October 21, 2017 – A Full Day in the Central Serengeti….

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I had awakened early today with the anticipation of viewing sunrise as there is nothing more magical than sitting out on the Serengeti Plain with all the sounds of nature around you and nothing else, while the horizon to the east begins its transition from a soft glow to the brightness of the new day. There is nothing like a sunrise on the Serengeti for all the reasons you can imagine and no matter how many times I’ve seen it before, it never fails to amaze me that I am here and experiencing it. The night was cool with steady breezes along with the frequent howls of the hyenas and an occasional low growl of the male lion to remind us were we were. I had slept exceptionally well last night and we were all looking forward to the full day we were planning to spend on a game drive.

With the sun fully up by 6:30am, I wondered over to the dining area to see if they had hot water for tea, which, of course, they did, so made myself a mug of Kilimanjaro Earl Grey and sat in a chair looking over the area in front of our camp just admiring the many sights and sounds that filled the air. Several groups of animals such as topis, zebra and even a small band of wildebeest, made their way by the camp in their daily trek looking for their perfect grass. It is like their daily commute, though certainly much less congested than those that we know.

Working on my blog before breakfast with the omelette chef in the background (he made a delicious omelette!)

The camp crew is up very early so had prepared everything already for breakfast, another buffet style meal, though now had a table out front to make eggs to order, including omelettes made to order. The omelette chef was wearing his white apron and chef’s hat as if we were in any fine restaurant for breakfast. As everyone met at the arranged time of 7am for our meal we had to keep reminding ourselves that we were in the middle of the Serengeti. The food was again delicious including the little mini mandazi, small pastries that were similar to donut holes, though not as sweet so were eaten with a bit of honey.

A Dik-Dik around one of the kopjes

Simon had brought the car around already and after breakfast, we grabbed our cameras and things we’d need for a full day away from camp along with our lunch boxes, and headed out for adventure. The air was cool with the sun low still low in the sky, but you could still feel the warmth of its rays on your skin in welcome contrast. We initially drove off to the east of camp out of the hills and towards the many kopjes that dominate the topography of this region of the Serengeti. Kopjes are small outcroppings of rocks that are like little islands in a sea of grass, each one serving as its own community. Lion prides will often remain around a single kopje for a time and then move to others in their territory as they serve as a fantastic vantage point to look out over the plain and to plan their next meal. They do this very much as the cheetah do on their termite hills. These islands of life also include smaller animals such as the dik-dik (the smallest of the antelope), the rock hyrax (a small animal that looks like a rodent, but is actually a relative of the elephant) and various reptiles including the blue and red agama lizard.

In the Serengeti National Park, you must drive on established trails, but they pretty much crisscross everywhere between the kopjes, often consisting of two very narrow tire tracks. We traveled from kopje to kopje heading further east into the bush until we finally came upon what seemed like an endless sea of wildebeest. Each time you thought that you had seen the bulk of the herd, though, you crested a hill and realized that it continued for ever and in all directions. We were in the middle of the main group of wildebeest that made up the Great Migration, the largest single movement of land animals in the world. They migrate in a circular motion following the grasses and were now in the Central Serengeti, but would soon move on to another more promising area depending on the weather. There are about two million wildebeest that migrate between the Serengeti and the Maasai Mara (the contiguous land across the border into Kenya) and even though we weren’t counting the animals before us, I am certain that we were seeing hundreds of thousands of wildebeest stretching out over the hills before us.

As we meandered along the trails amidst the herds of wildebeest, we would occasionally run across their predators, the lions here, that feast on the migration when it is here. One male lion slept in the shade of a kopje alongside its half eaten wildebeest kill from the morning or night before. Another, particularly handsome, male lion that we ran across was walking from a nearby watering hole to one of the larger kopjes as the wildebeest kept a wary eye on him to make sure he wasn’t still interested in them. He eventually meandered over to the kopjes and climbed to its highest point looking like a scene from The Lion King movie. We ran across many other lions that day, many with cubs and all of who looked quite healthy clearly relating to the presence of the wildebeest in the area. We had hoped to see a kill today, but it was not to be, though we were very happy to have seen the Great Migration in all of its glory.

We eventually made our way back to Seronera, the cluster of lodges and camps in the Central Serengeti, and where the airport sits. We decided to have lunch outside the visitor center there and then begin our afternoon game drive. We had seen lots of lions and cheetah in the morning, but we still hadn’t seen a leopard, so that was our main focus for the remainder of the day and with any luck, we’d find one. Leopards are most commonly found in river areas where they rest in their tree during the day and typically hunting at night. Leopards drag their prey into their to protect it from lions and hyenas and so they can feed on it over time. You can often spot what is left of old leopard kills hanging in the trees after they’ve abandoned the carcass and sought a new kill. They are quite powerful and one of their favorite animals to prey on are baby and younger wildebeest, carrying the entire animal into the tree with them.

During the afternoon we found many, many more lions, some with cubs and even found a group of four cheetah, which is very uncommon as they are solitary animals who typically hunt along. This group was made up of a mother and three adolescents who were probably all about ready to leave the nest. They were resting under a tree to avoid the hot sun which was unfortunate as it would have been amazing to have seen this group hunt. Cheetah will typically not pursue large prey on their own, sticking mainly with Thompson gazelle or impala, but in a group such as this they could have easily have tackled a wildebeest and that would have been a sight, For now we have to just be happy to watch them for a bit and then move on.

