Tuesday, September 24, 2019 – Babies, babies everywhere….

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One of FAME’s main missions from the very beginning has been child and maternal health, though it wasn’t until the fall of 2014 that they opened for routine deliveries here. The reason I remember that date is that Doug Smith was here as the CHOP rotator and was the attending physician for that very first planned delivery here. Since that time, the number of deliveries at FAME has continued to grow as has their reproductive health clinic volume. Considering that woman pay a fee to deliver at FAME as opposed to the government hospital where it’s free, that is a very strong statement in favor of the community’s trust in the care they receive here. The cost at FAME for their antenatal care is very little and the delivery itself is 80,000 TSh, or about $36. At the government hospital, though the delivery is free, the patient must bring their own supplies even down to the sutures if they happened to need a C-section.

Walking past the maternity ward towards clinic in the morning

With the growth of deliveries at FAME, though, there has been a growing need for neonatal care both for babies born here, as well as those who are brought or sent here following birth elsewhere for the exceptional care that is received. During our neurology months, the pediatric neurology residents have also provided pediatric and neonatal care as those who have come are also board eligible pediatricians in addition to child neurologists in training. Hypoxic-Ischemic Encephalopathy (HIE) injury is one that unfortunately occurs all to commonly in Africa for many reasons and having pediatricians, and especially those well versed in this primarily neurological condition, can be extremely important and it is the first hours after birth that can often make the biggest difference in regard to reducing their overall brain injury.

Kyra’s lecture

Though this wasn’t necessarily the purpose of their time here, the residents from CHOP (Children’s Hospital of Philadelphia), recognized as one of the best pediatric hospitals in the world, if not the best, have contributed greatly to this mission of FAME in an exclusively positive manner, and it has been my privilege to have brought them here. They are the most amazing clinicians who, in addition to loving neurology (very dear to my heart), are truly dedicated to children as are all pediatricians. They have always been huge part of this program from its inception given the number of children and adolescents that we see here during our stay.

My first ride in a boda boda

It was Kyra’s turn to give a talk this morning and considering that she’s going into cognitive neurology, it was appropriate for her to talk about evaluating cognition and the various disorders of cognition that we see along with their treatment, or unfortunately, for the most part, their lack of treatment. Regardless, it’s a very important part of the neurologic examination and we have many patients who see us complaining of memory loss, though quite a few of those have primarily issues with focus and attention rather than true memory loss. It is always important to screen for mood disorders or anxiety in those situations as these are very treatable problems that can be treated either with SSRI medications or counseling, though the latter is not readily available here. Perhaps, someday that will change, but for now we’re left with prescribing medications.

Somewhat skeptical in the boda boda

At morning report, the most striking revelation that was discussed was the fact that there were nine, yes NINE, deliveries yesterday, six being spontaneous vaginal deliveries and three being C-sections. That’s an incredible feat when you consider the size of FAME and that we only have a twenty-five bed maternity ward that was now completely full. All the mothers and babies were doing well, another amazing feat in of itself considering the overall higher rate of birth related difficulties in Africa in general along with the fact that not all of the women had received their antenatal care at FAME, but rather came in labor and were appropriately attended to. Hopefully, as the word continues to spread regarding the quality care received at FAME, the deliveries will continue to increase, though that will also require a greater number of doctors, nurses and maternity space over time. As with anything else, this will also require a greater amount of successful fundraising and donors willing to consider supporting these vital services to the Karatu community and beyond.

At the brick quarry

We had another busy day in clinic, but one thing that stood out, actually, was a visit we had from the wife of our patient with the epidural abscess or mass from the week prior and that Ray had initially seen. We had spoken with the patient and his son about the fact that we needed him to see the neurosurgeon in Arusha to probably undergo surgery, but his wife called this morning to ask if she could come speak with us to get more information. Andrea, who had seen him yesterday, agreed to speak with her and we had asked Kitashu to help with the discussion while I sat in to assist if needed. Kitashu, who I have now worked with for about two years, has to be one of the most compassionate individuals I have ever known and his demeanor is so immediately calming regardless of the situation, that I cannot imagine anyone better at speaking with families in these sensitive situations.

The brick quarry

We explained to the wife why he needed to see the neurosurgeon and very soon as time was of the essence in situations like these. She explained that they didn’t have all the money necessary for the surgery and that he didn’t have the government insurance (which most people don’t have) that would have covered the major cost of the surgery. It is always so difficult to sit there, knowing that the amount of money we were discussing was not that significant to us, but could ultimately be life changing to this family, yet we are unable to step forward to help in these situations as it would not be appropriate if we can’t do it for everyone. One of the biggest lessons you must learn here is that what sometimes seems like the right thing to do, isn’t, and you must resist reaching into your pocket as those actions are not sustainable nor do they solve anything but for one individual. These are very hard lessons, and sitting in a room explaining to a spouse why her husband needs surgery that they may not be able to afford to possibly prevent him from being a paraplegic, isn’t an easy task by anyone’s standards. Yet Andrea was stellar in this most difficult and delicate of situations that required a tremendous amount of empathy and strength of character.

Walking through Tloma village near the lodges

At some point during the day, I needed to bring Turtle down to the mechanic as the driver’s door was still out of commission and entering through the passenger side or climbing through the driver’s window, though possible, was not an ideal situation for someone with a history of both back and neck surgery. At the right moment, I told everyone that I’d be gone for 30 minutes and I zipped down to the tarmac to have the vehicle looked at, originally thinking that they could fix it quickly, but realizing once I was there that was highly unlikely. I left Turtle at the shop and decided to take a bijaji back to FAME as that would be the least expensive option short of taking a boda boda (motorcycle taxi) back which I didn’t even consider given the number of accidents I’ve seen here on them and not wanting to end up in the ED at FAME. So, I hailed a bijaji, never having ridden one before, and began my short ride back to FAME in style. Well, if climbing into Turtle wasn’t a good idea for me given my past orthopedic issues, then riding in a bijaji definitely wasn’t a good idea either. These three-wheeled motorcycles with a body have absolutely no suspension or shock absorbers and you feel every bump, which, had it been on the tarmac, wouldn’t have been a problem, but on the horribly rutted FAME road it was quite uncomfortable and something I will not experience again. Suddenly, I now realized that taking placing my life in danger on a boda boda may have actually been the smarter option here. I made it safely and didn’t suffer any new injuries that would have been difficult to explain to the others if I had.

Finding some friends during our walk

We finished early enough today to consider taking a nice walk for both exercise and exploration after clinic. It was a beautiful afternoon/evening as the temperature was very mild even though the sun was out and strong. I took Kyra, Andrea, Leah and Marissa for a walk down through the brick quarry that is adjacent to FAME across the road and then up the opposite side of the valley to the road that leads to Tloma village, one of the main Iraqw communities nearby and where Gibb’s Farm sits just above. The brick quarry is very interesting as this is where they dig the clay to form the bricks, dry them and then stack them into tall oven-like structures that are hollow inside where they stack wood to eventually ignite and fire the bricks to finish the process. How this all works as far as who owns the quarry or the bricks once they are made, I’m not sure, but they are eventually purchased and made into structures that are often left incomplete and may take years to finish. There is a long explanation for this behavior, but essentially it has to do with community and the fact that if you have money in your pocket, or in the bank, and someone you know is in need then it is considered an obligation to help them. Therefore, if you have your money tied up in bricks and half built buildings, you can’t give it to someone who may be in need and you won’t be effectively shunned for not sharing.

We walked through the brick quarry where there many men working at all phases of making bricks and eventually walked all the way to the Tloma village past several nice lodges and eventually intersected the Gibb’s road where we turned to walk uphill towards one of the shops where ebony and acacia woodcarvings are made in the Makonde style of southern Tanzania. These beautiful works of art and there are carvings of most animals, bowls and the “tree of life,” which is a tradition carving typically of people stacked on top of each other, but hollow inside and well-polished. We didn’t end up buying anything, but the owner of the shop remember me from a number of years ago as I had purchased a very large tree of life carving that is now in my office at Penn.

A Makonde tree of life

We walked back along the road through the Tloma community where we encountered many children, some young and some school age walking home from school in their uniforms. The greetings were nearly unanimous with a frequent “jambo” and a wave to us. The lighting was wonderful as the sun was low in the sky and would be setting very soon. We reached home just before sunset and were all happy to be back in our comfortable house to enjoy our dinners and a later movie. I had suggested “The Eagle Huntress,” a delightful documentary about the Mongolian practice of eagle hunting a young girl who is determined to become the first female to compete in the previously all-male competition to be the best eagle hunter in the region. For anyone interested in determination, wildlife, gender barriers and gorgeous cinemaphotography, this is the movie for you.

Arriving back at FAME

 

Monday, September 23, 2019 – It’s back to work at FAME…

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Everyone had a wonderful time over the weekend in the Serengeti, and how could they not have. We slept in tents for two nights under the beautiful stars and though our camping was as far from roughing it as one can get, it was still in the traditional style of game drives of the past with the sounds of wildlife throughout the night (much to Andrea and Marissa’s dismay). It is the only way to really experience the Serengeti short of camping on your own, but I’ll leave that to the tremendously more adventurous of which I can think of only one who has come with me so far, and that would be John Best. John had decided to climb Kilimanjaro after his time here at FAME and, if I’m not mistaken, chose to carry his own gear rather than the typical fashion of having more porters than clients which is how I did it back in 2015. Spending two nights in the Serengeti gave everyone a very good taste of what a magical place this is, where the animals are really secondary to the scenery itself, and where the term “endless plain” is an understatement. There is no other place like it on Earth.

The doors to our clinic

Meanwhile, everyone was exhausted from the weekend trip and dragging getting out of bed Monday morning for clinic. There were no major neurologic issues that had occurred over the weekend so that we had no patients that were in the wards needing a neurological evaluation on our return. At morning report, though, we did discuss two burn patients that were in the wards, one a young boy with very serious burns on over 60% of his body and requiring skin grafting that was actually going very well, but taking a long time due the fact that they were having to wait for the donor sites to heal before harvesting again. The child has been here since we had arrived weeks ago and will probably be hear much longer. There is also a woman on the ward service with severe burns who has been here for over a month, though I am not entirely certain of how she got them.

A typical Tanzanian cooking scene

Burn injuries are a tremendous issue here for many reasons, though the primary one has to do with the manner of cooking in the typical Tanzanian household, which is over an open flame utilizing either charcoal stoves or propane burners that sit in the middle of the kitchen. These are all very easy for small children to fall into while playing, for older adults with an unsteady gait to navigate around or for patients with epilepsy to fall into while having a seizure. We have seen so many of our epilepsy patients over the years that have been injured in this manner and many patients who come to see us for the first time with uncontrolled seizures have been horribly disfigured and disabled by these injuries in the past. We have seen children who have fallen into boiling pots of porridge or women who have spilled the contents of their cooking upon themselves. The burn injuries don’t necessarily have to involve epilepsy, though, as neither of the two patients in the ward have seizures. There were merely injuries caused by cooking over open flames in tight quarters where accidents are bound to happen.

