Saturday, September 14, 2019 – A morning clinic and then a “wellness” afternoon at Gibb’s….

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Our lunch table on the veranda

A year or so ago, I was asked to incorporate “wellness days” into our schedule here at FAME in order to accommodate the new program being adopted by residencies to help with the issue of doctor burnout. Though this is indeed a very serious issue that has been at the center of attention for nearly every governing body dealing with any level of medicine, it has been particularly critical in medical residencies where the old ways of working 24/7 and sleepless nights are no longer acceptable. Work hours were instituted, as well as nighttime call rotations, and these have certainly helped, but medical training can still end up being a very dark period for many residents, especially in their early years where now managing incredibly more complicated patients than when I trained over thirty years ago can bring even the most accomplished doctor to their knees. Wellness Days were instituted to allow residents to have a bit of breathing room during their normal busy schedules, allowing them to catch up on personal matters or to just have a free moment where they don’t have to worry about their beepers.

Ready for lunch…

The lunch buffet

On a side note, I’ll mention a funny story regarding the ringtone on my phone. Since the beginning of cellular phones, I have always kept the old fashioned “telephone” ringtone since that is what I have felt most comfortable with and is what I respond to most readily without having to think about it. About a year ago, while working as an attending on the ward service in the hospital, my phone would ring occasionally during rounds and I would notice an immediate reaction by the residents that would be best characterized as an immediate need for action and their hearts would skip a beat. It turns out that this was a simple Pavlovian response to my ringtone which just happened to be the same ringtone used by the stroke phone that the on call stroke resident would be carrying and responsible for. They asked me (very politely, of course) to change my ring, which I promptly did, but for only about two days as I just could not get used to it and, so, changed my ringtone back to the original tone that worked for me, but was disturbing for the residents.

The view from Gibb’s

A pathway at Gibb’s

Now, you might ask why I can’t just turn my ring off when I’m around the residents, which is a very good question, but the answer is that if I do that, I will never remember to turn it back and on and will then wind up missing calls. You might also ask what this has to do with wellness days? First, it was not only the residents who were having their Pavlovian moments with my ringtone, but it was also me as I was unable to alter my behavior after so many years using the same ringtone. But more importantly, the residents were suffering from very strong patterned negative response to the ringtone that had been caused by their days and nights of carrying the stroke phone while on that rotation. It would be interesting to do a study to see how long it takes for them to lose that response, or maybe someone has already looked at that, but regardless, the concept of wellness days is an attempt in some fashion to partially mitigate that behavior.

The lily pond at Gibb’s

Gibb’s Farm

So now back to our wellness days in Tanzania. My initial response when being asked to incorporate these days was that “every day in Tanzania is a wellness day,” but there was probably just a bit of self-centric thought in that reply as I would be projecting how I feel about my time here without looking at it through their eyes. And regardless, wellness days are now an integral part of the resident scheduling, most often requiring some manner of coverage when at home, though here we are able to not have clinic during that time and all of the residents can take it together. So, since instituting wellness days here, I have simply selected two half-days during the month for the residents to be completely off and to enjoy themselves during what would otherwise be clinic time. Today was one such day with plans to be in clinic during the morning and then spend most of the afternoon at Gibb’s Farm having lunch and relaxing there afterwards.

On the trail to the elephant caves….

The hikers

Along the trail in the NCA

Our previous Saturday had been very quiet and today was following the same pattern, although the patients did seem to trickle in throughout the morning. I’m not certain that any of the patients were necessarily “blog worthy” in regard to their medical aspects, but we did have another static encephalopathy child at the end of the clinic that came after we had closed registration, but the family had traveled a long way to see us and there was little thought of turning them away. It was a Maasai family and the patient was 9-years-old, having been normal at birth and then suffering a febrile illness in infancy that devastated him neurologically, leaving him with a very severe static encephalopathy and quadriparesis. He had briefly had seizures at the time of the febrile event, but has had none since by their report. He was clearly very well cared for by his family and had already been to rehab where they had been instructed in what types of physical therapy he could benefit from. He was significantly underweight, though, as he had some swallowing difficulties and this was a place where we could certainly intervene. Marissa placed him on some diazepam for his spasticity and contractures and we referred them to a feeding program that is available in Arusha at one of the hospitals there. In such a harsh environment as here in East Africa, we are constantly reminded of how wonderful it is that these children are so wonderfully cared for by their families as there are essentially no social safety nets here to help if anyone is in need. In the past, this would not have necessarily been the case as these children didn’t survive past infancy in most tribal cultures and it is only after the last decade or so that families have elected to keep these children and care for them.

The NCA ranger with a porcupine quill

The elephant caves

So, after everyone heading back to the house with some of us changing clothes, we loaded into Turtle and made the trek (drive) back up to Gibb’s Farm, using Marissa’s favorite shot cut going there as we would stop in town on our way back to fill up with fuel in Turtle given that we were going to Ngorongoro Crater the following day and I never like traveling without a full tank when possible. Gibb’s Farm, as most you have become accustomed to by reading my blog, is a top tier resort frequently, if not always, ranking among the top several resorts in the world. It is clearly my favorite in the region, for many reasons both sentimental and otherwise, and has been the favorite of the resident that I have brought in the past. I have never stayed at Gibb’s, but I have eaten lunch and dinner there on many occasions and can vouch for both meals being well worth their full price, though we are offered volunteer prices due to our volunteering at FAME. It is their way of acknowledging the work we do for the community and many of those who work at Gibb’s have come to see us both for themselves and their families over the years.

The vegetable gardens at Gibb’s

The vegetable garden at Gibb’s

Our lunch at Gibb’s is perhaps everyone’s favorite and I couldn’t think of better wellness afternoon than this, not only for the incredible food that is served, but also for the relaxing atmosphere in one of the most beautiful settings that I have experienced anywhere. We always sit on a table on the veranda with views of the entire countryside, birds singing and the most attentive service that one could ever ask for. Lunch is buffet style with salads, antipasti meats, soup, quiche, samosas and more, all made here on the premises including the cheeses. There are many main courses to select from and fresh baked breads. Coffee, of course, is included with the meal as this is a coffee plantation, after all. And then there are the deserts. After a very long lunch during which we’ve all had several plates and are all in agreement that each of us might very well explode, we decide what we all do for the afternoon. Ray, Marissa, Andrea, Leah and Kyra have all decided that they will hike to the elephant caves that are inside the Ngorongoro Conservation Area (or NCA) a short distance. I have been on the hike several times and chose to sit on the veranda working on my blog while Mike didn’t really have any excuse not to go other than that  he didn’t feel like it and really wanted to finish his book.

