Though having arrived here only several days ago, three to be exact, and having had only two full days of time to explore this amazing place, I had become incredibly fond of it along with our hosts, Enock and Amina, who had made my visit such a memorable one. Knowing that I would be back to visit again one day certainly made it easier to leave, but having worn nothing but shorts, a T-shirt and sandals, or sometimes not, while here would certainly be greatly missed. Having had absolutely no idea of where we were heading on Saturday had made it even that much more special than it already was and I would always recall these days as some of the finest I had experienced.

It was our last morning here and we had planned to leave shortly after an early breakfast so as not to get home too late for it would be another long drive to Moshi and then to Arusha. We enjoyed another meal in our little restaurant with plenty of coffee and fresh fruit along with some incredibly delicious French toast that they made for us special that morning. It couldn’t have been more special. We did have to settle up our bill, of course, and made sure to count up all of the beers we had consumed over the previous days along with our room and board. The cost for the four of us had been ridiculously inexpensive considering what we had gotten and I made sure to pass on a very nice tip to them for their wonderful hospitality.

After breakfast, we packed our bags and put everything in the Land Rover including the large cooler full of fresh fish save for the ice that we would find in Pangani on our way out. We departed just after 9:00 am, having said our goodbyes to everyone at the Ushongo Beach Bandas that had made our stay so memorable. As we left, we along the little path through which we had entered, hardly wide enough for our vehicle to fit, and needing several bicycles and a motorbike to move before we make it entirely out. This is a region of the coast that still remains mostly undiscovered and the lives of these villagers continue to be untouched by outsiders for the most part. It is extremely remote and difficult to access for anyone other than those who know the area, such as the few ex-pats from Arusha who maintain the few vacation homes here, or those such as me, who are lucky enough to have friends that introduce it to them.

We crossed back over the ferry and went in search of ice in the town of Pangani. It didn’t take long at for them to find it, though, and after completely unpacking the fairly bloody wrapped fish and then repacking it again with the ice, we were on our way, taking the shortcut again over the hills to get back to the main road on our way back to Moshi to pick up Turtle where we had left her at the Keys Hotel for safe keeping. We passed the Usambara mountains once again, as well as the North and South Pare, stopping briefly to get our lunch at the same service stop where we had been on Saturday. We pulled into Moshi as the sun was just barely still in the sky and began our drive home to Arusha in the two vehicles. There were fires that had erupted on Mt. Kilimanjaro and, as the sun began to set, the sky turned a brilliant golden orange from the smoke and particulate matter that filled the air.

We arrived home to Arusha, exhausted from the long day of travel, shortly after sunset, and all had dinner together after unloading the vehicles and dividing up the fish for everyone. I was leaving tomorrow night fairly late and had planned to have lunch with some friends, so wanted to head to bed early enough as I would need to repack my bags in the morning and ready everything for the flights home. It had been a truly remarkable visit for the month and, given the uncertainties of the pandemic, I had managed to work with several incredible clinicians who will go on during their careers to appreciate neurology that much more and we had seen many patients whose lives would be changed forever by the care that they received from their Tanzanian caregivers along with my assistance. I had managed to share some very meaningful experiences with my Tanzanian colleagues that had included our goat roast with Kitashu and our safari to Tarangire. I had spent time with my true friend, Daniel Tewa and his family, and had even done a house call with Daniel to visit a friend of his who had suffered a stroke. And finally, my short visit to the coast and the Ushongo Beach Bandas with my good friends had capped off this trip in a fashion that I have come accustomed to when visiting this country that I have come to regard as another home.

Given the incredible day we had yesterday, our plans for Monday were somewhat less ambitious as we had decided to spend most of the day at the resort and around Ushongo Beach with no plans for any further ocean adventures. Despite my still very painful ribs, I had managed to sleep, albeit with the assistance of some hefty doses of naproxen, and chose to spend a few extra minutes in bed rather than get up for the sunrise again. Leonard had wanted to scout around for property in the morning with the idea of perhaps someday building a small resort similar to the one we were staying in as he has been quite familiar with this beach for many years and always felt that it would be a perfect place to end up someday.

So, after another fantastically scrumptious breakfast in our little restaurant where it seemed like we were the only guests there most of the time, the four of us began our tour of the beach area both to the north and south of Ushongo Beach Bandas along with the help of a friend of Leonard’s who knew the area well. As we walked along the beach, there were several smaller resorts that were close by, as well as the Emayani Beach Lodge, a larger and more luxurious resort, though all of them were closed due to the lack of tourists given the ongoing pandemic. As I had mentioned earlier, though, the presence of COVID had been essentially non-existent during my time here and though we certainly weren’t hugging and kissing as is the usual custom here, there were no masks or social distancing being practiced either.

The Emayani Beach Lodge is a lovely resort that is owned by ex-pats Annette and Peter who also own the Tarangire Safari Lodge, and they have known both Frank and Susan for some time as Frank has been providing their workers with annual physicals since the beginning and they also send anyone ill to FAME for medical care. The main building of their lodge is a beautiful open structure that is used primarily for lounging and drinks and, I suppose, also for meals when the guests are there. Their rooms surround the main building on either side. We spent time walking through many of the properties, both waterfront and inland, and I, all the while keeping my eye out for any poisonous snakes crawling in the brush or in the trees, such as the deadly boomslang, one of the deadliest snakes in the world, whose venom is usually deadly in a very short time. Having now visited the Indian Ocean and seemingly paradise, it was not my intention to finally discover one of these creatures the hard way. Being a snake lover from a very young age, I have always looked for them wherever I’ve traveled in Africa, but have thankfully seen very few up close for there are some very deadly species here including many types of cobra, green and black mambas, numerous species of viper and then the boomslang.

We ventured back to our bandas around lunchtime and discovered that Enock and Amina had made us a huge plate of prawns in addition to our fresh fish and chips that were being served. The prawns had been cooked in garlic and lime juice and were just so incredibly tasty, but once again, it was left to Jones and me to share almost the entire pile of prawns as Leonard and Simon, though they did try them, were just not big fans of eating shellfish once again. We all had times for naps after lunch, having tired from all the walking up and down the beach in the morning, and later spent time with one of the fisherman who had brought his fresh catches to us once again both for dinner and to bring home. As he would sell the fish by the kilogram, Enock had to bring out his fancy balance scale to weigh everything. We chose what we would have for dinner and also what the other three would be bringing home with them, which did end up being quite a bit.

After the naps and all of the fish purchases, we decided to drive to Pangani for the day as I had really wanted to walk around the town a bit and explore. As we drove up along the opposite side of the river to the ferry landing, there were lots of locals on foot as well as several smaller trucks and vehicles already waiting for the ferry, which I suspect is on its own schedule, plying back and forth across the river the dawn to dusk. The fare is very little, for both passengers and vehicles, and all passengers have to pay separately from their vehicle regardless. Only the driver is allowed to ride within the vehicle for safety reasons according to my travel companions. On this occasion, we had decided to leave our Land Rover behind as we hardly needed it to walk around the town, which was only several blocks long, and we would save perhaps a dollar on the fare. We did have to find a willing shopkeeper, though, to keep an eye on the vehicle for us, as breaking into vehicles here, mostly to steal car parts is not too uncommon.

The initial look and feel of this town is one that seems to mostly reflect its earlier prominence in the region with many waterfront buildings that I am sure were once the center of activity, but are either no longer occupied or have been converted into other uses. Close to the ferry landing, there is a modern bank, but beyond that and the waterfront buildings that are ghosts of their former selves, there is very little to separate Pangani from any number of the other little villages you encounter while traveling. We initially walked down the street that paralleled the waterfront and was one block away as it seemed to have the most commercial activity with little street side shops selling just about everything. I remember that we had needed a cooler for all the fish and, sure enough, we found one quite quickly at one of the shops and decided to pick it up on our way back through town. We walked all the way to the east end of the town where the river fanned out into a very large area and the beach at the mouth seemed to go on forever.

We had been hoping to find someplace to have a beer, but had really seen none up until now, but heard the faint sound of music in the distance and eventually followed our ears. Sure enough, there was something that was certainly local club at the end of the road and adjacent to the beach that looked like a hangout for sailors and fishermen from town. We each ordered a beer and sat out back in these really funky benches that had fishing nets for backs, but were surprisingly comfortable, and watched locals walking across the incredibly wide beach down to the water. As we sat, the small outrigger fishing boats, called ngalawas, were all making their way home, with only their sails visible at first behind the small dunes of the beach until finally their hulls and passengers revealed themselves as they entered the river to our right. The lighting was lovely and their day, as was ours, was coming to close and it was time to head back to the ferry. We picked up our cooler at the shop as we walked and turned the corner to the ferry dock to wait for the next boat to dock and board.

