Amazingly, we were all on the road just moments after 6 am which had been our planned departure time from FAME as were traveling to Lake Manyara National Park where we would all be spending the day exploring the park and its amazing wildlife. We were picking up Peter, our medical student who is living in town, and Selena, a nurse at FAME who I have known for several years and I had offered to accompany us since she had never been to Manyara, nor had she ever been on a safari before, at the intersection of the FAME road and the tarmac. It was still well before sunrise as we set off heading east out of town, then up the hill to Rhotia and finally down towards Lake Manyara nestled in the valley below. The lake is very large so you can spot it well before you reach the edge of the rift, then descending down the steep grade towards the town of Mto wa Mbu where the entrance to the park lies.

I have spoken frequently in the past of the great National Parks of Northern Tanzania, each with their unique geographic features. Lake Manyara, Tarangire, Ngorongoro and perhaps the grandest of all wildlife parks, the Serengeti. Each has a distinct feature that distinguishes it from the others – Lake Manyara is dominated by lake ecology, Tarangire by river ecology, Ngorongoro Crater with its own unique micro environment existing within the crater, and finally, the Serengeti that means “endless plain” in Maa, the language of the Maasai.

Lake Manyara is a park that is often overlooked on many safari schedules as it is a rather small park and is overshadowed by the larger and more well-known parks. It has some very unique features, though, that make it a very valuable addition to any itinerary to Northern Tanzania. It is a very large and shallow lake that was formed in the Rift Valley with a number of hot springs that surround it. As you enter the park, you initially travel through a tropical forest for some distance before arriving at the lakeside in a marshy region where there are numerous species of birds that either migrate through this region or make this their home. There is a hippo pool here and a new overlook platform to look over this wet region that is full of life. As we arrived here, there was a herd of Cape buffalo and zebra mulling around and as we pulled into the overlook, there were a few older male Cape buffalo half submerged in the marsh looking for the more tender grasses. These older, solitary males are separated from the herd and their group is referred to as a geriatric herd.

Leaving the marshy area, we traveled along the lakeside, weaving in and out of the forest looking for more game. Large troops of baboons are everywhere and we often have to wait for them to clear off the road and allow us to pass. The other primates here include blue and vervet monkeys that are in smaller groups than the baboons and often in the trees above our heads. There are other nocturnal primates here, primarily the bush babies, but they are obviously seen only at night and night drives are allowed only in private reserves as the gates here close at 6:30 pm.

We quickly came upon a small group of elephants feeding on both sides of the road and rolled up to them so as not to disturb them too much. We sat for some time watching them as they got closer and closer to us which is perfectly fine as long as they are in charge of proximity and we’re quiet and not moving around too much. There were a few smaller, somewhat older, babies with the group who the mothers typically keep at their opposite sides from us to protect them. At one point, one them moved into the road immediately behind our vehicle and something must have startled her as she moved rather suddenly and then stood for a few moments facing us as if to decide whether we were a real threat or not. After deciding that we were harmless, she turned and ambled down the road a short distance to feed again.

Driving through the woodlands there were many herds of impala that included both the bachelor herds that are made up of only males who are constantly vying to win and harem of their own and the harems that are all females and babies except for a solitary male that has won the right to rule this herd. The male is constantly being challenged by other males and the dominant male will switch out many times over the course of the mating season.

Magi moto (hot springs) is prominent stop on a tour of the park and usually reached around lunchtime so has a bathroom and tables to eat. The hot springs are extremely hot and not something to relax in, but rather have lots of mineral deposits and algae that tolerates the high temperatures. There were several small flocks of flamingoes, something that Amisha was dying to see and was on her bucket list. We have several other safaris coming up so hopefully she’ll get a chance to see larger flocks in the future. There is a new boardwalk that goes well into the lake and everyone took the opportunity to walk to the end while I stayed back and kept an eye on the vehicle so we wouldn’t have to lock up. Having been driving since 6 am, I was happy to have a little rest.

The lake was incredibly high as the at least half of the walkway usually traverses a marshy area while now the lake came right up to where it started. Rains come down from the rift wall that is immediately to our right as we’re traveling south and there are many culverts and creeks that are dry now, but become swollen with rapidly flowing water at the first sign of a big rain. It is not difficult to get stuck on the wrong side during a rainstorm and have to wait hours for the water level to go down and enable one to pass.

We had a nice lunch of peanut butter and jelly sandwiches, hard boiled eggs, sliced carrots and cucumber, and pineapple. It was enough to refresh everyone and after lunch we loaded back into the Land Rover and continued to head south looking for lions that frequently spend their days down here. We did see two Klipspringer, which are smaller rock antelopes as we left Magi Moto, along with a dik dik, which is the smallest of the antelope, that was at the side of the road. We were unable to find any lions on this trip, but we did find other herds of wildebeest, zebra and Cape buffalo alongside the lake as we continued on until the road petered out requiring us to loop back around and begin our return trip to the entrance gate. During our trip out of the park we found many more elephants to watch as they fed on the trees and brush at the roadside. We also had the opportunity to see a giraffe, mostly from a distance, but several more closely. We arrived at the gate a little before 4 pm, having spent a full nine hours at the park game viewing.

Driving home to Karatu were able to stop a friend’s gift shop to look around and everyone was able to get ideas of things they wanted to bring home. Nish, who owns the shop, is a good friend who I have known for several years and lives in Karatu, having originally grown up in Mombasa, Kenya, which is on the coast. We arrived back in Karatu pretty much starving as, though our lunch had been tasty, it wasn’t entirely filling and we had eaten earlier than normal here. We decided on eating at Happy Day, the pub where one can find a decent meal on a Sunday and also where Peter was residing in one of their cottages. Unfortunately, as is most often the case in the restaurants here, it usually takes an inordinate amount of time to get your food after ordering. Now one might find that a plus when you’re in a paradise here as you can relax with a soft drink or beer and just enjoy the quiet, but when you’re starving and tired and looking forward to getting home to relax, it is not a welcome thing. It took us over an hour to get our food, which was entirely delicious when it arrived and we were finally able to quench our appetites. Pizzas, mac and cheese with bacon, and fried fish were all placed on the table in front of their appropriate recipient and was very much enjoyed by all and quite quickly devoured. We left Peter at his place and were back home shortly thereafter, all thoroughly worn out from the day, but very happy that we had a successful safari and looking forward to the next.

Saturdays are typically much slower at FAME so we were all looking forward to a bit of a break after the busy day we had had yesterday. We had all walked up to meet for morning report but soon discovered that all of the doctors hadn’t yet arrived so we would just begin our Saturday neurology clinic a bit early. We had promised the group of women from Arusha that we would see them first today and there were about fifteen patients who had come the day before that we couldn’t see and were told to come back this morning. I learned from Angel that you can’t take names and promise anyone anything as then patients may not come first thing in the morning and may wait until much later in the day to show up causing major issues with our scheduling. So, patients were told to merely show up again first thing in the morning and we do are best to get them in as soon as was possible. We also had dinner plans this evening at Gibb’s Farm and it is a must to get there before sunset so we could sit on the veranda drinking our Moscow Mules or whatever else tickled one’s fancy before heading off to an incredible dinner. Therefore, we clearly had some excellent incentive to finish clinic on time or earlier, if possible.