Rooms at Gibb’s overlooking the garden

The elephant cave walk is about a two hour roundtrip hike traveling uphill on the way into the NCA that crosses atop a very tall waterfall prior to arriving at the caves which are really holes that the elephants dig while extracting necessary minerals from the soil. It is rare to see the elephants there as they usually smell hikers long before they arrive and vanish into the forest. You can see other animals on the hike, though, which is the primary reason that you are accompanied by a ranger from the NCA. While Mike and I relaxed on the veranda doing our busywork, the others enjoyed their hike to the caves and were back shortly after 5 PM. Ray initially informed (more like accused) me that I had forgotten to tell them to bring water (which he bought at the NCA gate before hiking), but then reconsidered, later admitting that any reasonable person planning to take a hike in Africa wouldn’t have to ask if they needed to bring water with them. Regardless, they survived their “ordeal” and made it back to Gibb’s safe and sound. The others decided to take a tour of the gardens at Gibb’s, which are spectacular, while Ray came up to the lodge and join us on the veranda, though his primary motive was clearly the Moscow Mule that he ordered within moments of his arrival. We didn’t leave Gibb’s until well after sunset, having made the most of wellness time there.

Kyra walking about the livestock enclosures

We traveled through town rather than taking my shortcut, much to Marissa’s delight, as Turtle needed fuel for the following day. There was still lunch to be made (peanut butter and jelly or PB and honey sandwiches) and putting things together for the journey to the crater tomorrow. We were not leaving until shortly after 6:00 AM, which wasn’t too bad, but everyone wanted to get a decent sleep if possible.

“The most interesting man in the world…”

Heaven in a copper cup…the Moscow mule

After the hike enjoying some drinks at sunset

Friday, September 13, 2019 – An interesting day in clinic and an evening with Daniel and his family…

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We awakened to our second absolutely gorgeous morning of clear skies and sunshine. Since arriving nearly two weeks ago, we have had simply amazing weather, though the mornings have been typically overcast with the clouds burning off by late morning. Not a soul has complained given that it has been otherwise the perfect temperature wherever we have gone and quite conducive to our activities. Next week, we’ll be traveling for our mobile clinics and the hope is that any precipitation will hold off so the roads remain passable. Slippery mud here can deter travel even for the most robust of vehicles such as our Land Rover and getting stuck on the way to a mobile clinic can be a very depressing experience. We are in the dry season here so the likelihood of a torrential downpour is exceedingly small, thankfully.

Kyra and Dr. Annie presenting a case to Ray

Our morning began a bit quietly again, though we had a steady influx of patients throughout the day so that our final number was still respectable in the grand scheme of things. The flow of patients throughout our stay for the month can be very irregular and frustrating as it is not always steady or predictable and typically suffers from whatever factors may be affecting the populace here – weather, planting or harvest season, and elections. They have all affected our patient census in the past at various times.

The garden at FAME

One of our earlier patients for the day was a gentleman in his 40s who reported a three-year history of right eye visual loss and a two-year history of headaches that had worsened over the last year such that he was waking up night with headaches and associated with vomiting at times. His exam was very abnormal with no vision in his right eye, a right afferent pupillary defect, a right sixth nerve palsy, and an incredibly pale optic disc on the right. It was very clear from his history and examination that he was presenting with a right frontal mass lesion that had caused significant mass effect on the retro-orbital region. We sent him for a CT scan with and without contrast to help define what was present and what we were going to have to deal with for this gentleman. Of course, Ray had already declared where and what we would find on his scan (sort of like calling the pocket for the eight ball when playing pool). The patient went for his CT scan and, of course, the lesion was exactly where he had said it would be – a sphenoid wing meningioma the size of a large apple that was producing significant mass effect on the left hemisphere and causing a great deal of vasogenic edema. It was an ugly scan and hard to believe that he had actually walked into clinic to see us. He was placed on some steroids with the hope that they would help his headaches and the plan was to refer him to the neurosurgeon as soon as would be possible as long as he would be able to afford having something done in the end.

Talking with Daniel outside his Iraqw home

Marissa also had a great case for a pediatric neurologist that she pretty much diagnosed in the waiting room. Years ago, as a neurology resident, I had been taught the term “augenblick diagnosis” which means “in an eye-blink” and is a reference to how our brain processes certain information almost reflexively. This was an augenblick diagnosis for her and she quickly recognized the child as having Rett syndrome, a rare genetic disorder that affects 1 in 10,000 to 15,000 births and is very rarely inherited. This 9-year-old girl had started to have developmental regression at 18 months of age and then began having seizures at three years of age following that. She had briefly been placed on phenobarbital, but it was ineffective for her seizures and the family had stopped the medicine long ago. She was now having about three seizures daily and was severely impaired cognitively, not being able to do anything for herself whatsoever.

Daniel discussing the finer points of spear throwing

She was a very classic case of this syndrome, complete with her handwringing and, though we had very little to offer for the bulk of her symptoms, we were more than willing to tackle her seizures which were clearly a very disabling issue for her. We decided to place her on valproic acid as it would offer the best coverage all around for her events. By the way, the other diagnoses that we consider to be augenblick diagnoses are Parkinson’s disease and some of the other similar movement disorders that we encounter.

Mike and Leah comparing notes on their technique

In the afternoon, Mike had an interesting encounter with a very elderly Maasai patient and his son who had come to clinic with numerous constitutional symptoms including joint pains and headache and insisted that they wanted to get a CT scan of the head. He had a very hard time getting any detailed history from the patient or the son and the patient’s examination was completely normal, though again, he didn’t seem overly interested in participating in the examination. Overall, he was an extremely frustrating patient for Mike to evaluate, but he clearly did not have any red flag symptoms in his history of findings on his examination. Mike informed the patient and his son that he did not feel that the CT scan was necessary, but the pair remained quite insistent that they had come here for a scan and were not willing to leave without having it done.

Leah with an excellent attempt

We ended up having both Angel and Sangale (who is Maasai) become involved in the situation and we making no progress. At one point, the patient or his son had told them that they came here because FAME has “the mirror that looks at the brain,” referring to the CT scanner. I found this to be an incredibly insightful and profound comment serving to remind us of vast differences in understanding of Western Medicine here. We’ve had similar encounters here in the past, of patients coming and wanting testing that wasn’t indicated or appropriate presuming that it must be the best because it is a new technology unfamiliar to them. This, of course, happens at home in a similar fashion and it is not always the patient who makes this faulty assumption in these cases, but can at times be the physician. I remember when the first MRI came to Arusha a few years ago and was quickly followed by banners strung across several streets around town announcing that “the most advanced radiation therapy” had now arrived in Northern Tanzania. Technologies are only as good as the doctors who are applying them to the care of their patients.

Mike with the best of form

Towards the end of our day, we were called to the emergency room to help with a patient that had fallen from the back of motorcycle and was now confused and lethargic. We went there to find a 50ish-year-old Maasai gentleman on a gurney who was arousable, but not answering questions and was not oriented. He was also not moving his right side as well. His family said that he had fallen from the back of a motorcycle two days ago and that yesterday he had apparently become worse and not as responsive. Of course, he was not wearing a helmet on the motorcycle. Our other patient with the frontal mass was already in radiology having his IV placed, so there was a short delay in getting this patient to CT scan, but he eventually got there. We had been concerned about a subdural hematoma, but his brain was normal and, so, we scanned his cervical spine to make sure that he did not have a fracture that was resulting in his hemiparesis. All that was found was an osteophyte that could have caused a cord contusion perhaps, but nothing else was seen to explain his condition. It was felt that he had a significant concussion and possibly a reversible spine injury, but nothing was unstable and other than observation for the moment, we had no other specific therapy to offer. He was admitted to the inpatient ward and we’d see him again in the morning to check on him.