A bee-eater

A grey crowned crane

We eventually ran across a telltale sign of a leopard which is a large group of safari vehicles all stopped on the road. Sure enough, when we were finally upon them as we had originally seen them in the distance (the vehicles, that is), there was a beautiful leopard sitting up in her tree (the way it was straddling the branch made it more likely it was a female) resting, but awake and moving around. She didn’t have a kill with her that we could see, but she didn’t look interested in hunting so she had probably eaten that night. With the sighting of leopard, Neena, Whitley, and Sara had now seen the African big five consisting of the elephant, Cape buffalo, lion, leopard and rhino, albeit the rhino from quite a distance on the crater floor through binoculars from the overlook. Black rhinos in Tanzania are very endangered with perhaps only 200 existing in the wild, less than 30 of those being in the crater and the remainder in the Northern Serengeti primarily. I have had the luck to see eight rhinos in one day on the crater floor which was amazing luck and had actually seen a mother and calf in the Northern Serengeti before. White rhinos, that are almost twice the size of the black rhino, live in the southern part of the continent and are far more numerous as they are not endangered.

After spotting the leopard, with our game drive near complete, we continued to look for more animals as we roamed along the river area eventually heading back in the direction of our camp. We ran across more lions on the way, including an unusual group of four juvenile males, probably brothers, who were sleeping together under a tree in the shade. Though the females do most of the hunting for a pride, these four males would certainly be a dominant force when hunting together and would each eventually begin to look for their very own pride to adopt or take by force.

One of the smaller kopjes

Coke’s hartebeest

Our day had been quite worthy of the safari experience everyone had hoped for and the Serengeti once again did not fail to impress. I have been here numerous times and have seen the migration in the south and the north (even a difficult to see river crossing at the Mara River), but had never seen the migration spread out in front of me in such a fashion. As far as the eye could see, on every hilltop, in every direction, and then far beyond as we traveled through this conflagration of wildebeest there were more and more animals that were just never ending. Their honking was not deafening, but it was constant and reassuring, even soothing at times as we drove amongst the herd, that reminded us all of the importance of this miracle of nature that has existed long before civilization and long before humankind as we know it today. These animals migrated long before our ancestors’ ancestors and very likely were responsible for their survival.

We returned to camp well before sunset and with time enough for us all to relax and shower as the dust during the day was all encompassing. It was a lovely evening, much as the day had been for the air was never hot nor the humidity high. We all looked forward to another wonderful dinner and, of course, we weren’t disappointed. Sitting at our table that faced out overlooking the savannah in the fading sunlight, it was clear to each of us that what we had encountered today was truly a gift that would remain with each of us for the rest of our lives. It is difficult to fully describe the feeling one has driving through such an immense area as the Serengeti and to see what we have seen today, but save it to say that it is an experience of a lifetime.

October 20, 2017 – It’s morning report and then off to the Serengeti….

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Whitley’s rhino….in her dreams (hint, it’s two dimensional)

We hadn’t scheduled to today as a full day in clinic so as to allow us to leave by noon for a weekend safari that has become standard fare during this elective. Going on a game drive to one of the parks that are close is great, but having a chance to spend the night in a tented-camp is just something that goes far beyond. Last March, we traveled to Lake Ndutu, which is where the migration is that time of year. Unfortunately for us at the time, it was also far more wet than usual leading to our spending the day in the mud digging not only ourselves out, but also five or six other safari vehicles. Though it wasn’t the classic game drive we had expected, it was still an incredible experience that no one would forget.

Intrepid travelers on their way into the Serengeti

Atop Naabi Hill overlooking the Serengeti

This weekend, though, we were heading to the Central Serengeti. We had planned to leave a bit earlier than originally scheduled, as it is a reasonable long drive there from Karatu, albeit absolutely spectacular. Leaving town, you head to the Ngorongoro gate where you enter the Ngorongoro Conservation Area. Here, there are usually troops of baboons looking to steal your lunchbox from the car through even the smallest opening in the window, This happened to us last March and is always an exciting affair, especially when we were all sitting in the car to experience it. After leaving the gate, you’re driving up the crater rim through what seems like a primordial forest with deep ravines and trees that seem like they rise forever from the bottom. The road winds slowly to the top where you come upon an overlook that has a spectacular view of the crater which is 10 miles across, with steep walls that are 2000 feet.

A friendly face

Wildebeest

Seeing the crater for the first time is always an experience and I love bringing people here to see it. You then leave the overlook to drive about a third of the way around the crater towards the descent road (into the crater) where you leave the rim and descend onto the far eastern reaches of the Serengeti where Oldupai Gorge is located. The drive here is along a very rough and flat road that goes on forever until you reach the Southern Serengeti where Lake Ndutu is. It is here where you find the wildebeest migration in March and April as they follow the grasses (and where we got hopelessly stuck in the mud last trip). The road here turns northwest towards Naabi Hill and Naabi Gate which is the official entrance to the Serengeti from this direction. It is also the only road to western Tanzania, Mwanza and Lake Victoria so trucks travel this route commonly along with buses carrying locals back and forth to both sides of the Serengeti. It is here at Naabi Hill that we will begin our journey.

