Having spent the last four days continuing our “neuromobile” as someone close named it, we were looking for a little break to catch up on our administrative work. For the last several years, we have been collecting general data on the patients we’re seeing here, such as age, tribe, location of visit, return or new, diagnosis and medications we’re prescribing. It is helpful not only with the keeping track of our volume and demographics, but also something as simple as knowing what medications to order extra of before we arrive. In addition to our general neurology database, we also have been collecting somewhat different information regarding our epilepsy patients, such as seizure control and dose changes.

So, as we had not advertised today as a neurology day (that will continue next week), we decided that it would be a perfect day to begin gather data for our database. Somehow, I have managed to avoid participating directly in the data entry and Laurita and Kelley did not let me down as they immediately offered to do the work. Besides, I did have several other duties to attend to like catching up on my blog and, perhaps more importantly, get our vehicle since we had plans to leave later in the afternoon on safari which would be quite difficult without it. Soja called and told me everything had been repaired and it was ready to pick me up so I hitched a ride down with Moshe, who is in charge of everything that goes on at FAME. I had been sitting in back of the stretch Rover that was about to head to town with a number of FAME employees, but was rescued by Moshe at the last minute. The vehicle was finished and though it was a bit more expensive for the repairs than I had anticipated, it was still only a fraction of what it would have cost in the US. The steering rack and all bearings had been rebuilt and replaced, the hinges on the bonnet (hood) had been completely replaced, the emergency brake that hadn’t worked since the vehicle had been rebuilt was completely repaired and lastly, he had built a latch to keep the room from dropping on our heads when it was up on safari. All that for a little over $400!

I drove the Land Cruiser home and then finished posting my blogs when I got word that Yusef, our driver had arrived to FAME. We found Yusef and all when to have a quick lunch in FAME’s canteen before our departure. We had just a few things to finish up with and so Yusef checked out the vehicle and got it ready for our weekend safari. We ended up leaving right around 3pm which is what we had planned since I thought it would take about two hours to get to our lodge. That was a bit optimistic, though, as the Simba Tarangire Lodge is on the opposite end of Tarangire near a new entrance gate built in the Kigoma region adjacent to Lake Burunge. On the way, Yusef was stopped for speeding in a 50 kph zone. The traffic police have now begun to use electronic devices to record speed and I am very certain it was done as a revenue generator rather than a deterrent to speed. After talking with the officer for a bit of time, Yusef came back to the car and informed us that he would have to pay a penalty for his speeding and asked if we might have an extra 10,000 TSh, or about $5 – far more reasonable than any speeding ticket would have been in the US.

We eventually made the turn off the tarmac traveling to our lodge near the Sangaiwe gate of Tarangire. Not the best marked route such that we had to ask several townspeople all the way even while I was using my GPS navigation program knowing the coordinates of the lodge, we still were able to make it there and all before sunset. The Simba Tarangire Lodge is a relatively new facility and we were extended resident rates due to our working at FAME. It is a hybrid lodge/camp model where the “tents” are permanent with hard floors, bathroom with plumbing and hot water, an indoor and an outdoor shower, all overlooking Lake Burunge outside the park, but in the middle of a wildlife reserve so that herds of zebra and wildebeest roam in our view towards to the lake.

We were greeted with cold washcloths and cold juice as we got out of our vehicle from our long drive and the staff couldn’t have been more pleasant and helpful. They gave us a little rundown on the grounds, where meals were served, where we could watch sunset and then were our rooms were. You’re not able to walk to or from your rooms at night or in the dark as there are lots of dangerous animals close by that would not be very pleasant or safe to meet up with in the dark or otherwise. Laurita and Kelley were staying in one tent and I had my own for the two nights. We dropped our things off in the rooms and made a beeline for the observation deck that looked out towards the lake and was the best spot for viewing sunsets which was about to happen. We sat on the deck enjoying a cold beer after the day and couldn’t help but think of all the amazing things we’ve already done this trip and the amazing safari we were about to have.

We had asked for dinner at 7:30 and there was a choice of grilled chicken or pork chops. Yusef joined us for dinner as it the custom with safari guides here and we sat down to enjoy an incredible meal of vegetable crepes, followed by a wonderful vegetable bisque with homemade rolls and then our main course. Both the chicken and pork were great though I thought the pork was really exceptional. Desert was a delicious caramel flan-like dish (notice the Hispanic influence on the description that Laurita just gave me).

After dinner, we all sat out on the pool (Yes, they actually had a swimming pool) deck and stared up in the sky fully lit with stars the most beautiful Milky Way any of us had seen in some time. There was to had been a meteor shower this night, but we weren’t entirely clear if that included being in the Southern Hemisphere and half-way around the world or not. Regardless, we all saw a number of shooting stars somehow with me seeing less even though we were all looking at the same sky. As we sat on the edge of the deck and furthest away from the lights of the lodge, the askari continually came by to check the bushes just beyond our feet for any overenthusiastic animals that may have decided to take a closer look. Lions do roam these premises as the many bones of previous victims are readily apparent immediately upon leaving the confines of our camp. It was just a bit unnerving to Kelley and Laurita who pulled their feet closer in hopes of avoiding any curious felines. We all eventually realized it was way past our bedtimes considering we had to get up early for breakfast which was at 6:15am so we could get an early start on our first day of safari. We were all escorted back to our tents by spear wielding askari who continually shined their flashlights in all directions as you are not allowed to walk alone in camp after dark for obvious reasons.

I was fairly certain we’d all sleep well that night until I heard all the animal sounds that I was sure were new for Kelley and Laurita and could disrupt their sleep. I’ve heard them so many times here that they’re more relaxing to me and I drifted off to sleep after some reading with thoughts of a successful game drive in the morning.

We had our second day of clinic scheduled today at Rift Valley and had planned to leave a bit later in the morning as they had wanted us to stay later to see some children who were taking their exams in class. I was also supposed to hear from Soja this morning regarding our vehicle. Frank uses an expression here, “TIA” which isn’t what most neurologists think it is, but rather “this is Africa.” It encompasses life here which not only often unpredictable, but also most often not as expected. Time runs differently here and plans that have been made must often be changed to accommodate the unexpected. Having lived and traveled in this paradise now for a combined one year with all my trips I can attest to this as it has so often intersected with my life here in so many ways.

At morning report we learned of two patients that they wanted us to see in the wards, both admitted overnight, and both of whom were believed to have a neurological problem. Since I had to deal with the vehicle, I had Kelley and Laurita do the consults in the wards. Laurita’s patient was one who had come in with what was described as a psychotic episode and had a history of this occurring one before. He turned out to have a heavy alcohol history and each episode had occurred in the setting of heavy use. As she went to examine her patient, she immediately noted that his eyes were not conjugate (i.e. they didn’t move together) and, indeed, he had bilateral ophthalmoplegias which clearly defined his problem as a Wernicke’s encephalopathy secondary to thiamine deficiency as a result of his alcoholism. This is a potentially reversible problem by replacing thiamine before they receive any dextrose in their IV fluids, but unfortunately they had no thiamine in stock here. We had the pharmacy order it for us to come in by the following morning and meanwhile made sure they knew not to give him any dextrose containing IV fluids.

I had been unable to reach Soja regarding our vehicle which was not yet here, so I headed back to the wards to check on how the consults were going. I first visited Laurita who ran things by me and then entered the next room where Kelley’s patient was. Unfortunately, things were not going so well with this consult. As I entered, Kelley was doing chest compressions on the patient while he was being ventilated by a visiting nurse with an ambu bag. This had apparently been going on for about five minutes or so. Nurses from the ward and one clinical officer were also there. I helped with the code to the best of my ability (remember, we are neurologists) by sharing in the chest compressions and asked for the code cart and, eventually, Dr. Frank to intubate the patient. Without going into further details, I will tell you that the code was not successful and it was very tragic as this was a thirty-year-old patient who had come in late the night before with a poor mental status for which we had been asked to see him late that morning. When Kelley had gone into the room to do the consult he had thready pulse and irregular breathing. Despite intubating him we were never able to oxygenate him leading us to believe that this was likely a pulmonary embolus.