Cooking over an open flame

Last week, while we were off in Mang’ola, Dr. Ray had seen a patient before heading home that raised concern for a spinal cord injury – the patient presented with three weeks of difficulty walking and urinary retention and had an examination that clearly localized to the cord below the cervical spine, but was unclear whether it was thoracic or lumbar as he was not overtly myelopathic. He was admitted and underwent a CT scan that demonstrated what were preliminarily read as degenerative changes at the T6-T7 level. We had been away at Mang’ola on both days having left early in the morning so the patient had been discharged home as there was little to do immediately, but the final read came back with concern for an epidural process at that level and compression of the cord. This is not something that is easily seen on a CT scan and is where the MRI really shines, though it was still extremely concerning for an abscess or possibly TB given his presentation. We had him come back today to discuss what needed to be done and that was to send him to Arusha to the neurosurgeon. I contacted the surgeon and the cost of the surgery and hardware necessary would be 4.8 million shillings, or something a bit over $2000 USD. The family went home with that information and the hope that it might be able to be raised by them so he could be treated.

One of Denis’s paintings

Marissa’s paintings

Another interesting patient that was seen by Andrea today was a patient with progressively frequent attacks of vertigo who also had tinnitus and possibly some sensorineural hearing loss. They had seen the ENT docs in Arusha and had been recommended to have a CT scan of the temporal bones, but hadn’t done so yet. His exam was normal other than the hearing loss and we were concerned about the possibility of either Meniere’s disease or a mass in the cerebellopontine angle on the ipsilateral side. The other thought, and why the ENTs had wanted a CT scan of the temporal bone had to do with the possibility of dehiscence of the semicircular canal causing his vertigo, so we asked that the temporal bones also be imaged with the CT of the head. The study was negative for both the mass and the dehiscence, so we were left only with the possibility of Meniere’s disease and recommended that he go back to see the ENT docs in Arusha with his CT scan disc that they could now look at for any abnormalities.

Dinner Monday night

Dinner, take 2

We finished out the day of patients and went back home to rest, still exhausted from the weekend travels. The movie of the night was the original Lion King which made tremendous more sense now that they had all been to the Serengeti and to Pride Rock. There were lots of references that were now made clear as well as many of the names and Swahili words and phrases used in the movie. It was an early evening for everyone and there was an early educational lecture in the morning that Kyra was going to give on how to evaluate patients for cognitive impairment.

Sunset

The Lion King

Sunday, September 22, 2019 – A pre-dawn game drive in the Serengeti….

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Sunrise on the Serengeti

The rain of yesterday evening was a very brief event and the night was once again breezy and cool in the tent, perfect for sleeping under the cozy comforters, but making it all the more difficult to get up early in the morning. We were going for a pre-dawn game drive today at 6 AM, meaning that Mike and I were up again early and having coffee at the main tent by 5:30. It was cool outside, but so delightful that a light second layer did the trick for most of us. The camp staff were up and had some munchies to eat, though I was still full from dinner the night before. Sunrise on the Serengeti is a miraculous event that is truly difficult to describe. Once you’ve experienced it, though, the opening scene of The Lion King becomes that much more relevant as corny as that may sound. From the orange glow of the horizon to the east, it is clear what is happening and when the sphere of the sun begins to rise and meet the sky, there is an intensity that continues to build with the songs of the birds and the movement of the animals now that the day is upon them.

An early morning stretch

We left camp shortly after 6 AM and in the distance you could see four balloons from the two companies slowly rising after their lift-off and continuing downwind for the short, one-hour flight before landing and then enjoying a wonderful breakfast on the open plain. I had the good fortune to have been invited on a flight back in 2014, with Danielle Becker, as one of the pilots is a good friend and they happened to have had open spots in the gondola that day. Danielle and I shared a compartment in the giant basket that held 16 guests in eight small cubicles and the pilot in the center space. You are picked up at 4:30 AM and driven to the launch site where you receive instructions on what to do during takeoff and landing and what to do in an emergency. You lift off well before sunrise so that you are well in the air before it becomes light and you are then watching sunrise from a position that is well above the clouds and, given that the balloons fly in tandem, you have perfect views of the other gondola and its guests. It seems like you’re up forever, but the entire trip lasts only a bit more than an hour and then it’s time for the landing, a rather exciting event that’s over before you know it. We toasted the successful flight with champagne in the long tradition of ballooning and then sat down with all the other guests to enjoy an incredible breakfast before heading back to meet our guide at the visitor’s center.

A lilac-breasted roller in a tree

There are now two ballooning companies that fly here in Seronera, so there were four balloons in the air this morning, rising and falling with the thermals, as well as the hot air supplied by the burner on board. We watched the sun slowly rise to the horizon and then above as it illuminated the bush in the soft glow of the golden hour before the temperatures rise. With the rising sun we continued our trek past the lion pride we had seen the day before, still drawing a crowd of vehicles, and towards the river where we had seen our lion kill the day before. Near one of the crossings, there was another large pride of lions that we stopped to watch for a bit, but they eventually wandered into some tall grass where they could no longer be seen.

Balloon flight

Two balloons over the Serengeti

We soon left the river area and were heading off to the southwest in the direction of the where we had seen the young leopard hidden and her mother nearby so I knew that Dodo wanted to go back to see if we could find the leopards again and, this time, possibly a better view of the two. Driving up to the kopje where we had seen the young one yesterday, we were alone which wasn’t a good sign considering the crowd that a leopard will draw if it’s visible. With no leopard in sight, we soon left the kopje and drove over to where we had seen the mother at the base of the tree yesterday. She wasn’t there, but we received word that the two leopards were a short distance away and not far from the kopje where we had seen the cub. We reversed course and were quickly there with several other vehicles and as we pulled up, there in front of us was the mother leopard and her cub strolling in the tall grass heading in the direction of the kopje that we had visited earlier. The two were absolutely gorgeous, with their bright coats of open spots and sturdy tails.

A Marabou stork

An Agoma Lizard

The mother would slowly walk along while her cub would run ahead and then lay down in front briefly rest while mom caught up to it. Leopards are most often seen in a tree or up on the rocks from distance and rarely close up. They are solitary except for a mother and her offspring. I had seen only one leopard cub before, but it was from a far distance and in a tree, much different than what we now had before us. We sat and watched as they continued to move off towards the kopje and then we chose to drive back over to the rock where they were heading, though unfortunately, the word had gotten out by now and there probably dozens of vehicles already waiting for their arrival there. It was so crowded that it became very difficult once again to see anything, and so we stayed for an only a brief while, but were more than pleased with the time we had to watch them crossing the field. Leopards are so incredibly impressive to see when they are out of the trees and it was a rare sighting for us. Everyone in the vehicle was tickled that we were so lucky to have had that opportunity.

A mother leopard and it’s cub

On the move

From a distance

We left the kopje with just enough time to make it back to camp for breakfast and were glad we did as we were all starving. Our breakfast was as delicious as the day before, though I think everyone ordered a Spanish omelette today other than Dodo and Andrea, who ordered over easy and scrambled, respectively. We again had fruit, cereal, yogurt, muffins, and. Fresh squeezed juices. After our meal, we picked our food for our picnic lunches that we’d probably eat at Naabi gate on our way crossing back into the NCA heading home. We packed our bags and settled our bar bill for the two days we were in camp and headed out to Turtle to pack everything up. Our plan now was to head towards the Maasai Kopjes on our way out of the park with the intention of hitting Naabi Gate around 1 PM so we could get to Kitashu’s boma round 3 PM and visit.

Mom

baby

A closer shot of mom

Before leaving Seronera, though, we did have to add fuel to Turtle as we were still running on the original tank from Friday when we had left from Karatu. The fuel station there was of course run by TANAPA, the government park administration, which meant that I would again have to deal with the same bureaucracy as I did at the Serengeti gate and that had almost been a nightmare. The attendant at the station informed us that the machine for taking credit cards was down that morning and they were not allowed to take cash which had been instituted a few years ago to curtail corruption. There was one other option, though, and that was to use the M-pesa, which is the system here where you can put money on your phone and then pay for things with it. I guess it would be similar to ApplePay, only it works on debit system rather than credit. There was a small shop nearby in the worker’s compound where we could put the money on my phone so we traveled there to make the transaction.

A resting male

Two sisters

It was actually interesting to visit this area (I have in similar places before when traveling with Sokoine) as this is where all the Tanzanians who work at the lodges and shops live with their families during the year. It is a little village in itself with restaurants and stores for supplies and there were plenty of people waiting for the many buses that come through here. Dodo and I walked to several shops and finally found the right one where the man pointed to a woman sitting out front who would take care of it for us. I gave her my phone number and she confirmed the name with me whereupon I gave her 100,000 TSh to put on my phone. This is a huge amount of money for people here and it obviously spoke to the safety of these areas that you don’t have to worry about being robbed by anyone. We traveled back to the fuel station to take of things, but the adventure wasn’t over there. No one had asked me if I had ever used the M-pesa system before, which I hadn’t, and when I punched in the numbers to access the money, it asked me for a PIN. Having never used it, though, meant that I didn’t have a PIN. We worked on it for some time, continuing to dial the numbers and getting the wrong menu on the phone, until I finally tried putting in a PIN which seemed to get us closer to where we needed to be. I did have to call Airtel (the company my phone was using) once, to have them help me, and somehow, we got it to work. We put in the code for the fuel station and paid for 95,000 TSh worth of fuel, or about 40 liters, and we were finally off with about ¾ of a tank which was more than enough to get us home.

Cape buffalo with red-billed Ox-peckers

Close-up of a Cape Buffalo

The rest of our game drive in the Serengeti was a bit of a blur, but we continued to see more and more lions as we drove, to the point where the response was, “oh, just another lion.” It is truly amazing the number of lions the Serengeti supports and we were only exploring the central portion of the park. The drive back to Naabi Gate took about an hour or so, and thankfully, we had all the necessary paperwork to exit the Serengeti and to enter the NCA on our way home. We had our lunches at the gate where there were more vehicles and people than I had ever seen there and it was difficult to even find a table to sit at. We were on our way again in short order, though, and traveling back on what has to be one of the very worst washboard roads I have ever been on. To make matters worse, every so often, there are short stretches of very soft dirt that has to be taken slowly to avoid driving off the road or tipping. Thankfully, Dodo is a great driver, so we sped along the road quite safely and managed to maintain a good pace as we were trying to get to Kitashu’s boma by around 3 PM.

Handing out candies to the children

Mike in the dance line

Andrea and Leah with the women

I had to make one short stop at the Olduvai gate, which is just a short distance off the main road, to drop something off with a friend who was waiting there for us. When we pulled up, we discovered that the driver’s door wouldn’t open as the latch had loosened with the bumping from the rough road, so Dodo ended up having to climb out of the window. He worked on it briefly, but it wasn’t cooperative would have to be fixed later. Between the fuel station fiasco and Olduvai Gorge stop, we were a bit behind schedule, so ended up getting to Kitashu’s about 45 minutes late which was a shame as we had really wanted to spend some time there.

Mike jumping with Kitashu

One of Kitashu’s brothers jumping very high

Mike doing his best and succeeding

His boma is in the NCA on the Endulen Road which is very near the Crater Lodge. His entire extended family lives there in very traditional fashion with all of their livestock that grazes over the nearby hills when there is enough vegetation. On occasion, though, they will have to travel far with their animals to find adequate grazing, sometimes all the way to Ol Doinyo Lengai, the active volcano on the. Lake Natron road that is sacred to the Maasai as the Mountain of God.