The drive back to Ushongo Beach, through the small towns we had now seen several times, seemed to be quicker than the other night and we had much more light with which to see. I had bought more lobsters from the fisherman and was looking forward to another incredible dinner. We were planning to leave tomorrow morning after breakfast and I knew that I was going to miss the food here. After dinner, I spent the evening on the beach with the crabs and an incredibly clear sky chock full of more stars and planets than you could ever imagine. For many, many miles there was no artificial light to spoil this amazing view of the heavens above and it seemed as though I was there alone to witness this miraculous sight, save for the crabs. They were there, sharing this near religious experience with me, scurrying across the sand by the many thousands, feeding on what the rippling shallows would bring them, just as they have done for millions of years before. It was surely another day in paradise.

I had truly left Moshi and the Kilimanjaro region with little in the way of expectations and our drive to the shore had been a real adventure for me, traversing regions of this wonderful country that I had never seen before. Our journey the evening before had also been a wonderful drive through an increasingly more tropical landscape that provided an excellent clue of our final destination for the sun had long since set by the time of our arrival. I had been given my own bungalow, or banda (not to be confused with the form of Mexican music but rather a thatched hut in Africa), for the night and had slept quite soundly with the gentle sound of the ocean and thankful lack of mosquitos that were fended off by the netting that hung over me. I had planned an early rising to check out the sunrise here and, given that I hadn’t even seen my surroundings yet, I arose with the anticipation of actually seeing where we had been deposited after our six plus hour trip the day prior.

My banda sat on the beach only yards from the water and though there was still plenty of time before sunrise, there was more than enough light for me to see and verify that we were actually on the Indian Ocean, with its broad expanse of bright blue water stretching far to the east. I had pictured this moment in my mind during the night, but stepping out onto the sand and having it right there in front of me was a sight to behold. I was on a lovely tropical beach with nary a soul to be seen and the soft sand felt quite cool between my toes in the waning hours of dawn. I was certain now that that we had truly arrived in paradise and the following days would only serve to further that conviction. I wandered down to the water with my camera (which took all of about 10 seconds or less) and watched as the soft glow of the rising sun first lit the horizon and the clouds above in wonderful muted hues of orange and yellow, while still not fully declaring itself to the world at hand. Almost reluctantly taking a peek from the distant lands it had brightened only moments earlier, it then began to slowly rise with a concert of colors and then an explosion of light in only a matter of minutes. It was a sight to behold.

With the gradual parade of daylight, I began to notice all of the small boats that were slowly coming home after their night at sea. These were the lights I had seen the night before that were far off in the distance scattered across the dark horizon that was only marked by their presence. I came to discover that these were the sardine fisherman who spend the entire night on the water in their rickety boats, illuminated by large lights hung over the sides to attract the tiny fish soon gathered up by their nets. I grabbed my camera and decided to stroll up the beach to where they were all coming ashore and the residents of the tiny town were meeting them to offload their silvery cargo. It seemed as though absolutely everyone was out on the beach that morning to claim their portion of the catch (which I later learned was purchased by the women who would cook and package the sardines for sale at the market) and numerous cooking pots were set up for them to cook the tiny fish after sorting the gigantic piles into the sardines and any other unfortunate critters that may have accidently been swept up in all the commotion. It was a family affair as children were there pitching in with the duties, that is, when they were not running around and playing with each other. I strolled amongst the groups, with mostly woman doing the work, all dressed in the marvelously colorful patterns that I have so come to love about Africa, for it almost defines a great part of the culture here.

I spent a good hour there just taking in all the sights of this incredible village and it’s lovely people, not once feeling as though I was an outsider, though knowing full well that I was. Thankfully, this is not a touristy place as there are few resorts here and most of them cater to the ex-pats living in Arusha or Moshi. This is not an easy place to find or to get too, so I was very comfortable knowing that we were well off the beaten track and that those who come here do so very intentionally just for that reason. I had Leonard to thank for introducing me to such a magical place and I looked forward to exploring more of it over the next several days for we had only just arrived.

The sun had now fully engaged with the coming day and its intensity was something to behold as it began its steady climb in the sky. As much as this natural clock had let me know that the day was now upon us, my own internal clock began to chime with hunger pangs and I was definitely ready for some breakfast, or at the very least, a good cup of coffee. The sun was now well into the sky, but the temperature remained incredibly delightful as I wondered over to the little restaurant/bar that would serve as our dining area for the next several days. It was a small, thatched roof building that was open on the ocean side (again, only yards away) and, in addition to the six or so small tables and accompanying chairs, there was a bar and a cooler packed with beers. As we had discovered the night before, the locals from the nearby village and homes would suddenly appear from the surrounding dark to enjoy the evening together and even some dancing. They also dropped in throughout the day to socialize and catch up on any local gossip or news.

I sat down at one of the tables with my book in hand and no real expectation of any service until the others had awakened, but as soon as I sat, both Enoch and Amina, our hosts, seemed to appear out of the shadows (in reality, they were in the little kitchen building next door) and ask me if I’d like some breakfast. As all who know me, that is not a question that needs to be asked of me more than once (as Jon Rosenberg will gladly attest too, I am certain). They took my order for eggs, brought me some coffee in a big thermos (the standard here) and went back to the kitchen to begin working on breakfast for me. What appeared after a short time was, in reality, a feast fit for a king that included eggs, toast, fresh juice, hot peppers (very hot!), and more fresh fruit than you can possibly imagine. It was all incredible and, after I had finished, I just sat and relaxed with my book (King Leopold’s Ghost – highly recommended book on the atrocities committed in the Congo by the King of Belgium at the turn of the century) and continued to work on the thermos of coffee that seemed to be calling my name. Pure, unadulterated bliss in paradise.

As we were on absolutely no timetable here, it mattered not when the others finally appeared, but they eventually did and made their way to breakfast for an equally filling feast as I had enjoyed while I continued to relax with my book. Not far off our beach was Maziwe Island Marine Preserve that is a popular snorkeling site as there is a reef that surrounds the island and no scuba diving is allowed to further protect the reef from becoming a popular dive site and risking damage. I had wanted to visit the preserve, so we had spoken the night prior with one of the local guides who had offered to take me snorkeling at the island and I was pretty certain he would be looking for me in the late morning once the temperature had climbed from pleasant to warm. As expected, he arrived sometime around 11 am looking for me so we could head out to the island with plenty of time to snorkel in the afternoon. I had anticipated that I would be going out on my own and was surprised when Leonard, Simon and Jones told me that they would be joining us for the trip to Maziwe as I knew that none of them could swim so they certainly wouldn’t be joining us in the water. The journey to the island was about 45 minutes and was delightful given the incredible panorama that lay before us heading out to sea. At one point, there was nice sized group of dolphin that cruising along behind us in the distance and as we swung around to follow them, they quickly disappeared and resurfaced some distance away. None of the others had ever seen anything like it, so it was surely a thrill for them to see these amazing creatures leaping out of the water even if it was not right in front of us.

Maziwe Island, a small speck of sand that barely peeked above the surface of the ocean, has been devoid of vegetation for many years, but could still be spotted many miles away and served as a beacon by which we could easily navigate. The closer we came, the more brilliant the color of the water surrounding the island became until we were upon it and in the middle of a turquoise sea all around. We beached our little boat and unloaded the water for the others along with a tarp that we set up for them to sit under while we were out snorkeling. By now, the sun was dead overhead and quite hot so it would only be safe for them to wait for us in this manner with plenty of fluids to drink. I loaded back into the boat with the guide and his assistant and we left to head to the reef which was only a short distance and surrounded us completely. The water was crystal clear with the bottom easily visible below us as I put on my fins and mask and dropped into the water rolling backwards while holding onto my mask as I had learned so many years ago. As I cleared my snorkel and took my first look down towards the reef, I could hardly believe my eyes at the hundreds and thousands of colorful fish that inhabited this reserve, many by themselves, some in pairs and some in larger schools, but all with the single mission of scouring the reef in search of food. The only regret that I had was that I didn’t have my underwater camera (that I had bought for the Galapagos Islands several years ago) so that I have no way of sharing with you the immense beauty of this place.

