(PLEASE SEE LINK AT THE END OF THE BLOG IF YOU’RE IN A HURRY-THANKS!)

It only seemed appropriate on many levels for me to publish a blog this year on Giving Tuesday as my last trip in September marked a landmark of sorts for me. It was my twentieth trip to Tanzania and, even more so, it has been a wonderful decade of working together with Frank and Susan and everyone at FAME. I have had so much to be thankful for given the opportunities I’ve had and not a day goes by that I don’t remind myself how lucky I am. It has become increasingly clear to me, though, that my true gratitude lies not in what it has done for me, but rather in what it has allowed me to do for others. For it is in this context that the full essence of gratitude becomes obvious. It is in the difference we make in other’s lives, now our own.

This year has also been marked by a number of other milestones that are well worthy of mention. Before I do that, though, I should also reassure everyone that our neurology project at FAME has continued to grow with each passing year. I addition to the four neurology residents (three adult and one pediatric) I bring twice a year for a month each time, we are now also traveling with one lucky medical student who accompanies us to assist with our registry data and observe the work we do there. Additionally, we were fortunate enough to travel with two other incredibly talented clinicians last March – Marin Jacobwitz, a pediatric nurse practitioner, and Dr. Dan Licht, a pediatric neurologist, both from Children’s Hospital of Philadelphia – who will both be accompanying us again this coming March for their second visit. We are also now having other neurologists fill in the time between our visits – Dr. Joyce Liporace was there in August and Dr. Branch Coslett is there currently – to continue training the doctors at FAME in the evaluation and care of neurology patients.

During our last visit in September, we evaluated and treated more neurology patients than we ever had during our month clinic – 405 patients – all with the support and assistance of FAME and its staff. A special mention goes to Dr. Anne Ghati, an incredible caregiver who I have worked with now for many years and who, going forward, will be our neurologist on the ground, caring for our patients in between visits and new ones as they come. She is truly an inspiration and has had a positive impact on every resident who I have brought to FAME. They will all be better doctors having worked with her for her caring and compassion are truly contagious. And two other individuals who have been essential to our work are Angel and Katashu, FAME’s relentless social workers who have dedicated themselves to the success of our neurology project. They travel to the remote corners of Karatu district prior to each of our visits making announcements of our arrival to the communities and to ensure that everyone who travels to see us, often for days, understands what it is that we treat. And then when we arrive, they make sure that things run smoothly which is often a great undertaking considering the volume of patients that may show up on any given day. There is a tremendous amount of coordination and they do it seamlessly for us each and every time.

A very huge milestone occurred for FAME this year in that the much needed 24-bed Maternity Center opened and seemed to almost immediately fill with women coming to FAME to deliver with a great number of them coming from outside our district, further validating the fantastic reputation for health care delivery within Northern Tanzania. Once perk for us of the Maternity Center opening was that for the first time in many years, our clinic in September had its own facility in the old Ward 2 that had previously served as the maternity ward, less than half the size of the newly opened one. Though this ward will soon be repurposed, we are hopeful that it will occur after our March trip so we’ll have that luxury on at least one other occasion. A future dream of mine will be to secure funding to develop a dedicated “specialty center” where we and other specialties visiting FAME can see patients and have a home.

As many of you know, my life has become irrevocably intertwined with that of FAME over the last ten years and, in March of this year, I was incredibly honored by being asked to serve on the FAME Board of Directors. It is a vastly different role for me than I have been accustomed to at FAME, but as the only other physician on the board beside Frank, I have become acutely aware of my responsibilities and am, once again, grateful that I have been given this opportunity to serve others.

And finally, I’d like to mention the event that occurred this year that had the greatest impact on me personally. Last year, we had had the good fortune to work with a certain young medical student during our month at FAME who had greatly impressed me with his dedication and drive to learn as much as possible during our time together. Following this interaction, and through circumstances that I need not go into here, Abdulhamid Shaban was given the opportunity to travel to the University of Pennsylvania as a guest and to spend a month with our neurology service, a specialty that he had become totally enamored with after working with us in Tanzania. To put this opportunity in perspective, not to mention the sheer magnitude of traveling to the United States for a young man that had never left Tanzania, let alone flown on an airplane, you must remember that there are less than half a dozen neurologists in the entire country. There are virtually no neurologists on staff at the medical schools and there are only two neurology residency programs in all of Sub-Saharan Africa.

So, after our month in September, Abdulhamid traveled with two of us back to Philadelphia to spend a month observing the delivery of medical care in the United States. Without belaboring the point, I will tell you that he made the most of every waking moment he had here, spending time with multiple neurology services and seeing things that I believe he would never have imagined seeing. I could go on and on about his experiences here and I am not sure that I could truly convey the magnitude of impact that his visit had on him by his own admission. But I came to realize after a very short while, that as great as this impact on Abdulhamid was, it was equaled, and perhaps then some, by the lasting effect that he had on those of us here who had the privilege and honor of working with him. It was clear that what we take for granted was not so for Abdulhamid. I have so many fond memories of sharing new experiences with him, from the wonder of teaching him the neurologic examination to his first taste of shellfish during one of our nights out together. And when I wasn’t sharing those experiences, it was the residents or medical students spending those precious moments with him, whether it was at an Eagles Tailgate (yes, that’s true) with Leah or a day in New York City with Peter or bowling for the very first time after never knowing what it was before. This is what gratitude and thankfulness are all about, it is in those little things we do, often without our realization, that affect other’s lives, sometimes knowingly and sometime not. But most often without intentionally doing so. That is the true act of giving…..

On this day of giving, I would ask each of you reading this to choose to make a difference in someone’s life and to share in that sense of gratitude and thankfulness that I have been so lucky and blessed to have known over this last decade with FAME. I would ask that if you are able, please go to the FAME website to share on this Giving Tuesday.

https://www.globalgiving.org/projects/fame-giving-tuesday/

Thank you!

 

It had rained very heavily over night, but not in the early morning hours meaning that most of the trails would be drying by now. Mike was sticking with his plan to relax until our boat ride back to Kigoma some time before noon and I had remained steadfast in my hope to see the chimps one last time despite have a pretty significant pulled muscle in my right hip area that had been bothering me and getting worse over the last several days. Probably from carrying all that camera equipment on the first day of hiking. If I had any intelligence whatsoever, I would have been relaxing this morning as well, but I’ve already made it clear that isn’t my personality, for better or for worse. Ahadi had wanted to go hiking early given our short window of opportunity and so Mike and I were upstairs in the dining area before 7 am in hopes of snagging and early coffee and tea, respectively.

The lights were again continually blinking in the dining area as the power was continuing with its normal pattern of cycling more off than on, but, thankfully, it was light enough outside this morning to see our feed. Juma continued on his string of wonderful meals for us and didn’t disappoint on our last breakfast even despite the lack of power. Most everything is cooked with gas here where the typical cooking appliance is the short gas cylinder with a permanently mounted burner on top (hence all the burn injuries more common in epileptics).

Ahadi came by early at around 7:30 to check in with us and I was ready to head out whenever we heard from the trackers. We couldn’t go high into the surrounding hills as I had to be back by 11 am to shower, pack and eat before leaving at 11:30. There was only one tracker again today and they hadn’t seen anything all morning, so we decided to head south along the beach in hopes of finding the family that we had seen yesterday, but without spending too much time hunting for them. We hiked just inland from the beach for the most part, crossing several streams still flowing with runoff from the heavy rains last night and basically ended up at a location just shy of where our boats landed the day before.

Ahadi left me on the beach while he went inland looking for the tracker and listening for any sounds of the chimps that he might be able to hear. I waited for close to 30 minutes for him to return which gave me plenty of time to dwell on this amazing opportunity we’ve had to visit such a place as Gombe as it is tremendously more remote and less traveled than all the other sites I’ve been to in Tanzania. To see the chimps in their natural habitat and in a place where one of the greatest conservationists had studied them was more than I could have ever hoped for and was as meaningful to me personally as much of what I’ve done here in Africa to date. As a young child, my heroes were Heinrich Schliemann (discoverer of Troy and Mycenae), Louis Leakey and Jane Goodall, and one of my favorite books was The Last Days of Pompeii by Edward Bulwer-Lytton. I didn’t follow sports, but rather explorers and adventurers, and still do to this day. (Yes Leah, definitely a nerd alert!). Here I was standing alone on the shore of one of the most ancient lakes in the world in perhaps the most remote place I had ever been.