Cheetah on a termite hill

But I’m getting a bit ahead of myself, as we still need to attend morning report and then get everything prepared for the trip. Thankfully, there were no new consults for us and I had already let reception know that we wouldn’t be seeing any new patients today since we had all next week to see people. We had arranged for a driver/guide for this trip since I’m not as familiar with driving in the Serengeti as it is an incredibly immense park that seems to go on forever, hence the meaning of the Maa (language of the Maasai) word “serengit” which is “endless plains.” Simon, a good friend and guide who I have known for several years, would be traveling from Arusha this morning to meet us for the trip. We had planned to meet between 9 and 9:30am, but he had some car trouble in Mto wa Mbu requiring him to take a dala dala to Karatu and was a bit late. No matter, though, since I had forgotten to order lunch boxes for our drive and didn’t end up doing so until this morning meaning that they were still being prepared. We eventually left FAME by around 10:45am and met Simon in town, lunch boxes secured, just needed to fill our tanks with enough diesel fuel for the drive. We were finally off for the Ngorongoro gate, paid our fees and were on our way to the Serengeti with all the excitement one can imagine for such an adventure.

A group of lions resting

Naabi gate is almost always bustling with activity as anyone heading to the Serengeti has to pass through here, unless, of course, they have chosen to fly, in which case they will have missed half of the experience traveling through this vast park. We had decided to break into our lunch boxes here as there are lots of picnic tables and there is also a nice walk to the top of Naabi Hill with a nearly unobstructed view in all directions. Once finished with lunch, we popped the top on the Land Cruiser and began our trek to the Central Serengeti where our camp would be. We had planned to do a game drive on our way and were in the region of the Maasai Kopjes (a kopje, phonetically “käpē”, which means “little head,” is the Dutch/Afrikaans term for rock outcroppings) when it began to rain and then pour necessitating a rather rapid lowering of our roof to prevent our bags from becoming drenched.

Hyenas competing with vultures

Even with the rain, though, we had had a chance to see a lone cheetah sitting atop a termite mound (their favorite spot for a 360o view of the plain), tons of wildebeest, several lions including a mating pair (though not caught in the act), and a pair of hyenas devouring some kill with a host of vultures eyeing them quite aggressively, all before arriving to our camp by around 5pm or so. The rain had stopped, as it usually does here in the afternoon, and we were able to enjoy our arrival at camp without having to run for immediate cover.

Hyena close up

The camp was simply amazing. It was in a very secluded location with a great view out front of animals constantly traversing to and fro. We were welcomed with cool washcloths to wipe off the dust and grime and then invited into the lounge where we were treated to juice before our briefing on the camp. The lounge was a tent with sofas and chairs, a charging station and a bar. Next to it was the mess tent where all the dining tables were already arranged and set for each visiting party. We were taken to our tents (the girls stayed in one and I had an entire tent to myself) and were each given another brief orientation to the lights, shower, toilet, etc. You’re not allowed to walk around camp by yourself after dark, so all you would have to do is flash your flashlight towards the mess tent and someone would come running to escort you to wherever you needed to go. If you felt threatened at night, there were whistles in each tent that you could use to summon help. The tents were just spectacular.

After seeing the inside of their tent

Sara, Neena and Whitley in from of their tent

Dinner was served at 7:30pm and it was buffet style with an amazing eggplant soup, salads, beef, chicken, rice, beans and several other dishes. Everything was delicious and, best of all, we were smack in the middle of the Serengeti having an incredible meal. You couldn’t ask for anything more. After dinner, we all sat around the campfire, referred to everywhere as “bush TV,” for a bit before retiring to our tents for the night. We had planned to meet at 7am for breakfast and a departure time of 7:30am for our day on the Serengeti. It had been a wonderful day of travel and game viewing, but we had the entire day tomorrow to look for animals.

Roughing it in the Central Serengeti

Inside our tents

The washroom in the tent

October 19, 2017 – Off to Upper Kitete for the day…..

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The dispensary at Upper Kitete with our Land Cruiser parked out front

This was our last day of mobile clinic, as we would be providing the remainder of our patient care and education at FAME rather than in the villages. Upper Kitete would be our last visit for the week and it is the furthest away of all the clinics we currently provide. Yesterday, Neena had commented that Kambi ya Simba is a very remote area because of how far down a single dirt road you must travel to get there. Well, Upper Kitete travels down the very same road, only it is at least twice as far if not more. I guess that makes Upper Kitete doubly remote. It is a long way out, but well worth the drive if not just for the beauty of it all. It is the second to the last village on the plateau with the road ending at Lostete, and despite this, there are still multiple buses daily that ply this route.

A view from the dispensary of the surroundings in Upper Kitete

Before leaving for Upper Kitete, though, both Whitley and Neena had volunteered to give short lectures on CT scans and CSF analysis, respectively. It was probably silly for us to think that it could have been done in one session (45 minutes), so in the end, they covered everything in a little over an hour. But since it was so important and everyone from the lab and radiology had also come to hear the session, Gabriel felt that it should be completed today and not run into another day’s session. They were both very good lectures considering it is always a bit difficult to decide just how in-depth to make them considering we are not giving it to neurologists, but to general practitioners, many of whom have never worked or been instructed in neurology before.

Whitley’s talk on CT scans

A full house for Whitley’s and Neena’s lectures

Neena’s talk on CSF studies

After rounds we went to see the boy with tetanus who had been doing much better overnight. He had looked better yesterday evening with an increase in his symptomatic medications, but he still hadn’t received the tetanus immune globulin, as they hadn’t been able to find it yet in Arusha. Thankfully, though, he was more comfortable with the additional muscle relaxants and sedation so that he wasn’t continually crying out like he had been. His urine was also much more clear rather than the dark brown it had been when we first saw him.

