Wednesday, October 17, 2018 – We’re off to Qaru today….

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The dispensary at Qaru

Qaru is a very small town that is south of Karatu and on the road towards Haydom, where there is a larger teaching hospital, but is about three hours away. We had chosen Qaru to visit several years ago when looking for an additional site to hold our neurology mobile clinics and where there was also a nice dispensary that would serve well for us to work in while there. Qaru fit the bill perfectly for its health center had been recently built by an organization wishing to provide this resource to the community. There is a nearby school and in the past, we have been able to interact with the children during their recess time. I had also been fortunate enough to have shared in church choir rehearsal not long ago which was really a treat.

Our examination rooms at Qaru

Some children from Qaru

The drive to Qaru is less than 45 minutes and is on a main thoroughfare, albeit gravel, as there are very few paved roads other than the main highway traveling from Arusha to Karatu, as well as the road that travels east from Makuyuni towards Tarangire. Trying to describe what these vehicles take here from the standpoint of abuse would be very difficult. All of the roads have severe washboards, which is the natural effect of vehicles driving over loose surfaces such as sand and gravel. This makes for an incredibly bumpy ride which the vehicles here take day in and day out, giving their suspensions an incredible work out and eventually leading to necessary repairs and breakdowns. More about that later.

Amisha and Lindsay working with Dr. Shaban

Again, it is important to understand that the purpose of our neurology mobile clinics is perhaps less to provide care for patients who cannot reach FAME, but rather to bring the concept to them that neurological diseases can be treated effectively. The villages are not so remote that they are unable to get to a medical facility capable of treating them, but more that their illnesses are just accepted as part of their life without having explored an alternative. This can often be most impressive for patients with epilepsy where it is merely a matter of placing them on the right medication and they can be seizure free or at least nearly so. Epilepsy carries with it a huge social stigma and because of this and the incredibly limited access to adequate medical care in general in third world areas, the percentage of these patients who are treated is appallingly low and in the range of 10%. It can be so rewarding to see one of these patients who are young adults and have never known a life without seizures become seizure free with a simple medication. Thankfully, many of the patients we see are young children with epilepsy and so we are able to place them on the appropriate medications at a much earlier age.

Amisha, Lindsay and Dr. Shaban with a bibi

A selfie line

Another selfie

At Qaru, the number of patients waiting for us was rather small that can be for many reasons and is a common occurrence at the mobile clinics. We do advertise the clinics much the same way as we do for those we hold at FAME (where we are always packed), but since we’re at each village only one day, if that happens to be a day of planting or harvest or your cow has run away, then you may not be able to make it. There were several new patients with epilepsy and a few follow ups, as well as our normal smattering of patients with complaints that we couldn’t necessarily attribute to an underlying neurological process. Many of these are musculoskeletal in etiology, but some we’re just unable to attribute to anything. We have many patients, almost exclusively young adults, who complain of hemibody numbness and the only features of their examination will be the finding of sensory abnormalities, often quite patchy and without a good anatomic localization. Of course, we see these patients in the US, but much less frequent than we do here and at home we will evaluate these patients extensively and rarely find a cause for their complaints. Often, you will find some underlying psychological event that may have precipitated the complaints, such as the death of a family member, but other times you won’t and it leaves you very unsatisfied in not being able to have some unifying diagnosis.

Amisha with one of her patients

Anne, Hannah and Lindsay posing for a selfie

During our visit to Qaru, Frank called me to let me know about a patient, a tourist, who had come in with the worst headache of their life associated with vomiting and vertigo. This was obviously very concerning for a subarachnoid hemorrhage and our CT scanner here was unfortunately down so we were unable to get an imaging study. Her examination was non-focal so I recommended performing a lumbar puncture to rule out a hemorrhage. By the time we returned from Qaru, they were just in the process of getting the LP done, so Hannah evaluated the patient instead and then proceeded with obtaining the cerebrospinal fluid. We do not have the LP kits here that we are so used to using at home, and so Hannah went about positioning and prepping the patient with the nurse’s assistance while provided some coaching and moral support.

Directions

Dr. Anne

Managing to keep one’s self sterile in the setting where you have no drape to cover the back (those who perform these procedures will understand the reference) that allows you to constantly check your position with your fingers is not a simple proposition. Kudos to Hannah, though, for only having to change her gloves once during the whole affair as it was quite the challenge. Overall, it proved to be a very difficult procedure and, in the end, it was non-diagnostic as we had entered a venous plexus (this happens on occasion and is not something that can be avoided) and though we did find the CSF space, the fluid would not clear and we were unable to interpret the results. Our concern was high enough for the patient to have had a sub-arachnoid hemorrhage, though, and so we recommended that they be transferred by medivac to Nairobi in the morning as we did not recommend that they fly home to the US without having this fully evaluated.