The women’s dance line

Mike with some of the children who wanted a photo with him

There were many, many children at the boma, but we learned that there were many from other bomas who had come when they had heard that we would be visiting. There are “cultural bomas” throughout the NCA where safari companies bring their guests and pay them to put on dances (we had done this on our original trip here), but this visit was very different as we were guests of the boma due to our relationship with Kitashu. We had brought some small gifts with us – rice, sugar, soap, tea leaves and candies for the children – to show our thanks for having us. The woman of the boma immediately brought Leah, Andrea, Kyra and Marissa into a nearby hut to have them dress in traditional clothing and jewelry as we would be doing a dance with them and Mike also dressed in shukas and jewelry for the festivity.

Washing our hands prior to eating goat

Kitashu and Dodo slicing goat

We all walked to another area where the men and women demonstrated their dance and song with everyone participating (except Dodo and me). Mike hadn’t been feeling well prior to this, but managed to be a good sport and do some of the jumping that the Maasai men are famous for, though I suspect he could have gotten much higher had he been in full form. After the dancing, we went and walked around behind one of the animal enclosures to eat some roasted goat that Kitashu has prepared for us. The Maasai men never eat in front of the women of their village as it is believed that it is bad luck for the women to watch and that the men will become sick if they do. It was on skewers that it had been cooked on and after we all washed our hands, Kitashu proceeded to slice off chunks of tasty goat meat and pass them around to each of us in turn. The goat was cooked perfectly for us and was incredibly juicy and tender. I have eaten at a number of goat roasts in the past, and I will have to say that the meat is at tender and tasty as pretty much anything I have ever eaten before.

 

A scene from Kitashu’s boma

A scene from Kitashu’s boma

Once we had our fill and had again washed our hands, it was time to depart the boma so we would make it through the gate by 6 PM or else spend the night in the crater which wasn’t something we were planning. We ended up make it through the gate with literally minutes to spare and, for the first time in several days, breathed a sigh of relief with the smooth surface of the tarmac and the absence of the continual chatter and bouncing of the washboard roads we had been driving on since entering the NCA on Friday. It had been a wonderful adventure in the Serengeti and now it was back to our primary mission here, seeing neurology patients at FAME and working with the doctors here.

Saturday, September 21, 2019 – Waking up in the Serengeti….

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All loaded and ready to go

There can really be little dispute that the Serengeti is one of the most spectacular locations on the planet Earth and a sight that should not be missed if humanly possible. The word “Serengeti” comes from the Maasai word “siringet” which means “the land that goes on forever,” and it is an accurate assessment of the landscape here for it is truly an endless plain. Everyone’s introduction to the park last evening was only a small sampling of enormity of this place and we would be spending our second day in only a very small portion of this enormous park that embodies the true essence of Africa. The Serengeti contains the majority of the greatest land migration of wildebeest that travel in a circular fashion throughout the year in search of grass, stretching from the Southern Serengeti, thought the Central and then crossing the Mara River in the Northern where they calf in the Maasai Mara of Southern Kenya only to travel back into the Serengeti to complete their migration. The Southern Serengeti is the place to be in the wet season for all of the herds are there feeding on the luscious grasslands. The crossing of the Mara occurs in early September in most years, but it really depends on the weather.

A large family of giraffe

So, the second day of our trip began waking up in our tents that are more like a small house. The tented camps here can be semi-permanent or seasonal and typically consist of anywhere from 10-20 tents that are divided on either side of a central tent that contains areas for lounging, a bar and a dining area where there are tables set up for all the guests and are available for three meals a day, though most eat only two or even one meal in camp with the rest of them being eaten on the game drives and prepared by the kitchen. Overnight we had heard the sounds of hyenas and, in the morning, the lions, all of which sounded like they were only feet from our tents. We had decided to have breakfast at 7 am given the long and tiring drive the day before, though Mike and I were up early to have coffee and watch the sunrise. Everyone gathered on time for our breakfast which consisted of various fruits, cereal, yogurt, muffins and fresh juices. At the table, the staff took our orders for eggs however we desired them cooked along with bacon, sausage and toast. It was an incredibly filling meal that was easily going to last us the better part of the day, yet it was now time to pack our lunch for the road as we would be out game viewing for the entire day and not returning to camp until dinnertime.

More hippo viewing along the river

A young hippo out of water

The hippo pool

Leaving in the morning for a game drive is always so exciting for you never know what the day will hold. Dodo had decided to take us by the hippo pool for the early morning since some would be out of the water and we may be able to see a few crocs in the area. There is a very nice viewing area nearby where you can get out of the car without fear of being attacked by the hippos as the edge of the pool is steep enough to prevent it. There is a wooden rail at the viewing area that is meant to keep guests from getting too close to the pool, but of course there are always those who don’t seem to understand the significance, and possible danger, of these situations, thinking perhaps that this is a zoo. While I stood taking my photos of the hippos, there were those who just had to have those selfies as close as possible, putting themselves, and perhaps others in danger.

Leah, Kyra and Mike at the hippo pool

Mike and Kyra at the hippo pool

A vulture overhead

A vulture overhead

We left the hippo pool to drive along a wooded river area looking for leopards, though what we found were tsetse flies and lots of them. These flies are rather infamous in East Africa for carrying trypanosomiasis, or sleeping sickness, but luckily there are only very rare cases of this in Tanzania, and none in this region. They aren’t harmless, though, as they have a terrible bite and feed on the blood of their victims. They are incredibly slow, but are like heat seeking missiles when they find your vehicle, flying alongside at whatever speed your traveling until the enter through the top or the windows looking for a meal. It’s almost impossible to feel them when they land on you, that is until you realize that they have bitten you. Their bite is significantly more painful than a mosquito and can create a welt much more uncomfortable and long lasting. Thankfully, that is all they leave and there is no worry here for sleeping sickness.

An adult hippo out of water

As we came closer to one of the main roads, we noticed in the distance that there were a number of vehicles concentrated in one area and that can only mean one thing in this region – a large cat. As we drove closer we could see a very large pride of lions lounging in the grass and under a large tree. Lions sleep most of the day except when they are hunting and that is only done by a few females at a time. The males, a great number of females and many younger lions will all be lying in the shade for most of the day, resting and readying themselves for their larger nighttime hunts. We watched the lions for only a little while as they didn’t appear to be interested in doing much else other than sleeping.

A herd of Cape buffalo

As we drove around the river areas we saw plenty of wildlife that included small herds of zebra, lots and lots of birds, baboons, elephants, giraffes and just about everything in between. We were still trying to make a sighting of a cheetah or a leopard and, at one point, we did run across two cheetah, but they were lying under a tree a fair distance away and, although you could certainly see them with the binoculars, they didn’t appear to be planning to hunt anytime soon. We were near the park visitors center where there is a picnic area, but we weren’t quite ready for lunch, so decided instead to head further out and find another picnic area in which to eat our lunches. We head out along another line of trees where there are often leopards, but not were to be found today in this area so we continued on. Once again, we could see a number of vehicles next to a kopjes far off in the distance and, as we approached, it was quite clear that there was something to see here. It was a leopard that was resting well-hidden behind some bushes and under a large rock, resting in the shade. It was barely visible and you certainly could not take a photo with all the bushes around it. We queued up behind several other vehicles, each taking its turn to pull up alongside the leopard. There wasn’t much to see at this time.

A southern ground hornbill

We moved on to the picnic area where tables were at a premium as we were still in the high season here. There was also one of the large participatory camping vehicles there that usually have around twenty guests so this also occupied several tables to accommodate everyone on the tour. These companies usually provide tours that can be a month or more in length and travel through several countries in a large half truck, half bus-like vehicle where all the travelers are up high in a compartment that usually is open on the sides, with lower bins that pull out to provide all of their camping and cooking equipment. They set up their own tents and everyone shares I the cooking. I had looked into this for our trip back in 2009, but there wasn’t enough cost savings to justify it for me and even though I love camping and the outdoors, I just couldn’t see sitting in such a large vehicle for such a long time. In the end, had I chosen that style of trip, I wouldn’t have found fame and would certainly would not have been on my 20th trip back to Tanzania at this point in my life.

Mother and baby

Marissa’s fav – a baby nursing.

After lunch, we drove through an area that should have been ideal for cheetah as the grass was tall and there was plenty of small game for them to hunt, but they were nowhere to be found. We drove a big loop so ended up driving back by the rocks with the leopard, though it hadn’t moved and was still nearly invisible behind the bushes and under the rock. As we drove off and were a few hundred meters away from the Kopje, Dodo spotted a shape laying under a distant tree. With the binoculars you could clearly see another leopard resting there. As leopards are purely solitary animals, this was the mother of the one we had seen under the rock and she had stored her cub away while she had gone hunting. She was really too distant for any good photos, but it was great to know that there was a healthy mother and cub nearby.

Staying out of the sun

We continued our drive with the intention of finding a closer cheetah to view, but it just wasn’t to be this day. We were moving pretty fast alongside one of the many rivers that course through this area when I suddenly spotted the dark backs of two lion ears off in the distance amid the green bushes of the riverside. Dodo was able to eventually stop the vehicle and reverse and, sure enough, it was a lioness on her haunches and she was clearly scanning the opposite riverbank for distant prey. We decided to watch her for a while and in five or ten minutes, two other lions slowly came into the picture from our right. When they were finally together, they moved off as a hunting party traveling as a unit with one walking in front and constantly checking for prey. At one point, two of them climbed onto a small hillock which was rather odd as they were very visible from there, but we later determined that the group contained a mother with her adolescent daughter and son and it was the two less experienced animals that had exposed themselves.

The first lion we spotted

On the prowl

There was a small herd of zebra on the opposite side of the river that were aware of the lions and moved a good distance away, but we knew that there were a number of other animals still at a watering hole far off to the left which was where this trio of lions was heading. At this point, we were the only vehicle watching these lions as they slowly moved through the tall grass, now in an incredibly stealth fashion, and seemingly more determined with every minute. Dodo continued to move our vehicle for the best possible view while the lions slowly moved in the direction of the watering hole, still completely undetected by the animals at the watering hole. On several occasions, the lions were so concealed in the tall grass that we had difficulty spotting them even though we knew they were there right in front of us. We had now watched the lions maneuvering for an attack for probably 20 or minutes, but we were quite sure that our patience was going to pay off in the end.

A very hungry mother

The youngsters scounting out

Finally, the attack was on as the mother lion sprung from the grass to the other side of the river where there was a small beach and all the zebra in the pool began to scatter in all directions. I’m not really certain that her children contributed at all other than to perhaps block the passage of some escaping animals, but in this case, all it took was the one determined lioness to make the kill. When she leapt to the other bank which was a huge distance, she seemed to collapse with the impact, but very quickly righted herself and was immediately on the run again with a zebra in her sights. In a cloud of dust, she caught the zebra and very quickly had its throat in her jaws to suffocate and kill the animal prior to eating it. The zebra struggled for several minutes, kicking up more clouds of dust, but eventually succumbed to the more powerful attacker and lay still. The two adolescents strolled over to their mother still latched on to her prey and began to eat the zebra. Hopefully the two had learned something from their mother’s example, but at the moment, they seemed more interested in devouring the kill.