In addition to the fish, there were giant sea slugs lumbering along the bottom and giant clams that were nearly a foot across with the most iridescent of blue frills that guarded their rippled opening and would quickly close as I waved my hand above them. They were spectacular. I dove and dove, constantly looking for more unique specimens and finding them every time. On one dive, I found a very large stingray half buried in the sand and half hidden by some rocks, though his easily identifiable tail was more than enough to give him away. The countless species of fish were more than enough to overwhelm anyone for I had never seen so many in one place before even with many dives in the Caribbean. It was tiring to be out for so long bobbing on the surface, constantly dropping below the surface to every nook and cranny, and after more than an hour of doing so, I was pretty pooped and out and ready for a break. While lifting myself into the boat, though, as there was no ladder or steps for entry (this was a very rustic fishing boat and not a dive boat, mind you), I unfortunately slammed my ribs onto the gunwale. Not wanting to say anything as it was pretty darn embarrassing, I simply rode back to the island not entirely sure whether I had merely bruised my ribs or broken them, but when it came time to go out for more snorkeling, I politely said that I had seen enough (not true), was actually exhausted from the first dive (which was true), and didn’t want the others to have to wait any longer for me on the island (partly true). We packed up the tarp that the others had been sitting under and loaded all of the water back on the boat to start our journey home. I must admit that I wasn’t feeling quite as spry as I had been on our way out given even the subtle bouncing of the boat and the subsequent nights were a literal pain to get comfortable in bed as those of you who have injured your ribs in the past will recognize (I have done so skiing in the past), but it was still a great adventure to Maziwe, all the same, and a visit I won’t forget.

It was time to relax after we returned, but first it was time for a quick lunch of fresh fish cooked by our favorite cook, Enock. Later in the afternoon, the fisherman began to come by with their catches of the day and for us to pick out what we wanted to eat for dinner that night. One of the fish, which we all seemed to agree was a cobia, though I’m not entirely certain any of us knew for sure, was quite large, and Leonard decided to purchase the fish to bring home with us when we left which meant that we’d have to find an ice chest and then some ice before heading home in a few days. Then, to my heart’s desire, a fisherman came by with a number of spiny lobsters for sale. Needless to say, I absolutely love lobster! Leonard and Simon weren’t quite so sure they were willing to eat it as they had never tried it in the past and were quite suspicious of these strange looking creatures. Jones had tried it before and knew how good it was, so I purchased four of them to add to our fish and Enock agreed to cook them for us. For those who are familiar with spiny lobsters, they are missing the huge front claws we know so well on the Atlantic lobsters, but are what are found in the Pacific and Indian oceans. Their tails, though, are just as tasty as their relatives.

Dinner was another feast of fish and lobster and Enock has outdone himself with the meal. The lobsters had been steamed perfectly and I think I ate 2 ½ of the tails to Jones’s 1 ½  while we did convince Leonard and Simon, who were quite happy with their fish, to try several bites, but neither would attack an entire tail on their own. It was a great end to an incredible day and we all looked forward to Monday.

 

 

Having the opportunity to spend two nights in a fully legit hotel in Tanzania was a unique experience for me as prior to this the only nights spent away from FAME were either in the tented camps (which, by way of reference, are quite luxurious and beyond “glamping”) or a single night while on the road. Lounging the day before here at the Keys Hotel forced me to remember what it was like to simply enjoy myself with no schedule to keep and only my thoughts. I can’t recall having done anything similar in some time, or perhaps ever.

I awakened early and headed downstairs to enjoy some of the wonderful Kilimanjaro coffee and order some breakfast while waiting for Leonard, Pendo and Lenox to join me at some point as it wasn’t entirely clear to me when the others would be arriving from Arusha to begin our journey to the coast. Jones, who is Leonard’s brother, and Simon, a longtime friend, would be driving into town at some point with Simon’s Land Rover that we were taking on sort of a test drive as it had been newly rebuilt. Why we would be taking a six hour “test drive” was a bit beyond me, but I had learned long ago to put my trust in these friends and it had served me well so far. Jones would be driving Pendo’s car so that she could drive back to Arusha with Lenox and we would leave Turtle at the Keys Hotel, where they would keep a close eye on it for us until we returned.

Lenox looked surprisingly well in the morning having just had his tonsillectomy a little over 24 hours earlier and managed to drink some fruit juice for breakfast while the rest of us enjoyed fresh fruit, French Toast and eggs cooked to order. I’ll have to admit that I felt a bit guilty enjoying such good food in front of Lenox, but by no means guilty enough to skip the meal. The day was once again spectacularly clear and bright and the air quite crisp and almost cool until near noon time. We hadn’t heard from Simon and Jones, but knew they would be arriving sometime mid-morning.  When they finally did show up it was almost noon and with the time it took to get everything checked out and loaded, it was well after lunch before we were finally on the road. The traffic heading east out of Moshi was heavy given the single lane on either side of the only highway heading in the direction of Dar es Salaam, but we managed to make it to the outskirts of town in a decent time and begin our trek to the shore.

The road out of Moshi heads near due east towards the Kenya border until you reach the junction of the B1 highway that then travels south along several incredible mountain ranges prior to once again heading east towards the shore. The road is reasonably paved, heading through numerous small towns along the way where the speed limit drops to 50 kph (31 mph) and it’s important to closely as there are traffic police who would like nothing more than to ticket you as I have proven numerous times in the past. Our speed out of the towns is typically in the 80-100 kph range (50-62 mph!) which means that driving these very long distances feels like your traveling at a snail’s pace at times.

The highway we’re traveling skirts along immediately to the west of the North and South Pare mountain ranges with the Kenyan border just on the other side of them. The geography here is very flat other than the mountains and reminds me of the drive from LA to Las Vegas with it’s beautiful vistas and incredibly long stretches of long flat terrain. That highway in the southwest, though, had always been known for its insane speed limit which was essentially “safe and prudent,” which more simply meant there was none. It was the stuff of legend and where car enthusiasts first went with their newly purchased Corvettes and Porsches to “see what they could do.” We had no such luck in our classic Land Rover defender and were relegated to a meager 60 mph, unless, of course, we were traveling through a town when it was only half as fast, for the incredibly long stretches of highway. Thankfully, it was all new to me and I was now getting my change to take in this part of the country that I had long hoped to do. For those who know me and my passion for wanderlust and the open road, it was heaven for me just to be cruising across east Africa in a Land Rover and the many hours in the car was a small price to pay for another incredible journey that has become such a part of my life here.

We were heading into a region of Tanzania that is known for growing sisal and its massive plantations that stretch for as far as the eye can see. It is used primarily for making rope and baskets and it was hard for me to imagine how anyone could use all the sisal growing here for it stretched for miles and miles and many hours of our drive. The plants are a member of the agave family, best known to us for tequila, though these plants are only used for their fibrous leaves and the strands of sisal that go into making the ropes and baskets seen throughout the country in the markets, industry and in people’s homes. From the moment we made the turn onto Highway B1, the sisal plants became our closest friends and remained with us for the rest of the day until we reached the shore. Rows and rows of sisal plants fanning out to the horizon dominated the countryside and were broken up only by the small towns that housed the families who supplied the work force needed for such an industry.

The North and South Pare mountains to our left were absolutely spectacular ranges as their peaks sought the sky and small pockets of level ground within them contained tiny enclaves of houses that formed hamlets high on the mountain tops where only foot trails or an occasional small road dared to reach. But these mountains were only an introduction to the mighty Usumbara ranges that were still to the south and would soon be upon us. Before the Usumbara, though, we needed sustenance and as my stomach began to growl, for breakfast had been hours before, we somewhat miraculously came upon two rest stops that could have been right out of the Northeast corridor and I-95. I had never seen one here in Tanzania, but admittedly, this was first experience on one of the country’s long stretches of highway that sits between major centers of the population. These rest stops were here to service the routine travel by bus of the majority of individuals who make this trek and are run by the larger of these bus companies. There were several counters for various types of food, but I followed Simon and Jones to a buffet where woman doled out helpings of rice, Chagga stew (bananas and meat), roasted chicken and various vegetables. You pay by the plate and Leonard had gone to buy our tickets for the food while we headed to some outside tables where large speakers blared out music broken only by the occasional announcement of one of the buses leaving for its destination.

Happy to have had lunch for I had no idea when or where our next meal was to come from, nor for that matter how far we had to travel to reach our final destination for the day, we loaded back into the Land Rover and were on our way again, now heading a bit more southeast in direction as the shore lay directly to the east. As we passed close along the edge of the Usumbaras it was easy to see why they were such a popular attraction for outdoor activities such as camping and climbing. They appeared quite unique with large undulating cliff faces and numerous flat areas on top that once again housed small villages that were easily visible to the naked eye and had to be truly miraculous places to live with their expansive views of the land below. There are roads that lead into the mountains and, quite likely, to the villages on top and I thought how amazing it would be to one day return here to further explore the area.