A crowd for clinic at Upper Kitete

Patients waiting to be seen at Upper Kitete

We finally got everyone corralled into the Land Cruiser and we were off for Upper Kitete with George driving again given the rough road and long distance. Also, Upper Kitete has no cell service so having a breakdown there means you would have to send word with someone heading towards home and hope that rescue would be coming before nightfall. It’s not happened to us in the past and I will continue to do my best to prevent it from ever occurring as the accommodations there would be difficult at best. We secured lunch in town yet once again and were then fully provisioned for our trek into Mbulumbulu and the far reaches of Karatu district.

Whitley taking a history from a patient in the “bat cave”

Whitley examining a patient at Upper Kitete

We’ve been using the same dispensary at Upper Kitete since I started going there in 2011 (Kambi ya Simba’s dispensary had been fully updated a few years ago prior to a visit by the prime minister), and the facility could use a good revamping. There is an outdoor alcove where we’ve set up our pharmacy in the past, but today it was being used for well baby visits by the clinical office (more in a minute) so we set that up at the end of the outdoor walkway outside of the labor room. The labor room that has served as one of our exam rooms in the past was now unusable for us as there was a patient in labor in the room (I guess that makes sense) with women running in and out during our clinic. That meant that we only had two exam rooms to use. One was the nurse’s office that I affectionately call the “bat cave” as there is a square piece of the ceiling missing in one corner of the room and one can often hear the squeaking of bats during the day and the room has a faint smell of bat droppings that is at first a bit unnerving. This was Whitley’s room for the day and though it wasn’t something she cherished, she stood in there like a trooper and didn’t complain. The other exam room was the clinical officer’s room which actually worked out quite well and it was gracious of him to allow us to use it for the day. Sara and Neena worked out of this room and alternated on patients.

Sara and Baraka examining a very pleasant patient

Whitley gathering a history on a patient

Whitley worked with Dr. Jacob for the day and Baraka translated for Sara and Neena. Dr. Jacob is new to FAME and had never worked with us before, so Whitley was again working with him on the neurologic examination along with how to take a good neurologic history.

Dr. Jacob examining a patient

Neena and Baraka getting a history from a patient

When we arrived at the dispensary, there were many, many patients there which was certainly encouraging, but it would have also been quite a handful for us to manage there in a day since we’re usually starting at around 11am by the time we get everything set up. Thankfully, about half of the patients waiting were for the well-baby clinic where they all get their weights checked along with a general checkup. The baby’s are weighed on a simple mercantile scale and each baby has their own handmade, unique sling for them to sit in during the procedure. Most babies are fine with the process, swinging contentedly as their mothers attach them to the scale and then there are others who scream bloody murder as they’re weighed. I brought Sara out to watch as it was certainly something she had never seen before and certainly wasn’t how things were done at CHOP.

A mother weighs her baby

Once we finally figured out who was there to see us, we were able to begin triaging patients and making a list. We had old notes with us for patients who had been seen there previously, as it is obviously imperative that we maintain some sense of continuity. Once the list was made and it was checked to see if we had old notes for those we had seen before, it was clear to begin seeing patients. As the day wore on, the list seemed to always have the same number remaining, as patients seemed to show up throughout the day. Regardless, it was not overwhelming and we were able to see all the patients necessary, that is except for a gentleman who showed up after 4pm and it was impossible for us to see him and still get back to Karatu in the daylight hours.

Neena examining a patient with Baraka’s help

Sara and Baraka examining a very pleasant patient

All patients were interesting, but Sara saw a young girl with cognitive impairment since birth along with generalized weakness, hypotonia and very myopathic looking facial features that were very suspicious for some form of congenital myopathy. She had been brought in by her grandmother so it was difficult to look for any hereditary features and her grandmother wasn’t very helpful in giving us any details of her past history or developmental milestones. We are unable to check muscle enzymes here so we wouldn’t have that to help us and it was decided that she would come back to see us when we returned in March.

Sara examining a young patient at Upper Kitete

A young patient at Upper Kitete

The clinic finished late, which was unfortunate as I had hoped to show the residents “The Overlook” which has become somewhat of a tradition – it is a spot in Upper Kitete that sits high on the escarpment and provides an incredible view of the Rift Valley below. I’ve been there many times, but today was a bit hazy with all the dust being driven into the air so it probably wouldn’t have been as spectacular as normal and missing it wasn’t such a tragedy. We didn’t arrive home until well after 6pm with the sun going down quickly. We were planning to head for the Central Serengeti tomorrow after morning report barring any complicated consultations in the wards. We spent the evening packing, but did have to run down to the clinic for one late night outpatient consult on an expat. We all slept well that night with the anticipation of going on safari for the weekend.

Sara and Baraka gathering a history

Sara examining a patient at Upper Kitete

October 18, 2017 – Off to Kambi ya Simba, but first an interesting case…

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It was day three of our mobile clinic week and we would be heading off to Kambi ya Simba, or Lion Camp, today. It is in the Mbulumbulu region of Karatu District that sits between the Ngorongoro Highlands and the escarpment dropping into the Rift Valley below. The land is very fertile with the soil washing down from the Highlands and there are farms the entire way. As you drive further and further along this plateau, though, it becomes narrower and narrower as you reach the end of the road at Lostete, where the steep slopes meet the escarpment. It is a long narrow triangle of land that is some of the most beautiful scenery that you can find anywhere in the world.