A view to the east from Daniel’s home

Our plans for the evening were to visit Daniel Tewa and his family for coffee and dinner. I’ve spoken about Daniel so many times on this blog, so for those of you who are already quite familiar with my story of Daniel, feel free to skip the following paragraph(s). I first met Daniel Tewa in 2009, when, here on safari along with my two children, he had been asked to work with us on our short volunteer stint that we had requested as part of our safari package. We would be painting at the Ayalabee school outside of Karatu and Daniel was to be our host for the three days. We had immediately bonded and he then asked us over to his home to give us a presentation of Iraqw history and culture which is something that he provides for numerous safari guests of various companies throughout the year. When I returned the following year for my first visit to volunteer at FAME, I contacted Daniel and it was if we had just seen each other the day before. He remembered my children’s names and many other details from our prior visit the year before.

Daniel discussing the Iraqw wedding skirts

Kyra trying on a wedding skirt

On that trip, I visited Daniel and had dinner at his home and with his family. Despite having met hundreds of guests who had come for his demonstrations over the previous years, I had been the first one to contact him and return and was now the first to have ever come to his home for dinner. It was an amazing honor for me and I remember that dinner today like it was yesterday. That was nineteen visits, and nineteen dinners, ago, as he has insisted on every one of my subsequent visits that we come for dinner no matter how large our group is. What used to be just me has gradually grown larger every succeeding year and the dinner has now moved from the small living room of their Bantu house to his daughter, Isabella’s, home which is just a short walk from Daniel’s home and had a larger dining room. Megan Richie was the first to go there with me, and given that she was a vegetarian, not something encountered often here, Daniel’s brother-in-law, who is a chef, had made dinner for us and had more than enough vegetarian dishes to make Megan quite happy. Since that time, we have visited his home on numerous occasions, having dinner at least once each trip, as well as at other times to stop by for coffee. He has adopted me into his family, and I have met nearly all of his twelve children along the way. Whenever I have tried to discuss the fact that our group has increased in size and that perhaps it is becoming a burden for him to have us, he will hear none of it, continuing to insist that we honor his family with each of our visits. It is with this past history between us that I bring each group of residents to his home to share one of my African families with them and to meet this amazing individual.

Ray, Marissa, Mike, Kyra in an Iraqw family portrait

Daniel’s home is an amalgamation of the old and new Tanzania in some ways. Out back, he has one of the only, if not the only, original style Iraqw houses like that in which he had grown up, but were later outlawed by President Nyerere when he recognized that to build his country after independence in 1961, they needed everyone to live together in larger communities in order to develop an infrastructure that could support the country. College students and others come from far away to study his house and hear his talks. The house is mostly underground, open on only one side, and covered by layers of brush, then grass and then dirt in order to detect anyone walking on top of it at night such as the Maasai who would come to steal their cattle. The Maasai, it turns out, believe that all cattle were God’s gift to them and that they are not stealing cattle, but rather taking what was rightfully theirs. A treaty between the Iraqw and Maasai was not signed until 1986. Daniel shared his spear throwing talents with us (very impressive), while Mike impressed us all by applying his javelin throwing knowledge to the Iraqw spear and succeeding quite handily.

Ray, Leah, Me, Andrea and Mike in another family portrait

We sat outside with Daniel in the setting sun and eventual strong moonlight having his wonderful African coffee – fresh cow’s milk boiled with the coffee  – and everyone, other than those who are not coffee drinkers or are lactose intolerant, loved it. We eventually walked the short distance to his eldest daughter’s home, Isabella, where we would be eating our dinner. One of his other daughter’s was also there to help and we proceeded to have an amazing meal that everyone loved. It was very special and I know that everyone was very taken with Daniel’s comments about what it meant to him and everyone in Karatu that we were coming to FAME to help. It has been a very, very special relationship that we have had over the years and one that we both greatly cherish.

Dinner with Daniel at Isabella’s

 

 

 

Thursday, September 12, 2019 – Dinner at the Manor Lodge

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Today was another educational lecture and Ray had volunteered to do one. He presented the patient who had the subdural hematoma and did it from a perspective of why it wasn’t a stroke. Knowing Ray, who wins teaching awards right and left and is a master clinician, there was little question that he would do a brilliant job of it and he did. We only have 30 minutes to do the presentation and even with his 32 slides, he managed to finish with time to spare. We opened up the clinic door and readied ourselves for clinic, though it seemed that were fewer patients here at the beginning of the day.dd

Ray giving his talk

I had hoped to do some more work in the morning after report, so went with Leah down to the Lilac Café, where I could type without being interrupted. Ray had agreed to cover clinic and only if there was a specific issue that needed my attention, would they be contacting me. Though I most usually partake in coffee here which is served in a French press, I chose this morning to order a Caffé Latte on Leah’s recommendation. It was served in beautiful layers and in a tall glass with a wonderful top layer of steamed milk and a personalized message on it that was written in chocolate. Denis is also a very talented artist who I have brought supplies for over the last trips to keep him painting. He did a wonderful portrait of me for my sixtieth birthday that I have hanging in my apartment at home and was given to me at an amazing surprise party at the Highview Inn that Jackie, Jess ad Paulina had put together.

My Caffé Latte

We have always had an issue with our clinic as far as triaging patients that has occurred for several reasons. Here at FAME, it is much more appropriate medically for patients with non-neurological disease to be seen at the general outpatient clinic (OPD) despite the fact that we have Dr. Annie working with us, who is certainly qualified to treat anything that comes our way. When we make our announcements to the community and on the flyers that are placed around the district, we list the types of neurologic symptoms and conditions that we treat and those are again repeated when the patient is registering. Despite all of this, we will still have patients come complaining of a clearly non-neurological problem – groin swell, goiters, throat pain, etc. Part of the problem is also that we have a flat fee to be seen in our clinic where the patient gets their visit, one month (or sometimes more), and any necessary labs for a flat rate of 5000 Tanzanian shillings or slightly over $2. Their visit is, therefore, subsidized as these services would be costlier if done through the OPD and, hence, the incentive for patients to be seen in the neurology clinic.

My message from Denis

When this occurs (a patient with a non-neurological disease) it will often depend on whether the patient is being seen by Dr. Annie with a resident in which case we try to take care of it on our own as long as it’s not going to be too expensive. This morning, Andrea and Annie diagnosed someone with probable cholecystitis and refereed them for an ultrasound and then to be followed up in the OPD. We also tolerate some of the musculoskeletal patients, though have little to do for them other them some ibuprofen.