Yet here, in this incredibly remote location in the middle of the Dark Continent and directly across from the Congo, I found the telltale signs of man’s destruction of this planet – washed up plastic and Styrofoam. The World Without Us is a well-written book about the true legacy of man and how long it would take the man-made structures and pollutants to disappear if we suddenly vanished from the Earth. Tiny plastic beads that are byproducts of plastic production are probably one of the widely distributed pollutants currently known and can be found in the furthest reaches of the most remote oceans and sees and will take hundreds of thousands of years to degrade. Here I was on the shore of Lake Tanganyika, remote for me, but certainly not the most remote place on the Earth, so why I was so shocked, I’m not certain. It is total naivete, yet it was still there and seemed just so out of place to me to be depressing.

Ahadi found the tracker who hadn’t yet located any chimps and it was too far for us to walk to the next valley, so we started back along the same trail. It was a gorgeous day and the weather was even a tad breezy and cool. About half-way back, Ahadi still made an attempt to find the chimps as we walked up into the forest several hundred meters where he left me again so he could race upwards, but there were no sounds of the chimps. This time, I was left along a forest trail in the deep overgrowth, listening mostly to the sounds of the birds until one of the other guides we had run into earlier and was with the two women who arrived to camp yesterday walked up along the same trail having left his clients down on the beach to wait. This just didn’t seem to be the day for chimps, though I remained satisfied that we had three excellent days of trekking and absolutely no regrets.

We got back to camp early and I was able to pack and shower in leisure (still no hot water, though) and Juma made us another lunch for we had to leave. As we were saying our goodbyes to Ahadi, a day group arrive from a nearby country wanting to head out at noon with the hope of seeing the chimps. By the looks of the group they weren’t going to be very happy if they did see them and they also didn’t look like the type that were ready to hike up in the mountains as we done for the last three days. We wished Ahadi luck and I hoped for his sake that he would be successful in finding them.

Our bags were loaded into the boat and we began our journey down this prehistoric coast towards Kigoma. Juma was with us as his job had really just been to take care of us at Gombe and, for that, he had been overly successful. One our way south we passed the local water taxi, a much larger though similarly designed craft as ours, that is packed with people and is half as fast, taking four hours to Kigoma. As the boat came closer, I could see one non-African on it and it was Dr. Collins returning from two nights in Kigoma. We both spotted each other and waved our goodbyes. We landed at the Hotel Tanganyika on the south west side of Kigoma and found our ride so that we were to the airport in plenty of time. We were screened for Ebola with a temperature scan and were allowed to board as if either of us had a fever we might still be there.

Our flight was leaving at 3:25 pm and was surprisingly on time and as we lifted off the runway, the beautiful waters of the lake remained visible out the window for the longest time. In fact, they were visible for much longer than I would have imagined until I realized that were heading due north when Dar es Salaam was far to our east. I had thought the flight was stopping in Tabora, a small city half-way across the country in a direct line to Dar, but when I pointed out to Mike that we weren’t heading in that direction, but rather due north along the lakeshore, it became just a little concerning as to where we were actually heading. The terrain became far more mountainous than it should for Tanzania and when I looked at the map on my phone, sure enough, we were no longer in Tanzania, but rather had entered Burundi en route to their former capitol city of Bujumbura.

We were on the right flight, but had no idea we were heading there and we were also starving since it was now a bit late, both in time and for the flight to reach Dar. We now had a very short connection and needed some sustenance so bought the last four samosas at the snack bar and inhaled them before they announced that our flight from Dar to Kilimanjaro was actually delayed by an hour. I immediately got up to buy some sodas since we were going to be there for another hour, but the snack bar mysteriously closed just as they made the announcement delay. To make matters worse, our flight was stopping in Zanzibar (the opposite direction), so we wouldn’t be getting into Kili until after 10 pm.

Thankfully, we had a transfer already arranged so wouldn’t have to bother Pendo and Leonard with picking us up given house dangerous it is to drive at night here. No sense risking everyone’s lives. We arrived to their home well after 11 pm, but, of course, in typical Tanzanian fashion, and, even more so, “Pendo fashion” as anyone who has had the pleasure of her hospitality knows, there was a full meal on the table waiting for us of spaghetti and meatballs. Knowing Mike to have never turned down a meal in his life regardless of how tired he was, we both sat at the table and enjoyed our midnight “snack” in this incredible country of the most loving and gracious individuals I know. Pendo and Leonard are, of course, family, but their generosity still goes far above and beyond!

 

 

For reasons that I won’t go into here, Leah was scheduled to depart Gombe this morning as she had an early flight scheduled out of Kigoma en route to Dar and then home. We had all agreed that leaving by 8 am would be more than enough time for the two hour boat ride back south and short drive to the airport so we had set breakfast for an hour earlier. Once again, the power was out in our tents and as we arrived for breakfast, it seemed to blink on for a few moments and then would mysteriously vanish for a much longer time so as to be of little use for anything constructive. We eventually concluded that it was most likely an issue with the solar panels and storing power overnight as that seemed to be when things really went south. No matter, though, as it all added to the ambience of Gombe and made us feel more as though we were in the incredibly remote location that we were. Our clothes had been drenched, and remained so, either from the sweat of our treks or the intermittent, and at times, heavy downpours that occurred during the days. They were not a nuisance as it gave the place a magical feeling whether we were in our tents or on the trail trekking through the dense forests with vines that seemed to reach for the sky.

After a wonderful breakfast of French toast, crepes and fruit, we went to the tents to get Leah’s baggage which included an impressively large and blocky suitcase that doubled as a steamer trunk (sorry, Leah) and carried, or really dragged, everything out to the boat. She was heading back to Kigoma in the same boat which we had come in, though this morning, there seemed to be an issue getting it started, but not for lack of effort. The pull cord didn’t want to fully recoil necessitating that the cover come off, but it took some time to locate the correct wrench, or spanner as it is known here, for one of the three bolts holding it on. The pull cord was playing coy as it then decided to recoil and once everything was put back together, decided to not again leaving the boat hand to start the process all over again. This went on for several more tries and I know that Leah was probably stressing out horribly, but we were trying to joke about it as much as we could knowing that she really had plenty of time and I was pretty, though not completely, confident that they would get the engine started and be on their way. Sure enough, it did eventually start, though they did have to resort to their backup pull cord with the cover left off (those of you motorheads will know what I’m talking about with outboard engines) to get it going.

With Leah on her way, it was left up to Mike and I to travel with Ahadi in search of the chimps. While we were waiting for news from the tracker (there was only a single one today where before there had been two), a very fancy boat pulled up on the beach from one of the more exclusive camps north of us and unloaded an elderly couple. Mike and I both joked how much better we liked our boat as it had more character and fit more with what our expectations were. Years ago, when I had volunteered with the kids at a school in Karatu, we had said the same thing about Gibb’s Farm in that it was fine for lunch, but way to fancy and out of place for what we were doing. Once Ahadi had rounded us up, though, we were herded onto the fancy boat along with the elderly couple for a short trip south towards the place where we had landed on Sunday looking for a hot trail.

Once on land, the three of us immediately marched off into the canyon, heading pretty much uphill for some time, much of it going side slope on very steep and slippery hillsides where a simple misstep could put you down on your side if not down the hill. And then there was the bushwhacking, which, simply put, is traveling straight though the dense underbrush without the aid of a machete require you to constantly untangle yourself from the vines that feel like they’re grabbing at you or the ones that have thorns and really are. As we continued to go up, we eventually ran into three or four members of the T-family high up in a tree above us where we had plenty of time to watch them before they decided to move on.

At that point, we continued to follow them and were eventually reconnected with them down much lower on the hillside, where the elderly couple and Scandinavian family met up with us to continue watching them. We all stood below a big tree in which they were feeding with several youngsters moving about the branches and playing. They eventually decided to descend which meant that we needed to move a bit to give them room, though the elderly couple were so mesmerized by the moment that they really didn’t give them enough room nor did they see the guides motioning them to move back. We were all wearing our surgical masks, which, if I didn’t mention it before, are required whenever you are viewing the chimps nearby as they have learned that over the years the most common killer of the chimps are diseases that were directly transmitted by visitors or researchers. The most famous of these was a polio epidemic that killed and disabled a number of chimps in 1966 during the initial years of Goodall’s research.

Several of the chimps were sky high in a palm tree eating palm nuts and could barely be sees as anything other than black blobs at the top of the tree. When the chimps did descent the trees nearby, they took off at a fast enough clip that it was difficult for us to follow them further given the steep terrain, so we decided to return to the boats. Initially, though, they were taking us through the brush in a short pursuit that would have been very perilous as neither the elderly couple nor the Scandinavian family looked to be either fit enough or dressed  in preparation for the bushwhacking and side sloping we had done earlier alone with Ahadi. Thankfully for all of us, as it would have been quite a slog for the others, we turned around and were on the beach in no time, ready to board the fancy boats (the family had come in another) to head back to camp.