Certainly, the mood of our visit changed in one fell swoop and it quickly brought to us the often cold reality of life here. Despite our presence and our best efforts, we can only do so much. For Kelley, though, it was tough defeat way too close to home and as we stood in the room after it was over debriefing for a moment, I could see how personally she took it and knew she would need time by herself to gather her thoughts. Events like this can happen to anyone, anywhere, but when you spend your life training to save lives and reduce suffering, it is not something you can ever prepare for in any fashion. I knew that it would take some time for her to resolve things in her own mind and we needed to give her as much room as possible to do this on her own.

In this setting, I discovered that our vehicle still needed more repairs and was not ready so sought out Susan to see about borrowing one of FAME’s Land Rovers to use for our clinic which I knew wouldn’t be an issue. We all eventually piled into their stretch Rover and stopped by Soja’s on the way to get all the meds and supplies that had been left in our Land Cruiser and we would need for the day at Oldeani. It was another beautiful day and we arrived to RVCV about an hour later then we had anticipated originally. We began again to see our patients, though there were fewer than we had hoped. We had a wonderful lunch this day of homemade squash and carrot soup, homemade bread with tuna and cheese, potato and ham salad and a green salad. After lunch we saw the few remaining patients and then headed for home. We stopped by Soja’s on the way, but our vehicle was still being worked on so were on our way back to FAME without it again.

This night we had plans for dinner at Gibb’s Farm. It is another one of those magical places that is a must for us and I bring every volunteer here for dinner. It is a five star resort, but in an entirely local fashion where everything is as it was when it was a coffee plantation and they serve five star home grown food. Their veranda is spectacular with it’s view of Karatu from high above and off towards Lake Eyasi in the distance. It sits high on the Ngorongoro Crater rim and immediately adjacent to the Conservation Area. I know most of the waiters there and we sat on the veranda through sunset and dark having drinks prior to going inside for dinner. We were served an amazing four course meal with silverware than anyone could count. The homemade bread and butter melted in our mouths. Dinner took over two hours and it was so relaxing. We didn’t leave until after 10pm and were all more than ready for bed with the day’s activities before us. It was another incredible day and even with the events that occurred, we were still grateful to be here. As with anything, we are formed by those experiences we learn from and, in such a way, become who we are today and are better for it. We change the lives of those who we interact with and by doing so are changed ourselves.

It is hump day, but in no way does this reflect our sentiments as we all wish we could continue our for weeks more. Today we will be traveling to the village of Oldeani, about 30 minutes away and the location of Rift Valley Children’s Village which I have spoken of many times before. Mama India, or India Howell, is from Boston and came here well over twelve years ago much in the way we all end up coming to Tanzania. You will find that the majority of ex-pats working and living here originally came on vacation to safari and fell in love with the people and country deciding to discard their former life in the US for one of doing good here. India founded Rift Valley Children’s Village, or RVCV for short, about twelve years ago as a sanctuary for abandoned and orphaned children here. She realized, though, that these children would never feel safe unless they knew this was their home and so she and her business partner, Peter, have adopted all of the children who live there. There are now some 100 children there, from infants to the late teens, and when they are ready for college they leave the village to make a new life, but Mama India and Peter will always be their parents. She partnered with the local village to improve first the primary school and now the secondary school so all her kids as well as those in the village will have a chance to go on with their education. She has also sponsored visits from FAME on a regular basis to provide free health care to the villagers so the community will be healthier, benefiting her children. Unfortunately, the grant to fund that health care has ended, but the neurology visits, which we have done in conjunction with the FAME general medicine visits since 2011, were beneficial enough to continue and so we are going it alone for the first time since I’ve been here to see both villagers and children with neurological disease.

The drive to Oldeani is quite simply another with the same spectacular views as the rest I have described. The road there is off of the tarmac that heads to the Ngorongoro gate and travels along ridges and down into deep valleys where we cross now dry creek beds that are raging in the wet season. We eventually arrive at coffee plantations that surround the village of Oldeani and the Children’s Village and as we pull through the gates of RVCV we see our patients sitting outside the clinic rooms where we will see them. There are not the usual crowds here that I’m used to seeing when FAME also does their clinic, but there are enough for us to get started. Dr. Badyano has today and tomorrow off, so Dr. Mary is working with us and today she will be working with Kelley. The majority of patients here are children so I bounce back and forth between the rooms to check on Laurita and Kelley as we go. Several we are asked to see because of poor attention in school and possible delays and others because of epilepsy. They are split with follow up patients, for whom most we have prior notes, and new patients.

RVCV is perhaps one of the best volunteer jobs to get in Tanzania given the prestige of the facility and the opportunity work in such a magical place. The children all live in different houses with house “mamas” who care for them and the volunteers focus mainly on their activities during the day and helping with education of children not yet in school. We always look forward to lunch at RVCV as we eat what their volunteers eat and it is always one of the best lunches you could ever imagine. Today is quesadillas, fried beans, ground meat, salsa Fresca and fresh fruit. Oh yes, and cake for dessert. Simply delicious. Though we all definitely feel like napping after such a lunch, we fight the urge and forge on to see the afternoon patients which are quite few. The numbers are down most likely as we didn’t advertise here to the community since we weren’t sure until recently that we would be having this clinic.

We left early enough to enjoy a different route I know heading back with more amazing scenery of rural homes and fields of crops that are healthy and full. We arrived back to Karatu to make another visit to the dress shops for everyone to pick up things, order new things and try on clothes that have been ordered. Selina accompanied us again to help with translation as the women in the dress shop speak no English whatsoever. We travel back to FAME and I drove my vehicle down to Soja, who is the mechanic that works on all of FAME’s vehicles and is a good friend of Frank’s. Alex followed me in the old RAV so I wouldn’t have the walk the fair distance back to FAME. The Land Cruiser was leaking power steering fluid and needed to have the steering rack rebuilt. I was assured by Soja that we’d get it back the following morning so I could drive it to Oldeani again as we had a second day of clinic there tomorrow.

Every Tuesday morning is reserved for an education meeting with the doctors and it is typically given by the visiting volunteers whether it be neurology, on/gyn, cardiology, medicine, or infectious disease. Usually, FAME has only one specialty come to visit at a time as it can otherwise become a bit unwieldy as resources here such as the doctors and nurses are quite limited. FAME’s mission is for western volunteers to share their knowledge and expertise with the staff here whether nurses or doctors.

The request for this morning’s lecture was Parkinson’s disease so Kelley and Laurita spent the evening (and some of the night for Kelley who stayed up quite late) preparing a PowerPoint presentation for the doctors. Dr. Msuya is in charge of the educational programs and Dr. Lisso, who is the head doctor, oversees all of the programs here including which doctors we work with on given days. The morning lectures are supposed to be 30 minutes long and we were running a few minutes late this morning so it was already going to be a challenge to get everything in. Dr. Lisso is usually a stickler with time and I have seen him cut off presenters in mid-sentence before, so when they were pushing 45 minutes for their lecture and Lisso hadn’t yet interrupted them, it was clear that they had everyone’s attention. Both did a great job with their presentations and there were tons of great questions afterwards which was a clear sign that they had also done an excellent job stimulating interest.