Today was also exciting as we were expecting to see Abdulhamid Shaban, who Is a senior medical student at Muhimbili University and had worked with us last October as an interpreter, but ended up discovering just how much he loved neurology (how could he not having worked with the likes of Lindsay, Amisha, Hannah and John). Abdulhamid grew up in Karatu and has known FAME for many years, as well as having a family connection there. He is now coming back to work with us again as an interpreter this month as he is on leave, but most importantly, he will be returning with us to Philadelphia where he will be spending a month at Penn for a neurology observorship with our department. This was made possible through the Center for Global Health at the University of Pennsylvania who have graciously agreed to cover the cost of Abdulhamid’s travel and living costs during his stay. It all came about through everyone’s connection with FAME and is a tremendous opportunity for Abdulhamid in his professional career.

Leah, Rievo, Ray and Mike Baer discussing a case

In the afternoon, several of us listened to a talk that Marin Jocobwitz and Dan Licht were giving for neurology grand rounds at CHOP about their experiences here working with us last March. Listening to the lecture live from across the globe (thankfully the timing worked out) was truly remarkable and made even more so by the fact that we had Kitashu here listening as well. He was featured in the talk on several occasions and mentioned frequently. We had visited Kitashu’s boma while Dan and Marin were here and seeing his face when she was discussing that visit and other times she referred to him during the talk was really priceless.

A group shot in front of the Manor

Inside the Manor

A view from the Veranda

Our plans for the evening included dinner and drinks at The Manor Lodge nearby. It is one of the high end resorts in the Karatu region for those who are either coming and going to the Crater and is one of the Elewana Collection of resorts in East Africa. It was designed to look like the South African wine country, which I’ve never visited, but regardless, it’s a beautiful estate with well-manicured lawns and private cottages for the guests. They have a stable with horses, a pool and a large Manor house where the dining room is in addition to a billiard room downstairs that Ray and Kyra were apparently quite happy to see. Looking out from the veranda on the back of the Manor house and looking west, the sun was slowly setting in a nearly cloudless sky. We sat out back on the deck with fire pits burning nearby to help warm as the temperatures dropped along with the sun. They had wonderful drinks (the Moscow Mule is my favorite as it is everywhere here) and hors d’oeuvres and we spent a long time enjoying both before heading off to dinner which we were quite thankful was just across the deck outside rather than in the more formal dining room.

hor d’oeuvres

A view to the west

Their dinner is a fixed price five-course meal with choice of entrée. The entrées included a winter beef stew, red snapper, and an eggplant/mozzarella dish. All the dishes were delicious and well-received by everyone. There was more silverware on the table than I’ve seen in any restaurant I think and with each course, both a fork and a knife were removed from the setting in succession. The service was impeccable and the timing of the courses were perfect such that we spent a very long time at dinner which was what we had wished for in such a beautiful location. We had arrived before 5:30 that evening and remained there until after almost 10 PM. It was a night to remember and we had brought Annie with us as she deserved it having worked with us now for over a week.

Having drinks on the veranda

We arrived home and everyone was pretty exhausted so went to their rooms to hit the sack. Within a few minutes, I heard something out of Leah and Kyra’s room and it turned out that they had muddy water coming out of their sink. When I went in to investigate, I found that the hot water in the sink was the culprit and when the mud quickly cleared, it became like a steam vent at old faithful. Either that or something that we could use to steam milk for our cappuccinos. In any event, there was an issue with the hot water and it was unclear what was the issue and what needed to be done. We would have to wait until the morning to get someone to look at it and discover the situation.

I think everyone slept a little more soundly that night.

Wednesday, September 11, 2019 – Neurology clinic and an evening at Happy Day….

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Thankfully, Wednesday is a morning for us to sleep in. Between our educational talks at 7:30 AM and arising at the crack of dawn for our game drives on Sundays, it is always a joy to get that extra sleep as the mornings here are so delightfully cool. After morning report, I had planned to meet with Leah at the Lilac Café to discuss some aspects of the work she was doing here with us. The Lilac Café is a small restaurant on campus that came into being with the opening of the inpatient hospital ward as it would be necessary to not only feed the inpatients, but also their families who were visiting. The café is a lovely and relaxing place to spend time and the mornings are even more so. It is so relaxing that you can feel the stress drain from your body half way there. Leah has been spending her mornings there working (I’ve told her that it’s her office) and then coming to shadow us in the afternoons. I don’t think she has yet tired of the Caffé Lattes nor will she do so soon. The Lilac is also where many of FAME’s smaller administrative meetings occur as it’s very conducive to getting things done.

As we left the house on our way to morning report, it began to drizzle just a bit which is really the very precipitation that we’ve had since we’ve been here and very likely the reason the day started a bit slow as patients may have decided to come on another day. If it does begin to rain more seriously, the roads become very muddy and more difficult to travel, but even so, most people here seem to ignore the heavy rains and do what they have to do. It always amazes me at how everyone travels through the mud and dust to get to clinic, but somehow don’t look like they have when they get here. Just walking to clinic on a rainy day, I seem to accumulate a pound of mud on each of my soles making walking just a bit difficult.

Views around our house

With the slow day, the patients trickled in and we still ended up seeing eighteen neurology patients, so not all was lost. An interesting patient that Mike saw today was an older gentleman with a chronic history neck pain that was worsening and he now had difficulty walking. The symptoms had been going on for over two years and he was now myelopathic on examination meaning that we were mostly concerned about him having spinal cord compression secondary to cervical spondylosis or arthritis. The is a very common condition in which the arthritis causes severe narrowing of the spinal canal over a long period of time and eventually compresses the spinal cord. The only treatment for this is to do surgical decompression and fusion of that segment of the cervical spine where you’ve operated. He would need an MRI to confirm the diagnosis prior to any potential intervention. We were back to the same question as before as far as whether the family could afford the surgery and, if they could not, there would be little reason in getting the MRI scan.

I contacted the neurosurgeon again in Arusha at ALMC, or Selian Hospital, and she got back to me rather quickly with a price of 2,000,000 shillings, or about $869 depending on the days exchange rate, for the surgery and fusion, but not for the MRI scan as he would have to get that done first. To be honest, a price of less than $1000 is pretty amazing when you consider that to have the same surgery done in the US would yield a hospital bill of at least $200,000, though that’s not necessarily what the hospital would get paid. That’s the problem with making those comparisons as the hospital wouldn’t really get paid that total amount, but probably something closer to a quarter of that total amount. Regardless, it is still significantly cheaper here in absolute terms, but not in relative terms when you consider what the average per capita income is in Tanzania and even far less here in Karatu District. Mike spoke with the son who indicated that the family was going to sell everything they had to raise money for the MRI and we weren’t able to give them the amount for the surgery, but they were aware that would be an additional amount.