Despite it being Saturday and seeming as though we had thoroughly stamped out neurologic disease in Karatu yesterday with our clinic, there were still quite a few patients waiting to be seen when we arrived to the emergency area where we hold our clinic. With Angel’s assistance, we decided that we would cap today’s clinic at around thirty patients, which typically means that you’ll see a few extra as they are sent to us from the outpatient clinic throughout the day. Luckily, though, there were few of these over the course of the day meaning that we would very likely finish on time.

In the afternoon, Amisha was asked to consult on a three-month-old Maasai baby in the ward who had presented with a history of fever and obtundation and would definitely need an LP as we felt very strongly that the baby had meningitis. We have no ability yet to culture here, so the LP would really be done to characterize things rather than to catch a specific bug. The baby had a bulging fontanelle and had seized and clearly had meningismus along with axial rigidity. He had already received the appropriate antibiotics when Amisha first saw him and later in the evening we also added another antibiotic for better coverage. Amisha brought the baby over to the emergency room so we could do the procedure there, but John was still seeing patients, so he eventually moved along with his patient to an outer room that is very small and is typically used for obtaining vitals. You have to learn to go with the flow here and so if moving to another room along with your patient will allow someone else the ability to care for a patient in need, then that’s what you do.

We set up for the spinal tap and enlisted Steve to help us with the procedure, as well as the case in general given the fact that we were fairly certain that we were dealing with an infectious process. Steve, of course, would repeatedly remind us that he doesn’t treat children. This is clearly reminiscent of my first visit here only to find that one morning they had a long line of children that had been referred to me from Loliondo, a district north of here by the Kenyan border. Though I have cared for children for my entire career, I did point out to Frank that I’m not a pediatric neurologist. His reply was something that has been permanently imprinted in my brain: “No, but you’re the closest thing to a pediatric neurologist that we have in all of Tanzania right now.” I think this is probably a corollary to TIA (this is Africa), and something that does make practical sense here where it wouldn’t fly for one second in the States, where one would never consider wandering out of their comfort zone while treating patients. Steve pitched in completely in the care of this child and assisted in the LP which went incredibly smooth.

Amisha completed the spinal tap without difficulty and obtained the necessary fluid to send to the lab so we would have a better of what we were dealing with. The fluid was surprisingly clear considering what our suspicions were, but we would have to wait for the results from the lab to make any decisions in the child’s treatment plan. He was on phenobarbital for the seizures and antibiotics for the presumed meningitis and it was now more of a waiting period for the child to improve or to have some labs back that would send us in another direction.

John saw a patient today who had developed a severe headache followed five days later by unilateral ptosis (droopy eyelid), diplopia and a large fixed pupil that had come to FAME one month prior and underwent a CT scan that was normal. This is a clinical scenario that is fairly classic for a posterior communicating artery that is compressing the third nerve and causes a fixed and dilated pupil, ophthalmoplegia (weakness of specific eye muscles controlled by the third cranial nerve) and ptosis, or drooping of the eyelid on that side. The plain CT scan essentially ruled out any bleeding, though one could argue that she didn’t appear to have a subarachnoid hemorrhage when she came to clinic. The other possibility would be that she didn’t have a subarachnoid hemorrhage, but rather a thrombosed aneurysm that had suddenly enlarged and compressed the third nerve, producing the physical findings we saw here. She desperately needed to have a vascular imaging study, but unfortunately that is not something that is available here, or in any part of Northern Tanzania for that matter. We did the next best thing, though, and requested that she undergo a contrasted CT scan that would give us some of the information we were looking for, if not all.

Lindsay, John and I sat in front of the monitor on the CT scanner scrutinizing the axial and coronal cuts knowing pretty much what we were looking for and just couldn’t see anything there. We were looking for an aneurysm, or enlargement of the posterior communicating artery, that would be compressing the third cranial nerve and causing the patients deficits on exam. At home, we’d have a CT angiogram that would give us detailed imaging of the blood vessels and, if there were something amiss, we’d be able to see it in multiple views and angles. Here, though, we were looking at a very much less than optimal imaging study that would show us what we needed if we were lucky. I took videos with my iPhone of each of the CT sequences as I clicked through them, an incredibly crude, but effective technique that I just learned from the residents as this is often what they do at home to send quick images to their supervising residents or fellows when on call. Sending actual CT studies by email is impossible as the data is so large, so these pictures or videos will have to suffice for the moment.

Later, I sent the videos and details of the case by email to Sean Grady, chair of neurosurgery at Penn and a long-time friend since our days training at the University of Virginia, to get his opinion. He got back to me almost immediately after having reviewed the images and agreed with us that there was nothing in the area of interest. Unfortunately, that doesn’t mean that the patient is out of the woods as she may very well still have an aneurysm compressing the third nerve, but because it is thrombosed, or essentially filled with clot, we just can’t see it on our contrasted CT scan due to the low sensitivity of the study in this area where there is a lot of artifact from bone. We will have to relay our recommendations to the patient that she travel to Dar es Salaam to see the only neurosurgeon in the country, or possibly to Nairobi if they can afford it, to hopefully have the correct studies, and, if she does have an aneurysm there, have it clipped to prevent a later rupture and subarachnoid hemorrhage. Unfortunately, the options are very limited and, as is all too often the case here, she will choose not to go to Dar and will have to roll the dice, hoping that nothing catastrophic happens in the future. If the gods are will her, she might do well, but it is a big chance to take and not one that any of us would choose in this situation.

Our clinic was finally over and we were all looking forward to our trip up to Gibb’s Farm. This is a working coffee plantation and farm that has been in existence for many years and has become our favorite place to relax and wind down after days of seeing patients. It is one of the many safari lodges here in Karatu that cater to the many tourists who have come to see the wonderful wildlife parks of Northern Tanzania – Tarangire, Manyara, Ngorongoro Crater and the Serengeti. Karatu sits on the small highway that traverses the landscape here and the tarmac (pavement) ends just beyond the village as you ascend the crater rim heading to the Ngorongoro Gate and eventually into the Crater or on to the Serengeti traverses the Ngorongoro Conservation Area before you reach the most magnificent of wildlife parks and home of the great migration of wildebeest and zebra, the largest land migration on earth.

The management at Gibb’s Farm has been quite gracious in that they allow volunteers from FAME to come enjoy their amenities for a reduced rate as a way of saying thanks for what FAME is doing for the community here. Spending an evening at Gibb’s is something that is very difficult to describe and must be experienced to really understand the effect this incredibly lovely resort has on your mind and body. Just writing about it is relaxing to me as I imagine all of the images there. I first visited there in 2009, and have been fortunate enough to go back on each of my return visits to Tanzania. There have been changes over the years, but all for the better, and perhaps one of my favorite spots on here or anywhere on this planet. We arrived just before sunset so everyone could take in the amazing view from the lawns in front of the main lodge building and then sat at one of the two large tables on the veranda, overlooking the lawns. A very large jacaranda tree loomed high above our heads with its almost fluorescent lavender blooms glowing in the dimming light. The sounds of the birds and animals filled the air and for the moment it was difficult to even imagine that anything else existed in the world.