Just after the kill with the zebra still kicking

Just prior to the kill, another vehicle had pulled up on the opposite side of the river having either spotted us watching or possibly the lions, but either way, we were now sharing our lions with someone else. Once the kill was completed, though, Dodo very quickly drove us to the other side where the view of the lions with the zebra was a bit closer and we would be able to watch their behavior feeding together. On a previous kill that I had seen with four female lions all of similar age, there had been a tremendous amount of jostling for position, snarling and general poor behavior between them with lots of growls and roars. These lions today, though, were much more civil to each other, if not to the zebra, as it was a mother and her offspring. Each lion alternated between sitting and standing as they began to feed and there were absolutely no harsh words that could be seen spoken between them. We continued to watch for some time until finally, one at a time, they walked away from the kill having filled their stomachs to the brim. It seemed as though the young male was the last to leave the carcass and I was surprised that there were no vultures yet on the scene as they are typically incredibly efficient in this process, but the African vultures rely entirely on their keen eyesight and not their sense of smell as do the American vultures, such as the turkey vulture.

We eventually left the lions, who were now in their post-prandial stupors resting comfortable nearby their kill, and continued on our game drive hoping to see cheetahs if we could find them. As we drove near the small airport we saw a few vehicles looking at something, but as we approached they began pulling away. They informed us that a cheetah had been walking across the road which we had just missed by a matter of minutes. It was surprising that we were have so much difficulty finding them as they are usually very easy to spot and fairly numerous, but the Serengeti has been extremely dry and the grasses rather short for the most part which is not conducive to cheetahs hunting. They’re around, but just not readily apparent in the regions we’ve been scouring.

It wasn’t exceptionally late, but between our exhaustion from being out all day and our excitement of the kill we had witnessed, everyone was ready to begin heading back to camp. As we were driving back and were only a short distance from camp, we came to a culvert under the road and, out of the corner of my eye, I spotted a tail and then a spotted body just to the side of the road in the grass. I yelled “leopard,” and then “cheetah,” not having been totally sure of what I had seen, but when we backed up to see, it was gone, but Dodo felt very strongly that it had been a leopard as one was living in this area and may well have been hiding in the culvert. We backed up to see if it would come out again, but there was the steady traffic of safari vehicles traveling in both directions, heading to their respective camps at the end of the day and it was very unlikely that the leopard would surface. We eventually gave up and made our way the very short distance to camp. Shortly after we arrived back to camp, it began to rain, so it was excellent timing for us having missed the need to put down the top while on the road and it was so relaxing for Mike and I to be sitting under the edge of the main tent drinking our Safari beers and listening to the softness of the rain as it fell and struck the tent. We had an excellent day on the trail, having seen a lion kill following a long hunt, an event that is not always seen when coming to the Serengeti regardless of effort.

Dodo and I sharing coffee in the morning

We had another lovely dinner and everyone, except for me as I was blogging, hit the sack early as we were going to leave on a pre-dawn game drive at 6 AM the following morning.

 

A very young elephant (?a week old) teething on a tree limb

Tiny baby

Friday, September 20, 2019 – A half-day of clinic and then off to the Serengeti….

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The resident rotation to Tanzania not only includes an amazing amount of neurology given the number of patients seen here and the diversity of the neurologic disorders, but it also includes exposure to this countries rich cultural heritage, as well as its equally impressive wildlife. We’ve already visited two parks for day drives, Lake Manyara first followed by Ngorongoro Crater, which we did both on Sundays as we have traditionally not worked those days making it perfectly reasonable to spend them either at the parks close by or spending them doing something outdoors (such as our hikes down into Empakai Crater that we’ve done in the past. To get to the Serengeti from Karatu, though, it requires a minimum of two nights given the distance as that allows for a full day of game viewing in between the long drive on the other two days. But before I get to the Serengeti, we have a half day clinic that we have to tend to.

Crossing into the Serengeti

It was the end of our mobile clinic week and we have traditionally done a half-day clinic so that we could leave sometime after noon to arrive to our camp in the Serengeti before dark as driving in the park after sunset is very much frowned upon and actually against the law. Unfortunately, while we were away, many patients were told to return on Friday to see us as I’m not certain that everyone knew that we’d only be there in the morning despite my having supplied a schedule specifically to avoid any conflicts. Thankfully, though, the turnout was still manageable with some strict discipline by everyone along with some strong encouragement on my part. Kitashu had been at his brother’s wedding the weekend before near Loliondo, a predominantly Maasai region far north on the Kenyan border, and had told several people there to come see us on Friday for their neurological issues. Mike ended up taking care of the entire group that comprised four patients, but since they were all family members they really could be split up due to the language and history taking necessary.

Giraffe on the backside of Ngorongoro

In addition, the gentleman who we had seen previously with the large meningioma had returned to go over the results of his scan. This was a bit complicated given that he was going to require surgery so we contacted the neurosurgeon in Arusha (the only one outside of Dar in the country) to find out how much such a surgery would cost. He would also need to have an MRI done prior to surgery which would be an additional cost. Kitashu helped with giving him all of the information not only because the patient was Maasai, but also due to issues with cost and whether he would be able to consider it. Thankfully, the patient indicated that he was going to go home and sell some livestock along with other family members to have his surgery. I speaking with the neurosurgeon, we discovered that the older gentleman who we had seen with the large chronic subdural hematoma had not followed through with seeing the neurosurgeon which was very disappointing given the fact that he will not have any chance of recovery and will very like succumb to it in the end.

The largest herd I’ve seen of Grant’s gazelle

We finished the morning with about 15 patients or so and were finished by around 12:30 PM. There were still some labs to check and Dr. Annie would take care of giving those patients their results while we were on our way to the Serengeti. Somehow, one of the patients that Marissa and Andrea had seen in the morning and was depressed, so they had given the patient fluoxetine (Prozac), turned out to be pregnant (how Annie discovered this after the initial visit I’m not entirely sure) and this prompted a vigorous WhatsApp discussion while we were en route regarding what we could do for the woman. Unfortunately, not of these medications are safe in pregnancy and certainly not to start a medication unless there were extenuating circumstances. In the end, the decision was that she really couldn’t be started on a new medication and it would have to wait until after her pregnancy and possibly even breast feeding due to the selection of medications that we have here.

Marissa’s favorite sight – a nursing baby. These are Coke’s hartebeest

For our trip to the Serengeti, as in all the trips we’ve taken there in the past, I find a guide to drive us as I’m not comfortable navigating the vastness of this park and its extreme remoteness. Having a breakdown in the Serengeti can be a disaster for many reasons, not that having a breakdown anywhere in Tanzania isn’t a major problem given the fact that there is no AAA here to come help. For this trip, I had asked a someone I had met recently to drive us as I had an immediate feeling that he was very knowledgeable, experienced and dependable. His name is Samwell Bariye Dodo and after taking care of the particulars, he had agreed to come to Karatu to pick up the vehicle in the morning, fuel it up and have it cleaned as well as check it out to make sure that it was worthy of the trip. He had taken care of all of that and met us at our house to load our bags and get under way.

Hyena and gazelle

We would be driving to the Central Serengeti where we had booked two nights at the Thorntree camp just north of the Seronera, which is where the small airport servicing the Central Serengeti. The Serengeti is an incredibly large park that is divided into the Southern, Central and Northern sections, as well as the Western Corridor that is a strip jutting out to the west and follows the Grumeti River. The Western Corridor is the least visited region of the park. The Northern Serengeti runs to the Kenyan border where it extends north and becomes the Maasai Mara, which is the name of the game park in Kenya containing this contiguous area. The Central Serengeti’s geography is dominated by the famous Kopjes that are small, rocky hills jutting up from the flat plains that go on forever.

Just to give you a perspective on how close we were

Before our trip, it was necessary for me to go the NMB bank in town to pay for our transit across the Ngorongoro Conservation Area. The road to the Serengeti is the very same road we travel to the get to the crater and, in fact, you drive around the crater rim road all the way to the opposite side of the crater where the descent road is before continuing on rather than down into the crater. Everything went smoothly at the crater gate and we were soon on our way past all the sites we had seen the weekend before. The visibility was tremendously better than it had been previously given that it was now afternoon. As you leave the rim road and begin your descent down to the plains below, the immensity of the region suddenly becomes apparent and this is just a small sample of what we’d be seeing one we reached the park. You drive past Olduvai (or the proper spelling of Oldupai as I like to use) Gorge, the single most famous anthropologic site in the world and the home to the discovery of oldest man many years ago by Mary Leaky. Unfortunately, we wouldn’t be visiting this site today, but I have been there many times before and it is a simply magical place that clearly deserves its place in history.

Joined by the other hyena

Carrying it’s prey away

From the Olduvai region, you travel along until you reach the road to Lake Ndutu which is the place to be in the rainy season as all of the wildebeest herds are there with their new calves having been delivered on the way down from Kenya during the great migration. At this point, you enter Serengeti National Park, though the entrance gate is still another 20 minutes or so at Naabi Hill. Both Dodo and I went in to take care of the entrance payment, though in typical the typical bureaucratic fashion here, there was an issue that arose. I had been sent two quotes for the NCA transits (there and back) that I had paid for at NMB, but every time in the past, I had paid for the Serengeti quote with my credit card. Apparently, in the time since March, they had changed the procedure and were no longer allowing payment at the gate for any guided vehicle, only self-drive vehicles, meaning that I was supposed to have paid at the bank in advance. The only other option was for me to obtain the log in information for the company who booked the quote and then to make payment on the website with my credit card. It sounded very arcane, though I know they had their reasons for it. What should have been a several minute transaction ended up taking us about an hour with multiple back and forth phone calls to get the necessary information. Everyone remained very calm and we eventually got all the information to load into the computer, though the first credit card I tried didn’t work due to security  reasons, my good old Wells Fargo debit card came through and we were good to go.

Elephants at dusk

baby elephant at duck

We were now about an hour behind schedule which was a bit disappointing for me as up until then I had managed to keep everything moving on schedule, and we still had a long way to get to our camp and do some game viewing on our way. You are not supposed to be driving after 6 PM in the park, or at the very least sunset, but since we were on our way to our camp and had been held up at the gate, I was pretty sure that no one would be hassling us about that. It was a gorgeous sunset that took quite a long time to happen as there were multiple layers of clouds in the distance. The sky began to change to every shade of orange imaginable and we had to stop Dodo multiple times for everyone to take photos.

Baby elephant

Sunset on the Serengeti

At one point as we were driving, a hyena suddenly appeared on our left, darted across the road and grabbed a dead Thompson gazelle that was off to our right. We’re not sure how the gazelle had died as we didn’t see any other predators in the vicinity (hyenas will often chase off cheetah and even a single lion), but sure enough, the gazelle was dead when the hyena reached it. It began tearing immediately at the abdomen of the gazelle and began to devour the animal in very short order. A second hyena came up to feed, but kept its eyes on us as we were only several meters away and it was spoked by our presence. We were so close that we could easily hear the bone crunching by the hyenas who have the most powerful jaws of all the animals here and, even more so, we were close enough to smell the gazelle’s abdominal contents once it had been opened up. It was not very pleasant making me think that the gazelle may have been dead for at least a short while before the hyenas came upon it. As we were on our way to camp for dinner and truly looking forward to it, we all wished to keep our appetites, so eventually drove off prior to the arrival of any vultures to finish off the carcass.