As we had seen all of our patients before lunch (2 PM), we were considering a trip to the village of Manyara where the African Galleria is so that everyone could buy gifts for home. I had also asked Ema to check out Turtle to make sure that she was in excellent running order for our game drive on Sunday as well as the mobile clinics we are planning for next week. He had called Angel while we were at lunch to let us know that he wanted to take Turtle down to town to top off some fluids and when I told her that tomorrow morning would be best, she noted that he was actually already with the car downtown so that we had to scratch our plans to go to the Galleria and would do it another day. I remained back at the clinic to see whether any new patients came in the afternoon (they did not) while everyone else went back to the house to relax. I was happy to sit in clinic and get some typing done which is what I would have been doing at home, so it really wasn’t any kind of a burden.

As I had mentioned previously, connectivity to the outside world here has always been an issue for everyone, including me and my accompanying residents. That’s not to say that there is a lack of infrastructure here to enable one to so, just that it can be a bit complicated at times. To begin with, and to orient those who are not familiar with the communications infrastructure here, everything is based on cell technology. For all practical purposes, there are no land lines here and there is cable technology. On the flip side, there are a great number of cell towers and the coverage overall is excellent. Deep in the Ngorongoro Crater and in the middle of the Serengeti, cell service is excellent and you can make calls and get your email with ease. On the other hand, cell technology can also become easily overloaded depending on the number of people accessing your local cell tower. Sitting in Citizen’s Bank Park (The Phillies home stadium) for a ball game is like being in a cell wasteland as 30,000+ fans are all trying to access the same cell tower.

We had gone to town the other day so that everyone would have local sim cards mostly to access everyone’s email and WhatsApp (our main communications app here) and that seemed to be taken care of. Ke Zhang, FAME’s networking guru and otherwise all around amazing guy (currently a first year interventional radiology resident in Boston), had spent his last visit here working on revamping the WiFi network at FAME and also linking in the volunteer houses which was going to be godsend. They had needed some network switches which I brought when I came, but after plugging in everything, there still was no internet at the houses and so Sangale was working on trying to get things more operational. He eventually found a problem in one of the pairs of fiberoptic cables and once replaced, everything worked like a charm, and we had internet down at the Raynes House. It was like a new era here at FAME.

The gang at Happy Day

I made it back to the house well before 5 PM and shortly thereafter, Ray, Mike and Kyra went out for an afternoon hike. They were gone for a good bit of time, always a concern here where you can actually run into some stray Cape buffalos or elephants as we’re just on the border with the Conservation Area and many animals will stray over into the coffee fields and towards FAME. Of course, they eventually returned safe and sound having only made a few wrong turns along the path I had shown them last week. Ema was not yet back with Turtle and we had planned to go to Happy Day tonight, so I was getting just a bit worried about that. Of course, he showed up with more than enough time to spare, so at 7 PM we all piled into the Land Rover and departed for town. Happy Day is a small little Pub where, on Wednesday nights, all of the ex-pats in the area will meet to relax and share stories. On arriving there, it was immediately apparent that Happy Day had received a significant remodeling upgrade since my last visit there. The deck now had lovely and colorful outdoor couches rather than the picnic benches that I had become accustomed to over the years since coming to FAME and enjoying evenings at Happy Day. It was quite a welcome change, though, considering how comfortable they were and it easily brought the pub up several notches on the luxury scale in everyone’s mind. It was a great relaxing evening enjoying stories among our group, Reema and Margaret and our friend, Nish, owner of the African Galleria, as most of the other ex-pats had departed earlier.

Tuesday, September 10, 2019 – A wearing day for a pediatric neurologist….

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Tuesdays are our educational days here that begin at 7:30 AM with a half hour lecture by one of the visiting volunteers typically. This would be our first of several lectures during our visit here and Marissa had volunteered to discuss Cerebral Palsy which was incredibly apropos to the day that she was about to have in clinic. The lectures here are sometimes challenging for a number of reasons, only one of which is the language barrier. Though every caregiver at FAME speaks English and both rounds and medical records are in English, it is often difficult to be certain that the language we are using, both the English and medical, are being perfectly understood by the doctors in the audience. Speakers tend to use medical terms that may not be common and it is natural for speakers to sometimes talk fast, both out of some level of anxiety and the time constraints that exist as we only have 30 minutes to cover a topic. I will often briefly stop the talk to make sure that everyone understands what the speaker said or to give the generic name instead of the brand name which is not used here. Over the years, I have become accustomed to doing this as it is not second nature and the clinicians here are far too polite to interrupt a speaker and ask them to clarify. They leave that to Frank and me.

Marissa’s talk was perfectly constructed to cover all of the various types of cerebral palsy, the typical causes and the treatments that can be offered (not many) in these patients. It was at the right level – remember, the clinicians that we work with here are either clinical officers (essentially independently practicing nurse practitioners or physicians assistants), assistant medical officers (two years of additional training beyond the clinical officer) and MDs who have only completed an internship and no residency. Residency trained physicians are more of a rarity here as there is no system to support education such as we have at home in Medicare. Our residency programs are support by Medicare which allows residents to be paid a salary whereas here, one must pay for the majority of residencies (when they are available), which is out of the realm of reality for most individuals, or they will have to have a sponsor. There are very few specialty residencies in the country, too boot.

After Marissa’s talk it was time for morning report and the very first patient presented, by nature of her room, was the young 2-year-old infant with the encephalopathy that we had been following. Her summary was so brief that I nearly missed and wasn’t entirely sure that I had heard it correctly, but 30 minutes before our lecture, she had vomited while her mother was feeding her and then coded after an apparent aspiration. Despite all attempts to resuscitate her, she died. I found all of this out after report, because as I said, I didn’t catch everything when it was originally presented. Marissa and I discussed it after we were certain that she had passed and were both very disappointed that we hadn’t been able to do more this child. She died without a definitive diagnosis which is always frustrating for us, but we had little else to look at. Her second LP had been very benign other than a possible elevated opening pressure which may have indicated elevated intracranial pressure related to whatever process what going on. She very likely died from the aspiration, but her increased ICP and the underlying process she was suffering from also very likely played a significant role in her death. It was very unfortunate and it had affected both Marissa and I as we were the two that had been involved with her case.

The family member of the gentleman with the subdural hematoma from yesterday came in this morning to speak to us, but the patient didn’t come as it was difficult for them to get him here. We explained everything to him and the fact that they would need to go to Arusha for surgery to evacuate the hemorrhage. He would very likely recover some of his function specifically in regard to his confusion and possibly his right sided weakness as well. I had reached out to the neurosurgeon in Arusha to make her aware of the patient and had also asked what funds they would need to bring with them in order to be treated at Arusha Lutheran Medical Center, where she worked. The amount was 500,000 Tanzanian shillings, or about $217, for the surgery and care that was required. The family indicated that he would go back to his village to raise the money and they would travel to Arusha the following day. As the patient had been stable for the last month, we didn’t feel that another day delay would be a huge issue.

Dr. Annie wearing her new piki piki helmet given to her by the last group here.