We sat having our drinks, mostly Moscow Mules in their copper mugs, all realizing just how incredibly fortunate we were to be here and share this experience. It never gets old for me, but knowing that the others are experiencing it for the first time is enough to make it seem like it’s my very first visit and something fresh and new. Somehow, we began to talk about birthdays at some point and Steve divulged that today was actually his birthday and he had just decided not to tell anyone. On my next trip inside to order drinks (totally unnecessary as we were waited on hand and foot), I let them know that it was his birthday and asked if they could have the staff come and sing to him along with maybe a small cake after dinner. The plot was set and I was confident that Steve was completely unaware that anything was amiss. We sat outside until well after it was dark having our second round of drinks, just enjoying each other’s company, and finally went inside well after 7:30 to sit at our table for dinner. Before that, though, we all went up to visit one of the artist’s studios who I had purchased something from before. He is a lovely man who I had met there several years ago and visit every time I’m here. Last spring, he had a child here at FAME so I was able to see him here and congratulate him.

Dinner was a wonderful affair as everything is locally grown and very fresh. Every course was incredibly scrumptious and the staff were so attentive that we were in need of absolutely nothing throughout dinner having an ample supply of fresh baked bread and butter. Before desert was to be served we heard the staff back in the kitchen begin their procession that I have so many times. “Jambo, Jambo Bwana, Mzuri sana….” This is their welcoming song for the mzungu and tourists that I’ve heard at birthdays and after coming off of Kilimanjaro following our summitting three years ago. The staff danced throughout the dining area and among the other guests banging pots for drums with everyone singing the words and clapping. Steve was enjoying the whole affair, completely unaware that the celebration was for him, clapping and singing along and completely unaware that Amisha, sitting directly across from him, was videoing the entire event to catch his reaction. As the procession eventually made it to our table and the staff surrounded Steve, he finally became aware that they were celebrating his birthday and he had such a look of total surprise. It was such a genuine moment and all of us were so grateful that we were able to share his birthday with him as he had planned to let it slip by without notice. It also reminded me of my sixtieth surprise birthday party here two years ago in March that Jess, Jackie and Paulina masterminded without a hint of awareness by me. I think these are the times that we cherish the most and realize just how much each of us is appreciated. They are the times that we allow those who love and respect us to express themselves and honor us. They are the times that we will always remember.

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We drove home from Gibb’s fully satiated both physically and spiritually. We were leaving early in the morning to go on safari in Lake Manyara National Park and would have to make our lunches for the trip. Also, Amisha wanted to check on the little baby with the presumed meningitis so I walked up the hospital with her while the others worked on our peanut butter sandwiches and hardboiled eggs for tomorrow. It had been a great day and evening and we all slept very well with dreams of wild animals and incredible sights.

Over the last several years, we have come up with a pretty good system for just how to schedule our neurology clinics during each of the months that I am here with the residents. We knew that to build the program we would have to come on a recurring basis (hence the visit every six months) to develop a trusting relationship not only with the clinicians here, but also with the patients and families who come to see us and appreciate our care. Also, with the help of Paula Gremley back in 2011, we had developed the Neurology Mobile Clinics to bring access to our care to some of the more remote areas of the Karatu District. This model seemed to work very well as the clinics were very well attended and patients that wouldn’t normally come to FAME for medical care were introduced to us and could continue seeing us in the villages, but could also come to FAME if that was necessary. What began in 2010 with my teaching the clinicians here how to do a neurological examination and treat these patients when they just happened to come for care, has now evolved into a well-organized, month-long clinic in which we are seeing an around 300 patients each visit.

Our visits are now comprised of an approximately week-long, clinic that we do here at FAME, a week of mobile clinics where we travel to more remote villages in the district, and then several days of clinic back at FAME where we can see follow up patients or patients who missed us the first time around. All of the clinics, including the mobile clinics in the villages, are well announced to the community by staff at FAME that includes Alex, our volunteer coordinator and neurology clinics coordinator, and Angel, our social worker. They travel throughout the district announcing our arrival typically a month in advance and inform potential patients of the types of disorders that we treat (despite this along with triaging when they come, we still see a fair amount of non-neurological patients that slip through). In addition, Angel has a list of patients who had come to FAME in the time between our visits with neurological disorders and it was felt that they should come back to see us. Often, I am contacted back home by email regarding these patients so that we can initiate care and then they will come back to see us when we get here.

The first few days after our arrival are reserved for those patients Angel will call and are otherwise unannounced This allows everyone to get a good feel how things run here which is a bit different than back home. Every patient is seen with an interpreter (who also might be a clinician) and it sometimes requires two interpreters if the patient doesn’t speak Swahili which is not uncommon in some of the local Iraqw and Maasai population. The medications we have to use are limited and some are different than we have back home and many are in different doses than we have. The options in regard to testing is much different and the types of therapies we have at our disposal are much more limited than we have at home. But in the end, it is still mostly the same disorders that we are treating here as at home, though the differentials may vary quite a bit because of our location. The principles of medicine are still the same, of course, and it is all a matter of taking a good history, performing a good examination and developing your differential. For us, the neuroanatomy is just the same as it is at home, though we don’t have the MRI scans or even CT scans, that are often obtained before we see the patients, to fall back on when we are forming our differentials. It is actually medicine the way medicine was meant to be practiced and which is an all too uncommon event in today’s world.

For some reason, I hadn’t remembered what our schedule was this trip and, for an equally odd reason, I hadn’t looked at the schedule on my computer since composing it to send to Alex well over a month ago. So, it is with this preface that we arrived to clinic on Friday morning expecting another unannounced, and therefore rather quiet, day. Well, it was an announced day and what we encountered outside the emergency ward (having been taken over this month to be our neurology clinic) was a bit of a mob scene with patients everywhere waiting for Angel to get them registered and then have their vitals taken so we could begin to see then. First, though, at morning report they presented a young gentleman having come in overnight with new onset left hemiplegia following left neck pain and having been found to be HIV positive which was a new diagnosis. The patient would also need to be seen in consultation by one of the residents so this needed to be done in addition to seeing all the patients that were now on our doorstep.

We had three exam “rooms” for patients to be seen in and I told Angel that we could start by registering thirty patients for the day as I knew that I would be asked to see other patients by the clinicians here throughout the day so we would inevitably see more than that. John went off to see the patient in the ward and Angel began the process of registering the patients we could see and having other people come back tomorrow. One group of women from Arusha has traveled to see us and weren’t in the group that we could see today, but there was just no way we could add them, so, with Susan’s help, they finally agreed to spend the night and we see them first thing in the morning. Later in the morning, the residents suggested setting up a fourth station to see patients which we put in the hallway adjacent to one of the other stations and the stations would share an examination table. So, it was with this arrangement that we began to plod away seeing patients for our first “announced” clinic day of the season and quickly expanded the number of patients we would see too well above the thirty that we had originally intended.

Lindsay also had to break off at the beginning to see a patient that Frank has asked us to see with back pain and was a local ex-pat here. He had come this morning to see us as more of an appointment which was perfectly reasonable I felt, but we chose to see him across the way in the general OPD so as not cause any issues with feeling that we were seeing him ahead of our other patients, as we were not, but this could be an obvious perception if one wasn’t aware of the reality and it was more appropriate in this situation to just prevent any sense of impropriety. Additionally, Ståle, who is the gentleman that runs a home in Mto wa Mbu and who I have known for several years, came this morning with his car full of neurologically impaired children. Somehow, he has been tasked with caring for a number of young men with muscular dystrophy, most who we diagnosed and have treated for several years, and brings all of them on the same day packed into his Land Rover with all of their wheelchairs tied to the top. Thankfully, he had gotten here early enough for us to make certain his kids would be seen given the difficulty he has getting everyone here.