After morning report, we began organizing for our trip to Upper Kitete. This is another village along the Great Rift in the Mbulumbulu region that is past Kambi ya Simba on the same road and about twice as far. The scenery on the drive is equally stunning, and perhaps even more so, as the border of the Ngorongoro Conservation Area and mountain range that marks it closes in towards the rift narrowing the plateau of rich farmlands we are traversing until it is no more. This is where the mountains that include Empakaai Crater meet the escarpment of the rift and drop off to the floor of the Great Rift Valley leading northward to Oldoinyo Lengai, Lake Natron and, eventually the border with Kenya. Upper Kitete is the second to the last village along this plateau with Lositete being the last and along a rough and often impassable road.

The health center in Upper Kitete is quite old and a new building that was recently completed was not yet ready for our use. We had a number of patients waiting for us as we arrived and others came once the word of our presence seemed to circulate. The clinical officer there was trying to be helpful, but was a bit too enthusiastic at times and gave a long speech to the patients telling them what we were there for and how the clinic would proceed. I don’t think it was very helpful, though, and we had to once again screen our patients to make sure we were seeing neurological problems and not just everyday aches and pains. We started off using the medical officer’s office and one of the rooms we normally use that I affectionately call the “bat cave.” In the corner of the room there is a large opening in the ceiling where you can often hear the bats as they spend the day in the attic. The smell of bat urine and guano is also noticeable, but only mildly so as it’s not all too offensive. I’ve never seen a bat flying or otherwise in all the times I’ve come here so I think we’re pretty safe in not encountering one as we work. The labor and delivery room, which we normally use as our second room was unfortunately occupied by a patient and not available to us.

Kelley and Laurita began seeing patients, Laurita in the bat cave and Kelley in the office. Sokoine had showed me a young girl who was screening and who had a “crooked neck” that he wasn’t sure was neurologic or not. I took one look at her and unwrapped the fabric she had covering her head and neck, and it was quite clear that she had torticollis, a very definite neurological disorder. Laurita ended up seeing her, but I didn’t tell her my diagnosis so she could make it herself, which of course she did in very short order. It had come on acutely a month prior and was very uncomfortable for her. We have very few of the medications here to treat it, but we did have diazepam (Valium) that was prescribed in very small doses. We also told her to use warm compresses along with the diazepam and asked that she return to FAME in two weeks to see how she was doing.

The rest of the patients were a smattering of typical pathology – headaches, seizures, numbness and tingling being the most common complaints. At midday we had our lunch of Tanzanian street food again with a few new items having been added to our menu. One was a skewer of goat meat, a few vegetables and boiled, peeled potato that wasn’t bad. The samosas, though, were the best of the bunch and very much appreciated by each of us.

At one point during the day, Kelley came looking for me as her patient was in need of occipital nerve blocks and she needed my assistance in performing them. I went to the vehicle to get the medications and when I came back she was no where to be found. I went to every room looking for her and asked the others if they knew where she was. No one knew. I proceeded to pop my head in every room to look and it reminded me of something from a slapstick comedy. The nurse was seeing babies in the medical office, Laurita and Badyano were in the bat cave seeing patients and when I opened the door of labor and delivery, I unexpectedly walked in on the clinical officer performing a pelvic exam on his patient. I called Kelley’s name several times with no response and was getting pretty angry at one point that I couldn’t find her and none of our support staff were aware of her location. I called for Kelley on one last occasion and heard a faint reply coming from the new building which I had been told wasn’t ready for us. She and Selina had been directed there after the medical office had been needed again for baby visits. I finally relaxed a bit after learning that I hadn’t actually lost one of my residents in Africa which would have been difficult to explain, especially to Dr. Price, our residency director. I fear that he would make me cover the remainder of their duties which isn’t something I’d even like to think about.

Following my brief lapse in sanity, I helped Kelley with the occipital nerve blocks which are something we often do in the US for patients whose headaches are from inflammation and can often be relieved with a combination of a steroid and a local anesthetic. The patient tolerated the procedure just fine and was on his way in short order.

We finished seeing patients at not too late an hour and decided to return directly to Karatu and FAME. The drive back was on a different road that parallels the escarpment that falls off to the Great Rift Valley and the views are spectacular. You can see for many miles down to Lake Manyara and up towards the village of Engaruka, a very important historical and archeological site in the history of the Maasai in this region. I know it seems like everywhere we go here in Tanzania the scenery is totally amazing, but that is the truth. This country has possibly the most diverse and beautiful of any on this earth. No matter which direction you turn you are seeing something entirely new.

After dropping all the FAME staff off in town other than Ema, our driver and who lives next to FAME, we returned to catch up on email after which we sat on the veranda and watched another colorful sunset. It is so relaxing to just sit and look off into the distance with its lovely jacaranda trees of unique purple lavender and the coffee plantations beyond. The distant mountains are all overlap in a gorgeous sketch marking the horizon and lands beyond. We are all so lucky to be here and to experience this land and these gracious people in such a fashion. We are their guests, but are truly treated like family and for that we are so grateful. This experience is like no other.

When I first came to volunteer in 2010, FAME had been providing monthly medical care to an extremely remote area around Lake Eyasi, about a five hour drive from Karatu. These mobile clinics were a week long affair that required a huge amount of resources where typically half the staff of FAME along with other hired help would travel in the FAME mobile clinic/bus and several Land Rovers to set up a clinic and lab and serve long lines of patients. That project was funded by a grant that ended after three years. I was lucky enough to travel on three of those clinics during my time here as they were really adventures, both in the sense of exploration as well as the medical sense. We saw amazing scenery along the drive (and I was able to drive my own vehicle once), often through regions with very little in the way of roads so you had to feel you way along, across dry lake beds and rivers that were sometimes not so dry, all to serve an area where the Hadza lived, the last hunter gatherers of Tanzania. In addition to the FAME staff, the operations for the clinic were organized by Paula Gremley and Amir Bakari Mwinjuma, two wonderfully generous people who worked to provide health care in under served areas of Tanzania.

It was Paula and Amir who first suggested organizing a smaller version of the mobile clinic to provide just neurological care to some smaller villages in the Karatu district. I first traveled to the villages of Kambi ya Simba and Upper Kitete with Paula and Amir sometime in 2011 or 2012, and have been providing neurological care to this area since that time with the help of FAME. I quickly realized that these “mini mobile clinics,” as I first called them, were an important part of providing neurological care to a community where it wasn’t as much an issue about access, but rather the fact that many of these patients had treatable disorders such as epilepsy and were completely unaware that they could be treated. A trip to FAME for healthcare was not impossible for the residents of these villages, they just had never sought treatment or had often been treated with subtherapeutic doses of medication that were never effective for obvious reasons.

The FAME Neuology Mobile Clinic has now been a service that we’ve provided every six months during our visits here and since 2013 has also included the neurology residents that accompany me here. In addition to Kambi ya Simba and Upper Kitete, we have also continued to provide neurological care at Rift Valley Children’s Village in Oldeani. One of our weeks here is devoted to these mobile clinics where we take our vehicle, a nurse to dispense medications, our outreach coordinator (Sokoine), one of FAME’s doctors, a social worker, and an interpreter. Ema, a mainstay at FAME since its inception, most often comes as a driver in case anything should happen to our vehicle along the way. We bring along all the medications we may need to dispense during our clinic, our lunches (usually purchased on our way out of town – all Tanzanian street food and delicious), drinks and whatever else we may need for the day.

This was our week for mobile clinics and today was the first day we would hit the road to provide neurological care to the villages. The first day of clinic used to be hectic as it seemed I was always running around to make sure we had everything, but that has no longer been an issue as our medication box (a very large Rubbermaid tote) is made up well in advance and Sokoine has prepared everything for us. We usually plan to leave around 9am, but typically something will come up such as a patient to see in the ward though this morning, things went smoothly. We attend rounds at 8am with the other doctors and at 8:30, I was able to break away to get the vehicle packed and things organized. We left shortly after 9am and stopped in town at several shops to pick up things for lunch as well as some power steering fluid as it turned out ours was leaking and needed to be refilled. After all of that was done, we were on the road and headed for our first village of the week, Kambi ya Simba.