Kambi ya Simba is about half-way to Lostete, so today’s drive will be about 45 minutes along a fairly rough and bumpy road (especially according Neena, who was sitting in the back and bouncy seat of the vehicle) that is decent in the dry season and becomes a slip and slide immediately in any rain. I have become hopelessly stuck on this road in the past so, for the better part of valor, I have been willing to have one of the drivers from FAME come with us in the event of a downpour or a breakdown as there is often no cell service out here. As many who know me, I’m rarely a passenger in the States, but here in Tanzania I have learned to tolerate it.

Selina (left) and Angel sitting outside of our exam rooms

At morning report this morning, we heard of a young Maasai boy who came in last night with a story that he had gotten into a fight with another boy a week or so ago and now appeared to have tetanus. It was later found to be a bit more involved (as is often the case as you don’t always get the full story the first time around) and he had apparently had some abdominal symptoms at which point his family had taken him to a dispensary, but he hadn’t improved. They then took him to a local healer who performed a traditional procedure by making incisions over his abdomen and placing crushed tree root into the wounds. It was quite likely that this was the source of the tetanus inoculation and it had nothing to do at all with the fight that had occurred.

The young Maasai boy with tetanus

We all went in to see the boy after morning report as it isn’t often that you get to see a patient with tetanus. He was lying in bed with his back completely arched in an opisthotonic manner quite classic for this condition among others and all of his muscles were in complete spasm. He was moaning in discomfort even though they had given him diazepam and chlorpromazine, as it was clear that he would need more of the medicine to make him comfortable. The only treatment for this condition is really to give tetanus immune globulin and symptomatic medications with muscle relaxants and sedation and to prevent complications. Regardless of what you do, it typically takes a month of more for the condition to abate as you have to develop new nerve endings due to the toxin. Respiratory function can also be compromised so the patient needs to be monitored quite closely.

Neena and Baraka evaluating a patient

The patient’s urine was also very dark and his sodium level was also quite high so we were worried about rhabdomyolysis, or breakdown of his muscle from the severe spasms he was having, which could cause significant kidney damage. We made recommendations for him to be well hydrated, but not to drop his sodium to quickly, which could also create another major neurologic problem for him. At that point, we left for mobile clinic in Kambi ya Simba and planned to see him when we returned late in the day.

Neena examining a patient with Baraka’s assistance

When we travel to Mbulumbulu, there are no services there such a drinking water, food or fuel, so we have to leave with a full tank, water and, most importantly for me (those who know me know how serious I take lunch), food for lunch. We usually grab some Tanzania snack food, mindazi, vitumbua and samosas, before we leave town along with some drinks, such as Fanta Passion or Stoney Tangaweezi. Finally stocked up with lunch, we were on our way. The day was lovely and the drive, although quite dusty and bumpy, was again through some of the most beautiful scenery one can imagine.

Whitley evaluating a patient with Baraka translatign

Whitley and Baraka evaluating a patient

I have been traveling to Kambi ya Simba for mobile clinic since 2011, when I first went there with Paula Gremley and Amiri Mwinjuma, who were two individuals that worked with FAME on the bigger mobile clinics to Lake Eyasi in the past. It was their original idea to bring me there for the neurology mobile clinics and I have carried on the work over the last several years. We originally were doing two days each at Kambi ya Simba and Upper Kitete, but with the addition of Qaru and now doing RVCV on our own, we have reduced all the mobile clinics to a single day at each site.

Sara working on the neurologic examination with Dr. Jacob

The volume at Kambi ya Simba was adequate, but not overwhelming. Unfortunately, I don’t believe we had any children for Sara to see today, but she worked with Dr. Jacob, a new clinical officer, and instructed him on the neurologic examination and taking a good neurologic history. Neena and Whitley worked together which meant that they alternated seeing patients. Baraka translated for them and things went well. We worked through the patients, taking a short time out for lunch and we’re on our way home at a decent time considering the 45-minute drive back to Karatu.

Sara working with Dr. Jacob

Wednesday nights have become a social night in Karatu for all the expats, mostly volunteers, working anywhere in the vicinity and it was once again a rather large turnout. We had eaten our dinner at home beforehand, so only went to see everyone, have a drink and head home at a very decent time. Whitley and Neena were doing an add-on educational lecture in the morning at 7:30am so we couldn’t really stay out too late. Being able to share similar experiences with everyone else in town is a good thing, I think, as it has become a larger community over the last several years and everyone has a fine sense of purpose.

October 17, 2017 – Rift Valley Children’s Village….

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Neena’s headache talk

It was Tuesday morning again and time for another education meeting during which I have the residents each cover a topic that Dr. Msuya, who is in charge of coordinating education for the doctors, chooses would be most beneficial for them to hear. This morning’s talk was on headache and Neena was giving the talk. She made it interactive and decided to have the rest of us pretent we each had one of the more common headache syndromes and that we would answer questions that she was pose to us as if taking a history from a patient.Whitley played a mzungu with a migraine and dressed the part of a safari going with migraine headaches. Neena selected me to play the role of a “bebe,” who is an old woman as in grandmother and who had muscle contraction or tension headaches. Sara played the part of a patient with a chronic daily headache. The talk went well and we did get the Tanzania doctors to participate which is often not easy for they are for the most part, quite a quiet bunch on the whole.