Ståle is a saint for the work he does with these children and for his dedication. Every resident who has met him and the children he cares for has been changed for the better seeing the dedication he has to these kids and the wonderful outlook these children have despite knowing the condition they have and what the future holds for them. He did inform me today that one child who we have probably cared for now for four or five years with what I believe was a paralytic illness, and probably poliomyelitis, that he had contracted well before he first saw us, died about a month ago from pulmonary complications as his spine had gradually become more and more flexed and he had no respiratory reserve. Living with Ståle, though, he had had a great outlook and a wonderful personality and had been well-cared for throughout his shortened life.

So, it was on this background that we saw the remainder of Ståle’s kids, all mostly with Duchenne’s muscular dystrophy, though one with something else, and continued on with our incredibly busy day. Of course, it was immediately after adding our fourth station that would sit just as you enter the emergency ward, that we started see these boys, all in wheelchairs, and immediately ran into a traffic jam which was quite comical, but everyone just soaked it up to TIA, “this is Africa.” One of the older boys we have been seeing who had been quite depressed early, was no doing incredibly well and Ståle told us that he had come completely out of his shell and was not was now the life of the partly. It is really so incredibly touching seeing these boys and young men who are obviously suffering, but have chosen to make the most of it and have done such an amazing job. It is truly an honor to be taking care of them and I look forward to continuing to do this over the coming years.

One of his young boys who had recently moved to his home just several months ago and had been assumed to have Duchenne’s muscular dystrophy was clearly different from the other children. I saw him with Amisha and we really had no history unfortunately as he couldn’t give us any and Ståle had no family members of his that he spoken with nor were they around. Sadly, many of the boys that he takes in have been abandoned by their families prior to him taking them in and, therefore, we have no history to go on. The boy was unable to walk, but had no psuedohypertrophy of his calves and the majority of his atrophy was in his shoulders and arms. He also had some mild wasting of his temporalis muscles and given this constellation of findings, it became clear to us that he had either fascio-scapulo-humeral or limb-girdle dystrophy, both of which have a tremendously better overall prognosis than Duchenne’s as they have a normal life span, albeit with significant disability. Still, that was some bit of good news that we were able to relay given the typical unfortunate news we have to deliver with the diagnosis of Duchenne’s.

Finally, in the midst of our incredibly busy clinic, as had briefly stepped away for something, I came back to find that a patient had been brought in to see us on a stretcher and was promptly placed in the emergency room where Hannah was already seeing patients. Dr. Gabriel had mentioned to me previously that there was a patient he wanted us to see (and appropriately so) who had been in the hospital here in July with presumed encephalitis and wasn’t recovering. Unfortunately, after bringing the patient in, he promptly began with focal seizures that appeared to be epilepsia partialis continua and is something that can often be difficult to treat. According to his family, these had begun about a week prior and were essentially occurring on a regular basis. His original presentation was such that he was found unresponsive by his family at home and then had been brought into a local hospital where he remained unresponsive for about another 48 hours before being transferred to FAME. Here is was clear that he had an encephalitis and underwent an LP and was placed on antibiotics and acyclovir. He eventually had a CT scan showing numerous large early hypodensities in the brain and more specifically, the bilateral temporal lobes, the most common location for injuries that occur in herpes encephalitis.

He had been treated with a 21-day course of oral acyclovir, but had never really woken up. He had also been placed on carbamazepine for his seizures as well, but at a relatively low dose considering the injuries to his brain and the propensity of to have seizures for the rest of his life. As he lay on the emergency room gurney, unresponsive with continuous jerking of his left face, arm and leg, his family stood by patiently awaiting our input into the situation and whether we had anything at all to offer their 28-year-old family member. There was no issue with handling the seizure part of the equation, but having our very own infectious disease specialist here was certainly a blessing as this is something that we would absolutely have consulted ID on at home and very much looked forward to their input. We have no confirmatory tests here such as a PCR on the spinal fluid, so the diagnosis would be based on the clinical features that were quite suspicious for HSV encephalitis with treatment that had been delayed by at least several days as he was found down at home with an unknown duration, been in an outside hospital with no specific treatment for at least two days and eventually transferred her and treatment was initiated quite quickly. Herpes simplex encephalitis is something that must be treated immediately upon consideration of the diagnosis as the virus rapidly multiplies and the damage it causes becomes more extensive and it is irreversible once it occurs. The mortality rate for HSV encephalitis can be very high even treated and the morbidity is great with chronic seizures and very common severe cognitive deficits.

We had to tell the family that he would not recover any of his function and would almost unquestionable remain unresponsive if he did not succumb to some complication. His seizures, though, we could possibly improve by increasing his carbamazepine and, if that did not work, we could add phenobarbital later. EPC can be very difficult to treat at times and this nature of the disorder is most often related to the nature of the underlying insult that is causing it to occur.

Our other patients were the typical mix of epilepsy, Parkinson’s disease, headache and back pain to name a few. Thankfully, we had no plans for the night as this turned out to be the largest, if not the largest, number of patients we had seen in a single day. We had seen approximately 41 outpatients for the day and when we add the inpatient that John had seem, it became 42 patients. That’s a large number of patients for us and clinic ran until about 6 pm, which wasn’t a problem for us, but we had to keep the staff late and, perhaps more importantly, our pharmacy closed and the last few patients were unable to fill their prescriptions and would have to come back the following morning after the pharmacy had opened.

We all walked back to the house together that night, quite exhausted after such a big day, and very much looked forward to spending a very quiet night given the day that we’d all had.

One of the responsibilities for volunteers who travel to FAME is that they contribute to the education of the clinicians here at FAME and these lectures are given on Tuesdays and some Thursdays. At morning report yesterday, they announced that they apparently did not have anything scheduled for today, so Steve volunteered to a lecture on meningitis at the last minute. The lecture was well attended considering that it was 7:30 am and Steve did a great job which really isn’t surprising considering that he has been a master educator for his entire career and there are countless physicians who he has trained over the years and who are now master educators themselves. Though there is only a thirty-minute timeslot for each lecture, I have become quite familiar with their tolerance for speaking overtime, so when Steve was still speaking at 8:15 and hadn’t been yanked off stage, it was clear that he had caught their attention. There were a number of very good questions asked that were followed by the Tanzanian manner of congratulations with three claps accompanied by a hearty “pasha, pasha, pasha,” or at least something that sounds like that.

Following morning report, Steve joined the ward team for rounds while the entire neuro team prepared for another day of outpatient clinic. I was again an unannounced day so was relatively quiet and manageable at the start with a slow accumulation of patients throughout the day. Our patients once again ran the gamut of neurological disorders, but as is par for the course, also included a few non-neurological patients who manage to slip through our triage process. As we are offering to see patients for the flat fee of 5000 Tanzanian Shillings (TSh) (less than $2.50) which includes the visit, medications for a month and any labs that need to be drawn, it is not surprising that we typically have many patients coming who hope to be seen whether they have a neurological illness or not. I have spent countless hours working on our triage process over the last several years, but it is very difficult for anyone who doesn’t really have a good grasp of neurology to truly be effective in this role.