It was early and both Mike and I were quite ready for lunch so we showered and met Juma to our lunch shortly after noontime. We were the only two in camp now, though somewhat later, two American women arrived, but did not go out for the afternoon as there were no chimps found by the trackers nearby. It was a quiet afternoon for the two of us and I spent most of it catching up on some blogs, though was neither able to post them or upload photos as we had no internet other than the weak signal we could get around camp, that is when both the power was on and the WiFi was working or we could hike to the end of the beach to download our email and that was about it. Dinner was a wonderful beef stew and large helping of rice and greens. Everything that Juma made was amazingly delicious and both Mike and I commented to each other that there was no way either of us could cook like that from scratch using whatever ingredients you had around the kitchen without a recipe.

Tomorrow, we were to leave camp for a flight out of Kigoma at around 3:25 pm, which meant there was enough time to perhaps get one more chimp trek in if we returned by 11 am. Mike had decided that he would prefer to relax and who could blame him as we had had three incredible days of seeing chimps where there are some visitors who never see them this time of year. I am more the type to squeeze every last moment of opportunity, to leave nothing left on the table, but I will gladly admit that it is very, if not most, often to a fault where I wear everyone else out and, of that, I need to be more cognoscente in the future.

We awoke in the morning to a very heavy downpour made louder bouncing off the roof of our tent. The power had gone out sometime overnight and given the early hour, it was difficult to see anything in the dark, and even more so in the bathroom so showers were out for the morning. Given that we had decided not to worry about the boiler situation and the lack of hot water, we all elected to move the timing of our showers until later in the day after our trekking. We had actually planned for an early departure, though this was move back due to the rain and the need for the trackers to locate the chimps for us, otherwise we’d be searching the wet forest floor most likely for naught. Juma had prepared our breakfast which was eggs, toast, crepes and more delicious fresh fruit – watermelon, pineapple, melon and avocado – the latter going incredibly well with the eggs and toast.

Once finished with breakfast, we were ready for another long hike in the forest once Ahadi had heard from everyone regarding the hopeful whereabouts of the chimps. The forest here is incredibly dense with an immense canopy reaching skyward and thousands of vines of every size either soaring down from up high or reaching across the trail at foot or waist level. At times you felt as though you might become hopelessly wrapped up in the undergrowth, never to be seen again. There are more than a thousand trails that wind and crisscross through the valleys and up the mountains here and it amazed us all at the incredible skill Ahadi demonstrated in navigating them. Other than up and down, it was difficult to tell which direction we were traveling most of the time.

We started our hike today by heading towards Jane’s Peak in an almost reverse of what we had done yesterday. After reaching the peak, we continued on a different tack going up and up into the mountains until we finally came across a very huge family of chimps, eleven all told, that were all in the same tree and feeding. It was extremely exciting to hear, though, that one of the chimps in the family was Gremlin, a name I remember quite well from hearing about these amazing animals for so many years in books and films. What was even more extraordinary was that Gremlin, having been born in 1970, was now 49 years of age and had an infant with her (chimps are named at 3 years of age, so the infant did not yet have a name), having been the oldest known chimp here at Gombe (or anywhere as far as I know) to become pregnant and deliver a baby.

We learned later, that most chimps have babies about every 4-5 years, though some can speed up their reproduction rate and it all depends on the type of mother she is. Infants will usually stay with their mother for four years or slightly more, so to speed things up means that though you are generating more offspring (i.e. getting more of your genes into the coming generations), they will have less instruction and supervision from their mother which could become evident in those chimps survivability later. So, it really depends on what type of mothering and upbringing you have that will shape your personality and your ability to integrate successfully in society. Sound familiar?

We sat and watched the chimps for the longest time as they moved about in the tree looking for more food as it’s the dry season here and food is scarce for them. One of the chimps was looking for a bit more as there was a female in estrus and one of the larger males would continually seek her out to mate, an act that was extremely brief but occurred numerous times in the tree while we were there.

At one point, the leader of the family decided that it was time to move and the entire group slowly descended from the tree, most walking directly past us only several meters away. When this happens, you don’t back up or move and you try to avoid eye contract as that can be threatening for them. It was incredible at just how close they were to us and we all just stood incredibly still. I did notice, at one point, that Ahadi, who was standing close to Leah, grabbed her arm just to be certain that nothing would happen to her as being so near, you realized just how big the adult chimps were, and especially the males.

I would have to say that I had both a sense of eeriness and excitement as the group slowly moved by us in the forest. We had come to see them in their natural habitat and to spend a few moments with these glorious beings, yet they were also our ancestors, distant relatives who share so much in common from genes to behavior, though who have been hunted for food and captured for research or zoos over the years. It was a haunting revelation at that moment and I was unsure of whether I was looking through a window or into a mirror as I gazed upon these nearly human forms moving past us in the tall grass. For someone whose interest has been in physical anthropology for so many years and considers Olduvai (Oldupai for those purists like me) Gorge the center of my universe, or Mecca, I could only envision Australopithecus moving through the same forest grasses more than two million years ago.

The chimps moved along at a pace we could initially follow, finding another tree to feed in so that we had another excellent chance to sit and observe their behavior. The one male who had been mating earlier was at the base of a smaller tree and soon began shaking the limbs and beating the bushes in a curious fashion when Ahadi informed us that he was telling the female in estrus that he wanted her to come down from the trees to mate with him. This went on for perhaps several minutes (perhaps she was playing hard to get) when, finally, the female who he had mated with previously slowly came down out of the tree to meet with him and succumb to his demands. There was absolutely no coincidence in her actions nor his as this was clearly a behavior well recognized to Ahadi and now something that we were also lucky enough to observe.

Eventually, the chimps began to move quickly down the very steep slope into the valley below where we were unable to follow them and, so, we began our hike back down in the opposite direction towards Jane’s Peak where we would again pass and then descend down into camp. Thankfully, we arrived back at a much earlier time than yesterday and in much better shape. I was not dehydrated and there were no pre-syncopal symptoms nor a necessary gallon of water to drink. We had paced ourselves on the trail and were now ready for a nice lunch from Juma and a quiet afternoon. Ahadi suggested that we go to see Jane’s House after lunch and some short, or actually not so short for me, naps.

I had planned to sleep for only 30 minutes, but that didn’t happen as it was so nice in the tents and the waves and intermittent rain were so relaxing in the background. We had planned to meet Ahadi at 4 pm and I was awakened by Mike telling me that Ahadi was waiting out front for us. A quick splash of cold water (remember, we have no hot water) on the face allowed me to become quickly coherent and presentable and the four of us walked down the beach a short way to the cinderblock building where Jane had lived all those years while doing her research here at Gombe and hosting graduate students, most of whom were from Stanford, where she became faculty and spent up to half of the year.

Ahadi had planned for us to speak with Dr. Anton, who we had met briefly and were all made aware that he was a baboon researcher and had been here at Gombe for many years. Dr. Anton is actually Dr. Anthony Collins, a primate researcher specializing in baboons who has been here at Gombe for many, many years and has firsthand knowledge of many of the events that took place in the past here as well as a very detailed knowledge of the chimp families despite his primary interest in baboons. As we sat in Jane’s living room and in her easy chairs with the waves softly crashing in the background (not softly enough, though given my unilateral hearing loss), it was so easy to listen to his stories of the past here at Gombe and imagine what life here must have been like in those days.

As many know, Jane and Hugo van Lawick, a nature and wildlife photographer already in Africa and encouraged to go to Gombe by Louis Leaky to film the chimpanzees, married after several years and had a son, whose nickname was Grub. Their son spent a number of years with his parents in Gombe, where they essentially created a cage for him to play in for fear of the chimpanzees harming him given their behavior of hunting and eating other baby primates in the forest. There had actually been a documented occasion of the Gombe chimps having taken a human baby earlier and this was enough for them to take the necessary precautions. To this day, small babies ae not allowed at Gombe and staff housing still has very strong wire cages on the fronts of their homes to prevent not only chimps from causing harm, but also to prevent baboons from wreaking havoc.

Dr. Collins also told us of the kidnapping that occurred in 1975 of three Stanford students and a Dutch woman by rebels that came across the lake from then Zaire and were eventually paid a ransom to release them unharmed. There had also been a death at Gombe when, in 1969, a young researcher was found dead days after having gone missing and without any clues. So, in addition to the continuous work that had been occurring at Gombe Stream and the Kasalela Valley, there had also been a fair share of controversies, though, through it all, the research institute that Jane Goodall had created has remained and continues to record the lives of these most famous of chimps.