Marissa’s day was made up of almost all children with profound neurological disabilities secondary to either birth related injuries or childhood infections that had, unfortunately, occurred previously. Many of the children were cortically blind (typically related to occipital lobe involvement of their prior process) and had profound static encephalopathies, meaning that they had global impairment of cognitive function and were able to do very little, let alone anything for themselves. Most of their stories were very similar, whether their injury had occurred at birth or later, but the most significant fact was that their families had cared for each them impeccably with whatever resources they had. Most of these families bring their children to us with the hope that there is some cure, but unfortunately, that is not the case as there is no primary treatment for them other than to treat symptomatically – physical therapy, treat their epilepsy if it’s present, and possibly their spasticity with baclofen which we do have here. Several of the mothers were in tears when Marissa told them that their children would not recover, others had been aware of this without being told and took the news with far less emotion. Regardless, it was difficult for Marissa as she presented case after case of these children and felt that she had very little to offer them. I reassured her that they were far better off having seen her and that her care would now enable the families to focus on what could be done rather than continually searching for a cure that didn’t exist.

I have spoken on several occasions in the past of Ståle Anda, a wonderful Norwegian man who runs an orphanage in Mto wa Mbu, and cares for many neurologically impaired Maasai children, a number of who have muscular dystrophy and we have seen over the years. Ståle came here several years ago and, like everyone else here, decided to stay and open his orphanage to care for these children whether it was in his orphanage or whether he would assist with their care with them living at home. Either way, he has served as a saint here for many children who would otherwise have been abandoned and died. Ståle couldn’t make it today, but we saw several patients that he sent up including one young man with a muscular dystrophy or congenital myopathy. Unfortunately, the boy was now well into his teens with severe muscle wasting that was mostly proximal as one would expect. Thankfully, this is one of Ray’s areas of interest so he chose to tackle the case with Mike Baer, who is planning to go into neuromuscular disease. There was very little of his history or family history that was obtainable as he was now in the orphanage and given his advanced disease it was very difficult to further characterize his progression of disease over the years that would have been essential to make the diagnosis in the absence of other information such as genetic testing. Ray noted that his best guess in this patient would an autosomal recessive limb-girdle dystrophy, but, unfortunately, that would be the best we could do with the information at hand.

During the day, Frank advised me that a patient was traveling here from Arusha to be seen and that he wanted our help with them as they had developed monocular visual impairment the day prior. The patient was in his mid-fifties with diabetes and hypertension and reported that he had been driving the day before when he suddenly lost most of the vision in his right eye. Frank had Sehewa, our nurse anesthetist/optometrist see him first, and he dilated his eye and did a brief examination, but we felt the problem was going to be vascular and more likely in our realm. He had some hemorrhage on his fundoscopic examination raising the question of central retinal vein occlusion, though it was not florid enough to warrant the “blood and thunder” description that is most often used for this entity. After thoroughly analyzing the case, it was felt that the patient had an ischemic optic neuropathy, which is an ischemic event of the optic nerve, so there was very little else to do at this point other than placing him on aspirin and providing further secondary risk management with a high dose statin and good blood pressure control. The prognosis for his condition would be that 40% of these patients have some recovery of their vision so he would very likely be left with some deficit going forward.

Towards the end of the day, Kyra had an interesting elderly gentleman who presented to clinic, brought by his son who I know, who has had a month-long history of difficulty with gait and back pain. His bowel and bladder function were normal. He had had no prior evaluations and on examination was found to have left leg weakness and right leg sensory changes with about a T7 sensory level making us concerned for a thoracic cord process. Though he did not have any clear symptoms to suggest systemic or pulmonary TB, we frequently worry about Pott’s disease here as we have seen several acute cases and many patients with the sequelae of this very disabling condition. Pott’s disease, or tuberculous involvement of the vertebrae (tuberculous spondylitis), can often present with neurological symptoms due to the erosion and collapse of the vertebral body as well as extension of the infection into the spinal canal, both causing cord compression.

We have had patients come to see us, as with many other catastrophic neurological disorders, many years after their bout with Pott’s disease, who are in a wheelchair with a paraplegia and chronic back pain. We have little to offer these patients other than to treat their pain as the neurological deficits once present are rarely reversible in the condition as with many other conditions affecting the spinal cord. We decided to obtain a plain film of the thoracic spine first as if this study demonstrated bony pathology in the spine it would have answered our question without going to additional testing, though a CT scan at that point would also have been helpful to know the extent of destruction, perhaps. The study, though, was negative, essentially ruling out the condition in regard to it causing his neurologic deficits, and now he would need to undergo an MRI scan of the spine to further visualize what was causing the issue and, hopefully, it would treatable. They had indicated that they would try to go to Arusha to have the MRI done to get the answer.

We made it home that evening after a very long day in clinic and Marissa have seen a tremendous number of devastated children. Ray’s first question for me as I walked through the door was whether we had any Zoloft handy for her. It would be impossible for her, or anyone else for that matter, to have seen that many children with these heart-wrenching stories and not to have been affected as she was. Regardless of the fact that we are doing unquestionable good here, we must also resolve ourselves to the fact much of what we see we are unable to treat, most that would otherwise be untreatable at home, though some that are the result of the limited resources available here and the reality of the region in which we are practicing.

Monday, September 9, 2019 – A long week of clinics….  

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This is the start of our first full week of neurology clinic at FAME and typically our biggest day. Because we had actually decided to announce the clinics on Friday and Saturday, though, it seemed less crazy today than normal. That may also have had to do with our new space and the fact that some of our patients were waiting outside and some inside giving us the perception that there were a few less patients. Regardless, we had plenty of patients waiting for us at the start of the day. Interestingly, each of our visits during the year, one in the dry season (our fall) and one in the wet season (our spring), have consistently had a significant difference in the number of patients with the busier season being the dry now by a factor of one-third. Over the last several years, we have seen approximately 400 patients in the dry and 300 patients in the wet season, consistently. The reason for this seems to be not only the difficulty in transportation in the wet season as some of the roads to the more remote areas may be impassable, but also the fact that some of the planting occurs in the wet season. Either way, the experience for the doctors here and the residents has continued to be a positive one and, for this reason, we have continued to come back year after year. We’ve already seen approximately 75 patients in our first three days of work here which, though not a record, has certainly been a good start for us.

A very important medical document requested by Marissa, Andrea, Leah and Kyra….

Morning report was rather short, and the first thing that we noticed is that we did not hear about our poor Hadza woman which would mean that she had passed about Saturday night into Sunday morning given that we were not at report yesterday. We confirmed this fact later after report and were grateful to hear that her suffering was not prolonged. She was really not on support of any kind as she had not received feeding and her IVF had been stopped. There was nothing in her appearance to suggest that she was suffering any physical pain so there was no need for us to administer anything from that standpoint. She had very likely slowly slipped away as a result of her intracranial hemorrhage and probable hydrocephalus.

Though the volume of patients seemed lighter than normal, we still managed to see the same number of patients that we had on the other days and the neurological illnesses that we saw remained essentially the same with an excellent distribution of disorders. The pathology that we see here is actually excellent from a teaching perspective and the residents have a great learning experience from that standpoint as do the FAME medical staff that we’re working with and any others sharing in the experience.