The drive to the Mbulumbulu region is through Rhotia Valley that parallels the great rift and is tremendously beautiful. Even in the dry season now, the fields are full of crops and the residents are all out working in them, waving as we travel by. The land here is perfect for farming with the influence of volcanic activity now topped with fertile soil. We pass field after field of crops as we travel and through some small villages with all the normal activities that one would expect along with those milling about the small shops that are no more than clapboard shack with a door and window. Many are just made of sticks and dirt with anything for a roof that will repel the rains, or sometimes not. Older men sitting on benches outside the shops, conversing or playing games. Two old men playing checkers that I would have loved to photograph, but we were on a mission and unless we’re providing medical care to them they are typically less than enthusiastic about having their pictures taken. These are a very private people and their daily activities are their own, not to be shared, but rather respected.

Since my first coming to Kambi ya Simba they have build a new community health clinic so we have a place to set up shop with desks and chairs. Previously we would see patients in the small labor ward sitting on beds in a less than optimal situation. When we arrived there were lots of patients since and waiting for us and the first thing to do was to create a list and screen our patients to make sure every patient had a neurological problem as we are not practicing general medicine here as that would alienate us with the government nurse and clinical office who provide that. We had about twenty patients to see and considering we were starting now at 11am, we capped the list to make sure we wouldn’t end up spending the night here. In the past, we had spent two days at each village, but this visit we were only spending one so it was a bit more necessary that we saw everyone possible. Dr. Badyano will be accompanying us for the week and today he worked with Kelley so she could teach him about neurology and our examination. We try to work with the doctors who have expressed an interest in learning neurology and Badyano has impressed all of us since being here. Laurita worked with Salina as an interpreter today and the two will switch off tomorrow so both will have a chance to work with Dr. Badyano during the week.

The Mbulumbulu region is almost exclusive Iraqw, many of who have never traveled beyond the borders of the community and speak no Swahili. Therefore, we must often rely on have three-way conversations using an Iraqw to Swahili translator and a Swahili to English translator. It is hard enough to take histories here that when this occurs it often becomes quite unwieldy. Ema, our driver and jack of all trades, speaks Swahili and Iraqw, but no English. Luckily, Salina speaks Iraqw and English making it much easier, but it seemed that Laurita drew the straw to the see the Iraqw only speaking patients today. Clinic was a mix of return and new patient and all types of pathology. We have maintained notes on all the patients from the beginning of our mobile clinics, but the notes, though alphabetized in the past, seem to be in some disarray and at times difficult to find. What we’d do for a database that we could use here, but there is no mechanism at the current time to tie into FAME’s database or even reliably access it online given the Internet situation here. Perhaps a project for the future and something to discuss with Susan.

We took our lunch break around 1:30pm and sat in the car to eat. Samosas, “vitumbua,” (fried rice cakes), chapati, and other assorted staples of a Tanzanian lunch. They are delicious and definitely help with our hunger pangs. We completed our patient list at a reasonable time and left Kambi ya Simba for home, arriving back into Karatu at 5:30pm to drop off all the staff in town and make our way back to FAME. Monday dinner is fried chicken with potatoes and green beans which are just perfect for our relaxing time along with a beer to watch the always marvelous sunset from our back porch. We just couldn’t ask for more than we have here. It has been a very bright moon that doesn’t rise until later in the evening so the stars have been phenomenal. The Milky Way looks like a thick belt of white across the pitch black sky along and with the clearly visible red planet of Mars make us all feel like wanna be astronomers.

Having to awaken at 5:45am isn’t something one looks forward to after a night of dancing, but thankfully we had arrived home early enough the night before that each of us was in excellent shape for our adventure to Empakaai Crater. We had planned to meet Sokoine and several others along with our guide, Phillipo, at the TFA (Tanzania Farmer’s Association) gas station downtown. Phillipo was our guide from last March and is a registered Maasai guide who regularly takes visitors to the Crater. Halima and Rahama, both nurses at FAME, were coming along with us to visit a young mother who recently had twins at FAME and lives in the Conservation Area on our route. David, another nurse at FAME was going to hike into the Crater with us.

October is the busy season for Ngorongoro Crater and the Serengeti so we had planned to arrive at the Ngorongoro Gate early enough to miss most of the crowds. As they say, though, best laid plans of mice and men…. You have to check in at the office to get your final permit to enter and the “system” was down so there was a mass of safari guides all waiting to get their permits. Thankfully, Sokoine was nice enough to wait in line as I’m sure I would have been constantly shuffled to the back being the only mzungu there. I had previously mentioned picking up our paperwork at the headquarters the day before, but it turned out that there was a problem with our paperwork. I had paid everything in US dollars and that was fine for us, but the Tanzanian citizens fee had to be pain in shillings. So even though I had paid enough for everything, there was apparently no remedy as we were told that the computer system did recognize paying dollars for the Tanzanians. We were eventually told to wait for the boss to arrive and then we might get permission to pass through the gate, but would have to pay the TSh at the main headquarters in the park which was in somewhat the opposite direction than we were heading. The boss told us OK, but we were set back by at least an hour at the gate and another 30 minutes wasted going to the main office on the opposite side of the Crater from where we were planning to drive. So after a considerable delay and having to pay an extra $30 in TSh (my overpaid receipt with $ is theoretically refundable, but it would take months here to do that and it’s simply not worth it), we were finally on our way and driving into some of the most beautiful and extreme landscape one can ever really imagine, the Ngorongoro Highlands. This is the heart of the Ngorongoro Massai community where they graze their cattle, sheep and goats and share the Conservation Area with the tourists so that it is a dual use land. Luckily for us, there is very little tourist traffic into the Highlands as most vehicles would be heading either into the big crater or around and past it on their way to the Serengeti through the Naabi Hill gate.

The drive around the big crater rim is spectacular to say the least. The walls of Ngorongoro Crater are 2000 feet high and the crater itself is over 10 miles across. There are a string of three main craters that are actually calderas and on the opposite end is Oldoinyo Lengai, or Mountain of God to the Maasai, and a still active volcano. Driving up the to the rim from the gate is like traveling back in time to the age of the dinosaurs as the forests become thick and ancient and in the morning the clouds are rolling over the rim adding to the feeling that you are in another time. Arriving at the rim overlook, it was very chilly and with the clouds still rolling over, the views were somewhat limited. We knew they would be better later in the day, though, so we pressed on to Empakaai.

Driving across the Highlands there are innumerable Maasai bomas everywhere, but the land remains open and distances are vast. Sokoine grew up here so we had entrusted our day with he and Phillipo as this was their home. Countless herds of livestock were grazing, each with their owners or owner’s children keeping an eye on them so that no mischief could occur. Herds of zebra also roamed the landscape and we encountered an occasional jackal or two in search of their next meal. We found one running along with a mole it had caught in it’s mouth and a clear sense that it wasn’t willing to share its trophy with anyone. As we left the plains of the highlands we ascended towards the rim of Empakaai Crater and through thick forest that lines the slopes on both sides of the rim. We finally had a good view of the crater, another caldera, and the lake that occupies the majority of its floor. We found a good spot to leave our car in the shade near the beginning of the trail that takes you to the floor. Out of nowhere, a small family of Maasai women and children appeared to show us jewelry that they hoped to sell. We decided to hike first and shop later, so we loaded up with our cameras and water and began our descent down the dusty trail towards the crater floor. Every step seemed to take us further back in history towards a time before man as we know him. It was very easy to imagine our distant ancestors on this trail long before us seeking out game or new lands. The trees were like none we’ve ever seen before and Phillipo identified one to us as one of the Maasai Gods of which there are several. He described using strips of its bark in the Maasai circumcision ceremony due to its sacred nature.