We passed through the larger town of Korogwe and, several kilometers further, reached an intersection where, had we planned to head to Dar es Salaam, would have continued further south, but instead turned to the northeast toward the city of Tanga and the coast. Tanga is one of the larger cities in the country and is primarily an industrial town that was headquarters for much of the shipping during the German colonial period for the country. Up to this point, I will have to admit, I had absolutely no idea of where we were heading or what our actual plans were for the next several days. All that I had known was that we were heading for the coast and “Tanga,” but that is both the name of the town and the region here, and I wasn’t even sure where we would be spending the night. I Tanzania, I have never asked too many questions regarding plans when traveling with Leonard as I have never needed too. As the person who has typically made all the travel plans in our family (which, by the way, I had always chosen to do and no one else), it seemed to be a welcome rest from those duties and, besides, he knew tremendously more than I did about the country and seemed to know exactly what I’d enjoy in the process.

After entering the town of Muheza and stopping to refuel, we left the tarmac and headed east along what was about a 40 km “shortcut” to the shore. At this point, since we were diverting from what I had thought was our destination, the city of Tanga, I chose to ask exactly where we were heading for I was still studying the maps in the remaining daylight that existed. It was easy to see on the map that this road led to the town of Pangani that was at the mouth of the river by the same name as it entered the Indian Ocean. The shortcut was entertaining enough as Simon drove like a banshee, hoping to get to Pangani before sunset, and was little deterred by the Land Cruiser that seemed to manage staying just ahead of us on the road and kicking up loads of dust. It was clear that the passenger in the Land Cruiser was a nun and each time we pulled up close to the vehicle with the intention of passing it (mind you, this was a narrow dirt road with nary the space for the two vehicles side by side), they would spurt ahead clearly not wishing us to pass. There was something less literal about this process and at times seemed like there was divine intervention, but thankfully, their destination was only about half way and we all breathed a huge sigh of relief as they pulled into one of the larger parochial schools that sit here quite isolated and remote.

We eventually came to the crest of our route and far in the distance was the Indian Ocean. It was bluer than blue and gorgeous to behold after having spent years in the country without seeing it except for in air while traveling through Zanzibar or Dar es Salaam as merely a short layover on my way to and from Doha. We began our descent to the shore and reached it soon after, intersecting the coast road (also dirt) just north of Pangani. As we drove into town around sunset, there plenty of souls on the street who were either coming or going and, as we turned a corner, I could see a ferry stop sitting in the distance. I love ferries and had no idea that we’d be on one to get to our destination, so it was certainly a pleasant surprise for me and, as we pulled up the gate the ferry was there and being loaded so it was perfect timing. Though it was a short distance across the river, it was still exciting for me and, as the sun was slowly setting up river to the west, it made it quite a scene. As Simon drove the Rover onto the ferry, the rest of us walked on, for only the driver can remain in the vehicle for safety reasons, and we sat along with all the other passengers as the ambient light very quickly drifted to dark as it does here close to the equator.

Arriving on the far side of the river, we all climbed back into the Rover to continue our journey to exactly where, I wasn’t quite certain, but it was becoming more and more evident that we would not be staying with family for I knew of none that lived in this region. It became quickly very dark as we left the ferry landing and all that was visible to me was what I could see directly in front of us, illuminated by our headlights, as we traveled at a rather high rate of speed initially along a somewhat wide dirt road, but it quickly turned into a path wide enough only for a single vehicle with dense vegetation and trees occupying either side. We traveled in this fashion for perhaps half an hour, making various turns that I would have hard pressed to recreate if had ever needed to return on my own.

Eventually, we happened upon some signs at a fork in the road that seemed to be important for we exited the vehicle to be certain of which direction we needed to head. Thankfully, the others knew exactly where we needed to go as I had absolutely no idea where we were, and soon we were pulling into a small village crowded with townspeople along a short and very narrow road with structures lining both sides of it tightly. I could see in our headlights that the roofs were thatched and the low eaves seemed to leave little clearance for us to drive under given the narrowness of the roadway. As we passed through and seemingly reached the end of the road, both literally and figuratively, we pulled up to a shack that was marked “reception” We were greeted by our host who helped us with our bags and showed us to our rooms, though in the complete darkness, it was very difficult to tell anything about where I was. It was clear that we were on the beach for the small waves crashing a short distance away were telltale sign as was the sand we walking on. My room was a small banda, or little hut, that had its own bathroom and shower in the back, though I was told no hot water in my hut which was just fine with me.

We were then let to a small structure with a thatched roof that was otherwise open to the night air and served as the bar and restaurant with several tables for us to sit at and eat. In short order, we were served an incredibly delicious grilled fish dinner with rice and vegies and, as we ate, I watched the thousands of crabs who came out each night and were scurrying along the wet sand by the water’s edge. I had no idea where we were nor what it looked like, but somehow, I knew that we were in paradise and, the following morning, I was to discover just how right I was.

It was another glorious day in Ngorongoro Highlands with the sun shining very early as I awakened readying myself for another last day at FAME, having had so many of these over the last ten years. It has become a more routine and simpler task for me these days as it’s really not saying goodbye any longer, but more a “see you five months,” and something to which everyone here has become accustomed. There are other volunteers, like me, who have found a home here and return on a regular basis, but I had realized quite early on that for this project to really work, it would require that not only the patients here knew that I was coming back, but also the staff at FAME. For as much as it means to come here and provide care to the patients, it is really about supporting the medical staff and for them to feel comfortable in that fact.

I still had at least a third of the charts to go through this morning before returning them all to Kitashu and so I sat down at our kitchen table with a cup of tea and began plugging away on my laptop with the new EMR and the stack of cardboard charts, that will soon become obsolete even here in remote East Africa. I had discovered last night that we were missing a few charts and, though, thankfully I had a record of their visit in the EMR, there was some missing information for our database that had been overlooked during the installation of the new system. I had been able to obtain this information as long as I had the paper chart in hand as the information still existed there, but for those missing charts, which was typically because the patient had received care elsewhere at FAME following their visit with us, I would have to locate the charts. Knowing that I was leaving, I met with Kitashu to give him a list of the approximately twenty missing charts so he could find them later and email me the missing data. Of course, he did this within a day.

I made certain to hang around late enough that morning for tea time to come along as it would be several months before I would again have the pleasure of drinking Samwell’s remarkable Chai Masala that is so lovingly brewed each and every morning at FAME so that everyone can continue to partake in that remnant of colonialism that still exists in much of East Africa. I enjoyed my tea, stopped by Jackie’s office to give her some of my nice clean American dollars in exchange for some beat up bills that she had accumulated and would not be acceptable here at the bank so that I could bring them back to the US for her. They are very particular about the need for US dollars here to be pristine and recent, lessening the likelihood of them being counterfeit, or at least that’s in principle. Regardless, that was fine with me as I did have left over cash that was perfectly suitable and no worries about exchanging the beat up bills on my return to the States. I walked through the administration building to say goodbye to everyone and then down to the outpatient clinic. I met with Kitashu to hand over the huge stack of charts we had, though not nearly as huge as that on other visits where there are nearly three times as many patients seen.

I was on the road and heading out of Karatu surprisingly on time, which is a rare occasion for me, not because of the inability to manage my time, but rather due to the unexpected things that pop up at the last minute and need to be completed. Amazingly, everything had been finished early and it was now just a matter of taking my time with Turtle, listening to The Gipsy Kings, and enjoying the sights down the escarpment, of Lake Manyara, Mto wa Mbu, Makuyuni, and on towards Arusha and the towering Mt. Meru. It is certainly helpful that I now know this route like the back of hand, having driven it dozens of times over the years and it has become my familiar commute, though has lost none of its shear magnificence as a result.

Our plan on my arrival was that I would be departing the next day with Leonard, his brother and a friend for the coast region of Tanga and the Indian Ocean, though, to be honest, I knew little more than that. On my arrival, I discovered that one of their children had been scheduled at the last minute for a tonsillectomy that was to be performed that night in Moshi, about 2 hours away. I wasn’t certain as to what our plans were for the coast, but went along with the family to the care center where they were to have surgery as I was part of the family and I knew that they would value my support through the process. I met the surgeon, whom I was very much impressed with, and sat around as we waiting for all of the admission procedures to be finished. Leonard and Pendo would be staying at the care center with their son after his surgery, but we would need to find a place for me and, thankfully, right down the road was a wonderful, old hotel, The Keys Hotel, that turned out to be one of those incredibly pleasant surprises. It turned out to be one of the nicest and most relaxing places I’ve stayed here in Tanzania.