We had several patients with essential tremor and others with epilepsy. One of our patients with epilepsy was a gentleman who was accompanied by his son and had been on phenobarbital for many years and had a very dull affect. Phenobarbital is still the first line anticonvulsant that is recommended by the World Health Organization, but it has such significant side effects that we use it only in children under two years of age. After that, we are using medications such as carbamazepine, phenytoin and valproic acid as they have excellent tolerability with good response rates. We also have a few newer medications such as lamotrigine and levetiracetam, but unfortunately, these medications are very expensive compared to the cost of the three listed above and orders of magnitude more expensive than phenobarbital. The patient had what sounded very much like localization-related epilepsy based on the semiology of their seizures, though, so we placed him on one of the other agents that he would tolerate much better and we hoped that he would perk up some once off of his phenobarbital. The taper of his phenobarb would take six months or more given the length of time that he has been on the medication so as to prevent any withdrawal seizures or the possibility of status epilepticus.

Amisha continued seeing kids which made her very happy, though one of them who we had seen on our last visit had continued to deteriorate. He was a ten-year-old boy who we had first seen about a year ago and diagnosed with muscular dystrophy. We had placed him on steroids which is the recommended treatment for Duchenne’s muscular dystrophy and recommended that he come back to see us in March when we were here, but unfortunately had not come. He was from the Loliondo District which is about a seven-hour bus ride north of us near the Kenya border and a region that is quite large with little in the way of medical facilities. I had visited a hospital in Wasso several years ago that was staffed by physicians from a religious organization and partnered with the government, but at the time I was there, they were understaffed with only a few junior physicians and far too many patients which is all too often the situation here. It was an incredibly overwhelming experience for me and they had asked if I could look at a few patients for them, one of who was a young woman with a severe anoxic injury that had occurred while undergoing a C-section and was quite tragic as she had regained no function was mostly in a persistent vegetative state as far as I could tell based on my one examination.

This young boy was living in an orphanage and had been brought to clinic by one of the women who care for him. She noted that he had improved some with the steroids, but it was unclear just how long he had been on them and he was clearly no longer taking them. His pseudohypertrophied calf muscles were quite impressive and could easily be seen through his pants. He was still able to ambulate, but with the expected hips forward and exaggerated back to compensate for his hip girdle weakness. We brought the other residents in while examining him so they could see the Gower sign, an extremely classic maneuver done on patients with muscular dystrophy, but not specific to MD necessarily and more a sign of proximal lower extremity weakness. We had him lay on his back on the floor and then try to stand without holding on to anything and, as expected, he rolled over, got onto his knees and then pushed himself up walking his hands up his thighs to stand.

He was a wonderfully cheerful child who brightened everyone’s day despite what we all knew about his future. He still had several years of life left and we wanted to make them as functional as possible, so we restarted his steroids and gave him a pneumococcal vaccine (typically given to children under 5 which took some persistence on my part to convince the nurses in the RCH clinic to give to him) as he would be somewhat more prone to infection on the steroids. Hopefully he will be back in six months to see us, but it is always difficult to tell here as these things aren’t in our control and decisions such as these are often made with many variables in play.

One of John’s cases was a patient with cognitive changes who had been admitted on several occasions for her psychosis and had also had some confusing results for her syphilis tests with both positive and negative results that required some additional thought to interpret. The patient’s history was pretty much consistent with a primary psychiatric disorder, but with the positive syphilis testing in the past it became a bit more complicated. Thankfully, we had our very own infectious disease consultant here and brought Steve into the mix to help us decide on a treatment plan. He, of course, gave us a dissertation on the how the RPR could be falsely negative in active disease where the antibodies are so prevalent that they overwhelm the test and cause what is referred to as a “prozone” effect, which of course none of us had heard of before. In the end, we decided to treat her for syphilis given the benign nature of the treatment (which consists of three weekly IM injections of penicillin) and the significance of not treating it if, in fact, that was what she was suffering from.

We finished clinic at a reasonable time today as it was again an unadvertised clinic day (tomorrow we were anticipating getting slammed) and only those patients who had been called by Angel were coming to see us. We were back to the house early and everyone wanted to run to town for some groceries as well as to see what was there since they had been here for two days and still hadn’t had a chance to explore the environs of Karatu. It was still quite light out when we left for town, driving “Turtle,” the current name of my Land Rover, down the dusty 2.7 km road on our way to central Karatu.

As I mentioned before, Karatu reminds me of a frontier town from the Old West or the Yukon Territory with it’s one paved road and all of the activity that takes place on either side of the main thoroughfare. There are the piki pikis (motorcycle taxis) that run up and down the main drag and the side streets along with all of the bijajis (three wheeled covered carts that are basically a motorcycle with a body that shuttle passengers to their destinations) and there are many of them. Finally, there are the dala dala, which are the little mini vans that travel along a route within town and from town to town. Each of these is marked with a different color strip to tell where each of them is going to. I have always avoided riding the dala dala for several reasons. First, they manage to pack every last inch of space with either passengers, goats or chickens and there are probably twenty seats in a vehicle that is slightly smaller than our minivans. Secondly, I have been entirely unable to figure out just where each of them is planning to travel and ending up someplace I hadn’t planned doesn’t seem like it would be very much fun. I stay off of the piki pikis and bijajis basically out of principle.

We parked Turtle just around the corner from the vegetable market and the shops where we usually buy our supplies. We walked through the vegetable market which is covered and dark with a dirt floor and is made up of small kiosks, each having essentially the same items with only a small variation from shop to shop. You can buy pretty much anything that grows here whether it be fruits, vegetables or grain. Lindsay was planning to make some guacamole on Friday night so she was in heaven with all the fresh vegetables and roamed the market with her new baskets she had purchased picking out hot peppers, tomatoes, onions and anything else she could throw into the mix. The vegetable market is an incredibly colorful place and it has been a favorite of mine since I first arrived here many years ago. Wandering up and down the aisles is just such a pleasure and I could easily spend the entire day there.

We spent some time leisurely walking around the market area and purchased some much need supplies (potato chips, plantain chips, bar soap and such) as we also went on a search for the new “Coke Zero Sugar” (not to confused with Coke Zero as per Hannah who has researched this issue in depth for some reason that I am not sure I understand). It was getting darker with the coming of dusk and beyond, but the streets seemed to come alive with more and more of the local population and it was clear that this was the time for socializing and taking care of the whatever business propositions were necessary. The weather was quite seasonable and refreshing and as we all piled into the Land Rover for our short drive home, we looked forward to our dinners waiting for us in the Raynes House. After dinner, we all went out back with the lights off and enjoyed stargazing for some time. Most of the planets were quite visible and the milky way shown with all its brilliance. Unbeknownst to us, this was something on Amisha’s bucket list and could now be checked off. The nights here are cool and refreshing and the sounds of nature after sunset are so relaxing that it seems as though the world we left is a million miles away and from another time. There are no sounds of man or industry here, just those that ancient man had heard hundreds of thousands of years before us and the ones we hear today, lulling us into sense of serenity that is much needed after our day’s work here. We are all very grateful for it.