We finally arrived to the floor and left the forest to walk out onto a surreal landscape of grass and alkali encrusted mud with a large lake in front of us. There were huge flocks of greater flamingos that flew back and forth across the near shore in a beautiful display of color and form. They were very loud and sounded like a muffled herd of wildebeest as they mingled amongst themselves in some sort of organization I am sure. They were quite skittish, though, and as we walked along the shore in their direction, it didn’t take long for them take flight and move to another nearby spot that was far enough away for them to feel comfortable.

There was another group of hikers, two tourists and their guide, who had walked in the opposite direction of us, but were visible in the distance. Several small groups of Maasai cattle were grazing on the opposite shore from us and were hardly a distraction. This lake is frequented by other animals such as Cape buffalo, Reedbuck and several types of monkeys, but is also the home of lions and leopards so one must be ever vigilant. We have Phillipo there to protect us with his Maasai spear, but somehow were all a bit dubious and would rather not take our chances today. We spent an hour or so on the floor of this truly unique landscape before we decided to make the ascent back to the rim. The trail went straight up the slope, save for a few yards of brief downhill here and there and it was a real test of endurance. Being more than twice the age of everyone else present other than Phillipo, I did have to take more breaks, but also felt a real sense of accomplishment in the fact that we made it up faster than Phillipo had predicted, even with my rests. Kelley and Laura, of course, bolted up the hill, though we’re respectful enough of their elder to take some breaks. Despite this, we made it back up to the vehicle in less than the expected time and found the Maasai family patiently waiting for our return. Laura and Kelley both bought a few bracelets from them feeling some obligation for the fact that they had waited, when it reality, they spend their days there hoping to sell things to visitors. Everyone was happy in the end so all was well.

We hadn’t brought lunch with us as we had had the intention of hiking in the morning, but our delay at the gate and having to go to the main office had all but negated that possibility. It was now almost 2pm and everyone was starving so we made a beeline for one of the local villages were Sokoine knew there would be a market going on. Maasai markets occur in each village either monthly or sometimes twice a month on a regular basis and which is where you can buy almost anything from home staples to jewelry to the local home brew and even a cow if you’d like. We drove into the center of the village during the height of the market which was quite and entry considering no roads of even trails were present and we were driving quite a big vehicle. I parked and as we all exited the vehicle it was quite clear that we were somewhat of an attraction for them – the only three mzungu for miles around and quite possible the first ever to their market. We walked around looking for food and the only grilled beef we could fine was pretty sparse as far as the beef was concerned. We had told Sokoine that we were under his care and would eat whatever he thought was appropriate, but even he and Phillipo seemed to think that this was inadequate. Luckily, Phillipo called to a friend just down the road in the village of Nainokanoka who had a restaurant and could prepare lunch for us. We all piled back into the Land Cruiser and made our way to town, all with the thought of a delicious lunch.

We arrived to Nainokanoka in very short order and drove into town in much the same fashion as when we arrived to the Maasai Market. We pulled up in front of a shack with a tarp covering the front and were directed to head inside and take a seat at a small table that had six chairs, one for each of us. Rustic would not totally encompass the ambience of this establishment, but we were all thrilled that we’d be having a very genuine experience in very short order. They brought us each a bowl of goat soup – a meat broth with chunks of goat – followed by a chapati for each of us. Though we were all starving at the time and probably would have been happy with just about anything, the soup and goat meat were actually quite tasty and the chapati was perfect for dipping into the broth. While we were all eating, there were chickens of various ages scurrying around the floor and trying their best to keep from underfoot. When the small group of goats came through, though, it was just a bit disturbing considering we were in the process of eating one of their brothers or sisters. Thankfully, goats are not a vengeful animal otherwise it might have gotten out of hand. Never the less, I still had the feeling that they were coming through asking, “where’s Charlie, he was here just a minute ago?” The owner of the restaurant was tickled to have us there, undoubtedly the only mzungu to have ever eaten there, so we took pictures with every various combination of family member. The kitchen was tiny with an open fire and the cook was working on preparing more chapati as we were leaving.

We departed Nainokanoka after picking up Halima and Rahama from their visit and began our exodus from the conservation area. The drive back to the rim and then around to the overlook before our descent back to civilization was a long one, but once again, the scenery was spectacular. Back at the overlook we stopped to take a few more photos and then headed down. At the gate, we amazingly had no issues this time and so it was back on the tarmac and back to Karatu where we arrived in time for another lovely sunset.

The land we traversed today was some of the most unique and picturesque in the world. It is also some of the most important as man first walked upright here and it was easy to imagine him trekking along the landscape as we made our travels in this marvelous country. This is a rugged and, at times, an unforgiving place, but for those with the stamina and ability to survive, it is also a home far unlike any other on this planet. There is also a resilience here unlike any other I have known before.

We have spent five long and very full days seeing neurology patients here at FAME and had decided on working Saturday as well to finish whoever might be left. Lifestyles are different here so opening on a Saturday is not necessarily a death sentence for having a full clinic as it would be at home where it is so difficult to take time off of work. If they are working, most here work for themselves so that is not at all an issue.

Last March, I had asked if Renata, Daniel Tewa’s granddaughter, would like to work with us on a Saturday when she wasn’t in school. She was a natural at translating for us and, even better, she spoke fluent Iraqw when we had patients who didn’t speak Swahili. Last night, I again asked if she could spend the day with us and she was more than thrilled, so I picked her up at her home at 8am. She was ready for work including the reflex hammer I had given her last March. She was again a superstar and Dr. Laura taught her the neurological examination throughout the morning so that she was actually examining patients by the end of the morning. She is very smart and I have no doubt that if she wants to go into medicine she will be successful at it. Hopefully, she’ll even consider neurology!

As we were planning to go hiking into Empakai Crater the following day, I needed to go to the bank and to the Ngorongoro Conservation Area office to get our permits. Some time ago to prevent the temptation to embezzle money, the authorities did away with using cash at the various offices and gates of the parks. They set up a system whereby you go to the bank and deposit money into the appropriate account and then have to go to the office with the receipt for you deposit for them to give the necessary permits to enter. I went to the office with Sokoine to sort our how much we needed to deposit since we had the three of us, three Tanzanian citizens and two Maasai who live in the conservation area and don’t have to pay. I dropped Sokoine back at FAME and then ran back to the bank just before closing time on a Saturday which was needlessly to say quite crowded. I gave the appropriate amount of US dollars and then ran back to the conservation area office to show her my receipt and get our entrance permits. I finished this just before noon when all of the offices would close until Monday.

We finished our neurology clinic early (thanks to Laura and Kelley since they were seeing the patients without me that morning) and all met for our favorite lunch of rice and beans. Both Laura and Kelley wanted to shop for cloth to have some clothes made so it was decided that we would all go shopping with Renata in tow as our interpreter. It was not long, though, that we ran into Salina in town so she tagged along to help with translation at the shops. There was a patient that Laura had seen earlier in the week who owned a fabric shop, but it wasn’t entirely clear to us where her shop was other than Sokoine telling me that it was near the new bank in town. We first went to find her, but could not after an exhaustive search, so we abandoned that and decided to go to a shop where I had brought residents previously with good experiences. That shop had nice cloth, but the tailors we had used before apparently were not there any longer and we couldn’t be certain that the clothes would be made exactly to order. We continued to search for an acceptable shop in town when we finally heard back from Laura’s patient, Witnes, who said she would meet us near the new bank and take us to her shop which was close. Well, she walked us through backyards and fields loaded with pigs, cats, dogs and whatever else one could imagine until we finally arrived at her small shop. The girls immediately began looking at cloth and almost as quickly found some they liked. After ordering some skirts, Laura needed to check on something for her niece, but didn’t know how to size it. Witnes left through a back door and conveniently returned moments later with a baby about the approximate size of Laura’s niece so all was well. By this time, we had attracted the attention of some of Witnes’ normal patrons who began to collect along with some of their children. One was the cutest thing with tiny braids covering her entire head so that I initially thought she had a wig on.