By the time we had taken care of everything at the care center, which also meant going to the market for cartons of ice cream, it was well after 9 pm and none of us had eaten dinner. Luckily, the kitchen at the hotel was open until 10 pm, so Leonard and Pendo order food that sent to the care center for them, and I finally sat down to enjoy a nice meal after having been traveling the entire day it seemed. I relaxed on the back deck that overlooked the pool (yes, they actually had a pool) and ordered my favorite soft drink, Stoney Tangawizi, which is the tastiest ginger ale you can imagine and available mainly in East Africa. Deciding on what to eat, I went with the “kuku choma,” or barbecued chicken and was so happy that I did since it turned out to be one of the most delicious dishes I had had in some time. I ordered only a half chicken and can’t imagine having tried to eat an entire one by myself.

Exhausted from the day and all of the excitement with the surgery, I went up to my air conditioned room (a rarity in Northern Tanzania) and read a bit before bed, knowing that I’d be awakened at some point by a message from Pendo as I had asked her to let me know when the surgery was over and all was well. The next morning, I went downstairs only to discover that breakfast was included with the room and proceeded to relax with a wonderful pot of Kilimanjaro coffee that was later accompanied by perfect French toast and fruit. All had gone well with the surgery, but it wouldn’t be until the evening that they would be discharged, so it was decided that we would just stay in Moshi for another night and I would get a room for Leonard, Pendo and their son to stay. We would just delay our trip to the coast by a day to be certain that all was well.

Having the day to spend at the Keys Hotel was just so incredibly relaxing as I was able to catch up on work and reading and, in the afternoon, walked over to the care center to spend time with some of their immediate family who had come to visit. Sitting with everyone out in front of the building in the plastic chairs, it was very special for me as I was there not as a visitor or a guest, but rather as a part of their extended family. We all sat sharing stories for a long time, until it was getting dark and time for me to walk back to the hotel and begin to think about dinner. I had had a delicious pizza, perhaps the best I had tasted in Tanzania, from their wood fired oven for lunch, so decided to have kuku choma again for dinner, though with a salad instead of chips tonight. The evening was lovely with a slight chill to the air that was much appreciated. Leonard, Pendo and their son would be coming over later this evening after they were discharged and we had decided that we would leave for the shore in the morning. The others would be heading back to Arusha as long as all was well following surgery.

 

 

 

The primary role of our work here at FAME from my very first visit and including the present has been to work with the doctors and nurses to provide them with all the necessary skills to evaluate and treat neurological illnesses in the residents of Northern Tanzania. By doing so, we would be fulfilling one the main missions of FAME and improving the health of the community relying on them for their medical care. Early on, though, we also realized the need to keep internal documentation of the types of patients that we were seeing and where they were coming from, to what tribes they belong, the diseases that we were treating, and what medications we were using to be certain that we were addressing their needs and would have the necessary resources available for each of their visits. Beginning in 2015, that internal documentation became an organized database that now contains well over 2500 patient-visits and provides an incredible cross-section of the neurological health of a large community in Northern Tanzania and a wealth of information that will enable us to not only continue to provide this care, but to do so in a more efficient and effective manner over time. Furthermore, the knowledge that is gained from this record may well translate to other similar communities in Tanzania, and even throughout Africa, as well as to other specialties beyond neurology.

This database has been continually maintained by the residents who have accompanied me here and, more recently, by a select group of medical students from the University of Pennsylvania who have not only demonstrated a keen interest in neurology, but have also shown their desire to pursue it as a career. Though it has never been the intention of FAME to provide medical students with a global health experience, the volume of data that we have been collecting has made this role very helpful, if not essential. Despite the fact that I saw far fewer patients than we do on a normal visit (140 as opposed to 400), I would still be responsible for making sure that we have all the necessary documentation to input each patient into our database, both new patients and return, as well as additional information for all of our epilepsy patients concerning their seizure control. My plan for today, of course, was to spend as much time as would be necessary to complete that task which was slightly more complex given the new EMR (electronic medical record) that we had just started using the first day I began seeing patients this trip.

Thankfully, FAME had seen fit to actually hire their own IT person who would be managing the EMR internally and that made my life tremendously easier. The EMR that FAME selected would have to be one that would be usable in Tanzania for Tanzanians and was not being developed for the volunteers who are coming, most of whom are very familiar with systems such as Epic that cost millions of dollars to install and would have been total overkill. The main problem that I encountered with the new EMR actually had to do with the report feature as I wanted to be able to pull up all of the neurology patients we had seen for the month and that feature just didn’t exist when I began to play with it. Thankfully, though, Valence, FAME’s new IT specialist, was able to go into the system and find the report that I was looking for which saved me an incredible amount of time. As with every new system, though, there are often oversights that weren’t anticipated and a glaring one that I discovered, at least from neurology’s perspective, was that the data regarding tribe and village was not being recorded in the patient demographics in searchable field. Some of the questions that we had been looking over the last several years had to do with whether there were differences in neurological disease, rates of return, and demographics between the various tribal affiliations and locations throughout the region that we draw from. This information, which had been included in FAME’s older demographic database and on the paper charts, would now require that I go back through all of the paper charts to update our records and make certain that we would have the necessary information to input into the neurology database, otherwise, it would be incomplete.

I came up to clinic around 8:30 am as I knew that Kitashu was going to be there to help me gather all the charts together. Then, I was able to create a list of all the patients we had seen in the EMR which allowed me to tell if one of the paper charts was missing as often happens if someone comes and takes it for various reasons. I sat down to start the process of going through about 120 charts (quite a big stack) when Kitashu came in to ask me if it was possible for me to see a young man whose father had brought him to clinic today as he could not find the boy yesterday. This was somewhat of an interesting excuse and I wasn’t quite sure whether to take it totally seriously, but in the end, it turned out to be very legitimate.

I invited the young man, who was about 24-years-old, and his father to come into the exam room where I had all of the charts strewn across the desk and table after finally getting them chronologically organized. Dr. Adam was there with me to translate, though it turned out that both the son and the father spoke very good English. Despite this, I typically want to have a Swahili speaking person in the room as certain things can be lost in translation and just to be careful, I have always stuck with this practice. When I asked what I could do for them, there was an initial bit of a silence, and then began a very long and saga that involve the son being away at college several years ago, becoming mixed up with other youths smoking marijuana, being sent home from school and the father taking him to the hospital not once, but several times for what sounded mostly like psychiatric admissions rather than just for drug rehab (which is really hard to find in Tanzania for the most part).

Over the last several years, though, the son had been following with district mental health officer and had been on a fairly strong antipsychotic medication, chlorpromazine, that had actually worked very well for him and it was only when he went off of the medication that he would become agitated or aggressive with others. The father was blaming the marijuana for his son’s issues, and even though this might be partly true, after I had clarified that the son did indeed have auditory hallucinations and paranoia, I was completely confidence that this young man, whose issues began initially when he was 18-year-old, had a pretty run of the mill case of schizophrenia that had been well controlled on the chlorpromazine. Though the marijuana may have temporarily made him acutely psychotic, or, should I say, more psychotic, it was not the underlying problem and marijuana or no marijuana, the boy would have had the same issues and needed to be on medications.

The father, meanwhile, had done a remarkable job of not only keeping his son safe, but also doing what was clearly the best for this boy by taking him to the hospital on several occasions to try to find help for him. Unfortunately, there are no psychiatrists around to manage these case, which is why we are often seeing them in our clinic, but I did know of a psychologist in Arusha who Frank has referred patients to in the past, and I promised the father that we would reach out to get that information for him as he was willing to do whatever was necessary for his son. Hopefully, we can make that connection for them and find some relief for this very caring father. In the US, the son would undoubtedly be in a group home as he was very well dressed and appeared to be functional on his medications.

I was finally able to get back to my charts, and other than meeting with Susan and Kitashu for a debriefing meeting, I spent the rest of the afternoon working on them and was able to complete perhaps just over half. I had wanted to get in my last bike ride of the visit and was determined to do so as this would be my last opportunity. I hopped on my bike and pedaled down the FAME road into town, paralleling the tarmac along the Tumaini School Road and then connected up with the main road out of town towards Rhotia. It was actually a bit cooler than I had expected, even with the late afternoon sun bearing down on me, and it was great last day for a ride. I returned home, showered and met Abdulhamid in town for my last nyamachoma dinner, one of my favorites here. I took care of a few more charts before bed and knew that I still had a few hours of work to do in the morning.