In the living room, there were many books by Goodall as well as about her along with those on the various aspects of similar research being done elsewhere, all of which we were free to look through and read while we were there. Dr. Collins actually lives in the house and his work desk sits in the living with all of his papers and projects. Jane’s bedroom is off the living room and remains intact as do the kitchen, storeroom and the room currently used by Dr. Collins. What so impressed me about visiting the house was not the thrill that I received being there which one would have totally predicted knowing me (I have lived and breathed this this work since I was a small boy and was inspired by my mother), but rather the remarkable interest that both Leah and Mike demonstrated for a subject I thought was so narrow, yet so incredibly dear to my heart. If there was ever a “nerd alert,” this was it and I was so proud that we were all members of the same club at that moment.

The rain had abated well before our visit to Jane’s house, and when we said goodbye to Dr. Collins, we all headed back down the beach, our beach, to the distant point where we had been told to go no further, though Mike continually questioned this, as if there were something lurking in the underbrush, waiting to snag us if we dared even set foot in this forbidden zone. The reality, of course, was that there were no monsters there, and the real reason we visited these rocks each evening wasn’t to push the limits of survival, or even to watch the sunsets, but rather to get the only cell service nearby other than the tops of the nearby hills that were not accessible to us other than when hiking with Ahadi, when there was little time to rest, let alone to sit and download email.

The sunset this night was brilliant and you could easily see across the lake to the DRC, with its mountainous terrain raising up about its mysterious shores. We hiked home in the dark then went for dinner in the dining area where Juma had another delicious meal ready for us to eat.

 

 

 

 

All night long we were lulled by the constant sound of Lake Tanganyika’s waves on the beach with the water being only perhaps 15 meters from the front of our tents. It had been cool enough overnight for us to need the comforters, but only just so. It would not be completely accurate to say that we all enjoyed our cold showers in the morning, but we were all quite tolerant of the circumstances and the fact that we were in such an incredibly remote region of the globe where such conveniences cannot really be expected. Lake Tanganyika, as verified by Mike, a man of statistics, is the second oldest and the second deepest, but the longest freshwater lake on earth. Directly across from us is the Democratic Republic of the Congo, the DRC, which brings a whole new level of remoteness and intrigue to the table when you imagine crossing this lake. At times, the opposite shore is fully visible with its tall mountains, jungles and, of course, the Congo River.

We had planned to meet with Ahadi at 8 AM which meant we would be sitting for breakfast an hour earlier which we confirmed with Juma the night before. The way chimpanzee trekking is conducted here is very interesting as it isn’t as easy as just going out into the forest and looking for them or making an appointment with them. The families of the central group of chimps located here at Jane’s camp are constantly moving up and down the nearby valleys in search of the various fruits they seek which is their main diet. They will also eat small mammals, most commonly babies of both the local colobus monkey species and baboons, which are somewhat of a treat for them. There are both government researchers and local trackers that follow the chimp families on a regular basis here and, most importantly, the chimps are habituated, meaning that they do not run from humans, nor do they interact for the most part.

After checking with the trackers and researchers by radio to learn the approximate location of one of the families, Ahadi spent some time going through the rules of chimp trekking here which are very important for the continued ability to do what we are doing, as the chimps in Tanzania remain an endangered species. Visitors are to always remain at least 10 meters from the chimps and are to always wear surgical masks when nearby so as not to possibly transmit any illness to the chimps which is believed to be the main cause of death for a number of chimps in the past. There is no food allowed on treks and you have to keep any bags or loose clothing close by so as not to temp them. If a chimp approaches you in a threatening fashion, it is usually their intention to take a swipe at your leg and knock you down and the best way to protect yourself is to hug a tree so you don’t get your feet knocked out from under you.

We started our trek a bit after 8 AM. As I had planned to bring both of my cameras, one for me and one for Mike, along with my binoculars and extra lenses, I had my large photography backpack which I’m suspecting probably weighed in at over 10 kilograms. Our hike took us up and down through one valley and over into another and after about an hour or so, it was clear to me that the backpack was more than I could handle and I was getting quickly exhausted. Also, I was becoming dehydrated quickly as sweating profusely was an understatement and I was already completely soaked from head to waist. My ballcap was literally dripping and I was losing fluid very quickly. We hadn’t brought a lot of water, totally my mistake knowing how much I sweat, and we still had a long way to go.

The trails were totally amazing. At times they would be perfectly passable and, at other times, you were completely bushwhacking through the thickest of vines, some with thorns, and others so strong you couldn’t break them even with all of your body weight. They grabbed at your feet, constantly trying to trip you up and often coming very close to doing so. Much of the uphill and downhill movements were side slope so you would have to place your feet just so to prevent them from slipping downhill. It was truly remarkable hiking through the dense underbrush, and when we were breaking new trail, must have been what it was like for the original explorers of this continent. We obviously didn’t have machetes, but it would have felt natural if we had. We eventually came to a wonderful waterfall that was fully flowing and fell 25 meters from above us and into a wonderful pool with a heavy blowing mist above. I was just too exhausted to explore, but Leah checked it out for us and verified that the mist was delightfully cool.

After the waterfall, we finally met up with the trackers who were following a family of chimps that were up in a tree. It was part of the “G” family – Gaia, the oldest daughter of Gremlin (who I will mention later), along with two of her children, Google, born in 2010, and Gabo, born in 2015. We continued to watch the three chimps in the tree for some time along with some of the other guests at the camp until finally, the chimps decided to move on up the hill faster than we could follow them. We hiked down from the high point where we were and ended up crossing a steep ravine whose trail led us to Jane’s Peak, where there is an incredible vantage point to the valleys below and where she had spent a considerable amount of time following the chimp families with her binoculars prior to her being able to approach them much closer. From this point, we continued west towards camp, skirting along a ridge top before slowly, or sometimes more rapidly, towards the lake which we could often see in front of us and well below.

Having departed camp in the morning at 8:15, it wasn’t until after 3 PM that we finally returned making it an almost seven hour trek and though some of it was surely spent watching the chimps, it wasn’t more than an hour meaning that we had been hiking for approximately six hours in this reasonable hot and very humid climate with nothing to eat and, for me at least, not enough water to drink. We all desperately needed showers and were now looking very much forward to the cold showers in our tents that were just so incredibly refreshing.

I felt terribly dehydrated and, at one point, nearly passed out in the bathroom, so during our lunch I did my best to rehydrate as much as possible. After lunch, we all decided to take long naps and then later walked north along the beautiful beach in front of our tents to use the internet on our phones as this was the only place in camp where we could do so. The WiFI here had been working only intermittently and we had been unable to check email or text on it leaving us only with our phones at an outcropping on a most lovely beach and perfect spot for sunset. Since we had eaten so late, dinner plans were for 8 PM after which we all went to bed and prepared mentally and physically for another hike tomorrow.

 

We awakened quite early to meet our driver at 6 AM for our drive to the Dar airport. As I had mentioned earlier, we had requested bringing breakfast with us since the kitchen wasn’t opening until 6:30, but the breakfasts, which left much to be desired, were comprised of a piece of white bread (not toasted) with some jam, a banana, and a juice. Needless to say, we were all still quite hungry when we arrived at the airport. We went to check in, but were told that check in would be 7 AM for our flight, so we sat and waited. Thankfully, Leah noticed that the small sign about the check in desk had changed and now had our flight so we weren’t last in line, but after having checked in, found that our “new” departure would not be until 9:30 AM, much to our frustration. Thankfully, there was a small snack bar where we were able to get something to eat or drink given our less than satisfying breakfasts. I ordered two samosas and a diet Coke, a very hearty breakfast indeed.

It was time for our departure and we all boarded the plane which was a prop plane similar to what we had flown in from Kilimanjaro. The flight was two hours long as it completely crosses Tanzania from east to west, essentially following the same path as the railroad that was built here a number of years ago and can still be taken from Dar if you’re more adventurous. The railroad had been built to help bring goods not only from Western Tanzania, but also from the Congo, DRC, to the ports for export. Kigoma is still a business center for the region and it is the only access point to Gombe Stream National Park, famous for the site of Jane Goodall’s extraordinary work on the wild chimpanzees of Tanzania that began in the early 1960s and still continues today.

None of us had any idea of what to expect since none of us had ever been to this region before nor did we have much of a description of the area. I guess you can say that we all came based on the thought of visiting such a remote area and getting to see the chimps. But first, we had to land in Kigoma, which is probably one of the tiniest of commercial airports that I have ever been to. The single small building there says “departure lounge” on the right half and “arrival lounge” on the left half. There was nothing in between. The plane taxied onto the tarmac and let everyone off on the opposite of the place from the “lounges,” meaning that we had to first negotiate our way around the plane before we could head towards the terminal building. We had to show our passports to enter, which they recorded asking our destination, while informational signs warning of Ebola symptoms were on the wall behind the desk and at other locations. With the DRC being so close and reported cases of Ebola, no one takes anything for granted around here.