Amisha, Anne and Dr. Shaban assessing a newborn with HIE (hypoxic-ischemic enchephalopathy)

After Hannah and I had returned home from evaluating this patient, we all decided to head to town for some ice cream (instigated by Steve, I might add). We jumped into Turtle for the short ride to the market area and all picked out an ice cream bar of our choice, then happily enjoyed the treat standing out on the street watching all the locals making their last transactions of the evening and carrying out their final choirs. Tomorrow we would be off for our last mobile clinic to Upper Kitete, which is the furthest away that we travel, so much so that it is also a dead zone for all cellular service which puts us entirely out of reach to the rest of the world and to FAME for the entire day.

Tuesday, October 16, 2018 – A day at Kambi ya Simba, or Lion’s camp….

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The new dispensary

Today we were heading to Kambi ya Simba, a small village in the Mbulumbulu ward of the Karatu District and about 45 minutes from FAME. Before our departure, though, there was a lecture to be given and today John and Amisha would be speaking about movement disorders (for example, Parkinson’s disease) in both adult and pediatric neurology. The talk was very well received and they had video examples of some of the more classic cases included some that we had recorded here at FAME.

The new buildings at Kambi ya Simba

After the talk, we began to get everything together necessary for our visit to Kambi ya Simba. We would be taking Turtle as our transportation and because the weather was dry, I was going to do the driving to each location this week. The other members of our “crew” would include myself, the four neurology residents, our two interpreters, Emanuel and Shaban, our clinician, Dr. Anne (an assistant medical officer), Kitashu, our social worker, and Kitangile, our nurse. It is a totally self-contained clinic, meaning that we bring all of the medications we will prescribe to see our neurology patients and all of the tools that we would need to provide our care.

My “office” in the foreground, with the pharmacy in the distance. Our first clinic at Kambi ya Simba

Our examination “room.” Paula Gremley in the forground. Our first clinic at Kambi ya Simba

I had first gone there in 2011 with the assistance of Paula Gremley and Amiri Bakari Mwinjuma. The pair had been working with FAME in their large monthly mobile clinics to the Lake Eyasi region, and following one of these clinics, at Paula’s suggestion, we went out on a smaller neurology mobile clinic to some villages that we could work with on a daily basis rather than overnighting in the bush. The two clinics included Kambi ya Simba and Upper Kitete, both in the Mbulumbulu ward. That first clinic included myself, Paula and Amiri, a nurse, and a clinical officer. We brought a large box of medications and set up our “office” out in the open in the middle of the village near the church, with the “pharmacy,” comprised of the nurse and her medications, situated a short distance away. This was the extent of our mobile clinics for several years and at that time, I don’t even recall whether Kambi ya Simba even had a dispensary.

A scene from our very first clinic at Kambi ya Simba

Amisha examining one of her patients

The drive to Kambi ya Simba takes us through very extremely fertile farmlands past the Rhotia valley and on to the Mbulumbulu ward. Despite the dry season, there is quite a bit of green as we meander through the hills in this area that sits at the top of the escarpment of the Great Rift Valley and continues until the mountains of the Ngorongoro Highlands meet the drop off and the road ends. This region is populated by the Iraqw tribe almost exclusively and their farms cover the countryside, but not in the way our farms extend over thousands of acres. These are all smaller family-run farms here as there are no large farming corporations here.

John, Amisha and Emanuel evaluating a patient

John and Emanuel evaluating a patient

As we arrived at Kambi ya Simba, it was clearly evident that the new dispensary completed several years ago has continued to grow even in the last six months since the last time I was here. In addition to the large number of buildings that are here now, they have rebuilt the original dispensary that we had begun to work in and now there is a covered arcade connecting everything. There is even an area to drop patients off who are arriving by car or motorcycle. Amazingly, a large number of patients arrive to clinic on the backs of the motorcycle taxis here called piki-pikis. Watching a nearly paraplegic patient load onto one of these as one two passengers in addition to the driver can be a bit nerve-wracking to the say the least. But this is everyday life here and what people go through to access their medical care. It is a constant reminder for us all that these are struggles that most of us, but unfortunately not all, do not have to encounter at home. There is work to be done far and wide in this regard and we are always grateful to be making a small contribution here.

