they would be manageable. We took a different route to the river area this morning and crossed in a dry area as we headed for the public campsites to see what we could find. We quickly ran into a small group of lions positioned strategically on a small hill overlooking one of the prime watering holes in the area. They were clearly planning some type of ambush as there were herds of zebra and wildebeest in the area and we were definitely hoping to be there for the event if at all possible.

The group included three adult females and three adolescent youngsters. Initially resting, it was clear that they were maintaining a very close watch on the watering hole as well as the surrounding area in hopes of a meal. As we sat watching warthogs meander towards the water and hoping that they wouldn’t see the lions or react in any way, we were rooting for the lions with the hope that they would attack. One of the younger ones at one point charged after a warthog, but it was of no use as they were too far away and easily scurried out of reach of the clumsy lion with ease. There were herds of zebra and wildebeest in the area and one group of zebra were definitely moving slowly towards to the watering hole, The stallion leading the group continually inched closer, but unfortunately, he was moving across one of the access roads and as vehicles came and went from the spectacle, he would get spooked and move away from the water. This went on for some time until finally a group from the other side slowly walked to the watering hole while two of the older felines began to organize for an attack. The zebra had just gotten to the edge of the water when the lions seemed to prematurely jump. They ran down to the beach, but the zebra were to quick for them and were spared another day. At this point, we were not very impressed with the skill of these lions to say the least.

There were over fifteen vehicles now all positioned at various locations around the watering hole in hopes of seeing a successful lion kill. The guides were all trying to predict where the attack would occur and jockeyed each of their vehicles attempting to get the best view for their safari guests. In March of last year, we had followed a group of four females for most of a morning waiting for them to make a kill and were lucky enough to see it happen right in front of us and all alone. A lion kill, or an attack by any of the bigs cats, is perhaps one of the most impressive things I’ve witnessed in nature and an event that is not to be missed if possible. It is truly nature at its most raw and uncensored. It is incredibly powerful and you feel as though you are part of it, though it can only be watched with the realization that it is not a show for our benefit and that the prey would have died whether we were there or not. It is something not to be missed.

We continued to watch the lions for some time hoping that they would be more successful, but when we saw a family of elephants moving towards the watering hole we knew there would soon be some sparks flying. As I mentioned yesterday, lions and elephants are deadly enemies and the elephants would love nothing more than to stomp a lion to death if given the chance. So, as the elephants moved closer, they immediately attracted the attention of the lions who watched carefully as they approached. When the elephants got the scent of the lions and realized where they were, several of them made a beeline for the hill where the lions sat and very quickly displaced them from their resting place. Once the lions were on the retreat, the elephants again focused on the watering hole and began to drink and carouse as if it were a big punch bowl. The lions, meanwhile, having been evicted from their lofty perch above the watering hole, reconvened on the flat nearly in front of us so we could get some great photos, but we had still wanted to see a kill, unfortunately. We had been watching them for the better part of an hour or so at this point and decided to move on to see more things before lunchtime.

We drove through the Small Serengeti region of the park, named for the close resemblance to the wide open plains of this famous region of Tanzania several hours away from us. There were herds of zebra, wildebeest and Cape buffalo in this area, though we were really on the lookout for cheetahs as the grasses here are the right height for them to hunt while remaining hidden. This is also the area where we were stuck in the mud for hours last March during the wet season so I am always a bit reticent about driving here even though it’s now dry and someone else is driving. We circled through the Small Serengeti on several roads and eventually drove back towards the river as it was approaching lunchtime and we were heading for a new picnic area on the other side. The main picnic area of Tarangire is typically very crowded with vehicles and people, but has a beautiful overlook of the river and all the animals there are midday. Unfortunately, the Vervet monkeys have also figured out that it is the perfect place to find an easy lunch and they love to harass visitors with the hope that they more score a few scraps here or there. One such pair of Vervets planned a sneak attack on Megan Richie and me a few years ago and turned out to be far more aggressive than we had thought they’d be. I grabbed the food and Megan, having grown up in Indonesia and quite comfortable with these situations, decided that she’d protect me only to find out that one of the monkeys didn’t scare very easily. We were leaving the following day and I was quickly trying to figure out in my mind how I would explain to my chairman having had my resident mauled by a usually cute Vervet monkey in Tanzania. Thankfully, it did not come to that and Megan realized she had met her match so the two of us exited stage right with our food in hand to find another location for lunch. Had they been baboons, I don’t think we would have been so lucky.

We crossed the river and drove to the new lunch site which is high up on another overlook with views of much of the park. We didn’t have the picnic lunch we had had yesterday, but rather box lunches with lots of goodies. I’m certain that Laurita gravely missed the wonderful pasta of yesterday, but I knew she would make do with the lunch at hand. A hamburger, samosa, hard boiled egg, apple, and a piece of chocolate again. Not nearly as luxurious, but it quelled our hunger and we sat in the shade for a time before piling back in the Land Cruiser in search of new sights.