The arrival lounge had no chairs or other conveniences, but was really just a square room with a big opening on the tarmac side with a large platform on which they placed luggage as it came in, necessitating that passengers get their bags before they could put additional ones onto it. Of course, our bags were at the bottom of the cart they used to unload everything and then wheel over by hand. Regardless, we all had or baggage, which was a huge plus, and we were now ready to step outside and find our driver. Given the size of the aircraft (small) and the fact that were nearly last to get our luggage, this was a simple affair as there were few drivers left standing in the parking lot. We loaded everything and drove through the outskirts of town, towards the place where we’d find our transportation for the next leg of trip – a boat to take us to Gombe. We pulled up to an area where there were many, many boats of all sizes in the water and pulled up to shore. All were the very common wooden boats of this area, most with engines and some that were very much bigger than others. Joshua, from Gombe Safaris who we had booked with, met us there and introduced us to Juma, who was the captain of the boat we were to take, which though it was one of the smaller ones, looked quite sea worthy and had tarp over the top that was reassuring.

Our bags were loaded onto the boat and we all found seats for the two hours that would be necessary to reach the central part of Gombe where we were staying. It was immediately clear to me that we were also bringing the groceries to camp as there was a large basket in the middle of the boat which contained all sorts of fresh produce. There was also a string of freshly caught fish hanging on a nail on the inside of the hull which I was also pretty certain that we’d be eating either tonight or the next day. At some point as we were heading out of the harbor, Juma did suggest that we put on life vests which was probably more appreciated than not given the small size of our boat, the massive size of the lake and the length of our trip. Thankfully, there were no mishaps during the journey as we plied close to the heavily wooded shore, occasionally passing a small fishing village or boats out fishing with their tiny crews. Once we reached the park boundary, though, there no more villages to be seen and we still had quite a ways to go.

At one point, we pulled up along the beach and some guides and visitors came out of the forest and tall grass. They had apparently been looking for some of the chimps, but hadn’t seen any, which was unfortunate as most of them were only on a day trip from Kigoma and were heading back home empty handed. One of the visitors, though, did come back to camp with us. He turned out to be an anesthesiologist from Ireland who had been working in Tanzania and was now traveling on his own before heading back home. He would be spending the next two nights with us in camp and we enjoyed his company. There was also another group of three women who were in camp for two nights, but other than that, we were pretty much alone here. Before we arrived to camp and while still on the water, it began to rain on us, but there were no issues as it was quite refreshing.

On our way here, Katherine from FAME had texted me that she spoke with a friend of hers who works here at Gombe as a guide and that she had told him we were coming so we should look out for him. “Promise” was his name and as we initially got off the boat and were welcomed, I mentioned that we were looking for Promise as he knew that we were coming. Everyone looked at me like I was a bit crazy and seemed to have no idea who Promise was until finally, one of their faces lit up and then said, “Oh, you mean Ahadi!” Of course, Promise in English translates into Ahadi in Swahili which is what everyone here knew him by. Once we figured that out, all was well and, in very short order, we were able to meet Ahadi, who was as pleasant and reassuring as anyone I could imagine and he proceeded to help orient us to camp.

One of the first things we learned was that the baboons, who populate the camp along with the staff, can be very pesky at times and are well adept at opening the zippers of the tents requiring that they be locked at all times when you’re not present, unless you’d like to see them playing with your camera equipment high up in the trees or possibly wearing your clothes. Since neither of those things rank high on my to do list, we decided to keep the tent religiously locked when not present. The tents, though not entirely glamping as it was in the Serengeti, are really quite comfortable with two large beds on a permanent platform with running water and electricity (though not 100% dependable which I’ll go into later), a toilet and a shower. Unfortunately, the hot water is not currently working for the tents, but we all pretty much decided that was more than reasonable at such a remote place and cold showers would have to do.

Meals are eaten on the second floor of the rest house (you can choose to either stay in the rest house rooms or the tents with the latter being ever so slightly more expensive) and the food is cooked by, none the less, Juma, our captain. On our way here, he had handed each of a bag lunch on the boat that was a vegetarian burger on a huge bun with secret sauce that was really delicious, along with some mango juice to wash it down. When we finally arrived to camp, we were also offered lunch, by Juma, who must have thought our stomachs were bottomless. Of course, we had to eat the lunch so as not to offend anyone, and considering it was the amazing fresh fish that we had traveled on the boat with us, we weren’t about to argue. Later, though, when Juma asked us about dinner, we all immediately agreed that we were just fine for the evening and really didn’t need anything else to eat.

Tomorrow would be our first trek to see the chimps and I think that all of us were very excited over the possibility of seeing them in the forest, though at the time, we really had no inkling of what that was going to involve.

Thankfully, Marissa and Andrea had checked their flights on Air Kenya the day before to notice that they had been moved up an hour. We had originally intended to depart at 8 AM, but given their new departure time, it made more sense to leave a bit earlier so as to make sure we had plenty of time. We had people flying out at various times during the day and given that it is about an hour to get to the airport at Kilimanjaro, I had planned to arrange a shuttle for the Marissa and Andrea who were leaving the earliest. Leah, Mike and myself actually had transport from Arusha as part of our package of travel to Gombe Stream National Park and our flight was leaving at 7:40, while Kyra was departing at 10 PM on Emirates to eventually head to Morocco by way of Dubai. I had asked if Kyra could just come along with us since that made the most sense, and heard back that she could ride with the three of us for no extra fee. And in the end, we didn’t need the shuttle for Marissa and Andrea, who were heading home, as Pendo had to drive to Moshi for a funeral at the same time and could drop them off at the airport which was far better than taking a shuttle, not only in cost, but also for reliability.

We left FAME at about 7 AM, with Phoebe getting up early to say goodbye to us. I know it was sad for everyone to leave, though it was time for them to get home to their family and their other lives. I’ll be back in six months and, besides, FAME has always been constantly on my mind and even more so these days given my new commitment as a board member. We drove through Karatu with all the early activity of the merchants and the buses being boarded for far reaches of the Tanzania – Arusha, Dar, Dadoma, Loliondo – all destinations for everyday travelers on their way for business or to rejoin families. I have never taken a long bus ride in this country, and though it might seem exciting and adventurous, it can also be very dangerous as there are bus accidents all the time here.

We drove down to Manyara and had planned to stop briefly at the African Galleria to say goodbye to Nish and several people had wanted to get a few last pieces of Tanzanian artwork. Though I had said 10 minutes, it turned into closer to 30, which wasn’t a crisis, but I knew that traffic in Arusha can be a problem at times. We eventually left and stopped briefly for gas in Makuyuni, before continuing on to Arusha. The drive was reasonably fast until we reached the outskirts of Arusha and the traffic became a problem. I took a few shortcuts, but even with these, we arrived around 10:30 rather than the 9:30 I had anticipated. Pendo, of course, had a full breakfast on the table waiting for us and we were all starving, given the lack of breakfast items in our house, so it was very much appreciated. After breakfast, Marissa and Andrea gathered their things, loaded them into Pendo’s van and they were off for the airport.

The remaining four of us were left at home with the Gabriella, Gabriel, and another young family member, but in very short order, we all fell asleep on the couches in their family room, sleeping quite soundly for well over an hour. When we awakened, I realized that we’d all need something to eat before going to the airport, so we drove over to the Cinema, which is a small upscale mall that has an outside food court where there are a number of restaurants that all vie for your business by putting about six menus on the table, each with different waiters to take your order. This is somewhat of a mzungu hangout as there are lots of expats and young travelers who come here to eat a meal without the fear of getting ill which can often happen at some of the local restaurants if you’re not careful. We each ordered from one of the menus and then had a delicious meal that we finished just in time to head back to the house where Leonard’s sister-in-law, Grace, was waiting to drive us to Impala Hotel nearby where we had planned to meet our ride to the airport. I think everyone commented on what a welcome change it was to finally be in something other than the squeaky and bouncy Land Rover after an entire month, but I took absolutely no offense as I had a bit of the same feeling, though was already missing Turtle.

At the airport, Leah, Mike and I checked in for our Air Tanzania flight to begin our journey to Gombe, while poor Kyra had about four hours to wait for her Emirates flight and they hadn’t even begun checking passengers in yet. She had a long trip to Morocco, but we received word later that she made it safely to meet her husband. Our flight to Dar was uneventful other than a stop in Zanzibar which we had been aware of beforehand. As it was already nighttime, we did not even get a good view of the island.