Amisha and Hannah evaluating a patient

Lindsay and Shaban evaluating a patient

Lindsay and Shaban evaluating a patient

The clinic today was not as busy as it has been at times in the past and we have a smattering of return and new patients who have all be screened for neurological disorders. Our purpose here is not to supplant the government medical staff here providing care, but rather to work with them and provide specialty care that would not otherwise be available in most of Northern Tanzania. That they are allowing us here to practice in their community is not something that is merely a given, but rather a sign of trust that we respect. We all ate lunch together in our vehicle which is something we’ve done here since the beginning as we did not believe it polite to eat in front of the villagers, many of whom may only eat a single meal each day.

Hannah and Anne with a wonderful bebe they fell iin love with

Hannah and Anne evaluating their bebe

It was their well-baby visit day so there were very many cute babies here (making Amisha and everyone else very happy), all being weighed in their traditional manner, strapped into their personalized harnesses that each of their mothers sews for them, and then attached to a general produce scale. Some babies cry vehemently while others seem to just take it in stride, though most are in the middle, of course, reaching for mom with a clear sense of uneasiness in their eyes yet somehow managing to hold it together for the few moments it takes. These visits are a regular occurrence for them so I’m sure some of them have become accustomed to this ritual. This was all occurring outside of the room marked “vaccination” which Amisha found to be a great advertisement for this incredibly necessary process which is taken very seriously here while at home in the States that very small fraction of children who do not get their vaccinations, mostly for misguided reasons, has been increasing of late.

One of Amisha’s patients rolling on the ground. I was trying to ignore them

Some selfie action

We had seen our general mix of patients, headaches and epilepsy along with a few arthralgias, before lunch and still had several patients to get to after lunch who had showed up through the morning. The last patient we saw, though, was perhaps the most complicated. He was a gentleman in his thirties who came to see us in a wheelchair because he was unable to walk due to lower extremity “pain.” It is always so difficult from a cultural standpoint here when taking a history as what seems to be the main complaint isn’t always necessarily the case. I have many similar patients here were the main complaint is “pain,” but in actuality their examination belies a much different neurological process. It turns out that this gentleman has lost most of the use of his legs, with no effects in his upper extremities, about ten years prior and had never been evaluated medically other than by the district medical officers he had seem, mostly for other routine illnesses that they had treated.

Getting the weight on a child

Angel and Dr. Anne sitting with a bebe

In all fairness, this wasn’t something that a clinical officer or even an MD with a general background would have likely been able to have figured out given there is so little neurological training here other than what we bring or can be found at only some of the medical schools. His examination was myelopathic (meaning that he had a problem somewhere in his cord) as we surmised even before Lindsay had first tapped on one of his reflexes. The process, though, had occurred gradually over several years and was purely motor as the predominance of his sensory examination was fully intact. Without a sensory level, though, we were unable to tell exactly what level in the spinal cord we were dealing with, but it was clearly thoracic in nature. Going over the various possibilities of a spinal cord process that had occurred gradually over several years, was pure motor in nature, and had also had some subtle fluctuations early on, there seemed to be very few things we could come up with other than possibly a dural arterio-venous fistula of the spinal cord. Having pure motor findings with this entity is more the exception than the rule, but there was little else we could come up with for this gentleman and, perhaps more importantly, nothing that we could do to make him better at this late date. We had spoken to him about obtaining an imaging study, but it would likely make little difference for him and a CT scan, which was much more “affordable” would be far less helpful than an MRI.

Lunch in the vehicle

Lunch in the vehicle

Though we tried to explain to him what our thought processes were, in the end, the answer was the same, that very little could be done other than to make him more comfortable by using a medication such as baclofen for his spasticity which we prescribed. In the US, he would have most likely been seen very early on and eventually referred to a tertiary center where he would have undergone vascular imaging and eventually had an interventional process to hopefully fix his problem prior to it having caused permanent deficits. Even in the best of hands, though, this isn’t always a sure-thing and it is also possible that he would have ended up with the same deficits that he has currently.

The entire team at Kambi ya Simba

We left Kambi ya Simba in the mid-afternoon to make our way slowly back to Karatu, once again traveling through the gorgeous countryside that we had traversed earlier in the day. We dropped all the FAME employees in town as it was approaching 4:30 pm, and we drove back up the FAME road to our home for the month with our dinners awaiting us on the counter as they do every weekday. Tonight’s dinner was veggie wraps with delicious hummus and very much appreciated by everyone. Tomorrow we would be heading off in another direction, north towards the town of Qaru, near Endabash.

Some of the well babies being weighed

 

Monday, October 15, 2018 – A wellness day at Gibb’s Farm….