I know that I’ve mentioned the kuni boilers before, but perhaps it would be helpful to mention the story of the hot water situation here at FAME from the beginning. When I had first come to FAME in 2010 to volunteer, they were completely off the grid and on solar power which meant, of course, that any piece of equipment that was used here could not require any significant amperage of electricity. I recall that in the very first volunteer instructions it had said, “absolutely no hair dryers” and, even though I believe that still to be the case, it is more for practical reasons now than it was in the beginning when an appliance drawing that many amps would either blow the circuits or drain the battery. That also meant no conventional hot water heaters. Needless to say, taking an early morning shower in those days, when there was no hot water, was an exercise in speed and efficiency as our water here is well water that has always been ice cold at the outset.

I do recall that at one point, Frank had experimented with some fancy low power hot water heaters that were mounted to the outside wall (I do believe there was also a notice on each of them that said, “not be installed outside”), but these never worked probably and I’m not sure that I can recall them to have ever worked properly . Therefore, it was still the ice-cold early morning showers that were still the standard fare for everyone. I should probably mention that even regular homes here that utilize a small hot water heater do not have them running all the time for “on demand” hot water, but rather you must flip a switch on the wall to turn them on and then wait 10-15 minutes for the water to heat before a hot shower. In the early years, traveling on the large mobile clinics to the Lake Eyasi region where we spent 5 days and it was pretty much like camping most of the time, we would take “bucket showers,” where you would have a five-gallon bucket and a cup with which to shower. In the mornings, the village women would boil large pots of water for us to use for our showers and then it was a matter of mixing the hot and cold water in your bucket to get just the right temperature. I remember thinking then that it was the height of luxury to even have hot water in those situations.

When the kuni boilers came into existence at FAME, they were like a Godsend as we now had hot water, most often in the morning, but it would often last throughout the day depending on how many people were utilizing it. When the Raynes House is full, as is often the case when the residents are here, it will often not last long enough for everyone to shower in the morning, unfortunately. Stepping into the shower when you’re expecting a nice hot, or even warm, shower can be more than disappointing to find out that is the not the case. Of course, the kuni boilers are wood fired, meaning that not only do they have to be lit, but they also be loaded with wood and, even though they burn quite efficiently, it still requires that they are loaded with wood which is done by our Maasai askari, or guards, who are patrolling all night to keep us safe, but also stoke and light our kuni boilers in the morning.

Meanwhile, back to the power situation at FAME, as it no longer relies simply on solar power. Once the hospital and operating rooms were built, there was always a need for a backup situation as the power demands for these services became greater and greater, and, finally, with the addition of radiology and a CT scanner, the demands far exceeded what could be supplied even with a generator. It was finally the time for FAME to become part of the power grid here, but even that may not be what it seems to those of us in the western world, as power here is not as reliable as it is back home where you may lose it once in great while when a heavy storm comes through. Here, there are constant brown-outs, some which are scheduled, but most which are not. I can’t tell you how many times I have traveled to Arusha, planning to charge my computer and phone when I arrived, only to discover that the power was out here and it was a lost cause. At FAME, thankfully, we now have a generator that will kick on, typically, within six or so seconds from when the power goes out and this is not all too uncommon. Finding a generator large enough to run the necessary equipment here was not easy task as you can imagine, nor was laying the necessary power lines to carry it, but thankfully FAME has had the assistance of a master craftsman for a number of years to help with this planning, Nancy Allard, a rare combination of a an architect trained in Switzerland, and an ICU nurse trained in the US, who came to FAME, like all of us, while on Safari, and decided to move here for a number of years. Though she’s now back in the US working as a nurse, she continues to work on projects for FAME and is responsible for much of the growth that has occurred there. If it had not been for Nancy’s help, the Raynes House would not be what it is for us today.

As is usually the case, I set aside several days at the end of our scheduled clinic to see follow up patients and to wrap things up if there were still things that needed to be dealt with. We had asked the mother with the young baby with infantile spasms to return today to see us, and, somewhat embarrassingly, none of us realized initially that we had seen them several weeks ago and proceeded to take a completely new history until we finally realized our mistake. We had placed the child on high dose steroids, and though it was unlikely that we would see any reduction in the child’s seizures given the amount of time that they had been occurring, we had still felt it worth an attempt. As expected, she had not noticed any change in the frequency, and so, we discontinued them and started the child on valproate gradually titrating to a therapeutic dose. Ultimately, though, the child was severely impaired and delayed and it would be very unlikely that they would improve in function which is what we tried to explain in the most compassionate, but realistic manner possible.

We also evaluated a young Maasai man who we had seen in the past, who doesn’t necessarily have a neurological issue, but came to us last March with a very unique problem that we are still not 100% clear of what it is, but our experts at CHOP have weighed in and feel that it is very likely just an indolent osteomyelitis of the skull rather than anything else more exotic (though, I must say, this is certainly not something you see every day). He has essentially had a progressive course that has deformed his skull and has caused not only numerous eruptions of his scalp to occur, but has also had problems with his vision due to misalignment of his eyes from his skull deformities, which is what initially brought him to see us in the first place. He has been placed on a number of antibiotic courses in the past including intravenous antibiotics, but nothing that has likely been long enough to fully suppress the ongoing infection. Hopefully, we will be able to get on top of this sometime in the near future, but it’s quite difficult given the many limitations posed by what is available.

Tuesday was our last official day in clinic for this trip and I had decided to spend Wednesday working on completing charts and would leave Karatu on Thursday morning to head for Arusha. It was my last day to work with everyone who had been so amazingly helpful in making the clinic run so smoothly and I was grateful that, despite the absence of the residents, we were still able to see in the neighborhood of 140 neurology patients that we had either contacted to come for follow up visits or who had been referred from the other doctors at FAME to come see us. There were also those who just happened to come at the right time with a neurological problem and were directed to us by reception. I am certain that there were also some “word of mouth” referrals that had heard about our presence from others who had seen us, which was certainly fine as long as they had a neurological problem for us to evaluate.

I had missed working with Dr. Anne, who had unfortunately broken her ankle just prior to our arrival and had been laid up at home with her leg elevated for the entire month, but I know that she will be back working with us again in the future. There are always silver linings, though, and this one turned out to be in the form of Dr. Adam, someone who I had not had the chance to work with in the past as he had just come following our rather sudden departure in March with the COVID crisis looming. Adam, who was an incredibly quick learner and a remarkably capable physician, found neurology fascinating and will very likely become our second “FAME Neurologist,” someone who will have the necessary skills to follow and manage our patients there, but also the ability to evaluate and diagnose the more common neurological illnesses that we see. He and Dr. Anne will also be able to communicate their assessments of the more complex neurological patients so that we can assist remotely in those diagnoses as well.

I said goodbye to both Abdulhamid and Revo, my two incredibly capable brand new graduates who have worked with me on several occasions now and will hopefully work with me again in the future. I know that would be working at FAME the following day, though not seeing patients, and so I would not have to bid farewell to anyone else this day.

 

 

It has been such a special trip the prior Sunday and, having decided not spend three days traveling in the Serengeti on my own but rather have a few days to myself, today was a perfect day to once again host a group mostly made up of FAME employees to Tarangire. As I have mentioned before, most of the residents here have not gone on a game drive to any of the parks for several reasons despite the greatly reduced entrance fee for Tanzanian citizens. One of the reasons, of course, is the cost of hiring a vehicle and a driver for the day as this is mostly out of the reach for the average Tanzanian. The other reason is more of a cultural one that also considers the issue of cost and that is the difference between a society with disposable income and one that defines things based on necessity. For those of us in the West, we often consider travel as a necessity, but, in truth, it is not for you can’t provide for your family with travel and it is quite the opposite. The benefit of travel to us is provide relaxation or, at other times, to provide a sense of adventure to our lives by broadening our experiences. This is not the case for the vast majority of the world, though, where the knowledge of where your, or your family’s, next meal is going to come from is not always readily apparent.

So, it was with this in mind, that I once again offered to take a group to Tarangire, one of my favorite parks to drive in for several reasons. The animal viewing is superb and, in particular, the birds as well as the elephants which are the most numerous in this park. Another reason is the ease of driving there as the park is completely centered around its river ecology and the Tarangire River. In the dry season, which we were in now, the animals must all travel to the river for their water so huge families of elephants come from the surrounding hills to make their way to the river by midday and then travel back to the hills for safety later in the afternoon. The park is usually entered through the main gate, which was recently replaced with a very new building in which to register for the visit. I have driven here dozens and dozens of times and have a typical route that I take for the best chance to catch lions early on. While I was registering at the gate and taking care of payment, the others were taking care of popping the tops on Turtle and securing everything  for our game drive. Revo sat up front with me and also had the ability to stand up, though had no protection over his head from the sun as did the others in the back.