Whitley playing the role of a Mzungu with a migraine

Rift Valley Children’s Village, near the village of Oldeani, is an oasis in the center of paradise. Started over ten years ago by India Howell, it is a haven for children who have been orphaned or otherwise abandoned by their families for one reason or another and are in need of a home. India and her Tanzanian business partner, Peter, adopt all of the children who come when they are infants or older and remain here in separate houses run by “house mamas” until they are ready for college or to move on to other occupations. She has volunteers from the US that spend months up to a year working with the children and all of the children attend the government school that is physically next to the village. They have a nurse who provides physicals not only to the children who live there, but also to the residents of the community that is next to the village as India identified very early that no matter how well she took care of her kids, that if the community wasn’t healthy, it would affect her children negatively. This is perhaps an example of what we now know in global health. If you don’t use resources to help ensure your neighbors health, then it will very likely eventually your health negatively as there are no borders for diseases.

Schoolboys at Rift Valley Children’s Village

Dr. Anne and Sara evaluating a young women with microcephaly and static encephalopathy

The drive to RVCV is also a gorgeous one as it traverses some of the highlands and travels through more coffee plantations. The region is inhabited by farmers and coffee workers. Arriving to the gate of RVCV you realize that you are in a special place quite quickly. The children are one big family. As we drive in, there are quite a few patients waiting, though fortunately it turns out that many of them are for general medicine and will seeing the RVCH nurse during the day while we’re there. We have enough patients, though, to keep us busy and get started working in three rooms for the residents which will mean that things will go along quite speedily today. Dr. Anne will work with Sara today, while we have both Baraka and Emmanuel there to translate for us in the other rooms. They are both quite familiar with the Children’s Village.

Discussing the case

There are many children from the village to be seen, most with epilepsy and others with developmental delay, but there are also many adults from the nearby villages who have come to be seen. Some are new and others have been seen previously. A number of students were there to be evaluated by us to rule out neurologic issues as they were having difficulty in school, but we sometimes didn’t have the entire picture as they were unaccompanied for the visit. The children were very helpful, though, and could often give us surprisingly detailed histories.

Dr. Anne and one of the school boys.

Rift Valley Children’s Village has a large cadre of volunteers working there at any one time in addition to others working on associated projects such as microfinance and the Rift Valley Woman’s Group. Lunchtime is always a pleasure for us at RVCV, for as much as I love the rice and beans served at FAME for lunch, the meal there is always something new and is made fresh by the mamas who do all the cooking there. Today’s lunch consisted of freshly baked rolls, tuna salad and sliced cheese, along with salad and a wonderfully fresh soup that was either cream of celery or something very similar. For desert they had a fruit salad that was also incredibly fresh. Other times I’ve been there, we’ve had various cookies and sometimes cake for desert as well, but it was probably best that they had just the fruit salad today as I had seconds on the soup and probably would have overeaten.

Whitley evaluating a patient with complaints of memory loss

We had more patients for the afternoon, but it wasn’t overwhelming by any means. Again, with three rooms for the residents it meant that we were able to plow through patients quite quickly. After we were all finished, we still had plenty of time to run through all of the cases with Gretchen, their nurse, to go over the plan for each so she could follow up on them and make sure they were getting their necessary labs and refills. The trip home from RVCV is always gorgeous as I take a slightly different route that travels through rich farmland and small clusters of little structures where those who farm the land live. The homes are typically of thatched roofs and wooden sides and very basic. I’m sure it’s what they have lived in for hundreds of years in this region.

Whitley evaluating a patient with complaints of memory loss

We arrived home early enough to check on patients in the ward who we had been consulted on earlier and then get home in plenty of time to do some work. It was great to be able to relax and catch up on things.

October 16, 2017 – A day in Qaru….

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Sara and me prior to clinic starting in Qaru

Today we would begin our week of mobile clinics, traveling to villages in the more remote areas of Karatu district to provide neurological care, though most patients could make it to FAME if necessary. Glen was also leaving today, heading back to Botswana for some important meetings there regarding the Botswana-Penn Partnership and future goals for the program. His visit here had been productive and having the support of the Penn Center for Global Health has been essential for the continuation of our program and to determine future directions that will benefit FAME and possibly Penn.

Angel (second from left) triaging patients for us at the beginning of clinic

Whitley evaluating a patient with Emmanuel

It’s always a bit stressful for me when we start the week of mobile clinics as there are a number of logistics that need to be taken care of. Angel will be the point person for this visit, making certain that we have everything we need before we depart since we will always be an hour or more from home and there’s no running back to grab something forgotten. I have been traveling to Kambi ya Simba and Upper Kitete for 6-7 years to do a mobile clinic in those locations and we’ve recently added Qaru to our list of sites. The idea of our mobile clinics is to provide only neurological care to these communities as they have district health offices and clinical officers there who can provide general medical care. The villages are not remote enough that patients cannot get to FAME as we often have them come to get labs checked there after they’ve been on the medication for a month and to assess any possible adverse effects. Most of these patients, though, don’t realize that they have conditions that are treatable which is our main purpose here. There really is very little in neurology more gratifying than treating an epilepsy patient who has been seizing their entire life without ever ave been treated.

Neena and Dr. Anne evaluating a patient

Whitley evaluating an elderly patient with Sara working on her notes

The group we had today for mobile clinic included the three residents, me, Alex, one translator (Emmanuel), one clinician (Dr. Anne), Angel and Selena, our nurse who would be dispensing medications at clinic. We stopped at the tarmac at the end of the FAME road to buy things for lunch and get some bottled water and sodas for the day as we’d need something to drink. Our lunch consisted of lots of pastries – beef samosas, chapatti, vitumbua (fried rice cakes), and mandazi. Our course, most of us opted for the wazungu favorite drink of Fanta Passion. Once outfitted with our food and hydration, we embarked down the main road heading south of town in the direction of Qaru.