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NOTE: I do apologize for the seemingly long delay in getting these blogs posted. After our long days of work in addition to a few added issues (sorry, you’ll have to read the blogs), it is often difficult to sit at the computer and type at night.

John at the gate of FAME

After another successful game viewing drive at Tarangire, it was time to get back to neurology, but only for a half day clinic as I had scheduled this afternoon for a wellness day for the residents. Wellness days and wellness in general is a very hot topic as far as training programs are considered, not only for the residents, but also for faculty and other physicians alike. My only argument was really that this entire month is really like one big wellness day, but that wasn’t good enough and so today we would be working only a half day so that the afternoon would be free for the residents to do what they wished. I made several suggestions, but the one that always seems to win out is to go to Gibb’s Farm for their buffet lunch that is not to be missed. So, I decided once again to take one for the team and accompany the group for one of the best meals of our trip. First though, we would be working for the morning and trying to finish by around 1 pm for lunch.

Amisha trying to steal another baby

Morning report had some interesting discussions with one of the main ones being about antibiotic use and specifically giving children ampicillin and gentamicin for community-acquired pneumonia where it was argued that gentamicin did not add anything in that situation and was a potentially toxic medication. Now mind you, I had very little input in this discussion considering this is the furthest thing from my practice, but both Amisha and Steve weighed in heavily with their knowledge on the subject. Apparently, this is something that the Tanzanian Health Ministry has also placed a special interest in and is following what it believes to be the WHO recommendations on the matter. Dr. Msuya agreed with their argument and said that he had actually questioned the health ministry on the issue, but had never heard anything back from them and since this was essentially a directive, they would follow it until it was changed or rewritten in some way.

The vegetable garden that is the view from the Gibb’s bathroom

We did here about an interesting patient who had come in on Sunday – a man was attacked by a leopard in Ngorongoro Conservation Area and had suffered a compound fracture of the tibia in addition to a very severe injury of his hand most likely suffered in trying to defend himself. Leopards do not usually attack humans so there was some concern as to whether the leopard could have been rabid, but regardless, they were planning to track it and to kill it. Animals such as this, whether rabid or not, are often very likely to repeat the attacks once it becomes a pattern of theirs. His tibia fracture was significant enough that he was transferred to an orthopedic hospital in Moshi the following day. A few years ago, we had stumbled upon a leopard on the Ngorongoro Crater rim road while driving early one morning to go for a hike at another crater. The leopard had jumped into the road, looked at us and then just sauntered off to the side of the road where he sat for several minutes allowing us to take photos of him. As we drove on, we encountered a park ranger around the next bend, walking with a rifle, thankfully, and informed him of the leopard. Most often, though, these animals are far more afraid of us than we are of them.

The view from the veranda at Gibb’s Farm

Planning for half a day in clinic is always a bit of a crapshoot. I learned long ago that once you start, the work seems to accumulate and fill in whatever the amount of daylight hours there are. When we work a normal full day in clinic, I usually choose a patient number that is less than what we can actually do as I know patients will continue to come and somehow, I will be talked into seeing them. The other problem was that we wouldn’t be at FAME for the next three days as these were our mobile clinics off in the villages so we couldn’t tell people to just come back the following day. There are many patients who have we have been seeing for several years and when they come after we’ve already capped the clinic, it’s hard for me to turn them away. There are no appointments for patients, though we will sometimes see patients with a hardship of some sort over in the OPD so as not to create a huge stir over on our side which is what will happen if were to see patients out of order. It will happen occasionally when we have a pediatric patient as we try to have Amisha see all of those (to keep her happy) if possible.

The Penn Neuro team at Gibb’s (sans Hannah)

At one point, Hannah needed to repair her glasses so I sent her to Frank as I knew for certain that he would have at least a dozen tubes in his office. Sure enough, he had more, and Hannah returned to successfully repair her glasses. At the end of clinic, she had to run to the OPD for something so set her glasses on a chair with her charts. Shortly thereafter, we heard John asking whose glasses they were and, sure enough, he had picked them up and promptly glued two of his fingers together. He pulled them apart somewhat painfully and much to our amusement, after which we learned from Hannah that the enzymes in saliva will dissolve the superglue and in a far less painful manner.