We finally left Witnes’ shop after a fair amount of time and Laura wanted to stop at one of the other shops she had initially seen. The women in this shop were very helpful and both Laura and Kelley quickly found more cloth they liked and ordered a few more skirts. These are all hand made out of cloth produced in Tanzania and are in the most beautiful patterns you can imagine. The sewing machines are all manual and peddle powered. The workmanship is very fine and all this for a fraction of what you would have to pay in back at home if you could even find someone to do it. And even with that, you could never find such wonderful cloth. It was also a blessing that we had Salina and Renata with us to help translate what the girls wanted and I’m not sure what they would have done without the two of them. By now, we had spent several hours in town shopping and it was time for us to head home. We bade Salina farewell until Monday and Renata was heading to her parents shop on the other side of the tarmac. We will see Salina on Monday and Renata the week after next when we visit her family again.

We traveled back to FAME to relax for a few minutes before going out for dinner. We had plans to meet Sokoine along the tarmac and then head out for dinner at a good nyama chomwa spot. Nyama chomwa in Swahili literally means “burnt meat” and is there form of barbecue. When you enter the restaurant, you normally tell the butcher how many kilos (pre-cooked) you’d like and which piece of meat hanging that you would like and they put it on the grill for you. The restaurant we were attending tonight had enough guests eating that their meat was pre-grilled and you picked out you pieces and then they sliced it up for you. It’s served on a tray with pili-pili (hot sauce) and salt on the side along with separate “chipsees” which are French fries. We ate beef on this night, but you can order goat or lamb as well if desired. This and a cold beer makes a great dinner. It was the three of us, Alex and Sokoine and we very much enjoyed our dinners.

We left the restaurant with plans to go dancing at Carnivore, a pub that serves only grilled chicken, chipsees and fried plantains as well as beers and wine, but more importantly, they have a small dance floor and it has been a tradition for us to go dancing there since our last trip in March when we had an amazing amount of fun. Considering the three of us missed the pre-interview season Happy Hour back at home, I felt it was only fair for us to have a night out. As we left our dinner restaurant on our way to Carnivore, we bumped into Dr. Badyano on the street and he very quickly joined us with the intention of dancing. When we arrived at Carnivore, no one was dancing, but we quickly lit up the dance floor as the music was great and entirely inviting. Laura and Kelley were, of course, the life of the party and who would have expected anything less from them. We finally attracted a contingent of locals to dance with us discovering that some were a group of visiting teachers and another was a local businessman. Even the waitresses began dancing with everyone and it was the most fun I’ve had in sometime. As we had plans to go hiking in the Ngorongoro Conservation Area the following morning and leaving at 6:20am, we decided to head home shortly after 10pm or we were afraid we wouldn’t be able to get up. We drove home in the dark, all quite happy with our accomplishments for the day and equally happy with the recreation and the ability to let off some steam that night. Needless to say, we all slept well with dreams of seeing more of this paradise on the following day.

Since we were planning to work on Saturday, this wasn’t the last day of the week for us. We did have plans, though, to visit with Daniel Tewa and his family during the evening and have dinner with them, who there was much anticipation throughout the day. More on our evening with the Tewa family and dinner later.

As for patient updates, our 95-year-old Bebe was much more cooperative the following morning and was now willing to take food and medications. We were able to give her a mild antipsychotic medication (olanzapine) orally now and she continued to be more cooperative throughout the day. Her family was quite happy with the result of her treatment though, of course, her dementia will be no better as that is an irreversible process.

One of the main complaints that patients come to clinic with is often memory loss, perhaps not much different than we see in the States. When you’re dealing with an 80-year-old your initial impression will be to screen them for dementia, but when they’re younger it requires a bit more questioning to tell exactly where the problem is. When they’re in the 40-60 year-old range it’s most often poor attention and focus which is usually the result of depression and anxiety. We see many patients here who are depressed as I’ve mentioned in prior blogs such as the mother of five who lost her husband to cerebral malaria and is trying to figure out to cope. But something we have seen here more often than we get to see in our clinic at home are the 20-year-olds who are brought in with the chief complain of memory loss. When we get further history, it is more one of confusion and agitation and you immediately know what you’re dealing with.

Today was Kelley’s turn to deal with a patient such as this and whose diagnosis was schizophrenia. The patient had been brought in by his father and it was clear that he was getting more agitated the longer the interview took place. She was working with Dr. Ken today and by the time the interview was over (which was shortened due the patients growing restlessness), Sokoine had been called in to assist and the patient wanted nothing more to do with Kelley or Ken. I came back in to check on things and they made it clear that they were concerned about the patient’s status as far as his agitation and wanted to get a medication on board faster than was possible with an pill and it was likely he wouldn’t take one regardless. Thankfully, we have injectable haloperidol here (what I had used previously on Bebe) and we loaded up a syringe to give him the medication. As I mentioned, he wanted nothing to do with Kelley or Ken and would very likely not let them near him with a syringe. Sokoine isn’t a nurse, so that left me as the one to give him the intramuscular injection. I sat with him for a minute and then we asked him to uncover his upper arm from under his shukas (the traditional Maasai blankets they wear) and his jacket. He was very compliant and I gave him the injection without trouble whatsoever. Shortly thereafter, he calmed down enough for us to get some screening labs and we sent them on their way with an oral antipsychotic medication (olanzapine) to use on a standing basis. Unfortunately, his condition will not change going forward and the best we can hope is to manage his symptoms.

Our clinic day came to a close early enough today for everyone to make the regular FAME bus down to town which they were all very excited about. For us, it meant some time to sit in the volunteer office and catch up on emails and work before heading off for our evening with the Tewa family.

I’ve mentioned Daniel Tewa numerous times in my blog on previous trips, but for those of you who haven’t been following, I met Daniel in 2009 while on my original visit with my children and we reconnected on my return to FAME in 2010. We have been friends (family) since that time and I have spent time with his family on every return visit then. Daniel is an amazing individual with eleven of his own children and one adopted (after the mother died in childbirth) and he has put them all through college over the years. To say they are an incredible family is an understatement. Daniel and his wife, Elizabeth (who speaks no English and mainly Iraqw) are cultural ambassadors for the local Iraqw tribe and safari tours as well as college students come to visit with him so he can share stories about the history of Tanzania and more specifically, the Iraqw. In the 1990s he built a traditional underground Iraqw house, similar to what he lived in until he was 20 years old. They lived in these houses, along with all of their livestock, to protect them from the Maasai who they were in constant conflict with as the Maasai had the belief that God had created cattle for them and they were merely taking back what was rightfully theirs. That conflict didn’t end until a treaty was finally signed in 1986 after being approved by the Maasai and Iraqw elders. I bring the residents here to sit with Daniel while he shares his stories as part of the cultural experience for their visits. But in addition to his stories of Tanzania past, he is also always up to date on world politics and loves to question us about what are thoughts are about whatever is going on in the US at the time. Obviously, the current election on everyone’s minds this evening so it was the topic of discussion.

We sat with Daniel outside his home having drinks and enjoying each other’s company until well after dark. As we sat, young people from the neighboring secondary school continually marched by on their way to get water or do chores as they were all Iraqw and well-known to the Tewa family. At one point, young Renata, Daniel’s granddaughter who is now 12 and who I’ve known since 2010, came running up to give me the biggest of hugs. I introduced her to Kelley, Laura and Alex (our volunteer coordinator who we had invited to come along) and she eventually went off to help her mother prepare our dinner for later.