We drove to the river and crossed again and headed up a road that we had been on yesterday so I wasn’t quite sure where we were going as this lead to the Silale swamp and I didn’t think we were going back there. Within a few hundred yards, though, we immediately encountered a small group of lions lying in the shade of an Acacia tree. One of the other guides at the lunch area had apparently shared this information with Yusef at the picnic site so he had traveled to this spot with the hope that the lions would still be hanging out here. It was a male and three females and it was close enough to the river crossing where we had seen the group yesterday that they were undoubtedly one in the same. Lions roam over a very large area and are very territorial so you will never see two groups or prides that close. We sat watching them for a number of minutes when the male decided to get up and mosey over to one of the females. She quickly sat up and then it was readily apparent that they were a mating pair when he quickly mounted her. As quickly as it started, it was over and we were all amazed, especially Laurita and Kelley who swore that it was the highlight of their safari to see such an event. I knew that when lions mate they do so every 30 minutes for several days and Yusef informed us that the reason is that the male lion’s penis is very short so this is required to ensure that the female becomes pregnant. Since we knew that there would be another show very soon we decided to wait and were surprised when the male got up again in about 15 minutes readying himself for the next episode. This time he mounted one of the other females so it was obvious that at least two of them were in estrus. Both growl very intensely during the mating and it was again over almost as soon as it started. We were all by ourselves in the middle of nowhere watching these lions so we were in no rush to leave and continued to watch them for some time during which we witnessed a total of four matings with the two females. It is something that I’ve seen a few times before, but never with the enjoyment of listening to Laurita’s and Kelley’s commentaries that were hilarious even if half of them were in Spanish. Regardless, their laughter was the same in any language and equally infectious as you can only imagine the jokes being made at the expense of the lions mating ritual given the very short duration of each encounter despite it going on for days.

We eventually departed our little pride of procreating lions and were heading along the river in the direction of the main gate. After some time I asked Yusef if we could head back to the lions we had watched in the morning and he informed us that he had heard on the radio that they had actually made a kill while we were engrossed in the lions mating and that was where he was actually heading. So off we went at a somewhat faster clip as we all held on so as not to be thrown into the side of the vehicle which can easily break a rib or at the very least leave you quite bruised. We came upon the watering hole to a gaggle of vehicles with everyone focused on the very same group of lion sitting down to an afternoon meal of fresh wildebeest. The kill had occurred perhaps 30-60 minutes prior to our arrival and several of the lions were already satiated and lying in the shade as the kill was directly in the sun. We watched as one of the adults and the three younger lions all sat along the belly of the prey and quite intently ripping chunks of flesh and cracking bones that was audible to us even 50 yards away. Occasional spats would occur regarding someone’s position in the pecking order or at the kill, but they would only last a moment and then each would immediately go back to their ripping and shredding.

As we were watching this, a number of elephant families were approaching in the distance on their afternoon trek from the river back to their homes in the hills and they were clearly looking forward to a rest stop at the watering hole. It would be interesting to see what would happen when the elephants approached the watering hole this time as the lions had a kill and we knew what had happened earlier in the day when the elephants had won out. This time, though, the elephants left the lions alone on their side of the watering hole and merely strode to the other side and began drinking and throwing water on their backs. It seemed clear that the elephants knew that the lions would likely defend their kill and wouldn’t be so easily dislodged this time. We eventually left this scene to head out of the park and make our way back to Karatu. We had had a wonderful two days in Tarangire despite the tsetse flies and other than a few bites here and there, they were a distant memory. We had seen the darker side of Kelley (yes, there is a dark side) as she gleefully executed tsetse after tsetse with the assistance of Laurita and me, though it was clear that she enjoyed their demise much more than either of us did.

The drive back to Karatu was unusually quick. We dropped Yusef off on the tarmac as he had to meet with some friends and we made our way back to FAME. Alex had said he was cooking us dinner tonight and little did we know what feast he was planning for us tonight. Kelley and Laurita were in their pajamas when we went over to his house next door and I was wearing my gym shorts and T-shirt. Shortly after our arrival for dinner, the rest of the FAME family showed up – Susan, Frank, Verena, Nurse Barbara and Annie Birch – so we gave excuses for our dress as we hadn’t been aware of the guest list. Joyce wasn’t feeling well so missed an incredible meal of real Gyros with homemade pita, sauce, wonderfully seasoned beef, homegrown lettuce and tomatoes and a rice and feta salad. Alex is an amazing cook and we were grateful for this meal after coming home from our weekend safari. We had seen nearly everything we wanted to see in Tarangire save for a leopard, so the girls will just have to return here someday to realize that experience. They did get to spend time at a wonderful lodge with a wonderful staff which also something to experience here. Needless to say, we were all very much looking forward to our beds this night as were were all very, very tired, but also very fulfilled.