Our lunch party at Gibb’s

We were actually able to get through all of our patient, though with little time to spare, and after collecting everyone in Turtle, we were on our way again to Gibb’s Farm, this time for their scrumptious buffet lunch. Now, if by wellness, we’re talking about mental health, this was certainly the solution. If by wellness, though, we’re talking about physical health, that’s another matter. That’s not to say that the food that is being served isn’t healthy because it absolutely is, but rather it is related to the amount that most of us eat. I won’t name names, and it didn’t occur this trip (Lindsay, Hannah, Amisha, Steve and Peter – I wouldn’t rat you out even if it did involve you, but it didn’t), but in the past, lunch goers have been noted to have three plates of food not including desert! It would be impossible to name all of the dishes, but leave it to say there were probably a dozen variations on vegetable salads, cold cuts, main dishes, a lovely cauliflower soup, cheeses, breads, samosas, quiche and various toppings. The desert selections included fruit, pancetta, a flan-like dish and a date cake. And oh, yes, it also included the famous Gibb’s Farm fresh-brewed coffee. It was truly a lovely and relaxing affair that included the seven of us and Kat, the social media coordinator here at FAME, who was acting as the volunteer coordinator in Alex’s absence as he had seen fit to abandon us and spend the week in Zanzibar.

The backdrop out the window at our lunch

After our relaxing lunch, we decided to spend some time visiting one of the local artist’s workshop here. Athuman Katongo is a wonderful artist who has been at Gibb’s for several years and I had bought something from him in the past. He makes paper from recycling cardboard and uses the local fabrics to create amazing montages of animals and people. He also makes some wonderful notecards that everyone found attractive and so we purchased probably over a dozen of them from here. His studio was filled not only with his finished artwork, but also with unfinished products that were equally stunning. Being in a paradise like this with such lovely artwork surrounding us in the presence of the artist himself was certainly an incredible treat for all of us.

With Athuman Katongo in his studio

We had originally thought of going shopping after our lunch, but Frank had texted me that he had a complicated epilepsy patient that had traveled from Arusha and wondered if we’d have time to see him. Frank is a very hard person to say “no” to so most of us drove home from Gibb’s (Hannah and Steve had a nice walk back to FAME through Tloma village) and Amisha and I went to work at the OPD to see the boy while the rest of the group headed back to the house to work on other things such as their presentations and charts. The boy was 14-years-old and had had epilepsy since the age of three, and all of the time poorly controlled. The history was quite convoluted, though thankfully mom spoke perfect English. He had been on multiple combinations of anticonvulsants, but none had ever really been pushed to their maximum nor had they been thought out very well. We came up with a good plan that involved an MRI (he had only had CT scans previously), levetiracetam and the possibility of using lacosamide if the levetiracetam didn’t work well, but they would have to check to see whether they could get it Arusha first. We had seen a patient on it here earlier in the month, but you never know if it was obtained in this country or not as there are some patients who travel to Rwanda for medications. We drew up very specific instructions for them to follow and going forward, they will communicate with us through Frank.

Hannah on her walk back from Gibb’s learning how to make a wood carving

Steve on his walk home being escorted by one of the local children

That night we watched Lion King as Steve had never seen it before. Halfway through the movie, we took a break to apply some Korean face masks that Amisha had brought and were intended to make us all feel more luxurious. I can honestly say, at least for myself, that I was unaware of any effect. Tomorrow, we would begin our mobile clinic push, first at Kambi ya Simba, which is about 45 minutes away.

Looking luxurious in our Korean face masks

 

 

Sunday, October 15, 2018 – A day with the elephants….

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On safari

Considering the wonderful safari we had had the week prior to Lake Manyara, everyone was perfectly happy (or at least willing) to awaken well before sunrise to begin our trek to Tarangire. Animals are more active in the morning hours and the evening and so we had wanted to arrive shortly after the gates open at 6:30 am. Packing the car and hitting the road at 5:30 meant that it was a bit cool and quite dark as the sun wouldn’t be rising for nearly an hour, but it would hopefully get us there shortly after opening. Tarangire is a wonderful park that is a bit larger than Lake Manyara, but still much smaller than Serengeti National Park. Still, there is lots to see there and we would not have time to explore the entire park. The biggest attraction is their population of elephants that rivals any other park in Tanzania, and perhaps Africa. Elephants spend their nights away from the river in the hills, each day making the journey to the river for their water. In the drier months, the river is packed with animals which usually means that lions are nearby and we were certainly hoping to see some today.

Lindsay and John enjoying a selfie moment with the elephants

The drive was uneventful other than my mandatory run in with the traffic police here. Sure enough, on the other side of Makuyuni, I was stopped for traveling 56 kph in a 50 kph zone. Once again, the zone was not marked, but I was told that it is 50 kph anytime you’re traveling through a populated area, which here means a few buildings and a crosswalk. I handed over my 30,000 TSh (less than $15 USD) and received a receipt on the spot that was spit out by the officer’s handheld device that had registered my details. Needless to say, I drove a bit slower for the remainder of the drive and made sure that I didn’t speed in any area that could be considered “populated.” Oh, and by the way, 50 kph is the same as 31 mph, so you can imagine how hard it is to keep you speed down to that range while driving on a highway.