In Dar, we met our airport shuttle that took us to the Tanzanite Executive Suite, the long awaited highlight for Mike as he had been talking about this ever since we booked our trip months ago. It was obviously more of a joke, though at times he seemed quite genuinely serious about it. After all, it was an “executive suite.” We drove from the airport to what seemed to be the main area of town and the driver eventually delivered us at the hotel after driving through a number of very narrow and bumpy streets. Our bags were brought up to reception, one floor above the street and we were given our rooms on the 8^th floor. Everything was extremely clean and we were greeted with a very cold and very fresh glass of mango juice. Since our flight was at 8 AM the following morning, we did ask if we could have breakfast to go (since breakfast was included but would not begin until 6:30), as we’d be leaving for the airport quite early. I think we were all asleep quite quickly despite the long naps we had taken earlier in the day. Tomorrow, we’d be flying to Kigoma and it would be off to Gombe Stream National Park after that.

There had been a tremendous amount of moving parts today given everyone’s different flight times, the travel from Karatu, and the distance to the airport, but all went incredibly well and, amazingly, everyone made it to their destinations as scheduled. Marissa and Andrea would be home tomorrow, while Kyra was on her adventure in Morocco with her husband. Leah, Mike and I were just beginning our expedition to the see the famous chimps of Gombe.

It was last full day at FAME as everyone would be departing tomorrow morning, most for different destinations. Andrea and Marissa would be heading home first through Nairobi, then Doha and finally back to Philly, arriving on Sunday. Kyra would be leaving for Morocco via Dubai, meeting up with her husband for ten days there before returning home. Mike, Leah and I would be heading first to Dar es Salaam, then to Kigoma en route to Gombe Stream National Park to hopefully see some chimpanzees.

As I had mentioned, I gave everyone permission to sleep in this morning and miss morning report since they had been getting up early every morning including those on safari. I went to morning report by myself and did my best to represent the neurology team, though there were no overnight neurology patients that needed our attention so it worked it quite well that the entire team wasn’t there. We had decided to have a very large debriefing meeting for the neurology clinic at 9 AM which was perfect as I had just a few things to finish up prior to the meeting regarding patients who we had seen recently and just needed some follow up. The debriefing meeting included most everyone who had anything to do with the neuro clinics, either at FAME or on mobile, and also included the upper management (i.e. Susan, Caroline and William) who are significantly involved with the clinic from a mission, cost and personnel standpoint, respectively.

When we started the meeting, it had been anticipated that we would spend about an hour or perhaps a bit more. The meeting ended up lasting 2 ½ hours and was incredibly produce dealing with lots of aspects of the clinic, from medications and availability to how we would schedule the clinic in the future and what our hopes were for the clinic going forward. There were lots of great ideas and lots of great dialogue such that I’m incredibly hopeful that we will continue to serve the neurological patients of the Karatu district and beyond as we have since 2010 and my very first visit here. FAME has grown tremendously since I first arrived and so has our neurology clinic, now being a part of the Penn and CHOP neurology residencies and the volume of patients that we see while we’re here.

The residents had a number of things they had wanted to do as well during the morning and they could get very little done considering that those they wanted to see were all in the meeting with me. I had told them the meeting would probably last a bit over an hour, so they were all hunting me down during the meeting, though I was able to tell them at some point when I needed to leave the meeting for a bathroom break as the meeting had been advertised as BYOC (bring your own coffee) since it was being held in administration and not the Lilac Café which used to be the norm. I finally met several of them down at the Lilac after the meeting, though, and quickly discovered that they had ordered what looked like the most delicious breakfast I had seen with eggs, toast, bacon and sausage. I hadn’t eaten any breakfast as we were out of most of the food in the house since we’d be leaving the following morning and we had also run out of all the breakfast bars that had been brought by the residents. Despite the fact that it was nearly lunchtime, I didn’t hesitate one moment when asked if I wanted to order something and replied, “I’ll take one of those.”

I did have a number of errands to run once we were done with the meeting and breakfast, and I had told Daniel Tewa that we’d stop by for coffee at around 1 PM, so it was important to get those things taken care of. I knew that everyone wanted to get their packing done today since we’d be leaving early the following morning, and I was also aware that there was some interest in relaxing for the day, so I left it up to everyone whether they wanted to come to Daniel’s with me or not. In the end, Kyra and Mike agreed to come along as Kyra wanted to visit the wood carver in Tloma Village and Mike wanted to visit the artist Katongo at Gibb’s Farm to possibly pick up a painting.

I had texted Daniel that there would only be three of us, but somehow, he didn’t get the message, and when we arrived to his house, he had coffee cups set up for everyone. I’ve been in this position before, and when it has happened in the past, Daniel always comments half-jokingly, that who’s ever there must drink the coffee for everyone. The coffee he makes is the true African coffee, which is boiled with milk and is absolutely delicious. The only problem with that is that Kyra can’t drink the coffee as it has the milk mixed in and she drank hot chocolate instead, leaving Mike and I alone to finish what Daniel felt was a respectable amount of the coffee. That meant at least three cups each and there is nothing timid about his coffee. We survived the caffeine infusion and, as we were saying our goodbyes to Daniel, he ran back to the sleeping area of his home and brought out seven ½ kilo bags of whole coffee beans for everyone, including Ray, to bring home. He is such an incredibly generous man and has never once asked me for anything in exchange for what he does for us and whenever I try, he just says that we’re family and he’s grateful for what we’re doing for his country.

From Daniel’s, who lives on the road to Gibb’s Farm, we made our way up to Tloma Village, but given all the coffee I had drink, I needed a bathroom, so instead we went to Gibb’s first so I could use their amazing bathroom in the check in area that is wide open to the outside and sports a view of their gardens and livestock. When I bring people here to visit, I always make sure that they visit this bathroom first on our way in. I said hello to all of the waiters that know me, while Mike and Kyra walked with Katongo to his studio to see what painting he had for sale. Mike had wanted a giraffe painting that he had done and was very cool, while Kyra, who hadn’t really been planning to purchase a painting, decided to buy a wonderful lion painting that he had finished with a lion couple on it.

On our way back down from Gibb’s, we did stop at the Wood Carvers where Kyra managed to pick up something small and I picked up two smallish pieces of uncarved ebony to use as stands, but that required some serious haggling, not something I typically enjoy, but I felt he was being unreasonable, so set the stands back down and started to walk away on two occasions before I was able to finally purchase them. With our errands all finished, we were finally able to head back to FAME to finish packing and ready ourselves for our trip to Arusha the next morning before going over to Frank and Susan’s for the evening with all the current volunteers.

Susan usually tries to have everyone over to their place at least once during their stay here and typically towards the end. Those accompanying me during our trip here really don’t have much interaction with her on a day to day basis as her role at FAME is more administrative than it is directly medical, and so the most interaction that everyone has is with Frank, whose personality is generally bigger than life and hard to miss. The visits to Frank and Susan’s house, though, allow everyone the chance to meet Susan in a more social setting and also allows Susan a chance to get to the know the residents better. For tonight’s event, it involved lots of munchies like popcorn, samosas, cheese and toast (there was apparently a run on crackers in Karatu and none were available) along with lots of beverages.

Nicky, their little sheepdog/dachshund mix (yes, her body habitus is quite bizarre) was out on the deck with everyone, along with Elvis, their Sekoke cat (a rare mix of domesticated and wild African cat from Kenya), who pretty much buddied up to Kyra, our cat lover, but in the end settled on Andrea’s lap for the longest of time. Oscar, their three-year old Rhodesian Ridgeback, was let out a little bit later so as not to knock every glass off the table and managed to make friends with everyone, but Mike turned out to be his real buddy as the two shared one large chair and appeared quite the couple. Frank typically disappears at 8 PM, his usual bedtime, but actually lasted until 8:30 tonight and in his usual custom, vanished for his bedtime without a good night so as not to break up the party. It’s always an incredibly relaxing evening where everyone can share whatever stories they like. Joyce Cuff and her sister Terry were also there, so it was fun sharing our old stories of the big mobile clinic to Lake Eyasi with everyone else. We also had a new volunteer, Greg, an internal medicine doc, there so he was also able to hear some of our old stories about FAME from ten years ago. It was a wonderful night and I think everyone walked home with a better appreciation of what FAME had been and has now become over the years.

It had now been nearly a month that we’d been away from home and three full weeks of seeing patient here at FAME. At had no indication by anyone’s mood or actions that they were homesick or tired of this place, but rather that it was becoming a second home as it has with me over the years. Today was our last day of neuro clinic, albeit unannounced, but we knew from the past that patients would come regardless and, besides, we had told several to come back today to see us in follow up or to have studies done. It was 18^th clinic day, all told, and we were nearing 400 patient visits which is what our fall trips have been consistently running as opposed to the spring trips which are usually around 300 patients. I believe that had it not been for the extended coffee picking this month, we would have seen many more as that is the major employment in this area and, as I’ve mentioned before, the season is only around 40 days so that to miss the opportunity of making the equivalent of $2 USD for a day of picking can be extremely costly for most residents here. Whenever we’re driving down the road to town in the morning, coffee pickers are walking up the road towards the fields with their 5 gallon buckets in hand, ready for their work that will bring some shillings to their family and food on the table.