Sara and Emmanuel examining a happy little boy with epilepsy and delay

examining an elderly women with back pain and numbness

Qaru is about 45 minutes south of Karatu on the road to Endabash and we had first visited this site last March when it had been very productive with many good patients for us. The road is very good save for long stretches of washboard bumps that are mostly annoying, but can still produce back and next pain. We pass through several other villages that all look quite similar, but we eventually come to Qaru after passing right through it realizing our mistake only a moment later and turning around after we told our Tanzanian friends in the vehicle that we were just checking in on them to make sure they were paying attention.

examining an elderly women with back pain and numbness

examining an elderly women with back pain and numbness

Sara and Emmanuel examining an elderly women with back pain and numbness

The district health center at Qaru is a very nice facility and had room enough for us to run three exam rooms, but the patient load started out slow so we used only two exam rooms for patients. It was very clean and the building we were in was quite separate from the main clinic where the routine medical patients were being seen by their district clinical officer. Most of the patients had been there in the morning, but had gone home since we hadn’t yet arrived and so they slowly filtered back in throughout the day. The volume of patients at our mobile clinics can be quite variable and may depend on the season (e.g. harvest time) or perhaps just what has been going on recently in the village.

Sara examining the little girl with abnormal movements

Sara examining the little girl with abnormal movements

The most interesting patient we saw today was a young child that Sara evaluated. She was seven years old and had definite developmental delays, but she was extremely social and interacted well with us. She was completely unable to walk, though, and had abnormal movements that looked mostly like a combination of both chorea and ataxia. On her examination, she was very hypotonic and was actually unable to stand on her own because she was so floppy in combination with the ataxia and her movements. She would sit on the ground with her legs flexed at the knees and splayed outward, scooting herself along until she found something she could grab onto and try to pull herself up, most often unsuccessfully. She didn’t have convulsive seizures, but she did have interesting sudden tonic extensions of entire body that looked somewhat myoclonic in nature. She was a lovely young girl who with a problem that appeared to be either congenital or genetic, perhaps mitochondrial, and would be something quite unlikely to have any treatment per se, but it would be nice to identify her problem. She had three younger siblings, all of whom were normal neurologically and very loving parents.

Sara and Neena discussing our little girl with the abnormal movements and myoclonic seizures

Patients continued to straggle in throughout the day and we worked until 5pm since we didn’t want to turn away patients as we wouldn’t be coming back and we weren’t confident they would get to FAME if we had asked them to. I believe we saw perhaps 14 patients for the day – not a bad day, but we certainly would have preferred more. We continue to get the word out about our clinics and the Qaru clinic added last visit was somewhat in response to the District Medical Officer having asked if we could go elsewhere in addition to the Mbulumbulu region where we had been going for several years. Our neurology mobile program is one that has been based on bringing the awareness of neurological disease to these remote villages rather than trying to see as many patients as possible.

Selena (sitting furthest) running our pharmacy

A happy crew in the Land Cruiser

The drive home from Qaru had beautiful views of the region south of Karatu and off into the distance. The soft lighting of the evening was in sharp contrast to the strong equatorial sun from earlier in the day. We arrived home before 6pm and had planned to work most of the evening as Neena was doing her presentation on headache the following morning and this required our participation as headache patients. Tomorrow, following the presentation, we would be traveling to Rift Valley Children’s Village for another mobile clinic.

The driver’s view on the road home from Qaru

October 15, 2017 – Tarangire National Park…

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It was Sunday again so in keeping with our tradition of “safari Sundays” while here on rotation, so we all awakened very early for a 5:30am departure from Karatu. The trip to Tarangire takes about 1:30 hours as we travel down the escarpment and through the village of Mto wa Mbu (Mosquito River) that lies at one end of Lake Manyara and traverse the valley towards Makuyuni where rather than turning left towards Arusha, we turn right in the direction of Babati. The north entrance to Tarangire National Park is on the way to Babati and just south of the shores of Lake Manyara.

A banded mongoose

Tarangire is a park that is dominated by river ecology and during the dry season, all of the animals must travel daily down to the river for their water as the many other watering holes are all dry. Tarangire is also home to an incredible population of elephants who travel daily from the protection of the hills during the night down to the river during the morning hours and back in the evening. There are huge herds of elephants wherever you look with many, many babies confirming the health of these wonderful animals. In addition to the elephants, there are also tremendous herds of wildebeest, zebra, and impala primarily with a smattering of waterbuck, eland, and Coke’s hartebeest. There are also lots of giraffe with many babies. As for predators, there are lions, cheetah and an occasional leopard. And then there are the monkeys. Numerous baboon tribes roam throughout the park along with vervet and blue monkeys.

A vervet monkey at the main lunch spot

An impala at the water’s edge

We arrived to the park sometime after 7am as I had to get gas in Mto wa Mbu and they thought I had “four” instead of “full’ so had put in only 40,000 TSh worth of diesel fuel when I needed at least twice that. It took me some time to eventually speak with another attendant who’s English was quite good and he suggested that I they just finish off the fill, pay for it and then do the second fill which is how we handled it and all went quite seamlessly, though we had spent more time at the service station than I had anticipated.

Shockingly, this is not a blue monkey, but rather a vervet monkey

An elephant keeping a very close eye on us.