Lilac breasted roller

A lilac breasted roller in flight

We pulled in the parking lot at Tarangire and while I went to pay our fees, the rest of the group used the bathrooms and prepared the vehicle for game viewing by popping the tops on Turtle so everyone could stand while we were in the park. Several people also went to the concession stand there to score some coffee which most had missed due to our very early departure from Karatu. Once paid and with everyone back in the vehicle we went through the entrance gate after showing our receipt for having paid our entrance fees.

John’s gorgeous black and while of elephants

We were now in the park proper and it was time to get into the mode of game spotting and viewing. I have a navigation application on my iPad in which I have loaded maps of all the areas I drive in as even without cell service here I will never get lost as long as I continue to receive a satellite signal. I have also recorded all the roads that I’ve driven on during my many safaris along with where I’ve seen lions and other interesting sights during our drives. Although I know most of the roads here in Tarangire by heart, it is still helpful to see where I’ve seen things before or to double check regarding a turn or two. Turtle is equipped with a two-way radio that is very helpful as all of the guides talk to each other and share sightings, but unfortunately, they all do so in Swahili which is of little use to me since I speak so little of it.

Baboons!

It took very little time for us to begin spotting the more common animals here that included zebra, wildebeest, warthogs, and impala. As we drove down and crossed over the river, we began to spot the many elephants here along with Cape buffalo and giraffe. The elephants here are the most fascinating, though, in their large extended families that are purely matriarchal and contained many, many babies. Driving along the river, we encountered family after family making their daily journey down to the river to bath and drink and generally carry on. My plan was to continue driving along the river and eventually reaching the Silela Swamp that sits on one end of the park and has a lovely lunch area overlooking this incredibly large area that is usually flooded with water, making it home to many, many animals. Before we get to the swamp and lunch, though, we have quite a bit of territory to cover and it is far from disappointing.

Our guide

A lioness

Lindsay and Hannah practicing their predator imitation

At one point, while watching a family of elephants making their way across the road in front of us, someone spotted a lion directly behind us also crossing the road. We quickly swung Turtle around along with another vehicle that had also been watching the elephants and found that the lioness was one of three who were slowly making their way across the river very likely in search of game. One of them was already across the river under a tree while the one we were watching had stopped on our side in the shade of a tree and yet a third was sitting above us under a tree. Eventually, they all followed the same path ending up in the shade of some trees and probably waiting for a passing herd of wildebeest or zebra. It is difficult to see lions during the day that are doing much else than sleeping so it was great that we at least got to see them walking, even if they were hunting at that very moment.

Amisha in her tse tse fly mode viewing an elephant

Baby elephant

John’s shot of Zebra

We had watched the lions for a good amount of time and had decided to get back on track heading for our lunch spot overlooking the Silela Swamp. As we rose higher to cross over the crest of a hill, the swamp came into view and as dry as most of the park was, the swamp was green and luscious and covered with elephants. There were huge herds or families of elephants that were spread across the lush green vegetation and numerous watering holes there were visible and many that were not. It was an amazing sight to see hundreds upon hundreds of these elegant creatures all interacting and enjoying themselves in the water and mud. We pulled into the picnic area with a number of other vehicles already there, but were able to find a nice table with an umbrella to shade us.

Lunch at Silela

A pair of elephants in the Silela swamp

Posing at our lunch spot

The view from the picnic area of the Silela Swamp is just incredible and the weather was absolutely perfect for our day in the park. We enjoyed our lunch of peanut butter sandwiches, in various combinations with jelly, Nutella, honey and bananas, along with hard boiled eggs, cheese, crackers and fruit. Everyone was happy to have some moments to relax with our beautiful views and there was absolutely no rush for us to head back out as we had the entire afternoon to make our way back to the entrance. After lunch, we drove along the edge of the swamp for some time admiring the hundreds and hundreds of elephants, some who were close up and others out in the middle of the swamp, though all enjoying the cool water and mud. Many were playing or flopping down in the mud no doubt to cool off and coat their hide against the insects and heat. Watching them relax and enjoy the day was great to see and gave us all such a sense of warmth and for those moments you can almost forget the outside world and share in their existence.