It was also everyone’s last morning report as the residents and Leah had already let me know that they would be sleeping in tomorrow rather than coming to report since we had no clinic. I had absolutely no issue as they had all earned that luxury given the days of hard work they had put in and the fact that we’d be getting up early on Saturday to leave for Arusha. Andrea had volunteered today to give the educational lecture on the different types of tremor and how to evaluate and treat them. Since she will be going into movement disorders, this is obviously her passion and it showed in her lecture which was complete, well-organized and well-received by the FAME clinicians. Also, as it was our last morning for the team to be at report, there were words of thanks by all the doctors, but especially by Dr. Anne, who had spent the month with us as she will be the FAME neurologist going forward, and Dr. Gabriel, FAME’s head doctor and someone who I have known now for many years. After the words of thanks came the mandatory claps, which are usually three, but this morning were six, the extra three as a sincere sign of appreciation. “Pasha, pasha, pasha, choma…” and then the six claps by everyone around the table.

Before this, though, Jacob, the overnight doctor, presented the ward and maternity cases to the group for any overnight changes. Our gentleman that Kyra had admitted with Wernicke encephalopathy had improved and was much less ataxic and less encephalopathic this morning after his supratherapeutic doses of thiamine which was great to see as we were worried about the oral thiamine replacement we had given him. As we had walked to report, we had noticed the FAME ambulance backed up the walkway near the ward which was a good sign as it meant that they were readying the patient with the meningioma for transport this morning to Arusha. Unfortunately, what we discovered from Jacob was that the patient had markedly improved overnight in regard to his encephalopathy (theoretically, a good thing) and that he was now refusing to be transferred to Arusha (a bad thing) after he found out the expense of surgery, despite the fact that his family was agreeable to him going and had already raised the money necessary to have him treated. Jacob had already. spent a great deal of time with him before rounds and the patient was adamant about not going and his family was now beginning to waffle.

The steroids would not continue to hold him for very long and his edema would eventually begin to reaccumulate and worsen and, if nothing were done for him, it was very likely that he would die due to complete obstruction of his ventricles and hydrocephalus. Mike went back after rounds to reassure me that the patient had capacity to make this decision as well as to make sure that his family was also well aware of the consequences. He was and they were, though they later indicated that they would likely drive themselves to Arusha rather than in the ambulance and were planning to see the neurosurgeon.  We made sure to make Dr. Rabiel, the neurosurgeon in Arusha, aware of the change in circumstances as Dr. Gabriel had called her yesterday afternoon and that we were hopeful that he would see her sooner rather than later as there was little question that he would be worsening in short order if nothing were done. If we had been at home, we would have made him sign something discharging him against medical advice, or AMA, but that would have been solely out of concern for medical legal reasons and of that we had little concern here.

Of the other interesting patients that we had for the day was the 91-year-old Maasai gentleman with the primarily proximal lower extremity weakness who we thought was mostly myelopathic, but without apparent sensory changes and normal ESR and ALT/AST (proxies for a CPK which we do not have here). He underwent his CT scan of the cervical and thoracic spine that were unremarkable as far as any destructive lesions anywhere, though I will admit that my abilities to look at CT scans of the spine in regard to the cord or other soft tissues aspects is a bit lacking since we rarely do them for obvious reasons as the MRI has become the gold standard for evaluating the spine. We remained at a loss for his diagnosis considering other possibilities such as spinal AVM or an inflammatory myelitis, both of which would be very difficult to diagnose with access only to a CT scanner. Unfortunately, we sent him home without a diagnosis, but will still be thinking about him with the idea of coming up with something.

On a completely different note, though, we had a rather frustrating woman who came in with complaints that seemed mostly non-neurologic, but we decided to evaluate her none the less. She did have a swollen left lower leg that we really couldn’t ignore and sent her for an ultrasound, that was negative for a DVT, but Dr. Gabriel did note that she had some tenderness and pain to palpation and suggested that we get a plain film to rule out a fracture or other pathology despite her lack of trauma. We went ahead and ordered the plain X-ray of the foot, not something we normally do, only to notice that there some hyperdensities posteriorly that were in the soft tissue above the ankle. We had no idea what these were, but were surprised when Dr. Alex, our radiologist, read them as calcifications that could be suggestive of cysticercosis of the muscle.

Now, this was a twist as we are totally aware that neurocysticercosis (pork tape worm cysts in the brain which are one of the most common causes of epilepsy worldwide) is present in this area (though it’s unclear if we’ve actually seen any to date), but in researching the possibility of cysticercosis of the muscle, it turns out that it is very rare and that if it is seen, patients should be screened for asymptomatic neurocysticercosis as this entity is so much more common than involvement of any other organ system. The following day, Dr. Gabriel did call the family explaining to them our concern and recommending a CT scan of the brain, but they elected not to do it and it was unclear if this was due to the cost or whether due to a local belief that X-rays take away years from someone’s life. Either way, it wasn’t going to be done which was unfortunate from an academic standpoint as it would have been very interesting to have answered that question.

So, we had lots of commotion for the afternoon with all of these complex patients, but we did have something very much to look forward to as we had made dinner reservations at Gibb’s Farm for the six of us this night and it was a much anticipated event. We had actually finished everything up a bit earlier than anticipated, but most importantly, we had exceeded the previous number for patients for a trip by one, having had 405 patient visits for the month and still wondered what the number would have been were it not for the extended coffee picking season. We did have to run back to Teddy’s, now the all-time favorite FAME seamstress as there had been a few other things she was making for people that needed to be picked up. We decided to do this on our way to Gibb’s and, as expected, there can never be a short visit to Teddy when bringing along a female majority. I do apologize if there is something a bit sexist about that statement, but having visited her shop multiple times now on three separate trips, I believe I have the clear data to validate my observations if anyone wishes to challenge me.

We finished up at Teddy’s and then made our way up to Gibb’s for our dinner. None of the others had dinner there before, so I knew it was going to be a real treat for all of them tonight. We had arrived after sunset with plans to have some drinks before dinner, but they had a table all ready for us and since everyone was more than ready to eat, we decided instead to be seated and get drinks with our dinner. Visiting Gibb’s for me is always such a pleasure, not only for its wonderful setting and the scenery, but also for the fact that all of the waiters there, most of who have been there for years, know me and greet me with hearty handshake and hug. I have cared for a number of them or their families over the last ten years and they all know the work I have done at FAME and are appreciative of it. Visiting Gibb’s Farm is clearly one of the highlights of the residents’ visit to FAME and I always make sure that we make it here at least once for dinner and once for lunch during our month long stay. I am sure that one can find other lodges that may have some better attribute here or there, but when it comes down to the entire package, there is really no other that comes close to Gibb’s Farm.

We finished dinner early enough for everyone to spend time in the gift shop with both Mike and Kyra finding wonderful bathrobes to purchase. Everyone had worn their new Tanzanian attire except for me and Mike, who had decided not to wear his infamous jumper to dinner, so he wore the bathrobe that he had purchased and I wore Kyra’s bathrobe for a group photo in front of the Gibb’s fireplace. It was a great ending to a wonderful evening.

Our morning report was very interesting today in that one of the patients who presented yesterday emergently to FAME was a young gentleman who had been attacked by a Cape buffalo. These events remind us that we’re definitely not in downtown Philadelphia as there is very little violent crime here other than the attacks by wild animals. Baboon or monkey bites have been relative common in the past given the total lack of fear these animals have at the Ngorongoro entrance gate and the picnic areas in Tarangire. At the gate, the baboons will very quickly enter any open window in a vehicle, target the lunch boxes or any food and be back out in a quick flash unless someone tries to stop them which they don’t appreciate and will quickly. provide a very nasty and dirty bite. Last year, a very unfortunate Maasai man from the NCA was brought in after being essentially eviscerated by an aggravated elephant and did not survive the night from his injuries. A Maasai women came in a few years ago with nasty hand wounds after tangling with a hyena who had successfully taken her infant from her hut and had to be referred to KCMC for more specific orthopedic repairs. Her infant was never found.