We awakened before sunrise as we had planned to get an early start for our safari today. We all met in the dinning area at 5:45am for an early breakfast and were greeted by the wonderful staff. Fresh coffee and juice, pancakes (crepes), homemade granola and eggs to order were on the menu this day. We talked again about our plans for the day and where we would be heading in the park. I was very excited because I hadn’t been to many regions of Tarangire since my original visit here in 2009, and it is a very large park with some amazing sights. Today we planned to visit the Silale Swamp which was at the very far end of the park and opposite the main gate that I normally used to enter when we come to visit for day trips. It would be at least several hours to reach this region.

The Sangaiwe gate was only a few minutes from the lodge and we entered the park just after the gate opened. Like most entrances to the parks, they take no cash and only credit cards so as to minimized theft by the workers which had been a significant problem in the past. Because I have a resident permit, I’m able to get into parks other than Ngorongoro for half the price of the normal day rate of which is a bit over $50 now with the new 18% tax that has been imposed (or finally instituted) after President Magafuli took office last October. Though it was a shock when it occurred overnight, the new prices and taxes for the parks and the Crater will hopefully all be for the best as they are intended to all benefit the wildlife and conservation here. Tourism and the wildlife they have here in Tanzania are their greatest financial assets not to mention the importance to our planet in the preservation of these unique species that have been so impacted by the presence of humans over the last several hundred years.

The Sangaiwe gate is located about 45 minutes from the river area which is where most of the animals congregate during the dry season. Tarangire is a region that is dominated by a river ecology so that during the dry season all of the animals travel from the surrounding hills to obtain water from the only source available. Families of elephants, large herds of wildebeest, zebra, and Cape buffalo migrate to the river on a daily basis. Meanwhile, Grant’s and Thompson gazelle, who don’t migrate and need much less water are found in the open areas of the park and countless groups of Impala reside in the woodland regions. Waterbuck, reedbuck, elan, and dikdik are scattered amongst the others throughout. Tarangire is also known for it’s exquisite birds including numerous types of vultures, eagles, hawks, plovers and Kelley’s favorite, the Lilac breasted roller.

As we leave the gate we begin our drive along the higher woodlands that are unfortunately the home to tsetse flies. These are the flies that carry trypanosomiasis, or sleeping sickness, but thankfully don’t in this region of Africa otherwise we would have been in big trouble long ago. The tsetse is a blood sucking fly whose bit is very painful (much worse than a mosquito) and they are masters of stealth until you feel the severe pain of their bite. Humans are obviously not their primary target otherwise they wouldn’t be so numerous and they are usually bothering the other large animals around including all the antelope and the Cape buffalo. They are attracted to anything that moves and this typically means a large animal, but in our case it means our vehicle and, unfortunately, us inside. They are like guided missiles and once locked on their target they are relentless and tireless in their quest to bite us. Since I’m riding behind Kelley and Laurita, I can watch their backs and swat the flies off and all that is available on me are my shoulders as my shirt is flapping enough in the back with the movement of the car and the wind so as to keep them off. The morning was fairly cold and I wore my only fleece which happened to be blue, a color they are attracted to while I had forgotten that they also like black which both Kelley and Laurita were wearing. Oops! Needless to say, we were all a setup for an impending tsetse fly disaster. It wasn’t pretty, but since it was their first exposure to these little conveyors of agony, the girls were only moderately annoyed, but worse was to come later in the day.

Once out of the woodlands, the tsetse pandemonium abated and we once again relaxed to enjoy the truly amazing sights of this park. As we traveled along the various river circuits whose trails were dry and dusty, but had been very wet and slippery in March during our visit. The early animals were just arriving to the river while the majority were still traversing the plains from their homes in the hills. When you see several safari vehicles stopped in one location, it usually means some kind of large cat, either a lion, cheetah or leopard, and this morning as we approached one of the river crossings we came upon this scene. Far up the dry river bed was a lioness just laying in the shade, but it was enough to attract a crowd. A family of elephants were milling about high above the river bed, though eventually decided it was time for cool mud and ambled down a path that was immediately next to the relaxing lioness. Not necessarily mortal enemies such as the big cats are to each other (lions will kill cheetahs on sight), elephants do not tolerate lions for a moment and when they realized her presence, they immediately charged after her, chasing her further away from us down the river bed. We turned our vehicle around to follow the lioness and after a few moments spotted the rest of her pride under a tree in the distance, a male and several other females doing what lions do during the which is mostly to sleep.