Jumping for joy at Silela Swamp

Hannah and the Silela Swamp

An oribi – not often seen at Tarangire

Along the swamp we were able to see some animals that were not up in the woodlands we had traversed. There were a pair of reedbuck, an antelope mostly spotted around water, and a lone oribi, another antelope that I hadn’t seen before. We doubled back and drove along many more families of elephants before finally leaving the swamp and driving up over one of the hills that parallel the river, spotting a small group of Klipspringers which I hadn’t seen before in this park. Large groups of zebra and wildebeest were absolutely everywhere we turned and there were also many giraffe. Unfortunately, we didn’t see as many lions that we had hoped, but knew that we would see them next weekend in the Serengeti.

Guide/Photographer

We didn’t leave the park until after 5 pm which meant that we would be arriving in Karatu after sunset, always a risky proposition here as driving at dusk is the most difficult with motorcycles and pedestrians popping up in front of you continuously. We were both starving and exhausted, though the exhaustion won out and we decided to head back to the house and scrounge for dinner. We had bread and cheese which was more than enough for us, though, so I made grilled cheese sandwiches for everyone and John has some of his chicken soup he had made along with his sandwich. The remainder of the evening was quite quiet with everyone passing out and heading to bed at various times. We would have a light day at clinic tomorrow for it was a wellness day in the afternoon and we had plans for lunch at Gibb’s Farm, always a highlight of the trip.

A tawny eagle

Saturday, October 13, 2018 – Another visit to Rift Valley Children’s Village….

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Walking in the morning

We were all quite energetic this morning (or at least I was energetic as the Hannah and John have running every morning) and decided to go out for a walk in the fields beyond the FAME property. FAME sits 2.7 km out of Karatu proper and is pretty much the last establishment on the road before you run into all the coffee plantations that back up to the border of the Ngorongoro Conservation Area. This is a huge region for excellent coffee given all of the volcanic soil and the Ngorongoro Highlands is particularly lush and rich in this regard. From our veranda we look out over fields of coffee as far as we can see into the distance as they run up the many hills and ridges here.

A panorama of our walk

The area that we walk is partially along a dirt road and then onto some trails that cross the fields and are used by the local workers to get to and from work and home. This time of year, the trails are well worn flat and easy to follow or even run on, but in the wet season the fields and trails become a quagmire, so much so that you usually have about a pound or more of clay caked to your shoes. This is fine from an exercise standpoint, but if can difficult to walk with that much muck on your shoes. The morning was absolutely gorgeous and my fleece vest lasted only about fifteen minutes before I was sweating and had to take it off, carrying it with me the rest of the way. We left at about 6:20 am and walked at a brisk pace so that we covered about 3.5 miles and arrived home after an hour, time enough for us to shower and make it to morning report on time.

Waiting for clinic

Waiting for clinic

There were no exciting patients that had come in overnight and we had no clinic patients as were leaving as soon as possible for the village of Oldeani and Rift Valley Children’s Village (RVCV). India Howell (Mama India) founded the children’s village in 2004, and over the years, they have continued to grow such that she now has nearly 100 children that call this their home and call her Mama. The children are all adopted and between she and her Tanzanian partner, Peter, the children are cared for and raised, attending the local schools, then secondary school and eventually college. She has partnered with the community to improve their schools by helping to fund certain programs and she has offered healthcare to the residents of the surrounding community as they knew that a healthy community would only improve the chance of success for their children.

Kitashu doing additional triage for our neuro patients

Registering for clinic – only the neurology patients were let through to our separate waiting area

It was on the backdrop of India creating her children’s village in Oldeani that Frank and Susan decided to locate FAME here in Karatu for several reasons, though an important one was its proximity and the fact that they could provide medical care to her children and the community. I guess you could say that the rest is history. Having FAME on the Northern Tanzania safari circuit where it would get some exposure to visits to the area who were interested in the community is perhaps the main reason that I am here having visited in 2009 while volunteering in the village of Ayalabe outside of Karatu. Nancy, our architect/nurse at FAME, came through while on safari several years later with Leonard Temba who was our guide and ended up coming back to FAME to stay after speaking with me in the States and deciding this is what she wanted to do. India had come to Africa in the same fashion. Having climbed Kilimanjaro, she returned to manage a safari lodge and then decided to create a home for orphaned and abandoned children here in Tanzania. Many, many of the expats and volunteers arrived here in the very same fashion, having fallen in love with this country and its people after visiting, not knowing that it would change their lives forever, and, of course, for the better.