A list of medications we use with prices and sample monthly cost for patients that Leah created for us. $1 = 2300 Tanzanian shillings

The case of the day, probably, was a gentleman of about 80-years-old that Mike saw who had been normal until about one month ago, and then had begun to lose his ability to walk and communicate properly. There had been some concern as to whether he was encephalopathic or aphasic on his examination as it is always more difficult to determine this when you’re dealing with one and sometimes two translators, but there was very little question that he had a right hemiparesis with increased tone. There was no history of trauma and he had not complained of a headache at any time. Our main suspicion was that he had an underlying mass lesion or a stroke and it would be necessary for us to get a CT scan of the brain with and without contrast with the possibility of a mass being on the differential. MRI scans are so much more sensitive for detecting tumors, but the closest MRI scanner to us is in Arusha and the cost is more than double that of the CT. Thankfully, the family was able to raise the funds necessary for the CT scan (200,000 Shillings, or about $86) and returned with the payment in several hours.

Watching our patient getting their CT scan

The price of the CT scan, though quite significant for local residents here, is dramatically less than it would be in the US (by magnitudes) and the cost can often be a hurdle that can’t be overcome here. In East Africa, patients and family members will go their village or other family members to help with the cost of medical care as these burdens are considered to be shared and not that of the individual. This is a very significant feature of the culture here and has to do with how community property is viewed. A wonderful discussion of this phenomenon can be found in African Friends and Money Matters that is well written and discusses specifically how both money and knowledge are shared in East Africa and are completely opposite of how we approach these issues at home in our own culture. Also, the issue here is that although there is a national health insurance that Tanzanians can buy into, most do not and have to pay out of pocket for any medical expenses that are necessary. This then necessitates that  patients are charged for services they receive at FAME and, though they are very, very reasonable, they can be quite out of reach for others. Both Angel and Kitashu will often work with patients to assess what they can afford and if there is anything that can be done for them, they will do it. If medical care were totally free at FAME, they would be immediately swamped with patients from all over the country who would have traveled days to get here for free medical care. That system would immediately fail as there would be no sustainability.

In addition to the issue of a patient being able to pay for their medical care (which, by the way is very reasonable at less than $2 for a new patient visit), it is imperative that one considers what you will do with the results of a positive test before it’s ordered. Sending someone for a costly test such as a CT scan or MRI scan should also include a discussion of what you might find and where that might lead in regard to potential treatments. Obtaining a scan demonstrating something that requires surgery when the patient or family is unable to afford the cost of surgery is really a needless study. Of course, that discussion will also include all of the possible alternatives such as traveling to Dar es Salaam if one has the government insurance perhaps, but in the end, to be seen in Northern Tanzania or elsewhere, one must have the necessary funds to pay or, at the very least, to provide a deposit. There are very few, if any, social safety nets here which can often be a struggle.

Our patient’s CT scan with a large chronic, and some subacute, subdural hemorrhage

Our patient returned towards the end of the day to have his CT scan and we were rather thankful that they were able to do it. The scan demonstrated a very large chronic (old) subdural hematoma with midline shift that was clearly causing his neurologic deficits. There had been no history of trauma or complaint of headaches and, yet, he had a finding that we usually associate with both of these factors. Given the amount of compression and midline shift, doing nothing at this point would probably ensure that he would worsen at some point and what he really needed to have done was to undergo an evacuation of hematoma which would hopefully relieve the pressure on his brain enough for it to rebound somewhat, though the expectation would be that he would not fully recover. At his age, it would be likely that the brain would not have enough resilience to reoccupy the space vacated by the evacuated blood. This can result in the situation where he will be more likely to reaccumulate fluid in the space, otherwise known as a subdural hygroma, or, worse yet, have a recurrent hemorrhage back into the same space. We discussed the CT scan with the patient’s son, who had accompanied his father to clinic, and rather than admitting him to the hospital since he had been stable for a month, he went home to return tomorrow morning so we could discuss the various options for treatment.

Our patient’s CT scan with a large chronic, and some subacute, subdural hemorrhage

As we had no internet at the house – just for perspective, we have never had internet at any of the houses – everyone (save Mike) wanted to stop by the Vodacom shop after work to get local sim cards for their phones so they would be able to contact the outside world on a more reliable basis than borrowing the data from my iPad (not that this was an issue, of course – please read that with a bit of sarcasm). We loaded into Turtle at the end of clinic and with little time to spare and made our way to the Voda shop with Phoebe in tow to help out if needed. The group piled into the shop to make their transactions while I waited out front with the vehicle and made lots of new friends, while also seeing many old ones, during the time I was out there. Stopping on the street anywhere in town we are very likely to attract attention and over the many years of being here, many of the local “street merchants” know me by name. I never buy anything from them, but they somehow continue to tolerate me and there are several young boys who I have seen grow up on the street trying to make ends meet. After about 45 minutes, everyone finally emerged from the shop with smiles on their faces, a definite sign that they had been successful in their quest.

The Vodacom shop

We drove back to FAME as our dinners were there waiting for us as was the veranda and a cold beer (for some of us). It had been Ray’s first day in clinic and I was genuinely interested in his impression of the patients and how things went. It was clear that he had an amazing time staffing the residents as I had imagined he would, for here it is medicine the way medicine was meant to be practiced (sorry for those who have heard this multiple times before from me). It is medicine for medicine’s sake and no other. We are the lucky ones to have had the opportunity to work here in this amazing country and with these amazing people.

Everything was settling down for the evening when I received a message from Dr. Gabriel that they had admitted a 30-year-old gentleman with the worst headache of his life. After asking a few questions and realizing that Gabriel wasn’t in the ward, most of us decided to head up to the ward and check out the patient. The story was just a bit different, though we certainly had some concerns about the patient, mostly from an infectious standpoint (he had a low grade temp) and had recommended a lumbar puncture to rule out meningitis. The LP would most likely not get done until the morning as the lab was apparently not set up at night to do the cell counts, so we told them to call us if he worsened, but that he should be placed on antibiotics if he spiked a greater temp than where he was. It was back to the house and we relaxed for the remainder of the night as we had our educational talk to attend at 7:30 the following morning.

 

Sunday, September 8, 2019 – A day at Lake Manyara….

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As many of you have come to know, Sundays here are reserved for me to take the team to a National Park on a game drive. Just as an FYI, “safari” in Swahili simply means “journey,” and has no specific relationship to a game drive. The work has become synonymous with traveling to the parks to see wild life and has stuck, obviously evidenced by the huge Safari industry that exists here in Tanzania and other African countries that have built up this aspect of their economy. If someone here asks you how your safari was, there are asking you how your travel here was and not how your game drive went. Today, we had decided to go to Lake Manyara National Park which is very close and is a great first experience for those who have not been here before or have not been on a game drive. It’s also one of my favorite parks for several reasons. It has spectacular views with a very diverse landscape and it’s incredibly easy for me to navigate as the lake is on one side of the road and the sheer cliffs of the escarpment are on the other side of the road. It’s difficult to make a wrong turn here. There are plenty of elephants and hippos here along with all of the other normal players and they also have plenty of Klipspringers, a small rock antelope that can very scarce in other parks and is not often seen. Everyone was very excited to be going on a game drive today.