Once back on the road, the sun was slowly creeping up behind the mountains to announce the new day with a sky of orange predicting the impending sunrise. It was overcast as we reached Makuyuni, but the weather overall was amazing and there was still al cool breeze from the dawn as the sun had yet to warm things up and was still quite low in the sky. We made our way to the park entrance along a 7 km dirt road with many irregularly spaced speed bumps and washboards that are sufficient to loosen any precious dental fillings with ease. I will always remember the entrance to Tarangire as it was the very first park we entered in 2009 when I was here with Daniel and Anna and up until that point, we had not been on safari nor seen a wild animal. Though it only seems like yesterday, I have been on so many safaris since then that it also seems like the distant past at times. Regardless, each safari is different and I see something new each trip not to mention the pleasure of taking the residents on safari as well and for most of whom this is their first experience traveling to Africa so it is also their first experience on safari.

We were heading the river that runs through the park and dominates life here, especially in the dry season when it center of all activities considering it is the only water source as all others have completely dried up. As we were descending down to cross over the river, though, there were several vehicles stopped which is usually a good sign that there are cats around. Off to the side of the road and a short bit away were two cheetahs resting in the shade of a tree. Cheetahs are usually solitary animals, but will travel in pairs as two brothers or two sisters, but never mixed. They are such gorgeous and majestic creatures that I can never see too many of them. It was getting warm so they were in the shade and relaxing as much as possible at least until the sun begins to dip in the late afternoon. We’re on our way after a few minutes of viewing and several photos and looking forward to the remainder of the day and what else we might see.

Coming down to the river, there were huge herds of wildebeest and zebra all in constant movement making their way towards the river either in single or as a group. The river is their lifeline at this time of year for without it, life would cease and the herds would move elsewhere. We traveled along the south side of the river for a time, moving in and out of the brush and eventually crossing it at a narrowing. On the north side there we again ran across another group of cheetahs, two at least and possibly more, sitting in the shade of the trees with the heat of the day increasing. We were traveling towards the Silala Swamp, a very large area on the south end of the park where, during the wet season, there are many animals congregating in the large wet areas. As we crested the hill to view the wide expanse of the swamp and stop at the picnic area for lunch that looks out over the area, we saw hundreds of elephants stretched along the open area off into the distance. They were broken up into families, but this was a sight I had never seen here, so many elephants in one place and all mixed together. There were also zebra and wildebeest throughout, but the impressive sight really was the number of elephants.

Jackel on the prowl

Southern Ground Hornbill

We sat on a picnic bench and table for our lunch along with a very large group of adolescents from the US that were on a group safari and had also stopped for lunch. They were traveling in the large vehicles used for this purpose that are like troop carries with seats and lots of storage down below for tents, food and personal belongings. These groups normally stay at the public campsites rather than at the tented camps or lodges that are far more expensive.

While at lunch I had spoken with a safari guide, who was somewhat taken aback that I was actually driving and guiding our vehicle, and learned that there was a lion about two kilometers down the road along the edge of the swamp. We drove down to the edge of the swamp after lunch and just about where predicted there was a solitary female lion sitting under a tree. She appeared to be covered in mud (or blood?) so I suspect she had probably taken some prey in the wet mud not to far from where she was sitting. She got up a few times, but for the most part was quite content to be resting during the heat of the day.

We had also had word that there might be a leopard in the other direction along the swamp so we decided to drive that way and up into the hills eventually looping around in the vicinity of the Tarangire Sopa Lodge. There were several families of elephants wallowing in the mud quite close to the road and there was definitely some jockeying for position go on. There were lots of rumbling noises coming from the groups, a sound just like what the tyrannosaurus rex made in the movie, Jurassic Park. It is a low baritone sound that you can feel in your bones. That was fairly frequent along with other less frequent trumpeting sounds that were clearly some communication of displeasure or warning made as the families jostled amongst themselves vying for the best mud. We watched them for several minutes and eventually departed in quest of our leopard.

Cheetah

We drove slow and kept our eyes peeled hopeful that we would fine the third species of big cat for the day, but alas it was not to be. Leopard’s are certainly quite elusive and the most difficult of them to fine, but I thought we had a good chance given the reports we had heard. I have seen many leopards over the last years, but the others will have to wait for a sighting perhaps in the Central Serengeti where we’ll be this coming weekend.

Baby elephant nursing

Traveling back towards the main gate we spotted many more animals and even another cheetah back on the main road. It was a long day for us having entered the park before 7:30am and not reaching the gate to exit until perhaps 3:30pm. That’s quite a long safari and I think everyone, including me, was quite tired from the day. We grabbed some cold Fantas before hitting the tarmac and were then on our way home. A quick stop at our friend’s art gallery to buy more presents for home and we were back to FAME in no time. We were all quite dusty and tired from the day, but thankfully Alex, our intrepid volunteer coordinator, had offered to make us dinner after our safari. We had homemade tortillas, corn salsa, grilled peppers and grilled meat. Glen made a cucumber and salsa appetizer to go along and we were all quite happy with a well-cooked meal at home.

Whitley in her National Geographic photographer pose

Tomorrow we will begin our mobile clinic week so will miss the lunches here at FAME. We begin at Qaru, south of Karatu, then Rift Valley Children’s Village on Tuesday, Kambi ya Simba on Wednesday and ending with Upper Kitete on Thursday. We’ll organize everything in the morning and be ready to hit the road by hopefully 9am or so.