As we made our way to one of the watering holes where I have encountered lion prides on several occasions and even have seen a kill after the fact, we saw numerous impala that included both large harems (a male with his many females) and bachelor herds that comprise only males that have not been successful in acquiring their own harem, but could one day challenge for that dominant role. The male of a harem can be replaced by a challenger at any time and, unlike lions, where the conquering male will kill off any of the offspring of his predecessor, a victorious male impala will not do this. Just before the watering hole, we ran into a huge gang of banded mongoose that were on both sides of the road and, despite the fact they are usually quite skittish and scatter as soon as you stop, this group continued their quest for food (typically insects and small reptiles) in our presence and much to everyone’s delight watching them. I have actually never seen them remain at their business for as long as they did this day.

There were a few giraffe along with zebra in the region of the watering hole, but not a feline to found when you need one, so we moved on connecting back to the main road that led us down to the first river crossing. Once on the other side, there are numerous “river circuits” that leave the main road and loop close to the river and then back again. Depending on the season, these routes can be quite an adventure on their own with huge pools of water submerging the trail for some distance. I had learned long ago that it’s not good practice to enter one of these pools without first seeing tire tracks entering and, hopefully, leaving on the far side just to be certain you won’t spend the day trying to figure a way out. I will tell you that I have not learned that the hard way in the past and am thankful that I drive a Land Rover as they will rarely ever became hopelessly stuck, in contrast to the Land Cruiser, which can. Some of you may recall, though, that there have two exceptions to this in my past, one of which occurred in bad weather on an incredibly slippery road, and the other, here in Tarangire, that was my fault for driving on a trail that I was familiar with in the dry season rather than the wet, and I became hopelessly stuck in the mud. We were miles from anywhere late in the day and it had started to rain on us in place where there was no hope in our hiking out given the lions, elephants and Cape buffalo in the area. We were rescued by Leonard, who just happened to be in the park, and a very sturdy row that we used to pull me out.

After driving a bit down the river on our way to my favorite lunch area in the Selela Swamp, we encountered several very large families of elephants. As we were watching one, we say another crossing the road far ahead and went to watch the second group. When they were finished crossing, I backed up the Land Rover to watch the first group who had just completed their crossing as well and paid particular attention not to get too close or to threaten them as there were little ones with the group. Watching out of my side mirrors, I had a perfect view of the road, but what I failed to see was that a male from the group had apparently taken offense to our approach, regardless of the distance, and was making a bee line for the road and our vehicle. I heard lots of commotion in the back, which is not all that unusual as I have had plenty of guests become a bit unnerved by the proximity of these huge animals as they walk close to the vehicle. I had turned the vehicle off, as I always do when we are stopped watching animals, and especially elephants, as they are less threatened by the quiet and if someone is taking photos, it makes for a sharper photo with the lack of vibration. Suddenly, I heard Abdulhamid yelling, “Dr. Mike, drive the car!!,” as, unbeknownst to me, he had flown from the very back of the Land Rover, where he had been watching the suddenly charging and trumpeting male elephant, to just behind my front seat, clearly for the effect of getting me to listen as quickly as possible and get the vehicle moving.

Regardless of the sense of urgency that everyone felt, it would be incredibly unlikely for an elephant to strike a safari vehicle in this situation, and I have no question that it was more for show than anything else, but it still seemed like a good idea for me to start the engine, engage the transmission, and move. And to do so quickly as I didn’t necessarily wish to test my hypothesis when it involved the safety of the others. As I slung the vehicle into gear and stepped on the gas, I could now see the elephant standing in the road and am pretty certain that I heard him trumpet a victory salute just for effect. There were several videos of the event, though I must admit that I am not proud of any of them as even though I don’t believe I had encroached on their space and have been around them as a driver many, many times, it should always be one’s intention never to stress or threaten these animals in any way and I felt as though it was a bit of a failure on my part for having done so.

After the commotion of being chased by an elephant, it seemed that we had probably encountered the most exciting event for the day and, though this did eventually prove to be the case, we had lots of exploring still to do I the park. The next river crossing, which is real crossing and not a bridge, was unfortunately washed out, but was not apparent until I had driven all the way down to it, requiring that we turn around, head back to the main road, and look for the final crossing which was a cement platform placed across the river bed and typically intact. Had that not been the case, it would have been a very long drive all the way back to the first crossing. Thankfully, we were in good shape and, once on the other side of the river, began to make our way towards the lunch spot overlooking Selela Swamp.

I guess it would be appropriate here to also mention one of the not so favorite attractions of Tarangire that seems to have become more prevalent in the recent years, much to everyone’s displeasure. These are the tsetse flies that are most common in wooded regions which is much of what Tarangire is made of in addition to the river area. Tsetse flies, which are most famous for carrying trypanosomiasis, or sleeping sickness, are absolutely an incredibly annoying biting fly that inflicts a very painful wound and also sucks your blood which it’s at it. They are like heat seeking missiles with a single mission in mind and they are relentless in their execution. Though they are incredible slow, they are also very sturdy and quite difficult to kill if unless you are planning to something other than just swatting them. It usually requires that you either trap them with your hand and actually crush them (yes, I know that is gross, but if you’ve ever been bitten by one you would certainly understand) or you smash them against the window with a book or something very solid. I cannot count the amount of times that I’ve seen them simply swatted like you would any other fly and have them just turn around, laugh at you, and fly away. Their bites are not only very painful, but they also leave a nasty wound that causes a large welt and will often last for days. Simply put, they are not fun at all. Just ask any of my residents who have encountered them.

Today wasn’t the worst of days that I have seen, but they were still quite bothersome to those in the back which is mostly were they seem to collect when driving and though that might be a plus for me as the driver, I do feel bad listening to everyone else swatting and cursing these little bastards. I have seen the sweetest of individuals completely transform when they’ve been introduced to these miniature torture machines. I won’t mention any names (Megan, Lauda, Kelley, Mindy, Susannah, Amisha and others), but please rest assured that even the most composed have quickly become a blubbering mess encountering the mighty tsetse. The one thing we have to be thankful for is that sleeping sickness is not endemic in any of the Tanzanian regions to which we travel.

Much of the lower portions of Tarangire had been burned recently, a practice that helps regenerate the grasses, and so we passed through very long stretches of blackness and ashes blowing with the wind. Dust devils rose to extreme heights as we made our way to the lunch area at Selela Swamp that was thankfully not thick with tsetse flies as that would have been incredibly uncomfortable. After a nice a relaxing lunch on the picnic benches, I set a course to drive along the swamp in the direction of the river, a route I had never taken before. As we drove along, I was convinced that there was a connection between the river road and the one we were on, but just couldn’t seem to find it, so ended up driving a short distance in the wrong direction before taking out my trusty iPad with its navigation package (thank you MotionX GPS), which I guess is akin to stopping at a service station for a guy, and, with Revo’s help, found the connection I had known must exist and we were back on the right track finally.

Heading back, Kitashu spotted two lions, one, a pregnant lioness which was an impossible find across the river on the far bank and virtually invisible, and the other, a young male, was much closer and had a kill hidden nearby. The male got up and began walking back to his kill, which, as we followed it slowly in reverse along the road, was at least a day old and quite easily identified by its rancid and very pungent odor. The male then walked off in the direction of the female and we lost him in the undergrowth. Here, in the parks, you must remain on the roads and, though they may consist of two tire tracks through the grass, it’s still the rule and there are heavy fines if you are caught violating them. And, I am sure, they would love nothing more than giving a mzungu driver such a fine if they were given the chance. In the Ngorongoro Conservation Area, there is no such rule, so you are able to follow predators, but at a good distance, of course.

By now, it was well into the midafternoon and we had at least an hour’s drive to get back to the main gate. Though the park is open until 6 pm, everyone was quite tired as we had left Karatu at 6 am, and game viewing can be very exhausting, not to mention game driving. We arrived to the gate around 4 pm to exit the park and on our way back to the tarmac discovered that it was market day in the village there. Kitashu’s sister lives in the area, so he called her and we waited in the center of the commotion for her to come while we were offered just about everything you can imagine to buy, perhaps short of a goat or a cow. Our next stop was in Mto wa Mbu, where the bananas are particularly good and I think everyone in the vehicle purchased a huge bunch of the fruit. I asked for 4 bananas as payment for my driving for the day, but was given 8 and wasn’t sure how I’d eat them in only the several days I had left at FAME, but I’d give it a try. We arrived back in Karatu by sunset, all quite exhausted, but very satisfied with the day having seen lions, which were Abdulhamid’s request in addition to the elephants, which they had gotten their fill of rather up close and personal. I think everyone had a wonderful day of game viewing and I was quite happy to have made it possible for them.