Prior to this trip, I had convinced Ray Price, our residency program director and colleague, to come with me to Tanzania with us for at least a part of the month. In turn, Ray had somehow convinced his wife to let him come with us despite having two small children at home, though I do believe his mother-in-law was still a bit skeptical of the proposed arrangement. Ray has been a huge part of this program since my move to Penn and has made it possible for me to bring the number of residents that I do. The rotation has also become a large part of our residency program and has attracted top candidates who have an interest in global health. Ray had had a meeting to attend in Minneapolis last week, so had made arrangements to fly from there into Kilimanjaro and then meet up with us at the park entrance at 6:45 AM, taking a very early (3:30 AM pickup) transport from the airport hotel where he slept a few hours before meeting his driver. Everything went like clockwork in that he made his three flights, got to the hotel, met his driver and then met us at the designated spot which was incredibly impressive considering all of the moving parts we had to deal with. Unfortunately, Ray made it to the meeting place, but his luggage did not as sadly, KLM had left it behind in Amsterdam to arrive on the next flight in and since there is only one flight a day, it would be coming in tonight and hopefully delivered to FAME tomorrow. Thankfully, he had packed an extra pair of safari pants and shirt in his carry-on luggage and I was able to loan him an extra safari hat that I had.

Our day didn’t begin quite as early as Ray’s, though we were up and out of the house a minute or two after 6 AM to make the 40 minute or so drive down to Manyara. We had our lunches, lots of water, camera gear, binoculars and lots of snacks (The hot and spicy Cheez-Its were a particularly popular choice for the trip). It was very overcast on our drive down towards Mto wa Mbu and remained that way throughout most of the day which was fine with us as it kept the temperature down, though on the occasion when the sun peeked through, the direct equatorial sun made its presence known and things heated up very quickly. Ray was in the parking lot waiting as we arrived to the park and, after a brief reunion, I went to pay our fees to enter the park. To begin with, I should mention that there are very few non-safari company guides who check in at the parks in general. Self-drives are perfectly legitimate here, but it’s just that they are by far the minority of vehicles in the park at any one time and that is by a magnitude of difference. On a day long drive in a park I may see one other safari vehicle driven by a non-guide. The problem this morning though was that the credit card machine was apparently not working, so after several attempts, I was told just to drive in the park and I could pay later when I was exciting. I was just a bit surprised at this as the parks here are very closely guarded national treasures and entrance to each of them is heavily scrutinized by armed park guards.

After using the restrooms, we popped the top on the vehicle and readied it for our game drive which included breaking out my camera equipment. I drove to the gate informing the guard that I was told to pay on my way out with the feeling that I was somehow going to be either arrested or shot on the spot at some point passing through, but thankfully neither of these events took place. For those of you who are worried, though, I will reassure you that Andrea is my designated alternate driver as she is the only other one here who can drive a stick shift. No worries, as I’ve reassured her that driving on the right hand side and shifting with your left hand isn’t really that tough.

Driving into the park, one first encounters a dense forest that goes on for several kilometers and though there are abundant animals here, they are somewhat hard to spot through the vegetation. Both greater and lesser hornbills fly overhead from tree to tree and you very quickly come across one of the many baboon troops that populate the park and love to sit in the road. The troops have consistently had many babies which is always good to see as it is a sign of the troop’s health. Our first stop is going to be the old hippo pool and platform, though, over the years, the pool has become overgrown and the platform quite rickety. Fortunately, there are still hippos here, they are just more difficult to see at times and are in different places. Driving up to the area, we quickly come across a large herd of Cape buffalo resting in the morning hours. Cape buffalo can be very dangerous animals when they are threatened and they are one of the only animals that will defend themselves against predators (lions) by forming a semicircle with the males facing our and ready to use their incredibly impressive and sharp horns to skewer whatever may be threatening them.

One animal more dangerous than the buffalo, though, is the hippo and we ran into one rather quickly who was crossing the road in front of us with her calf, making her even that much more dangerous. We quickly noticed that she was injured as she was unable to place any weight on her right front leg and was having difficulty lowering herself into the water. We remained a good distance from her while she was on land, but once in the water we were able to approach her and her calf as hippos are much more secure off land and would rarely attack. We watched the two from a close distance for some time before finishing our drive around the marsh where there were tremendous numbers of migrating birds that including pelicans, storks and flamingos. A beautiful African Fish Eagle sat very still on a nearby tree watching over the wetlands spotting for its next prey.

The edge of the lake at Maji Moto

The weather remained overcast for most of the day and the temperature was on the cooler side making for a more pleasant drive. During the drive, we did encounter our fair share of tsetse flies which were quite annoying for everyone other than Ray and I as they somehow stayed away from the front seat which was quite OK with me. Their bite is very painful and they are very difficult to detect until after they’ve bitten. The rule in the vehicle is that it’s fair game whenever a fly is spotted on someone to strike it as hard as is necessary to kill it. They are very slow and easy to swat, but unfortunately, they are very hardy and difficult to kill. When you think you’ve done one in, it simply flies away so it’s necessary to either crush them in your hand or stomp on them with your foot. The tsetse are famous for carrying sleeping sickness, or trypanosomiasis, but there is essentially none in Tanzania. Regardless, their bite is quite painful and develops into a nasty welt that may last for days. And, oh yes, they laugh at even the most powerful of bug sprays.

A view out the front

We spotted all the usual suspects on the drive that included elephants, giraffes, impala, wildebeest, zebra, wart hogs, and buffalo. We also spotted several pairs of klipspringers, which are the small rock antelope that live in certain areas of parks, but are most often seen here at Manyara. By the time we reached the picnic area at Maji Moto (hot water), named for the hot springs there, it was lunchtime. We had made sandwiches and hardboiled eggs with lots of snacks and sat together at a picnic table under a shade overlooking the lake. Before lunch, everyone had a chance to walk out onto the new boardwalk that reaches out into the lake while I sat with the vehicle.

Spending time on a game drive can be incredibly exhausting and we had begun our drive a little after seven. By the time we left the park after 3 PM, we had been there for eight hours straight with most of it driving other than our lunch. It had become a bit warmer in the afternoon, but overall, the weather had been just perfect for the entire day. Everyone had had a wonderful time in the park and I had enjoyed driving them. We stopped into the African Galleria on the way home and made it back to Karatu in time for dinner, so stopped at the downtown Lilac Café where we waiting the standard 45 minutes for our dinner, but everyone enjoyed it. We introduced Ray to the Raynes House where he settled in, though still without his luggage. Hopefully, it would be on the KLM flight arriving tonight and delivered tomorrow, but there was no way of knowing that for sure. Tomorrow we would begin our busy week-long neurology clinic at FAME and, the following week, the mobile clinics.