After all our talk of the history, politics and a thorough tour of the underground house (which he doesn’t live in as it is only for demonstration), we walked a short distance to his daughter’s house for dinner. Isabella and her husband, Christopher, are both teachers and have hosted us for dinner over the last several years as the group has become too big to eat in Daniel’s tiny living room as I did during my initial visits here. Danielle Becker was the last to each there when the dinners were traditional Iraqw as they have now become more Westernized and probably appreciated by the visiting residents. When we arrived, we were warmly greeted by everyone as they consider our visits to be a tremendous honor to their family, when it actually we who are so honored to be taken in to share dinner with their family. Daniel has referred to me as “professor” since we first met when my children and I were volunteering at the school in his village of Ayalabe. We sat for a bit in their living while we all couldn’t help paying attention to the television in the background playing Al Jazeera news, the first television we had seen since our arrival here weeks ago.

Isabella, Christopher and several other family members kept bringing out dishes of vegetables, rice, and meat and after all were in place we each took a dish to serve ourselves. At the moment we started serving, the electricity went out, but they had a battery powered light in the living room so all was well. The food was delicious and amazing, the best we’ve had here in Tanzania, and as we all finished our first plate, Daniel began to pass around the pots for everyone to take seconds. And he made sure no one went without seconds! It was just us and Daniel at the table even though there were extra seats as this is how honored guests are served. Christopher sat on the couch with his plate next to Renata while Isabella continually came in and out out of the room fussing with plates and preparing desert. Women don’t normally sit with the men at dinner as they are preparing food and that part of their tradition has continued. We were stuffed well before Isabella put desert on the table, but we all managed to have some. After dinner, Daniel presented each of us with a bag of coffee as a gift when each of us felt that it was us who should be giving them gifts. We walked back to Daniel’s house in the light of a nearly full moon that left strong shadows of each of us along the dirt roads so there was need for additional lighting. It was another incredibly lovely evening that we all remember. More importantly for me, it was another opportunity for me to connect with a man I will always admire and a family I will always consider as my own. This is why Tanzania means so much to me and to all of those it has touched over the years and find themselves returning again and again.

Well, I had all but caught up with my blogs and quite content until movie night. Last night, we decided to watch a movie on the computer and all huddled around a small screen Mac to watch “Looper,” a great sci-fi time travel movie which are my favorite. Kelley and I had seen it before, but it was Laura’s first time and she loved it as well. Not quite the same as watching it on a big screen television at home with surround sound, but equally as enjoyable considering we’re half-way around the world in a place with few of the luxuries of home and where we can often hear hyenas in the distance at night as we sleep. So, needless to say, I enjoyed the movie last night as opposed to typing my blog for the day, but it was worth it.

 

 As part of our room and board here, we have dinner cooked for us each weeknight and must fend for ourselves on the weekends. We come home to our house and on the counter are three hot pots, one for each of us with our dinner and fruit for dessert neatly tucked inside. Monday night is fried chicken and Wednesday night is pork loin with the other nights being potpourri. Each hot pot has one of our names on it and they are left in the appropriate house that each one of us is staying in. Two nights ago, we can home to “Dr. Mike,” “Dr. Kelley,” and “Bill” hot pots. I had no idea who Bill was as I was fairly certain there were no volunteers here with the name of Bill so we were quite confused. We presumed that they had just put the wrong name on it so Laura had absolutely no issue with eating “Bill’s” dinner and the spaghetti with veggie sauce (quite delicious!) disappeared in very short order. After we had all devoured our dinners (you develop quite an appetite working here considering there is no snacking in between meals), Laura went over to Alex’s house just to check and see if there really was a “Bill” here only to find out that a consultant mzungu computer expert from Kigali had arrived that day whose name was Bill and was staying with Alex. Oops!! Well, all turned out well in the end when Laura returned with her actual dinner (with the right name) after having discovered that Bill is actually “allergic” to onions and was more than happy to forego his dinner which was very quickly turned into leftovers in the refrigerator after Laura took a rare opportunity here to have seconds.

Our day in clinic began as most with both Laura and Kelley participating in morning rounds in the wards while I made preparation for our clinic which meant unlocking the ER and meeting with Sokoine to see what the schedule would be for the day. This morning I also decided to post my blog which meant battling with the Internet, a typical pastime here at FAME. We have multiple WiFi networks and can access a few of them, but nothing is hooked up to cable or satellite and so however you access the Internet, it’s over a cellular network. That means that it’s not only quite slow, but the speed and connectivity seem to fluctuate with the whims of the atmosphere while in reality it has to do with how many people are also accessing the Internet at the same time as you. To upload my photos, post the text and insert the photos in their appropriate place can take from 30-60 minutes of wrestling with the Internet. This is another expected source activity here and has to be planned for in your day. And then there is the time difference, of course. We’re checking our morning emails which are from the day before and then replying to them overnight so they can be read the following day. Not the most efficient, but it works in the end.

Today at lunchtime, FAME was celebrating the return of a few doctors and the departure of Dr. Anne, who will be going off to Assistant Medical Officer school for two years. This is a big event and means a special lunch for which all of us were excited. FAME continually sponsors their clinical officers and nurses to advance their training which is a hugely positive thing for everyone. It is difficult for someone to afford to go back to two years of schooling after they are already working and a big commitment for FAME for cover these costs, but the advantage of having highly trained clinicians if obvious and why FAME has the reputation in the country that they have. Meanwhile, though much less significant, it meant a fantastic lunch for the rest of us – half a roasted chicken, grilled plantains, shredded salad with tomatoes, watermelon, a banana, and cake! It’s a wonderful time for everyone as the entire staff comes out at the same time to participate in the celebration with kind words said for those being honored and lots of food. We were so glad to be a part of it.

Kelley’s patient today with advanced Parkinsonism was very interesting case. He was brought in by two of his sons and was very bradykinetic. He arrived in a wheelchair and was unable to ambulate. His exam was difficult due to the fact that he was so advanced and I he had never been seen by anyone at any medical center save for Karatu Lutheran Hospital where I can guarantee that he hadn’t seen a neurologist as there is only one other in Northern Tanzania and who’s at KCMC in Moshi. After our evaluation, it was clear that he had some underlying neurodegenerative process either representing advance PD, progressive supranuclear palsy or less specific disorder such as MSA-P. We decided to give him a medication trial with carbidopa/levodopa starting very slowly and will come back to see us in two weeks while we’re still here so that we can see if the medication is helping him and adjust it accordingly.

We also had a request to see one of the FAME staff today who was having acute back pain superimposed on a history of chronic back problems. Laura saw him and his exam was remarkable for only a missing left knee jerk, but was otherwise totally intact except for the pain which was quite substantial. Though we would manage the acute pain the same way regardless, I felt it would be helpful to obtain a CT scan of his back at some point and checked with Frank (i.e. The gatekeeper) as to whether we would get it sooner or later. Sooner won out and so we proceeded to warm up the brand new FAME CT scanner that would take an hour for it to be ready for us. Once ready to function, Laura and I went to the new radiology building where the scanner resides along with a complete radiology suite to do plain films, etc. We have a tech, but no radiologist at present, so the CT scan would be read by us, though we have plans to send it back to the US for a more qualified to look at. The study didn’t show anything concerning which was a relief in this situation, but we’ll have more information when we get the read from back home. There is a new MRI scanner in Arusha that was installed in March, but it is quite expensive to have this done as one can imagine.

I ended my clinical day by being called to the ward to see a 95 y/o Bebe (old woman) who had been brought by her family for confusion and refusing to eat or drink. She had a nine year history of a gradually progressive decline in function consistent with dementia and was no becoming more and more agitated such that she had to be restrained by her family in the ward. She was mumbling incoherent words and constantly resisting any attempts at restraint by her family. I did as good of an examination as I could given her agitation (she quickly grabbed my reflex hammer from me) – she had contractures of both lower extremities clearly indicating that she had been bedridden for some time. She had no other obvious findings other than her agitation and delirium likely superimposed on a chronic dementia. We were unable to consider any oral medications as she was refusing everything, but thankfully we had injectable haloperidol for her. The only issue was how much to give a 95 y/o Bebe? Well, 2.5 mg IM worked quite well and within about 30 minutes she was much more comfortable and calm. Hopefully, she will be willing to take food and medicine orally going forward.