I think we all slept well given our recent transcontinental flights and long overnight layover in Nairobi only several days prior. We were all still recovering from the stress of the trip and the missing baggage and the fact that none of us had gotten any sleep while in Nairobi. We were all quite sleep-deprived and certainly in dire need a good night’s sleep. The weather was quite cool the night before and remained that way in the morning as we were all getting ready for the first day of our fall neurology clinic for this year. It was overcast, but still amazingly beautiful outside as we walked the path towards the hospital and morning report that would begin at 8 am sharp. During my first years here, there was no inpatient hospital and therefore, no morning report. In fact, the compound was empty other than the volunteers as there was no overnight shift necessary without the inpatient hospital. I would arrive early to clinic in the old days and it was some time before other employees would arrive.

We met for report to hear about any overnight events of interest concerning the inpatients along with any necessary updates for us such as patients they may want us to see in consultation. Since this was our first day here, I did take a moment to introduce everyone in our group that not only included the residents, but also our infectious disease expert, Steve Gluckman, and our medical student, Peter Schwab. Steve is an incredibly experienced and capable global health physician who has traveled widely and is responsible for the Botswana-UPenn Partnership that has been in existence for nearly fifteen years with countless students and physicians from Penn having worked there and eventually created a medical school in Botswana where none existed before. We are incredibly fortunate to have him here with us and at FAME as he will be a wonderful resource for the Tanzanian doctors and us alike. I am so excited that he was able to make the trip and am hopeful that this will open the door to other specialties from Penn to assist FAME with their mission.

Today’s clinic was planned to be a bit less hectic than our announced clinics are and was primarily filled with patients who Angel, our coordinator, had called to come in today. Amazingly, she had contacted fifteen patients and twelve of them had showed as it is not always a simple thing getting here for most patients. Some come from a long distance and other things in their lives that can’t be postponed may not allow them to come. In the past, during the national elections, people were worried about leaving their homes to travel here and so the clinic was very slow on those occasions. Our clinic in March is also somewhat slower (only fractionally) as it is harvest time meaning that everyone is working in the fields and can’t come. It is wetter then as well and the roads are often difficult to pass on making it tough for patients and their families to come. The weather today was overcast in the morning, but became clear and beautiful during the day so there were no impediments from that standpoint that keep people from making it here.

The neurology clinic works out of the emergency room area that is across from the outpatient clinic which gives us our own waiting area for patients which has been very helpful in managing patient flow for often busy clinics. We see patients in the doctor’s night office, the emergency room and the hallway in between which gives us our three stations to see patients. We work with one clinician, and two translators and this visit we have been lucky enough to have a fourth-year medical student from Muhimbili University who is on holiday decide to spend his time with us and help us with the translation duties. Shaban is the son of the head of housekeeping here at FAME and I hadn’t met him before, but it was quickly clear to all of us that he is a very capable student interested in learning from us and we’re all very excited to have him with us. Our goal here is to work with as many clinicians as possible and though it would be amazing for us to have three from FAME, it would be impossible for that to happen as they are needed for all of the other duties here (outpatient clinic, ward, surgeries). Though it certainly benefits FAME by having us train them in neurology, the resources just do not allow for that many clinicians to be taken out of their daily routine when we are here. I am hopeful that in the future we will be able to fund a portion of a clinicians cost so that we would have a dedicated person to train that would theoretically not leave FAME with one less clinician. This has been a work in progress and that will come.

Perhaps the most exciting event of the day for me was to see Amisha when it became clear that she would have children to see. Of course, it is obvious that she loves taking care of children as she is not only a very qualified pediatrician having practiced before she went back to residency to become a pediatric neurologist, but there is something about the children here that is so endearing and can be overwhelming at times. Though there can be so many issues that one has to be careful of here when it comes to our relationships, I am certain that this feeling is not inappropriate in any manner. It comes from the totally genuine sense of no expectation by anyone and the fact that we are grateful to be here and they are equally grateful to have us here. Children everywhere are so unassuming and unaffected, but those here are perhaps even more so. They are truly disarming and their smiles could easily melt an entire iceberg in the blink of an eye. I think we all wish we were pediatricians here.

Amisha saw several children with episodes of unresponsiveness that were quite interesting. There was a two-year old who was having recurrent episodes of lethargy that we felt were clearly epileptic in nature and was started on carbamazepine. There was also a nine-year old with episodes of loss of consciousness that had been felt by others to possibly have been seizures but we felt were consistent and were most likely syncopal episodes. We obtained an EKG and recommended that she be followed over time. We had several patients with prior episodes of stroke that were most likely small vessel in nature, one of them with a thalamic pain syndrome. And, of course, we had our several cases of psychiatric disease, one with schizophrenia who we had seen before and was well controlled.

Overall, it ended up being a slow patient day for us which was totally fine as the residents were getting their bearings. We came back to our house early and it was a beautiful day for everyone to relax and, for those so inclined, to go out for a run on the local roads. It was also our night to go out to Happy Day, the local pub where all of the ex-pats and volunteers meet weekly to socialize and compare stories.

“Shida” is a fantastic word in the Swahili vocabulary. It means trouble or problem and is used prolifically when referring to something that just does not seem to be going the right way. So, in essence, we had been suffering from “baggage shida” from the minute I had arrived in Tanzania and it hadn’t let up. Lindsay’s bag was at the airport supposedly waiting for us and given the fact that they had already caused major issues, she didn’t want to have them transport it to their office in Arusha since that would be one more thing that they could mess up. I didn’t blame her at all and was more than happy to drive to the airport before sunrise to rescue her bag so that she wouldn’t have to worry any longer about whether she was going to have any clothes for the rest of the trip or not. John decided to come along with us in case his bag had miraculously arrived overnight or not.

There wasn’t much traffic that early in the morning so it was an uneventful ride to the airport, although I did pay particular attention to keeping my speed down so as not to attract the attention of any of the traffic police. Besides, I used all of my shillings the night before to pay for some repairs to the car and wouldn’t have had any money to pay them had they even been willing to take something from me with their new system in place. Lindsay’s bag was thankfully at the airport, though she did notice that it had a tag on it to be sent to Arusha (despite our instructions not to do so) and had we not gotten there so early in the morning, it would have likely been in limbo between the airport and Arusha for who knows how long. John’s bag was nowhere to be found meaning that I would have to work on continuing to check on it over the following days. We drove back to Arusha with Lindsay in a much better mood knowing that she wasn’t going to have to continue washing the same pair of underwear for the next month.

Pendo was, of course, working on a huge breakfast for all of us when we arrived home and I was certainly looking forward to that after having gotten up so early that morning for our drive to the airport. Eggs, fruit, delicious pancakes and fried potatoes with onions really hit the spot. The chai masala was equally appreciated by all of us. Meanwhile, I had asked Steve Gluckman to arrive at the Impala Lodge at around 9 am that morning for us to pick him up on our way out of town, but hadn’t been able to reach him yet (at least to my knowledge) to let him know that we’d be running late. Thankfully, he is a seasoned traveler in Africa and is quite familiar with how time works here in as much to things running on time. “TIA,” this is Africa. We packed the vehicle with all of our belongings after breakfast and began to say our goodbyes to everyone and by that time it was nearly 11 am. At least we were picking up Steve in the morning and not the afternoon, so we were well within the window of being acceptably late given the pace of things here. Thankfully, Steve was the lightest packer of us all and he had one small duffel and a small backpack making it simple to find a place for him and his baggage in our overstuffed Land Rover.