Our lion admiring the sunset

The sun continued to set in the most spectacular fashion and as we rounded a marshy area where you will often see lions, we came upon a large pride, all of who were lying comfortably in the final rays of sunshine except for one female that was sitting on her haunches, facing off to the west, and clearly looked as though she were admiring the beautiful sunset. It was a glorious sight with the orange glow of the setting sun, the lions, the green of the marsh in the foreground and the endless plains in the distance. We were all in awe of the moment and now one wanted to leave this spot. Both Dodo and I knew, though, that with the setting sun, it would soon become pitch black and we still have at least 30 minutes to camp. We left this magical sight of the lion admiring the sunset and continued our trek north towards camp.

Lion admiring sunset

Dodo knew the Serengeti like his second home so there were no wrong turns and he knew exactly where camp was for us. As we arrived, we were given cool wash clothes and fresh melon juice to wash down our dusty throats. We were in plenty of time for dinner and even had enough time for Mike and I to go to our tents to shower. We sat around our large table finally able to relax from the long drive here and very happy that we make it through safely. It was time now to enjoy a cold Safari beer for Mike and me and wine for everyone else. Dinner was a delicious affair of probably ten dishes that were brought to the table by the camp staff for each of us to serve ourselves. The homemade soup was amazing as it always is and every other dish was equally cooked to perfection. We retired to our tents, all exhausted form the day, and prepared for a very restful night. Some of us were a bit more concerned about the animals surrounding our camp, though I reassured everyone that the animals have no interest in coming into camp. The fact, though, that Andrea asked the camp staff four times what the emergency whistle was for and why it was there may give you some indication of was going to sleep more soundly that night and who wasn’t.

A happy man and his Safari

Thursday, September 19, 2019 – Rift Valley Children’s Village and the village of Oldeani….

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A turtle packed the gills

After our long days at Mang’ola and the drive that accompanies it, everyone, including me, was looking forward to a somewhat tamer route for our mobile clinic. Still, we wanted to get there at an early hour in case the clinic was swamped, so had decided to depart Karatu at 8 AM for the 45 minute ride to the village of Oldeani and Rift Valley Children’s Village (RVCV). Since it was Thursday morning, we had again been asked to do an education presentation and Mike agreed to speak about seizures and epilepsy, a topic that cannot be reinforced to often given the number of epilepsy patients we see here and the fact that there are a number of new doctors who haven’t heard our presentations before. His talk was wonderful, of course, and provided a very practical approach on how to treat these patients in Tanzania, where not all medications are readily available or affordable.

Turtle parked at RVCV

Looking out from the administration building hallway

Rift Valley Children’s Village is an amazing home to around 100 children that were either homeless or otherwise unable to be cared for by their families and have been adopted by India Howell (Mama India) and her Tanzanian business partner, Peter Leon Mmassy. The children range in age from infants through the mid-teens and all live at the village in houses that are run by house mothers who care for them. They attend school next door in the government school that India has partnered with to provide more teachers than the usual ratio of one teacher to three classrooms and not only do India’s children benefit, but so do the children from the local village.

One of the next important chores was to work on the health of her children and for that, India turned to Frank and Susan. One of the important reasons for FAME’s location in Karatu was the proximity to Oldeani and RVCV and India’s relationship to the two founders of FAME. India also found, though, that the health of the children going to school with her children was extremely important as was the health of the Oldeani community meaning that by providing better access to medical care would ensure the health of all. FAME was the key and from the very beginning they provided medical clinics at RVCV not only for the children at the village, but also for the community and all was funded by Tanzanian Children’s Fund, the parent organization for RVCV. When I first came to FAME, I also accompanied the medical team to these clinics, providing neurological care, and when I began the program with Penn that included residents, we developed a separate neurology clinic that ran in conjunction with the medical clinics. For a number of reasons, the medical clinics to Oldeani were ended in the last several years (patients from RVCV and Oldeani are now transported to FAME for their care), though we have continued to provide neurological care through our neurology clinics there every six months. Katie, the current nurse at RVCV, provides continuity care and communicates with me by email with any questions.

Taking vitals at the registration desk

Some assistance with the signs

So, it was on this framework that I was again on my way to RVCV for well-more than the twentieth time, driving through the incredible countryside that makes up the area that surrounds the village. For today’s drive, we had decided to take only one vehicle, that being Turtle, though we had a total of twelve people that included the residents, Leah and all the support staff. Turtle has seating for nine people, though with two beer crates in the aisle and four people seated across the back, we were able to fit everyone, albeit not the most comfortably. The road to Oldeani is thankfully not as rough as that to Mang’ola, though it does have its moments. The road initially runs along a ridge for several kilometers, but then descends into one deep valley and then another such that there are angled berms every dozen yards or so to divert the water from the road surface during the heavy rains to keep it from washing them out. Therefore, we descended and ascended in first gear to keep everyone happy given the tight quarters. The final part of the drive is through a coffee plantation where it is much love level.

Marissa’s pediatric exam room

The other half of Marissa’s pediatric exam room

RVCV is like an oasis and there is something about it that will lift anyone’s spirits. As you might imagine, this is a very desirable position for any volunteer and there are many, most of whom come for several months at a time. They also have internships for a number of the more dedicated positions that require more continuity and they may stay for a year or more. I should also mention that once the children finish secondary school and are ready for college, they move to quarters that are just outside the village and, then, when they finish their schooling, they will find a job and move on. I have known many of the older children there that have gone on for additional schooling and one of those is currently working as a nurse at FAME.

Patricia in the pharmacy

One of our pediatric patients

When we arrived at RVCV, it was apparent that everything was under excellent control as Katie, their nurse, had already prescreened all the patients for us, registered them, obtained charts for those patients who had them, and had pre-sorted the charts into the pediatric and adult cases. In addition, she had prepared four examination rooms for us to use which meant that the residents would be incredibly efficient in seeing patients. Unfortunately, the only thing we didn’t have waiting for us was the mob of patients that we had expected to see. What we later came to find out was that coffee picking season was still ongoing and given the fact that this was the main employment for the local population, they couldn’t afford to miss a day of picking as the season is on forty days. The pay for picking coffee is the equivalent of $2 a day which is a significant amount considering the average annual income in the region can be as low as several hundred dollars a year.

Revo, Leah and Kyra taking a history on a patient

Mike and Abulhamid evaluating a patient

Despite the fact that Katie had called many of our prior patients to come in for follow up, they didn’t show. We did see a number of children, much to Marissa’s delight, that were both from the children’s village as well as the local village, in addition to a number of other patients that we had seen previously. There were many epilepsy patients that were seen which has been quite typical of our patient distribution here and there were also a smattering of developmental delay patients. We ended up seeing perhaps 16 or 17 patients by the time lunch was ready for us. The mamas (house mothers) cook lunch for all the volunteers and interns and today’s lunch was a very delicious version of the Tanzania burrito – chapati with beans, ground beef, cheese and vegetables – and then homemade (everything here is homemade) brownies.

Dr. Annie and Marissa evaluating a patient

After lunch, we went to the duka, or store, where items made by the local women’s group were being sold. In addition to the RVCV, there has also been an ongoing project to empower women in the area by utilizing both microfinance opportunities along with vocational training that has continued to grow each year allowing women to earn money and support their families. The Rift Valley Women’s Group, in addition to selling their work in the small duka on the premises, has also begun to partner with many lodges throughout the northern safari circuit with plans to expand further to the coast of Tanzania and perhaps eventually to internet markets such as Etsy or to organizations such as Ten Thousand Villages in the US. Based on the reaction that everyone had today to the handicrafts for sale in the duka, there is little question that they would be incredibly successful. We all bought plenty of gifts for those at home and for ourselves and I am certain that every group I bring there will have exactly the very same reaction to their visit. For anyone who wishes to find out more about that the RVCV and the Rift Valley Women’s Group, you can find it at the Tanzanian Children’s Fund website:

www.tanzanianchildrensfund.org

After our visit to the duka, we walked back over to the clinic hoping that perhaps patients had come after working in the coffee fields, but there was no additional clientele for us to see. So, we packed up our equipment and the medicine box we had brought with us while I worked on scanning all the charts of the patients who we had seen and Katie made a duplicate copy of the notes for FAME. We loaded up Turtle with all the passengers and were on our way back to Karatu much earlier than we had been in the last several days, thankful that we had a bit of personal time considering the long days that we’d had previously during the week.

A friendly game of football

Mike showing off his stuff

The drive back was equally gorgeous as I take a little diversion that skips some of the bumpy road and instead passes through a somewhat breathtakingly steep valley inhabited by local farmers that is far steeper than the road we took in the morning. Despite the extra passengers in the vehicle, Turtle performed as I expected her to in that great Land Rover Defender tradition. I have often said that I am the luckiest guy in the world for as a child and young adult, I had always been an explorer at heart, and sometimes in practice, but had never thought that I’d be driving a Land Rover in East Africa. It is something I am now able to do twice a year and, while doing so, provide services not only to those in need here, but also education to the doctors of FAME and to my residents who become both better neurologists for having worked here and better persons for further realizing their potential in helping humanity.

Leah teaching the boys

We arrived back in Karatu early enough for us to take the short drive down to Manyara village to visit the African Galleria so that everyone could shop for some additional gifts before we left the area. I was also able to get to the local bank here to pay for our transit across the Ngorongoro Conservation Area which must be done in advance of our upcoming trip tomorrow the Serengeti. I was also able to stop in at Soja’s shop, the FAME mechanic, so that he could possibly replace the water temperature sensor in Turtle which had broken. He didn’t have a new replacement, but used one from another vehicle in their shop so that the gauge would be function for our trip over the weekend, while he would order the new part and swap it out with the temporary replacement that he installed.

While at Soja’s, I bumped into Nixon, a good friend and local businessman (who owns the Lilac café both at FAME and downtown), who reminded me that the meeting for the Karatu Rotary Club was tonight and that I had said that I might try to go. I ran everyone home and then drove back to the Lilac Café in town where the meeting was being held. I was glad I went as I know more than half of the members and their current project for the community is to install trash receptacles first along the main road. To understand this, you must first realize that there are virtually no public trash receptacles anywhere in the country and that trash is usually just discarded by individuals on the street. It is a very worth project and one that I hope builds momentum so that these receptacles can be placed through the town and not just on the main street.

Rift Valley CHildren’s Village Neurology Clinic team – top row, left to right – Kyra, Annie, Revo, Me, Abdulhamid, Kitashu, Kat. Bottom row, left to right – Mike, Marissa, Andrea, Leah and Patricia

I arrived home following the meeting to find everyone intently making sandwiches for lunch tomorrow on our drive to the Serengeti as well as getting packed for our two night stay there. We would work half a day in the morning and then try to leave shortly after noon. I had met a guide recently who I liked very much and asked him if he was possibly available for the weekend to take us to the Serengeti. His nickname is “Dodo,” and all of us are quite enthusiastic to have him accompany us.