And now that takes us back to movie night. The evenings here have been wonderful with clear skies and amazing sunsets. We try to make it to Joyce’s “dinner” (more on this in a moment) veranda to all share stories of the day and previous visits when FAME was in its infancy. It is so relaxing to just sit back in the soft rays of sunshine, the jacaranda trees lighting up the horizon and sun getting ready for its evening ritual. The Raynes House now has the beginnings of a roof and is really taking shape. I will plan to do a walk-through with Nancy to look at how things are progressing and begin to discuss furniture. The “dinner” veranda reference comes from the fact that the veranda on the new house will be the “breakfast” veranda so as not to impact on the great evening dinners we’ve had at Joyce’s. It was not a difficult concession to make.

I rose well before sunrise this morning to catch up on my writing. These mornings are so pleasant with the soft sounds of the awakening day outside between the many birds and other animals along with the sometimes far off shouts of the villagers traveling to or from their early destinations. The cool mornings have been a bit much to sit outside and write these days which is fine as our house is so cozy. I can’t wait for the Raynes House to be finished and ready for our occupancy, which should be by March, as it will give us a base for our continued work here. We will have a home to return to each visit.

As the days of the week roll on, the volume of the outpatient clinic lessens slightly as do our neurology patients and it seems like we are making some headway working through the numbers that we must see. We still have more than enough patients, though, to send a few home each day to return the following morning and be seen at the front of the line. Our patient flow also has improved in that our patients are now sent directly over to our waiting area where they can be screened and have their vital signs taken by nurses in a small room just outside the emergency room. This system is working so much better and it is clear that the patients are much happier not having to be walked back and forth in the process. This will clearly work well in the future.

We all ran up a few minutes early to attend to emails and texts as the only internet is up at the administration building and my phone works best there as well. Laura and Kelley attending morning rounds to hear how the ward patients were doing while I posted my blog and got things together for the days clinic. In addition to seeing whether there is any “business” for us on the wards, the two of them have much to add from a medicine standpoint given that they are so close to their intern years and mine was thirty years in the past. When I went to retrieve them from the ward as we were ready to see patients, they were discussing some non-neurologic aspects about a patient with Dr. Badyano which was great as I know that their contributions are very much appreciated by the staff here.

Kelley’s second patient of the day was another fascinating patient. We are seeing disorders here that they rarely, if ever, get to see at home so the experience here is invaluable. A 26-year-old Maasai man was brought in by his mother and the story was that he was well until after he underwent his circumcision ceremony at age 14, following which he began to develop leg weakness and difficulty walking. The Maasai circumcision ceremony is performed only every seven years and is one of the most revered of ceremonies they have as it is the time that the young men will leave their boma and go into the wilderness to become warriors. They used to have to kill a lion for this ritual, but that is obviously no longer the case. The other interesting nuance to the story is that everything here is always related to an event that occurred in the past as it is the only way they have to relate something in time. The passage of years is very difficult to convey in a story, but the relationship to an event is much easier.

After hearing the history, both Kelley and I were fully expecting the young man to have a neuromuscular problem such as muscular dystrophy, but in the end it was quite different from that. He was cognitively intact so that part of the exam didn’t lead to any new discoveries. The next part of the exam is to look at their fundus with the ophthalmoscope and when Kelley did that she thought the patient kept moving his eyes, but quickly discovered that it wasn’t his fault as he had nystagmus. Nystagmus is the subtle, or at times not so subtle, movement of the eyes and there can be various types of nystagmus. The important part, though, is that it indicates a central nervous system problem. So, from the outset of her exam it was clear that the problem wasn’t going to be a neuromuscular one, but rather a central nervous system disorder. Given the issue at hand, that is, his problem walking, we both immediately knew that his strength was going to be normal and source of his deficit would not be what we had both initially expected. He had dramatic cerebellar dysfunction, or ataxia, on every aspect of his examination and it was great that we were seeing him with Dr. Ken so he would clearly recognize this in the future. He even recalled the lecture he had been given in assistant medical officer school from which he recently returned that dealt with the ataxias and cerebellar dysfunction. I had seen a similar patient last week and regretted that the residents were here to see them, but here we had another patient with this rare group of disorders classified as the spinocerebellar ataxias. Kelley’s patient had loss of reflexes, though, as opposed to my patient who had clear evidence of corticospinal tract involvement so the two patients were very likely different versions of this group of disorders that are usually sorted out by doing genetic testing in the US. That obviously is unavailable here, but in reality it primarily serves to help with genetic counseling rather than with any treatment of which there are none. These are progressive disorders that eventually become quite disabling. We provided the counseling we could and the fact that this was something that could be passed on to his children as he was planning to be married shortly. Given his young age and the amount of difficulty he had walking at the present, it will not be long that he will need significant help getting around.

Kelley also had a very interesting Parkinson’s patient who was on carbidopa/levodopa already, but his dosing schedule was the problem. He had profound tremor that was actually responding to the medication as was his rigidity, but he was taking his medications only twice daily and a large amount with each dose so as to be causing him nausea. It was just a matter of scheduling his dosing to every four hours during the day with a smaller dose each time and he will tolerate his medication much better and it will work much more effectively throughout the day. This adjustment is not that different than what we often do in the US when Parkinson’s patients come to us and have been placed on the wrong dosing schedule.

Laura’s experience of the day was with interesting patients presenting often with complaints that also belied their true underlying problem. Multiple patients come complaining of memory loss and when you delve further into their history, it is really a psychiatric issue. We have seen a number of young patients who present with symptoms very suggestive of schizophrenia or schizoaffective disorder and are brought by their families to see us. Psychiatric care here is very primitive and most patients we see with these issues have never been truly diagnosed or even seen for their problem. We do have reasonable medications to treat them with for their psychosis and are able to explain to the family what the underlying problem is. It is also unfortunate that for most of them, this is a lifelong problem that can only be treated symptomatically and will never be cured. Laura also saw two young patients coming in with complaints of headache that also turned out to be something far different as both actually had epilepsy and were having recurrent seizures. After taking a thorough history and sorting out the details, the patients were put on medications and told to return for follow up to let us know how they were doing. Hopefully we will see them back and be able to adjust their medications as this is so often the problem here. We see so many patients in follow up who when we ask if they are still taking their medications, they tell us they are “over” meaning that they took their month of medication and despite having been told to come back for refills, they merely stopped them. It is often a cultural bias regarding the idea of taking chronic medications, but is also often related to being able to afford them. We have worked on a system for the neurology patients to be subsidize some of the cost of the medications as making a diagnosis of epilepsy or migraine and having the patients only take their medicine for a month or even two does not work well. Sokoine meets with the patients and their families after the visit to discuss with them what they can afford and we try to make sure they are aware that we will try to help them when they return for refills. Sometimes it works well and other times not so well. The effort is being made, though, and that is what counts.

Our day finished around five and today the staff working with us found a ride back to town so I didn’t have to make another trip to get everyone home. We got home early enough to relax on Joyce’s veranda and watch the sunset, which is always gorgeous, though quickly leads into the flood of mosquitoes with the darkness. Even with the bats flying low over our heads to devour the insects and fill their bellies before returning to their homes, we are bitten enough to eventually be forced back inside our houses where we ate our prepared dinners in comfort. Tonight was roast pork, cauliflower and we think perhaps sliced cassava or possibly breadfruit. We couldn’t be sure on the latter, but it was tasty and much appreciated just the same. It was off to an early bedtime and thoughts of another wonderful day in this amazing paradise.