So, the gentleman who ran afoul of the Cape buffalo was actually a bit lucky in that what he had was a bit hemopneumothorax that needed to be drained, and though there was concern that he would need ICU level care (not available at FAME), a chest tube overnight seemed to stabilize him. There was concern for his mental status in the morning and we were asked to evaluate him from a neuro perspective. Mike went to see him in the ward and he was totally intact to the degree that I joked that he followed commands better than 90% of the patients that we were seeing in clinic. He was a lucky individual as Cape buffalos can be very, very dangerous in situations where they feel threatened and they unlike many animals as they will defend themselves. If you’ve ever seen the video of the Cape buffalo completely upending an adult lion, throwing it at least ten feet in the air in a tumbling fashion, and using its razor sharp horns, you can certainly understand the need to avoid them at all costs. There had been talk of transferring him, but he looked so good I the morning the decision was to keep him at FAME and to continue treating his injuries.

We had a patient come today who was following up from our clinic in Mang’ola last week and he had looked mostly cerebellar on examination. He was now encephalopathic and tremendously worse such that we were fairly confident his diagnosis was Wernicke encephalopathy, which often occurs in the setting of alcohol abuse and is the result of dietary deficiencies usually related to thiamine deficiency. If it is severe and irreversible and more associated with confabulation, we call it Korsikoff syndrome. In the US, patients with a history of alcohol abuse are immediately given what is called a “banana bag” intravenously that contains thiamine, magnesium and folate primarily  which effectively prevents the acute exacerbation of Wernicke that can occur when patients are given dextrose intravenously prior to correcting their vitamin deficiencies. We have no banana bag here nor IV thiamine for that matter, but we did have thiamine tables to send with the only proviso that we are unable to know for certain whether it’s being fully absorbed or not. Regardless, it was the only thing that we had and so it was five tablets every eight hours for several days to totally supplement and correct a presumed thiamine deficiency. Kyra had seen the patient in Mang’ola, so also evaluated the patient here and we all agreed that he should be admitted to make sure that he got his thiamine. With Dr. Anne’s assistance, this was taken care of and Kyra wrote the orders for him to receive thiamine as well as some other vitamins, none of which were quite as important as the former supplement, though.

In the midst of everything going on, a young patient with an IV was wheeled into our clinic space on a gurney by one of the nurses saying that he had been sent to us directly from the OPD to be evaluated for episodes of unresponsiveness. There was really nowhere to place him with all the patients sitting waiting to be seen, so he was wheeled into one of the unused rooms in the ward, but I insisted that there be a nurse with him as we had no one to spare that could monitor him. Though this hadn’t happened yet this visit, it is not all too uncommon for patients to brought to us in this fashion having come in unresponsive, many times after having “swooned” at school or work. I recall one time that a patient was delivered to us in this manner and after briefly examining the patient and getting the history, it was clear to me that it was not anything serious and that they would wake up eventually. We left the patient on the gurney nearby, monitoring them occasionally until, sure enough, they awakened and were back to their normal self-following what we refer to as PNEE, or a psychogenic non-epileptic episode. These are a form conversion disorder and are most commonly a response to underlaying stresses, though it takes a good deal of time and therapy to determine exactly what they are and how to best deal with them.

For our patient, though, it was much simpler as after having taken an accurate history and examining him, it was quite clear that this was just a matter of several episodes of syncope in a patient who had been dehydrated. These are patients that we are often asked to evaluate at home to determine that they don’t have a neurological cause for their loss of consciousness, such as seizure, so it not at all that unreasonable to have us evaluate patients such as these, though typically it will be done in the ER if it is acute and they are not wheeled into our offices.

At the same time as the syncopal patient arrived in clinic, we had been called over to see a patient in the ER who had arrived unresponsive after having developed a severe headache, vomited and become less responsive the night before. Mike went over to see him right away (which is why we had no immediate person to evaluate the syncopal patient) and the patient was moving all extremities, but not following any commands and was very poorly responsive. We were most concerned about a subarachnoid hemorrhage and without any focality on his examination, this would have been suggestive of an aneurysmal bleed without significant parenchymal injury. We had another patient already in the scanner at the moment which had to be completed first, but he would be getting his study very soon and he was moved to the ward while he waited as it was clear he needed to be admitted.

He eventually had his study and it was not at all what any of us had expected. He had a very large, right sphenoid wing mass that was homogeneously enhancing and causing significant mass effect on his right lateral ventricle with right to left shift of the midline. There appeared to be some involvement of the cavernous sinus as well. The mass was most likely a meningioma and it was almost identical to the mass we had found in a gentleman two weeks prior, though that patient had a more gradual history over several years including complete loss of vision on the right secondary to optic nerve involvement. We were really unable to get any relevant history in our current patient given his severe encephalopathy. We spoke with his family at length regarding the fact that he had a potentially very treatable problem, but would need to be referred to the neurosurgeon in Arusha and transferred there the first thing in the morning as nighttime transfers are dangerous, risking the life of not on the patient, but also the lives of the support staff involved in the transfer. The family was agreeable so I proceeded to contact the neurosurgeon, as I had done several times already during this visit, to find out what the expectation would be for the amount of money they would need up front. We placed the patient on intravenous dexamethasone at the end of the day to help with some of his swelling and went back to finishing our work in the neuro clinic. We arranged for his transfer first thing in the morning by the FAME ambulance.

There are several important events that occur here in Karatu on Wednesdays. First, it’s meatloaf night for our dinner and Samwell cooks a very mean and moist meatloaf with some tanginess from a barbecue sauce that he uses and is probably homemade. It comes with a large side of mashed potatoes as well as green beans to add some color. I don’t know about the rest, but the meatloaf was clearly Mike’s and my favorite of the various dinners that we’re provided by the FAME kitchen five nights a week as part of room and board while volunteering here. In addition to these dinners (we have to fend for ourselves on the weekends), we’re also provided lunch every day which is perhaps my favorite food of all – five days a week it’s rice and beans with a local spinach made even more tasty by Samwell’s homemade pili pili, or hot sauce, that is made from the local hot peppers here which are very, very hot. This combination of food, the beans, rice, spinach and pili pili, may be my all-time favorite meal that I would choose if I were ever stranded on a deserted island. Tuesdays we have ugali, the East African staple that is a stiff porridge made from maize, and meat, while on Thursdays we have perhaps everyone else’s favorite, pilau, which is brown rice (cooked in meat stock) mixed with beef and then a coleslaw-like salad to go with it. Both of these, of course are made that much tastier by the addition of Samwell’s pili pili.

The second event that occurs on Wednesdays is our Happy Day night. Happy Day is a long-standing local pub that also has small bungalows where many of the long term volunteers at FAME have lived in the past, including Peter Schwab, the medical student who worked with us last October and is now a neurology resident at Penn. Happy Day (note the “Day” and not “Days” so as not to be confused with that popular sitcom) has been an institution here in Karatu since my very first trip, but has changed its ambience since taken over by new management. What used to be uncomfortable picnic benches on the outside deck are now very comfortable outdoor sofas and pillows, lots of them. It has been a tradition for years that all the ex-pats working in Karatu and surrounding areas come to Happy Day on Wednesday night to socialize and share stories. Frequent attendees include much of the staff from the School for Field Studies in Rhotia, which is quite close and is field school where college students come for study abroad programs. The mix of individuals depends on who is in town and who is around and is different every Wednesday night.

The third event on Wednesdays is much less of a sure thing and really depends on how much energy everyone has and what we have planned for the following day. If everyone is up to it, and that is not always the case, we will all make our way over to the other local hotspot which is the Golden Sparrow. “The Sparrow” hasn’t been around forever, but was the creation of the owner of the previous dance club which was called “Carnivore,” and was a little hole in the wall place that served the most scrumptious, though also the scrawniest, barbecued chicken and chips along with drinks. Seating for dinner was mostly outside on a dirt floor where they cooked the chicken whole on a huge grill and then literally whacked it into pieces with a huge cleaver before bringing it to your table to eat while dancing occurred inside on a tiny little dance floor that was nestled amidst the bar tables and stools.

Carnivore is no more and the owner, Martha, created a true dance club that would rival anything in a larger town and includes a DJ, disco lights and televisions around the dance floor. I will have to admit that in the past, there has been dancing on the tables though I will not mention any names (Mindy, Susan, Susannah, Whitley and Neena, I believe), but the tables have been changed and it’s no longer possible to do so. There is a very large outside seating area for dinners where they still serve their delicious chicken, but the most fun occurs inside on the dance floor. This night, we all loaded into Turtle and drove over to the Sparrow to let off some steam as we had working very hard for the month and were looking forward to our final day of clinic the next day, though no one really wanted to leave. Yes, there was dancing tonight, but none on the tables and we left before midnight to make sure that we’d all be in OK shape for the following day. It wa an incredibly enjoyable time, but not something that can happen every Wednesday night, that’s for sure.