 

Wednesday, September 18, 2019 – It’s back to Barazani for day 2 of our clinic….

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We had been so overwhelmed yesterday by the outpouring of patients, that it only made sense to return to Barazani and finish up what we had started. We had ended up seeing 42 patients the day before, or essentially ten seen by each resident. This was clearly the highest number of patients we had seen at any previous clinic and was only possible given the dispensary’s willingness to assist us in caring for their patients along with the outreach that was done both by FAME and the dispensary. We had anticipated seeing an addition 25 patients today, but in the end,  we had seen 29, making a two-day total at Barazani of 71 patients.

Barazani gang, Day 2

We were again planning to bring the entire neurology group that we had brought the day prior meaning that we would need two vehicles to travel Barazani and that everyone would once again be able to experience that wonderful road. It would be appropriate to mention here of the struggle that occurs with each and every rainy season to maintain the roads as passable given the raging torrents of rain that can fall in a matter of minutes and causing a deluge of mud and rocks that rain down from the nearby hills producing flash floods. One such storm that occurred several years ago when Danielle Becker and I were here completely severed the main road on this side of Mto wa Mbu at the entrance to Lake Manyara National Park. The park entrance had been a wonderful collection of small buildings for entrance and bathrooms that were below the level of the parking lot and were completely covered with large boulders to the depth of about 10 or so feet, nearly completely disappearing in the process. They’ve since built new entrance buildings and bathrooms, but the old structures still sit and their roofs are visible to everyone.

Mang’ola clinic

Danielle and I were left with a bit of a dilemma as any transportation through this region was impossible other than flying from Manyara or taking a bus to where the road had been washed out, crossing over the now empty riverbed with our luggage and boarding another bus on the other side. The problem was, we had a vehicle at FAME that needed to get back to Arusha and though leaving it FAME to be picked up later by someone else was an option, it was really a last resort for us. The road opened after three days and Frank suggested that we leave early (we still had three or four days left here) to make sure that it didn’t get washed out again by the next rain, but neither of wanted to cut our visit short, so we just stayed put and crossed our fingers, though, to be honest, I’m not sure which scenario we were praying for. If the road washed out again, we’d be stranded and would have no alternative other than to remain here in paradise.

The neurology team ready to get started

There are always inevitabilities like this wherever one lives, but it seems to be that much more frequent here in Africa. It is tremendously more necessary here that one “goes with the flow” for there is little alternative otherwise and so much more here is out of one’s control. That doesn’t mean that you tempt fate, but it does mean that you have to accept these risks and carry on. Thankfully, it has always worked out for us in the past and, while some of that might have been due to luck, a significant amount has also been related to a level of trust and belief that things would work out for the best. A bit of planning can certainly help as well.

We arrived early to the dispensary in Barazani and patients were already there waiting for us. Yohan prepared to begin registering patients, but most of the holdovers from yesterday had already been registered and were ready to be seen by us. Marissa ended up seeing a young child that had a weak and flaccid right leg probably following a febrile illness. Though polio has reportedly been eradicated here for several years now, I am always just a bit suspicious of this fact and tend to include it in my differential for an acute flaccid paralysis. The event happened some time ago, though, so it would not require any immediate treatment or reporting to the authorities, and it could also be just as likely, if not more, that this problem was secondary to an enterovirus. Regardless, there was little for us to do at the moment other than perhaps some physical therapy.

My office in Mang’ola

I believe it was Andrea who also had an interesting, though rather typical, presentation of Alzheimer’s disease in a not so elderly patient that had seen. Unfortunately, there is very little to offer these patients other than checking labs for reversible causes of dementia (HIV, syphilis, thyroid), though it is not that different at home where all we have to offer additionally are medications that only slightly delay the symptoms of the disease, but are not disease altering in any fashion. This is the holy grail of treating Alzheimer’s disease, a therapy that will in some way alter or halt the progression of the disease or even treat it before it is symptomatic, but it has yet to be found. Given the little we have to offer at home, it is even less so here in Tanzania.

We finished the day rather early and were able to see all the patients who had showed up in the morning. Our total for the morning was 29 patients and I learned later that another 15 patients has arrived wishing to be seen after we left for home. We were all starving as it was after 2 PM by the time we finished seeing patients and thankfully we were able to eat our lunchboxes prior to departing. The drive home seemed longer to me than yesterday’s, though I’m not exactly sure why. We had left ahead of the other vehicle and had managed to stay in front of them the entire way to avoid any dust. The road was just as bumpy as it had been before, and we arrived home well before the time we did yesterday. We had planned to go out to Happy Day again and possibly even the Golden Sparrow after that, but in the end, everyone was pretty beat from the two days of clinic in Mang’ola, so we ended up relaxing at home for the evening. Mike had a talk to give the following morning, so at least he had an excuse. The rest of us just worked on various personal projects before the exhaustion caught up with us.

Tuesday, September 17, 2019 – A new clinic in Mang’ola….

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The normal way we start our day….shoeing Andrea out of the house

As I’ve mentioned before, the neurology mobile clinics began in 2011, initially at the suggestion of Paula Gremely, a social worker who, with her partner, Amiri Barkari, were doing outreach in area and had been working with FAME on their week-long mobile clinics the Lake Eyasi region to provide medical care to the Datoga and Hadzabe in this very remote region of Northern Tanzania. I had been able to go on several of those clinics that had been funded by a Dutch non-profit, Malaria No More, to provide monthly clinics to this region for a period of three years. Paula had suggested that it might be worthwhile if she took me to some of the villages in the Mbulumbulu region of Karatu district to provide neurological care specifically. The first was in April 2011, to Kambi ya Simba and was very successful. We have continued to provide that clinic to Kambi ya Simba, which is where we were yesterday, though decided this year to forego our visit to Upper Kitete as patients from there can easily get to Kambi if they need to be seen.

The road to Mang’ola

Roadside scenery

We have continually looked for other sites to do our neurology mobile clinics, but it is not always as easy as it sounds as it must be done with the approval of not only the local health ministry officials, but also with the blessing of the local community. It is complicated and what may seem like a wonderful idea to us isn’t always how it seen by others and we must always be respectful of that so we can continue to work the way we do with the confidence of those we are trying to help. Our mission is not to provide what we feel a community needs, but rather to work with the community and to provide what they see as essential while applying our principles of practicing medicine. We must always remember that we are guests here and that it is essential that we are always welcomed, for without that, there can be no partnership.

The road to Barazani

The ditch blocking our entrance

This trip, the team at FAME had arranged for us to go to the region of Mang’ola which is east of Karatu near Lake Eyasi. The town of Barazani is the settlement there where we would be holding our clinic and I was really looking forward to this as we used to pass through this town on our way to the Lake Eyasi village of Gitamilanda, which is where we used to set up camp for the larger FAME mobile clinic several years ago. This is a region very much different than the areas surrounding Karatutown. As much as Karatu is like the frontier, Barazani is that and more. It is an outpost of civilization and an incredibly harsh environment where the principle produce is onions (acres and acres of them) that grow in the areas adjacent to Lake Eyasi which is a seasonal lake and mostly dry, but is very large. The Hadzabe, the last hunter gatherers in Tanzania, live in this region, still hunting with their bows and arrows, though the large game they have historically hunted is going away, leaving them to hunt only small birds, dik dik and baboons these days. They are a dying tribe with only 1500 members left and will likely not be around much longer. They are also one of the few remaining tribes who speak click language, a unique language used by a very small number of groups that are culturally diverse with little connection that anthropologists have found to explain the similar use of the unique language.

The Mang’ola/Barazani dispensary

The neuro team at the Mang’ola/Barazani dispensary

I had spent some time the Hadzabe in the past and they are an amazing group of people living off what is left of their original lands that they now share with the Datoga, who are herders, hence the issue with their game. The Hadza are bushmen and very culturally diverse than any other tribe in Tanzania. They are resilient, though only to a point, and once their game is gone, they will be left with nothing to hunt. It is a very sad thought to think of a dying culture in terms of extinction as it is not only their gene pool that will be lost, but their language and their way of being. I feel so incredibly fortunate to have spent time with them during my life, something very few people have gotten to do, and though it is unlikely that they will be gone during my lifetime, the knowledge of their trajectory still saddens me very much. I could not help to think about this with the loss of the Hadzabe woman that occurred the very first weekend we were here as they cannot afford to lose even a single individual without it affecting their tribe.

The clinic at Mang’ola

Dr. Annie making our morning announcement about what we see

So, today we were off to Mang’ola and Barazani to begin a new chapter in our neurology mobile clinic and to see what our reception would be there. But first, we had to make it there! I remember the road to Mang’ola being legendarily rough and treacherous with continuous washboards on the road (the rippling on the road caused by water running over it) and sometimes treacherous culverts where raging rivers would form and rip apart whatever semblance of a bridge or surface to cross had been there previously. I have several great stories about traveling this road in the past where we had to all pitch in and do road repairs in order for us to make it through some of these drainage areas. We had two vehicle again, which was very good as having to cram extra people in the Land Rover, some sitting on soda crates would have been even more uncomfortable for this long and bumpy ride.

A primary mode of transportation

The customary baby scale

I drove my group plus Dr. Annie and Angel, the latter knowing the directions as it had been so long since I’ve driven here. Describing what it is like to drive these roads would be difficult, but suffice it to say that it was 1-1/2 hours of pure concentration where you really couldn’t take your eye off the road even for a split second. The washboards were brutal and it is essential that you maintain your speed (usually about 50 kph, or 30 mph), otherwise they become bouncier and you just have to get up to speed again. Often, there will be a desired track that will be less rough, but it is not always obvious, so you are continually driving to either side of the road to see if you can find a smoother route. The roads are heavily crowned to prevent erosion, often with large drainage ditches on either side that would be catastrophic to run into. It also means that driving on either side of the road leaves the vehicle at a fairly steep angle that doesn’t bother me, but the others have to hold onto their seats to keep from falling off.

Yohan registering patients

Leah and the building that we saw patients in

Some portions of the road are incredibly rocky, most often the descents into and ascents out of the very deep culverts that essentially dry river beds which we continually cross during our journey. I’m frequently downshifting for the steep incline into and out of these culverts and to slow down over the rocks or just in trying to avoid the many huge holes that pockmark the road throughout. With all of this, though, the drive is strikingly beautiful during its entirely and the scene as we come over each and every rise seems more so than the one before it. As we arrive to Barazani, the entire upper valley containing Lake Eyasi comes into view and is stunning. There are lots of people here, perhaps more than you’d imagine given the remoteness of the area and the drive we’ve just taken, and they are all walking about taking care of their normal daily business.