It was still quite early as we began our drive over one of the hills towards the Silale Swamp, a very important natural area for the animals here. The swamp is massive and occupies the majority of the valley it sits in. It is very green even in the dry season and families of elephants can be spotted everywhere along with groups of buffalo. Wildebeest and zebra don’t seem to wallow through the mud of the swamp which I suspect is more for safety reasons as they would probably become mired and when speed is your main defense, that would be serious problem. The Cape buffalo use their size and horns as their defense against predators as well as their strength in numbers while the elephants are much less often targets of predators other than the smaller babies.

While over on the swamp side, Yusef heard news of some cheetahs a distance away across the river. Initially it was decided we’d lunch first, but then he decided to hightail it to the cheetah sighting so we all held on for dear life while we sped across the countryside in search of the world’s fastest land animal. It turned out that the location was up Tarangire Hill, a landmark far down river and when we came up the location, there were two cheetahs laying in the shade of a bush and several vehicles already watching them. Cheetahs are the most elegant of the cats and it is their speed that they are known for rather than their strength. It was so exciting for Laurita and Kelley to finally get to see a cheetah and now here were two. One cheetah was lying in the middle of the bush and more difficult to see, but it eventually came out and the two cheetahs greeted by washing each other’s face with their tongues. They didn’t seem to be interested in hunting so we watched them for a bit and then left to drive back over to the lunch spot overlooking the Silale swamp.

The lodge had packed us a picnic lunch rather than the usual lunch boxes and we found the perfect table that had a great view of the swamp with all it’s elephants and flocks of birds laid out before us. Lunch included a large container of pasta with ham, peppers and onions that was out of this world good, hamburgers, small individual quiches, apples for desert along with a small chocolate bar. We were all starving as we had stopped for a later lunch and it was so relaxing to sit in the shade and share such a feast among friends. The leftover pasta and anything else went to some young workers who were digging a new foundation near the bathroom in the heat of the midday.

After our rest, we all climbed back in the Land Cruiser for our second half of the day and decided to head back to visit the cheetahs we had seen before. They were still there, though perhaps somewhat more visible as they had adjusted themselves to avoid the strong midday sun. They were still the same gorgeous creatures we had seen just recently and were interacting again with each other. Cheetahs are typically solitary animals who hunt alone as well, but you will occasionally see them in pairs and much less frequently three of them together. When this happens, they are all of the same sex and almost undoubtedly males and often brothers. Females never travel together. Two years ago I had seen a threesome of males here in Tarangire on the small Serengeti drive. We decided finally to leave our two cheetahs, though it was admittedly difficult as they were the first for Laurita and Kelley and they are definitely amazing animals to see up close.

The remainder of our afternoon was spent driving along the river in search of other sights, but the tsetse flies were definitely becoming more of a nuisance and I was quite worried about Kelley’s sanity. She seemed to be our tsetse magnet, that person you always like to have along as the biting insects seem to favor them for some reason giving the others a bit of a reprieve. Unfortunately, Kelley was not quite as enthusiastic with her assumed role and had taken it upon herself to personally annihilate as many of these pests as she could using one of my work gloves I had brought along in the car. She enlisted Laurita who seemed to muster a similar hatred for the flies and chose to use the other glove as her weapon of choice. Between the two of them, they managed to scatter the lifeless carcasses all over the floor in short time. I would not want to run into these two in a dark alley if they had a grudge for any reason and especially if I saw them carrying those work gloves. Traveling back through the acacia woodlands where the bulk of the tsetse flies were earlier in the day, first Kelley and then Laurita covered themselves up in Maasai shukas (blankets that we had in the car) so very little of them was exposed for the flies, but they were somehow still occasionally finding their target and there would be on onslaught of brief action before covering themselves up again. I certainly wasn’t immune to the flies, but did seem to have less of them bothering me along the way so enjoyed watching the two of them ranting and raving in between my less frequent run ins with these devils.

We arrived back to camp just before six which was perfect as the gate to the park closes then and we had to be out by then. We were again greeted with cold washcloths and looked forward to relaxing for a few moments in our rooms though Laurita apparently went right to the observation deck where she could get internet coverage. Both girls are avidly playing in the resident fantasy football league and had to make sure their lineups were set for the following day. We later all met on the deck and enjoyed a cold beer together after a long day in the vehicle on our game drives. We had seen so much that day and we enjoyed reminiscing about the events including the war with the tsetse flies. We sat outside under the stars for dinner and later laid again on the deck to watch the Milky Way and shooting stars and this time even decided to try some long exposure photos. I had somehow left my quick release plate at home so my tripod was useless and we used a towel to prop up our cameras and get some photos. It was finally time for bed so off we went to our tents for a relaxing night with thoughts of more game drives tomorrow.