We were finally on our way, but did have to battle the traffic traveling through Arusha and heading west towards Karatu. I had one short stop on the way out to visit Sokoine as I had a gift for him. He gave me the good news that he had just been accepted into a business program at Arusha Technical College and had found sponsorship to cover the tuition so that he would shortly be starting a two-year program there. That was huge news and made me very proud of him. We finally made it out of the hustle and bustle of Arusha and were on our way to Karatu, traveling past the Maasai bomas and herds of Maasai cattle, goats and sheep grazing with their owners nearby, often sitting under the shade of an acacia tree resting. It seems such a quiet existence and so different from the heavily structured days that we live at home. Eventually past the town of Makyuni, where we make our turn to head across the Great Rift Valley and into the town of Mto wa Mbu, or mosquito river, where the entrance to Lake Manyara National Park sits. The Marabou storks were nesting in the trees high about the entrance and we managed to spot a few baboons along the roadside.

Arriving to Karatu, I am back home once again and this dusty and literally one-road town quickly becomes the entirety of our existence for the next month, save for our forays into the bush while on mobile clinic and when we travel to one of the many parks in the area for our game drives. Karatu is also the final stop at the end of the tarmac and civilization. Just beyond town is the Ngorongoro Gate and Conservation Area which contains the Ngorongoro Crater and much of the Eastern Serengeti. It is also the only road used to get to the Central Serengeti and so all Safari-goers travel through this frontier town that most reminds me of what it must have been like in the Klondike Gold Fields of the 1890s.

We arrived at FAME in time to grab some lunch (always a welcome treat) which was followed by a much-needed tour for the new volunteers given by Alex, FAME’s volunteer coordinator, who has been her now for over two years. My time was spent mainly greeting everyone and just trying to remember everyone’s name since I haven’t seen them for six months and at my best, this is a very difficult proposition for me. Once to the house, we unpacked our baggage and settled in, though I still needed to get Peter down to his cottage at the Happy Day Bar and Lodge so I dropped him off there and then headed back up the road to FAME. Tomorrow would be another day and each of us had our own idea of what it would be, yet I was the only one who actually had an idea of what to expect and I was so excited to what my fellow travelers would think of FAME.

I awoke early as three of the residents, Lindsay, Amisha, and John, as well as Peter, our medical student, would be arriving on the 9 am flight from Nairobi, the same flight I was on a day earlier. Also, I would have to pick up my bags that had arrived yesterday evening and I had no idea what to expect from that process. The drive to the airport on the main road is along the new four-lane highway for nearly half the distance after which it becomes the more typical two-lane thoroughfare where being stuck behind slow moving trucks is the norm. The new highway, though, has a 50 kph speed limit (just over 30 mph) which is unquestionably slow in anyone’s book and even more so in mine. And if driving that slow on a four-lane highway isn’t depressing enough, there is a 50 kph speed limit as you drive through any village along the way, some marked well and others not so well. Add to that the recent appearance of cameras that detect and record your speed that the traffic police are equipped with and it makes for a very long and sometimes quite exciting drive.

I was running a bit late as Pendo insisted in feeding me before I left the house that morning and it is virtually impossible to say no to her. I had intended to leave the house around 7:30 am as they were arriving at 9 am that morning on the same flight that I had taken the morning before. I was not in a hurry or rushing by any means and was constantly watching my speed as I traveled through the many towns on my journey. It is without question, though, that as hard as I was trying not to speed, that I would undoubtedly drive too fast at some point and draw the attention of the traffic police. As I was flagged over, there was little question in my mind that I had briefly sped and, sure enough, he presented me with a photo of my vehicle and the speed I was driving printed in the lower right-hand corner of the little digital screen. There was little hope of arguing about anything with the officer given the weight of the evidence before me, though I could certainly choose to put myself at their mercy.  What really worked, though, was when he discovered that I didn’t have a Tanzanian driver’s license (I use my PA license along with an International Driver’s License) and given their new system of reporting everything centrally (i.e. collecting no cash), this wouldn’t work very well. Or perhaps it was just my repeated apologies and that the fact that I promised I would be much more attentive going forward. Whichever it was, I was shortly back on my way to the airport.

Lindsay, Amisha, John and Peter all arrived on the Precision Air flight and were in the process of getting their visas when I arrived. That all went incredibly smoothly and they whisked through immigration without an issue. Unfortunately, I can’t say the same for their luggage. Lindsay had only one of her two checked bags arrive and the one that was missing was her personal gear for the trip meaning that she had no clothes whatsoever other than what she was wearing. The bag that did come was the checked bag with supplies for FAME. John got his personal bag, but his second duffel, the one containing the other half of FAME’s supplies was missing. So, as Yogi Berra was so famously quoted, it was “déjà vu all over again” when I went to stand in the same line I was in yesterday waiting to file for the missing baggage. We were really in no hurry, but the funniest was when John began translating for the Chinese group in front of us who were speaking Mandarin. I don’t think they had really expected that.

Hannah wasn’t arriving until 1 pm, so we chose to drive to Moshi, a town much smaller than Arusha and at the foot of Mt. Kilimanjaro. Leaving the airport, we did catch a glimpse of Kili’s summit which I told John was an omen that he would have to climb the peak after our time with FAME. We parked and walked a few blocks in Moshi, found a coffee house so everyone could get their caffeine fix and we were then back on the road to the airport to find Hannah. We were a bit late, but she had been in line for her visa for some time so we ended up arriving just before she came out with all of her things (missing no bags as she hadn’t flown on Precision Air thankfully) and we were back on the road again heading towards Arusha. It was great to have everyone together and tomorrow we would meet up with Steve Gluckman to complete our Penn contingent which was quite large this go around. We arrived to the Temba’s and unloaded the vehicle after which I met up with Jones at the garage to take care of some last- minute items that needed to be done on the Land Rover before I took it to FAME. Everyone relaxed after their long ordeal of traveling half-way around the world. Regardless of the missing bags, everyone was here safe, though Lindsay was certainly the most affected as she none of her clothes with her. Thankfully, later that night, her bag arrived to Kilimanjaro on a later flight so that we could pick it up first thing in the morning, though that meant another trip to the airport in the morning which was the opposite direction from FAME.

I arrived home from the garage in time for a lovely dinner that Pendo had put together for everyone. I have been staying with the Temba’s for the last eight years along with all of the residents who accompany me and it has really been through their generosity that things have always been so smooth upon our arrival. I couldn’t have done this with them and will always consider that they are an integral part of making all of this work time and time again. We went to sleep that night, three to a room (boys and girls) and fully content and dreaming of the journey ahead for each of us tomorrow.

My flight into Doha, Qatar was long, though comfortable. Somehow, because I have flown so much on the airline, I achieved “silver” status in their airline club which does allow me to board first (a plus on often packed flights), though I still fly economy unless, of course, I’m willing to shell out the additional money to upgrade to business. I did that once a year ago when they had a last-minute offer that was a fraction of the cost of that class, and, I must say, that it was like a vacation in itself. I can always dream the opportunity will represent itself someday. The flight attendants now greet me after takeoff – “Dr. Rubenstein, we just wanted to welcome you to the flight and let you how much we appreciate your flying with us. Please let us know if there is anything you need during the flight.” When Kathy was with me in April, she got a kick out of it…I think. Either that or she was just quite embarrassed. Hey, I’ll take whatever little I can get. I did have an empty seat next to me on the flight over so I should be thankful for that. The connection this time was just long enough for me to get through security on arrival to Doha. Their security check to enter the airport on arrival to Doha (having already gone through security to board your outbound flight) is as intense and thorough as any in the world. We must be thankful for this attention to detail in this age we live in.