A hallway in our clinic

One of our exam rooms

As we drive up to the dispensary, there are workers digging a ditch that we can cross at only a single point just wide enough for my Land Rover, thankfully. The clinical officer and nurses at the dispensary are waiting for us and were incredibly happy to see us which is always a good sign given that we had never been there before. They were welcoming and gracious and immediately asked how they could make us most comfortable in setting up our exam room and brought desks and chairs into each room for us. We had three rooms to start plus a vitals room, the latter later being used as another exam room once everyone was “vitaled” and registered. It was very clear from the outset that we had many patients waiting to be seen which required that we would come up with a maximum number of patients for the day and see what there was left over. We did have options for the overflow, though, in that our clinic the following day at Mto wa Mbu had been cancelled, allowing us to come back if we chose to and if that would be OK with the dispensary. The other option would be for patients to come to FAME, but that would be a hardship for most. In the end, we decided to return on Wednesday, meaning that everyone would be subjected to that lovely (a bit facetiously) drive again the following day.

Marissa and Revo seeing a young man and his mother

Andrea and Annie evaluating a patient

Dr. Annie and Angel again addressed all of the patients at the beginning of the clinic regarding the fact that we were neurologists and went on to describe exactly what it is that neurologists treat. The set up would essentially be the same as it was at Kambi ya Simba in that we triaged the patients who then had to wait to see us, sometime most of the day. The patients were, for the most part, excellent neurology cases with the standard fare of kichwa (headache) and dege dege (epilepsy), while there was also the smattering of sensory loss and then there were a few puzzling cases that took much more thought.

Leah scribing for Kyra and Abdulhamid

Definitely a closet pediatrician

Meanwhile, we had left Ray back at FAME as he was flying home this day, but didn’t need to leave for the journey to the airport until about. 3pm. Ray was giving the. Morning educational talk, which he chose to do on somatic disorders as they are just not recognized and treated well her for reasons I mentioned early. After that, though, they had him see a patient in the ward who had weakness in his legs for about a week or so. Ray felt the exam was most concerning for a cauda equina syndrome (where there is compression of the spinal roots in the lumbar region) and did have them do a CT scan, but didn’t see anything obvious and the diagnosis wasn’t entirely clear. They then found two outpatients for him to see, as well, which was fine keeping him busy, though knowing Ray, I think he was very anxious to get to the many other tasks he had that included reviewing medical student applications for residency that were just becoming available. He saw the patients happily (he was in his element here as the master diagnostician that he is) and had no problem making his departure for the airport.

A zen listening the residents

Of patients that we had in Barazani, there were two that stood out perhaps, and one was a patient in his 20s with epilepsy who also had what appeared to be significant cerebellar dysfunction. It had a been a progressive course such that he was mostly disabled at this point and there was little question that he probably had a metabolic or mitochondrial disorder that we would be unable to test for here nor would we be able to treat other than symptomatically and make sure that his epilepsy was under good control. The other patient was a gentleman who had a patient of sensory changes involving his upper extremities that most likely represented a somewhat asymmetric syrinx as this was the only way we could put him together. I believe that he had suffered some trauma in the past, but regardless, this wasn’t entirely a necessary component as a syrinx can certainly occur spontaneously in some patients.

Dr. Mike with a new friend

We finished our day here rather late which meant that some of the drive would occur in the looming dusk and darkness, a very difficult time to drive here and especially on that road. We had ended up seeing 42 patients, a record I believe for a neurology mobile clinic. I made sure that I repeated told the clinical officer and the nurses how much we had appreciated their assistance and how thankful we were for them allowing us to see their patients. We would be back first thing in the morning to see the remaining patients that at the time were in the low 20s.

Leah’s birthday cake from Happy Day

Making the best of no candles – with lit match

The drive home seemingly went much quicker to everyone’s delight, though it was already dark when we arrived back to Karatu. We dropped the other team members off in town and drove up to FAME, all of us incredibly weary from the long day in Barazani. It was Leah’s birthday, though, and I had called Katherine earlier in the day to have her order a cake at Happy Day, which she did, and brought it over. Everyone was showering at the time so Leah didn’t see it delivered and was genuinely surprised when we brought it out later for her and sang Happy. Birthday to her. It has been a great day in clinic, though exhausting, and after cake and celebration, I think everyone, including me, went to bed a bit early.

Monday, September 16, 2019 – It’s off to Kambi ya Simba for the day….

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The third week of our clinics here in the Karatu District have traditionally been reserved for our outreach clinics, or mobile clinics, to some of the local villages around Karatutown. The neurology mobile clinics began back in 2011, with clinics primarily to the Mbulumbulu region of the district, but have grown now to include other villages. We have managed to continue them despite limited funding and it has only been through the help of FAME as far as staffing. The clinics are announced in the villages where they will be held, similar to what we do for our clinics on campus, and the outreach coordinator/social worker will usually return again to the village weeks prior to our arrival to remind them of the disorders that we treat. The clinics are limited to only neurology patients as that is our primary purpose here and we are not interested in alienating the clinical officers and nurses who are staffing these dispensaries on the daily basis when we’re not there.

Kambi ya Simba

The team that we bring is large and over the last several years, we have required two vehicles for each of the clinics. We bring our entire group (myself, the residents and medical student, as well as Ray today), one clinician from FAME (Dr. Annie), our two Tanzanian medical students who have been acting as interpreters (Abdulhamid and Reivo), a social worker (either Angel or Kitashu), a nurse/pharmacist (Patricia or Yona), and a registrar (Yohan) to take care of registering the patients. We bring a large Rubbermaid container of medications with us for most neurological disorders including antihypertensives. In additional to the announcements made in advance regarding what types of symptoms we are willing to see, Dr. Annie will address the group of patients to let them know what we do and what we will see. The cost of being seen is identical to that at FAME, 5000 TSh, or just over 2 dollars, and includes the visit with us and medications. We are unable to do lab tests on site, but give the patients a prescription for the labs so that they could travel to FAME to get them and would not be charged an additional amount.

Waiting for our clinic to start

Our neuro team

Kambi ya Simba, or Lion’s camp, was the first site of our mobile neurology clinic and, back in the beginning, it was only me with a clinical officer, a nurse/pharmacist, Paula Gremley (who had her own non-profit for provided these services), and Amiri Bakari (Paula’s business partner) who drove us everywhere. We also went to the village of Upper Kitete which was further out on the escarpment, though still in the Karatu District. The Mbulumbulu region is inhabited primarily by the Iraqw tribe and the area is quite fertile and good for planting. For the last eight years, we have done various combinations of clinics at these two villages in addition to some others, but the numbers had been dwindling at Upper Kitete, and so it was decided that we would only go to Kambi ya Simba for this trip and patients would have to travel there if they wished to be seen by us.

Kitashu and Dr. Annie giving instructions to the patients including what ailments we see and those that we don’t

The dispensary/health center at Kambi ya Simba has had an interesting evolution in that the very first clinics here were held outdoors in a field where we would set up a desk for me to sit at and write while the “pharmacy” was another desk set some distance away. This was not at all an issue and it seemed to work quite well for both us and the patients. Several years ago, though, the health district decided to begin building a much more expansive health center at Kambi ya Simba that eventually warranted a visit from the Tanzanian Prime Minister. The health center today comprises numerous buildings and wards and is still expanding. Most of the facilities have not yet been fully utilized, but I am sure they will in the near future. There is a very large population in this area that would certainly benefit from a greater access to closer health care, though it is not difficult to get to Karatu from this region if needed.

Some of our early patients

So, we began our week of mobile clinics by setting off to Kambi ya Simba with our two vehicles, medications, and support staff for the 45 minute drive to their health center where our clinic would be held. This will be my 17th or 18th visit to this village for neurology mobile clinic so that I know the road very well at this point. When we arrive, it is usually customary for either Kitashu or Angel to speak with the clinical officer in charge to make sure that we are still welcome and the find out what the arrangements will be in regard to the number of rooms that we’re given. It usually depends on whether they are having their own clinic there that day, which they were today, and therefore we were only able to utilize two rooms as opposed to our hopeful three or four. With two rooms, the day would go a bit slower and we had enough patients that we weren’t able to finish and depart until later than we had hoped for.

The announcement of our clinic

Ray was able to accompany us today and since it was his last day working with us, he opted to staff most of the patients that were seen, though I was able to snag a few. The bulk of our patients here had headaches of various types, but none that were concerning enough to warrant further evaluation with other testing. Depending on other symptoms and comorbidities, many of the patients were placed on amitriptyline which is our main chronic headache medication here. Those who work with me are well aware of my being very partial to nortriptyline rather than amitriptyline due to its far less anticholinergic side effects, but unfortunately, the former is more expensive here in Tanzania for some inexplicable reason.

Ray staffing a patient with the residents

As is often the case with patients coming to see us for what are felt to be neurologic symptoms, their underlying problem turns out to be of a more psychiatric nature. The same is true for our patients at home. Anxiety most commonly presents with symptoms that are felt to be of a neurologic basis and then there are the psychosomatic illnesses such somatic symptom disorder and conversion disorder, both illnesses in which symptoms that are believed to be physical, are actually of a non-organic cause. Probably one of the most consistent conditions in this realm that we see both at home as well as here, are the non-epileptic events, or what used to be called pseudo seizures. We see these frequently here as we do in the US, and they can often be very difficult to treat in the long run, though they can frequently resolve over time. These disorders seem to be very difficult for non-neurologists to diagnose and manage and Ray is actually planning to do a lecture on the topic tomorrow morning for the FAME staff. The biggest issue in making the diagnosis, as Ray so deftly noted when we were discussing is lecture, is that you must first feel totally comfortable with your ability to make a neurologic diagnosis before you are able to rule out one.

Caught dozing….

So, several of our patients had symptoms of either depression or anxiety that we wished to use either an SSRI or SNRI medication for, but unfortunately, we discovered that FAME had actually run out of fluoxetine, which we were unaware of, and that we actually hadn’t brought the venlafaxine with us. This was a significant problem for us as we had wanted to put two women on fluoxetine for their anxiety during our morning clinic, but did not have the medications with us to give them. Luckily, there was a patient from Rift Valley Children’s Village who had been sent to FAME to see us, and when it was discovered that we weren’t there, they sent the patient over to Kambi ya Simba to see us instead. We asked if the vehicle from Rift Valley could possibly bring the two women to FAME when they left as it was on their way back home and, that way, the women could pick up their fluoxetine that we had prescribed them since we’d found out that it had been delivered that morning and was now in supply. Things often happen this way in Africa, and it is all a matter of taking advantage of the situations that you’re presented with rather than restricting yourself to those that have been planned. If you sit around waiting for those moments exclusively, you’ll miss tremendous opportunities in life. The two women traveled to FAME for their medications and would return later on the bus, but would otherwise not have been treated which would have been a shame.

Teddy’s dress shop

The rest of the clinic went smoothly, other than the fact that we ran later than we had anticipated given the fact that we only had two rooms in which to work and, though we weren’t necessarily swamped, it was still a long clinic. We finally departed around 4:30 or so which would put us in Karatu at bit after 5 PM and we had hoped to pick up the clothes that everyone had made by Teddy, a seamstress that we’ve used on the last two trips and everyone has been exceptionally happy with her work. I texted her to let her know that we’d be a bit late getting into town and, of course, she said that she’d be happy to have us stop by whenever.