Lining up for clinic

Amisha and one of her patients

We all loaded into Turtle, now repaired and running well, and began our drive towards the village of Oldeani along a lovely route through cultivated fields and eventually arriving to the coffee plantations that surround the children’s village. Working in the coffee fields is the main employment for the local villages here which is steady, though very physical, work. There is a very stark contrast driving past the homes of the adjacent village and then through the gates of RVCV where the buildings are brick and in good repair and the grounds are well kept. There are close to 100 children living here until they are ready to go away to school and possibly the university. Daniel, who grew here and worked as a translator for us over the last several years just found out that he would be attending clinical officer school which is a fantastic achievement and made everyone proud. Emanuel, one of our previous translators (not the current Emanuel working with us) recently graduated from nursing school and is now applying for jobs. Most of the children here excel in school and go on to college which is no small achievement here where the government decides who gets to go and who doesn’t and is based on their oft-changing rules.

Shaban going over very detailed instructions with a patient

Dr. Anne and Amisha with a pediatric patient

Driving into the parking circle in front of the administrative offices, there is a huge gathering of patients sitting on benches and waiting to be seen. Our first thought is how we are possibly going to see all these patients in one day starting at 10 am and we’re all relieved to find that the patients are not all neurology as nurse Gretchen is seeing patients today in their regular clinic. Still, as we arrive to the area where we’ll be working, it seems there are quite a few patients for us so we make sure with Kitashu that the patients are going to be properly screened and I revisit the criteria with him that we use here. We try not to see back or extremity pain, but rather weakness and numbness as these are neurologic complaints and not osteoarthritic in nature. We have worked hard to train those that help supervise these clinics where it is essential for multiple reasons that we’re seeing neurology and not pain or orthopedic problems. First, it’s not what we’re here to do and it gives us less time to work on what we’re good at doing. Secondly, we have limited funds and if they see us for the reduced single fee that covers labs and meds also, it takes away resources from those that may have needed it. Triage, though, it really tough. We commonly have patients come through who have told the nurse one thing and then it changes when they come in to see us. At FAME, it’s easy for us to send them over to the outpatient department, but here they would have to see Gretchen and she was definitely going to be a bit overwhelmed today.

Amisha and another cute peds patient

Dr. Anne and Amisha with patient and mother

John and his interpreter evaluating a patient

Many of the patients here we’ve seen before, some for as long as I’ve been coming. We see some of the children from RVCV with epilepsy or ADHD, but there are more patients from the community that are seen. This is an Iraqw community and so almost all of the villagers we see are from this tribe which is very similar to our other mobile clinics which are also in Iraqw communities. We probably see a larger percentage of epilepsy patients here than at other clinics, but otherwise, there is the typical smattering of diagnoses. Several of the patients are new to the clinic and we’ve diagnosed them with chronic illnesses such as epilepsy and they will require continued medications going forward. One of the patient had unfortunately come from a very long distance near Lake Eyasi meaning that they were out of the catchment area for the clinic and their continued care would not be covered as it was for the other patients. This is always an unfortunate position to be in because the medications can be expensive and it doesn’t serve much of a purpose to put a patient on a medication that works, but is not sustainable in the long run.

The bride and groom

Anne and Lindsay practicing their yoga

One of the highlights of our visit here is lunch as it is served in the kitchen house where all the volunteers at the children’s village eat every day. It is always fresh and delicious and there are often home baked desserts, but unfortunately not today. After lunch we went to the small duka (store) where they have for sale items made by the Rift Valley Women’s Cooperative, a group that is being supported and managed by the RVCV and has their handicrafts in lodges and shops throughout. It is beautiful work and I think all of us made sure we purchased something there. As we were shopping, we could hear the band playing for a local wedding. The wedding party typically is in a car followed by a van or truck loaded with musicians who play tunes that almost like a mariachi band to me – drum, trombone, and trumpet blaring while they are driving through town. After we walked back to clinic, the wedding procession came into the children’s village and parked with the bride and groom getting out to take pictures right in front of the administration building. One of them had apparently worked here in the past.

Lindsay on the slack line

Lindsay on the slack line

We had planned to finish early, but somehow the time got away from us and the afternoon stretched to after five. It wasn’t late for us, but I felt bad for the FAME staff that were with us as they would be getting home rather late. John had plans to cook dinner tonight and as soon as we arrived back home, everyone went into action with John calling out the orders. Hannah and Amisha went to cook rice at Steve’s while Lindsay and I stayed here to help John. Dicing ginger and onion, hot peppers and tomatoes while John worked on the cooking the chicken, sliced eggplant and green beans. We ended up having a real feast and all sat around the table enjoying our spoils. Peter had difficulty getting here on time, but there was more than enough for him to eat. He was going to spend the night here since we’d be leaving before dawn to drive to Tarangire in the morning. It would be another exciting game drive in the home of the elephants.

Dr. Anne trying the slack line

Lindsay and our feast courtesy of John