I had a little over an hour to make it to my next gate and it was a long walk through the airport. Doha is an amazing airport having been completely rebuilt in anticipation of the upcoming World Games here so there is an incredible amount of shopping to do here. Doing a brisk walk to my gate to make it for boarding, though, didn’t allow me to stop in any of the numerous shops as I would have enjoyed window shopping given that there are no bargains here. My flight to Nairobi has been booked full so I am once again thankful that between the short transit time in the airport (read, very sweaty) and the full flight, I am very happy to board first and get my baggage stowed, the air vent open and to take a breath.

I’m two hours from Nairobi currently and will be spending the night in their airport to take a short flight in the morning to Kilimanjaro that will complete my trip. Don’t shed any tears for me, though, as I do have access to an airport lounge (hopefully) and will be able to catch up on my email and messages. I have only been to the airport in Nairobi once before and that was on my first trip to Africa ten years ago. On that occasion, we had a quick connection there only to find out that somehow the local airline had cancelled our seats and put us on a later flight because an earlier flight had been cancelled and they needed the seats. At the last minute, of course, they had the three of us running across the tarmac with all of our baggage to board the flight as three seats had somehow mysteriously appeared. Hopefully, I will have a much different experience on this visit.

I arrive into Kilimanjaro on Sunday morning and am looking forward to having the day to reconnect with my family there. I typically try to arrive a day in advance of the residents to spend this time with the growing Temba family and to take care of whatever other errands that have accumulated for me during my six-month absence. I really look forward to this day to reacclimate and remember to drive on the left hand side of the road – no worries, as that has become second nature to me over here. We have a very large group visiting FAME this fall. On Monday, I will have Lindsay, John, Amisha and Peter arriving in the morning and Hannah arriving during the noon hour. Hannah will be coming from Cairo where she has spent a week with her husband on vacation and I’m sure we’ll hear lots of good stories of her travels there. John and Amisha will each be taking vacation time separately on the tail end of our visit here. I’ll pick everyone up at the airport and will probably plan to spend some time in Moshi with the others waiting for Hannah to land. The four residents, Peter (our first medical student to visit) and I will be staying at the Temba household for the night. Steve Gluckman, who is an infectious disease specialist at Penn and a well-seasoned Africa traveler having spent a number of years in Botswana with the Penn-Botswana Partnership, will arrive later in the afternoon and will overnight at the airport in the KIA Lodge. Steve will plan to travel to Arusha to meet us on Tuesday morning for our trip to Karatu and begin our visit with FAME.

So, as you can see, there are quite a few moving pieces that are involved in our travels here and though it is possible for everyone to arrange their own in-country travel, it has always been something that I have loved doing as I believe that it has given each of them more of a sense of being a local here. And it gives us all a time to bound before we begin our trek across the Great Rift Valley and into the Ngorongoro Highlands. And perhaps even more so, it gives me the opportunity share this gem of an African country and my second home with those who are so important to me.

Postscript – I’m safe in Nairobi and the airport hasn’t changed one iota in the 10 years since we were here last. That is other than the fact I now have access to an airline club with internet and food. For anyone who knows me, it is the latter that will always make me happy as I can actually live without the former. But then you wouldn’t have this post….

It always seems that I do my best reflecting when I am over seven miles in the sky. There is just something about soaring effortlessly far above the earth towards a destination that has become so familiar to me, but had been so distant for most of my life. It has now been ten years since I had first traveled to that “dark continent” and it is now daily it seems that I have to pinch myself to be reassured that this isn’t just a dream. I don’t really believe in destiny as it is up to each of us to make the most of our lives, but somehow this just all seems like it was meant to be and I can’t escape that reality. So, as I travel east towards my first stop in Doha, Qatar, I reflect mostly upon the lives that I have touched during this journey – patients I have seen, the amazing Tanzanians who I have worked with, the friends I have made both here and there, and, perhaps most importantly, the residents and fellows from Penn who I have exposed to the wonderful world of international health and health equities.

Several days ago, we had a small gathering in advance of our coming trip of what Neena Cherayil has now coined “The Tanzanite Gems,” that group of residents who have accompanied me to Tanzania over the last several years along with several of those who will be traveling with me this visit. It is quite difficult for me to describe to you just how proud I am of these truly remarkable individuals and I am so grateful every day for the fact that I have had the opportunity to work with each and every one of them. The list has now become so long, but each of them have left an indelible mark and occupy a place in my heart – Danielle, Megan, Doug, Ali, Thu, Lindsay, Jess, Jackie, Kelley, Laurita, Chris, Jamie, Nan, Whitley, Sara, Neena, Johannes, Susanna, Susan, and Mindy.

And what began as merely a global health experience, traveling to East Africa to not only teach the doctors there by working side by side with them, but also to treat patients has now become a full-fledged program in health equities both in Africa and at home. This has been defined as the principle that everyone should have the opportunity to attain their full health potential and, conversely, that no one should be disadvantaged from achieving this potential. A few years ago, with the help of our residency program director, Ray Price, and the cooperation of the several other faculty along with our residents, we began to provide neurology services at Puentes de Salud, a non-profit health center in Philadelphia that provides medical care primarily to Hispanic patients who have no insurance or are undocumented. The interest by our residents in this program was so great that we began looking for other venues that would allow us to provide neurological care to those patients without access. We then approached the University of Pennsylvania Refugee Clinic to assist with those patients arriving here in need of neurological care and though we have assisted a few patients, the numbers have been small for the sole reason that there has been a drastically reduced number of refugees being granted asylum since 2016.

Still in search for additional sites, we were fortunate enough to have been introduced to an amazing clinic in West Chester, Pennsylvania, by one of our particularly incredible residents, Adys Mendizabal (who will be coming to Tanzania in March 2019), who had worked there during her medical school training. Community Volunteers in Medicine (CVIM) is a free clinic for uninsured and underinsured patients living in Chester County and provides not only medical and dental care, but also has a dispensary that is better stocked than most pharmacies and is able to provide several millions of dollars of medications to patients in need. Since August of this year, we have now provided a monthly neurology clinic to patients referred to us by other volunteer caregivers at the clinic. We are also able to obtain diagnostic studies through the generosity of two local hospitals who have realized the need to maintain the health of the community. Though our relationship is new, it is clear that there is a tremendous need for our services here and the opportunity to give back has been well received. It is also clear that the quality of the medical and dental care that is delivered at CVIM, all by volunteers such as ourselves, is of the highest quality and most desperately needed by this community.

And so it is that we now have developed, in a thoughtful and programmatic manner, a purely clinical program that allows neurologists in training the opportunity to develop their own skills and values while furthering the cause of health equity and allowing those we have served, both patients and other caregivers, a better chance of reaching their full potential of a healthy life both here and abroad. Some of those residents will go on to dedicate their careers to global and international medicine, but all will have developed a far greater appreciation for the basic right of health for all. And perhaps most importantly, a renewed confidence in humanity and why each of them has chosen this career and to serve.