Mayhem at Teddy’s seamstress shop

Knowing that the visit would not be quick as everyone would want to try on their new clothes, I prepared Ray for the extended visit. As expected everyone was incredibly happy with the work that Teddy and her other seamstresses had completed and the most impressive work was the short sleeved jumpsuit that Mike had made for himself. It’s certainly a unique piece of clothing to be sure, but I’ll have to admit that I was incredibly impressed with the style and fit. By the time we got home that evening, I think everyone was exhausted following the busy day and upon returning home, it seemed that everyone was appropriately exhausted and ready to hit the sack. Tomorrow morning, we would be traveling to a clinic that was much further and would have to leave much earlier than we had today, It was off to bed to make sure that we all had enough rest before hitting the road once again tomorrow for a very early departure time of 7 am.

Mike tries on his jumpsuit at Teddy’s shop

Mike’s new jumpsuit

 

Sunday, September 15, 2019 – A day in the Crater and a visit to the Crater Lodge….

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Mr. and Mrs. Ostrich

The morning was very overcast and cold as we left in the near darkness of 6:15 AM. The gate to the Ngorongoro Conservation Area (NCA) opens at 6:30 and I had hoped to be there shortly after they opened so that we would be in the crater itself as early as possible. As much as the gates for the National Parks are guarded, it is even more so with the NCA and the Crater (they are a separate administration from the parks) such that getting in or out of the NCA, and, even more so the Crater, requires that all of your paperwork is in perfect order and even then, it may require an act of God. I have had countless delays sitting at the entrance gate at Ngorongoro waiting not only to be cleared to enter, but also at times waiting to get out.

Up close and personal

This morning, we must have had someone looking down upon us from afar as we were through the gate in record time and on our way up the crater rim heading towards the overlook which is the first glimpse of the crater one sees when entering the park. Unfortunately, and as is often the case, the clouds had completely engulfed the higher altitudes of the crater rim to the degree that there was almost zero visibility. As we rose higher and higher, winding our way towards the rim road, the clouds became more and more dense. As we reached the overlook, it was readily apparent that there was absolutely no way that we were going to see anything of the crater for some time to come, and for that matter, we were not going to see anything of the road, as well. I’ve driven here a number of times in similar weather, but it was becoming very difficult to even see the road in front of us, let alone the fabulous views that normally make this a spectacular drive. The windshield misted up several times which created a muddy mess with the dust being kicked up from other cars that were a long distance in front of us, causing us on two occasions to stop and pour water on the windscreen to wash it. Had I been able to stop more, I would have, but it was even difficult to see a turnoff until you were completely upon it.

A crowd with the lions…

The hippo pool

We eventually made it to the backside of the crater rim road overlooking the Serengeti in the distance and the clouds seemed to lift along with the visibility. The views on the backside are just spectacular and even with the clouds in the distance it was still amazing. I wasn’t worried that they would be missed by the others, though, as they would all be back here in a week on our way to the Serengeti and it would be midday. All except for Ray, that is, as he would be flying home on Tuesday as scheduled. He will just have to come back another time to see these views and hopefully he will do that.

A group shot at the lunch spot

Andrea taking her turn at the wheel in the crater.

Access to the crater is via three roads – a single one-way descent road, which we would be taking, a single one-way ascent road, and a single two-way road. As we exited the main road and turned onto the access to the descent road, the full view of the crater lay before us in all its stunning glory and it was the first glimpse that everyone had of this very deserving UNESCO World Heritage Site which is the largest dry volcanic caldera in the world. The crater is over ten miles in diameter with sides that are 2000 feet all around and enclosing a complete ecological zone in which the animals remain year round and do not migrate. It is also home to numerous lion prides and the endangered black rhino that has been making a comeback with the help of a very aggressive antipoaching program. As I was checking in at the ranger kiosk, the others popped the tops on the Land Rover and we were ready to begin our descent into the crater and what truly seems to be another world altogether. The road is incredibly steep and thankfully one way as we wind our way down to the crater floor alongside precipitous drops and the candelabra trees rising up about the edge of the road from time to time. Groups of black specks down below represent the many herds of wildebeest, zebra and Cape buffalo that occupy this vast ecosystem.

One of the rooms at the North Camp and the local zebra

A selfie at the Crater Lodge

Once on the floor and crossing alongside Lake Magadi (which means “soda” in Swahili) with all of the wildebeest and zebra on both sides of the road, we immediately spotted two lions tracking parallel alongside the dry lake shore. All of the wildebeest and zebra were lined up watching them incredibly intent, though it was quite unlikely that they would have anything to worry about considering the lions had lost any chance of surprise which is what they really need for a hunt as they are very short sprinters and tire quite quickly if they have to run any distance at all. There were also two ostriches that seemed almost unaware of the lions on the lakebed, but again, it was quite unlikely that they had anything to worry about either as lions rarely attack ostriches due to their sharp claws and very, very strong kicks from their legs that could easily injure them. The lions merely continued their journey across the dry lakebed seemingly unaffected by anyone who was watching them, man or beast.

Walking up to the lodge at Tree Camp

Driving in the crater is actually rather easy as all the landmarks are fully visible and it is nearly impossible to become lost anywhere on the floor. The roads within the crater crisscross the area and are diverted only by Lake Magadi, several large marshes and a river that meanders close the crater wall near the two-way road. It was very dry in most of the crater, yet there was plenty of wildlife to be see throughout. Unfortunately, the one animal most hope to see in the crater, the black rhino, was nowhere to be found today for two reasons. First, there was little vegetation for them to eat in the center of the crater nearer the lake where they are normally seen meaning that they were keeping very close to crater wall where there was plenty of food for them and where none of the roads run on that side. The other reason has to do with the rhino’s poor eyesight . The rhinos rely entirely on their hearing to detect threats (yes, rhinos are nervous nellies) and today was a rather windy day for its entirety. When it is windy, the rhinos tend to stay on the wall in the denser vegetation where they are safe. It took me several trips to Ngorongoro before I finally saw one and even then, it was at a far distance. They remain one of the more elusive of the animals to see here and the most elusive of the big five – elephant, Cape buffalo, lion, leopard and, last but not least, the rhino.

Ladislaus at the Tree Camp

Ladislaus addressing the goup

It was fairly crowded with vehicles today and at one point, we came upon a group of female lions in the grass that were being watched by no less than a dozen of vehicles. The trail where they were was passable by only one vehicle and with drivers coming from both sides, it created a considerable traffic jam that required maneuvering off the trail which was easier said than done given how sunken the tire ruts were from use. This meant that negotiating my vehicle out of the ruts required a major effort and some excitement for the passengers when tipping precariously sideways even though we far from reaching our limits. Vehicles were maneuvering to either side of the road and in either direction so, needless to say, there was a bit of mayhem. Everyone, though, was quite polite and there were no tempers flaring. Each driver is trying to give their guests the best possible experience on the game drive as this will be reflected in the tip the guide will receive at the end of their tour. I would never want to interfere in another driver’s opportunity to improve his lot in this manner.

The lodge at the Tree Camp

We had lunch at our typical lunch spot and, as usual, it was simply gorgeous there alongside the small lake with the marshes in the distance. There were many hippos here, but only two that were separated from the main herd and were wallowing in the shallower water near the shore adjacent to the bathrooms. We ate in the vehicle which is the standard here as there are black shouldered kites that are very adept at spotting a sandwich or piece of chicken in someone’s hand from thousands of feet above and then swooping in silently to snatch whatever it is that they’ve targeted, all without touching their victim, but scaring the hell out of whoever is on the receiving end of high speed heist. Every once in a while, some unsuspecting person will completely neglect the instructions they were given by their guide and ventures outside to eat, only to be bombarded from the sky by these rather effective bandits.

Me and Ladislaus posing

I had this happen to me once before when we were traveling back from the Serengeti and stopped for lunch at a picnic site high up on the rim. We were all sitting on wooden logs eating our lunch while keeping our eyes on two very creepy looking marabou storks that were definitely stalking our food and just waiting for a chance to steal something. We had some very nice lunch boxes that had been supplied to us by the camp in the Serengeti when we departed. I was just in the process of taking a bite of my grilled chicken with the piece several inches from my face, when suddenly this big dark shape appeared in my peripheral vision and before I knew it, my chicken was long gone, lodged in the talons of a huge black shouldered kite who had just found their lunch. I turned to Neena Cherayil, who was sitting beside me and witnessed the entire encounter, and calmly said, “that bird just took my chicken.” Having been long accustomed to their practice in the crater, I hadn’t suspected that they were also on the rim performing the same antics, but I learned my lesson well and went just a little bit hungry having lost the favorite part of my lunchbox.

A group photo on the veranda at the Crater Lodge

We had had a wonderful day in the crater, albeit without having sighted the elusive rhino, but we had seen a dozen or more lions, lots and lots of wildebeest, zebra and Cape buffalos, numerous hyenas including a large family den, jackals, and much more. I think everyone felt as though they had seen quite a bit and we were all exhausted. It was time to make our way up the ascent road and out of the crater proper. We had plans to visit a friend at the Ngorongoro Crater Lodge who had invited us for a tour and coffee. This is probably the most expensive and most exclusive lodge in the Ngorongoro region if not all of Northern Tanzania and we were all looking forward to a visit there.

The crater floor from the veranda

Ladislaus is the sommelier at the lodge and I have known him for several years. He is a wonderful individual and had been looking forward to showing us the lodge for some time. We parked the Land Rover and then walked down to the main lodge building of the North Camp. The lodge has only 30 rooms that are distributed among three camps – North, South, and Tree camp, with the latter being the smallest with only six rooms and a distance down the crater wall from the others. We first had coffee and hot chocolate with homemade chocolate chip cookies at the main lodge of the north camp before hopping on two golf carts to go down to the tree camp. This lodge was also gorgeous, though less formal than the other, with a live tree in the center traveling up through the entire building. There is an unobstructed view of the entire crater from both inside and on the veranda and we took lots of photos from there. Full length windows in each room adorn the bedroom and bathroom opposite the bath so the views of the crater are constantly present. Ladislaus offered us some drinks and we sat there enjoying the glorious views to the crater floor, some of us with beer, some with wine and me with my Stoney Tangawizi (I had to drive us back home and this is merely a strong ginger ale made by Coca-Cola here.

Me and Ladislaus posing

It was so incredibly relaxing, sitting there in the lodge with the wonderful views, amazing company, and enjoying our drinks, though each of us knew that it would be highly unlikely that any of us would ever be able to stay here due to the cost. For what you get here, though – each room has their own personal butler, unlimited wine and alcohol, and, essentially, a fully tailored experience – the cost seems appropriate whether we’re able to attain it or not. Still, it was a wonderful opportunity for us to see this historic lodge that has been here since the country had gained its independence.

Ladislaus commented he felt like an impala with his harem

A group photo at the overlook

Upon leaving the lodge and getting back onto the main road, who did we bump into but Kitashu, who was waiting at the bus stop to catch a ride home after spending time over the weekend with his brother who got married. We had him hop in the vehicle for a ride down to town, stopping at the overlook on our way as it had been totally fogged in earlier in the day. We were all starving and decided to have dinner at Happy Day along with Kitashu. It had been a very long day and relaxing before dinner with some drinks was what we had all needed. Any restaurant here takes a minimum of 45 minutes to get your food, so there’s plenty of time to relax and share stories with friends, which is what we did and all very much enjoyed the evening.

Kyra, and the cat, in heaven at Happy Day