When planning my trip several months ago, knowing that I would have total freedom as I would be alone for the month, I had thought that visiting the Serengeti in the midst of the pandemic, when there would be very few, if any, visitors there would be a great idea. Now, having spent several weeks at FAME on my own, I’ve come to realize the tremendous value of just having a day or two to myself and having blocks of downtime to both do busy work and relax. I’ve also realized that I haven’t spent enough time in my hammock reading, a crucial error on my part and some very serious poor planning. Not that it was planned this way, but the poles in the back of the house are the absolute perfect distance apart for hammocks, of which I have three at the house as it became impossible for me to reserve a spot when the residents are here. Here alone, I’ve set up one that I have all to myself now, but have had little opportunity to get in it until this morning. In the afternoons, unfortunately, the sun beams directly down on the back of the house making it unsuitable for hammock time, but the mornings are absolutely perfect for reading in the hammock as it is at sunset. That is, until the mosquitos decide to descent upon us and chase us indoors for the evening.

My plans for the two days was to finish a bunch of work that I had left over from Penn and also to get to my patient messages that were sitting in my inbox and needed me to attend to them. I also had some outside writing to do and was planning to get that done, as well. Both of those had to wait a bit for me to spend a few minutes, or maybe more than a few, in the hammock reading my book and just plain relaxing. I literally did not have any plans for the day that required me to leave the house, though that changed in short order when Nish invited me to come to the gallery for lunch as his cook was going to make us twice-baked potatoes, an opportunity that I did not wish to miss. After my hammock time and some work, I made the short journey down to the gallery and had a relaxing lunch with Nish. The potatoes were definitely worth the trip and very much lived up to their billing, so much so that Nish gave me the extra ones to bring home with me and have for dinner. Certainly not traditional Tanzanian culinary fare, but comfort food just the same.

I worked late into the evening, having my gifted dinner along with the some of the dinner that had been prepared for me by Samwell, a vegetable stew that went along great with the potatoes and I saved the chapati for the following day to make quesadillas, another non-traditional food item here, but one that is easy to make and very tasty indeed. I had been productive day for me, but not overwhelming as had been able to get my necessary downtime in and wet to bed that night not only feeling quite rested, but also very satisfied with the work that I had been able to accomplish.

For Saturday, I had promised Daniel Tewa that we would visit a friend of his together as she had apparently been hospitalized back in April, but he had given me no further information on what her affliction had been. I completed some work in the morning and headed over to this home at 1pm as we had previously arranged so that Isabella, his eldest daughter (Daniel has 11 children of his own and one adopted) could drive us to Qaru. I knew the village well as we had done several mobile clinics there until a bit over one year ago when we had switched to Mang’ola on Lake Eyasi which had a much better attendance. Isabella had a small Suzuki four-wheel drive that was quite comfortable on the tarmac, but was clearly not made for the incredibly bumpy road that was to take us to Qaru that day. The roads here are like washboards, terribly rippled so that it feels as though your teeth are going to fall out after just a short while on them. I had always thought that it was due to the vehicle traffic on the road, but learned after googling that it was actually due to the effect of water running over the flat surface of the road and having a natural rippling effect that leaves the roads this way. The Suzuki was so light that at times it seemed to want the leave the roadway altogether as it shimmied sideways from the bouncing.

We finally arrived to the village of Qaru and it turned out that his friend was staying with the nurse from the clinic who lived immediately next door to the dispensary where we had held our mobile clinics in the past. It was quite helpful that I knew my way around as I’m not sure that either Daniel or Isabella knew exactly where we were heading. We were greeted outside by the nurse who was caring for her and led into an inner courtyard and then into her room. As we entered and said hello to her lying in her bed, it was immediately clear to me that she had suffered a stroke as she was not moving her left side well at all and she didn’t seem to be looking very well to the left either. The fact that she had suffered the stroke was quite unfortunate enough, but to add insult to injury, her bed was positioned against the right side of the room such that she has been staring mostly at that wall for over four months and the full extent of her deficits, which included not only the left-sided field cut, but also some degree of neglect, had never been fully explained to everyone.

I took the opportunity to explain not only to her caretakers, but also to Daniel, that if you wanted her to pay full attention when addressing her, you would need to do so from her right side. This can be difficult to explain to those fluent in English, so it took a bit of extra time to fully explain the nature of a homonymous hemianopia to them and the fact that it was actually both eyes that didn’t see to the left and not just her left eye. Once I explained this to Daniel, he immediately tested the hypothesis by speaking to her from the left then moving to her right and comparing her attention. She immediately perked up when addressed from her right and Daniel was convinced. I instructed them to move her bed to the other side of the room so that she would be able to participate much better with visitors and it would help her rehab. They were doing physical therapy, so that part of the equation had already been dealt with in a satisfactory manner.

We all said our goodbyes after a brief, though thorough visit and loaded back into the Suzuki for our return trip. The road seemed to be definitively bumpier on the way back, but I’m certain that was only in my imagination or perhaps had to do with the fact that intense midday sun seemed to be continuously in our faces. I was texting Susan the drive home and, between the sun and the bumps, there were some very serious autocorrections that I did not catch until after they were sent and we both had a great laugh over it. Arriving back to Daniel’s home, and even though I needed to get back to do some work, it is always customary for he and I to sit in his small living room and share some of his amazing African coffee. No else in the family drinks and I think he looks forward to my visits so that he can enjoy it with someone. The coffee is boiled with fresh milk from his cows and with a little bit of sugar, is truly to die for if you consider yourself even a touch of a coffee lover. Though I have weaned myself from the addiction over the last several years, I do still love a good cup of coffee every once in a while, and it is occasions such as these that are the very best in which to savor that wonderful taste. The coffee of the Ngorongoro Highlands is some of the very best in the world and, having been prepared in Daniel’s home, it is a very special treat indeed.

I drove home, now well caffeinated, to sit down to some serious work at the kitchen table with my music playing. I did take a break to make some vegetable fried rice with a supply that I had taken during lunch a few days ago, making it with the sesame oil that had been found in town for me specifically for this occasion. Tomorrow, I would be taking some of the FAME gang on safari to Tarangire for the day and I planned to bring my leftovers from dinner with me for lunch.

In the absence of our normal neurology lectures that are given by the residents when they are here with me, our synchronous virtual lecture series continued with today’s session being a case conference format that would be given by my Tanzanian neurology team on the ground here. I had asked Dr. Adam, Abdulhamid, and Revo to each select a case that they had seen in the last weeks and present them to everyone here plus Mike Baer and Kelley Humbert, both veterans of the FAME Tanzania rotation, who had graciously agreed to sacrifice their sleep as the talk would be from 12:30-1:30 am East Coast time! It was a great exercise for my three awesome colleagues here as the format would require that they present the history, examination and differential with a discussion between each as a way of explaining their thought processes of each case. Mike, Kelley and I each weighed along the way asking questions as did the other docs here. It was a great inaugural case presentation session to our new neurology virtual lecture series and we forward to more of these in the future. For those of you with an interest in what was presented, Abdulhamid presented our patient with ALS, Adam presented a case of Parkinson’s disease, and Revo presented a case of absence epilepsy.

Our cases for the day were our typical grouping of epilepsy, headaches and numbness, but we did have one case in the ward and another that came in later in the day that garnered a bit of extra attention from us. We did hear at morning report that there was a woman on the ward service who had come in awake, but was now unresponsive and was clearly in need of our expertise to determine what was going on with her. I had asked Abdulhamid and Revo to head to the inpatient ward to evaluate her while Adam and I would get started on seeing outpatients that had already arrived that morning. When they came back a bit later, the story was not very good at all. She had apparently undergone a total abdominal hysterectomy several weeks prior and was recovering at home, but had come in the day prior with a headache and overnight had declined to where she was no longer responsive and her neurological examination was not very promising. She did not localize or respond to painful stimuli and her pupils were large and poorly responsive. We asked them to send her immediately for a CT scan of the head and, what we found, was not necessarily what we had expected, but fully explained her poor examination.

She had bilateral acute on subacute subdural hematomas with significant midline shift of the brain, or simply put, she had bleeding over the brain that was putting significant pressure more on one side then the other which was why she was no longer responsive. We were initially unable to obtain any history of a fall, though apparently later the family may have told the staff that she had indeed fallen. Regardless of whether she had or not, we now had the answer to why she was doing so poorly and I met with Dr. Lisso, the doctor on for the day covering the inpatients, to tell him that I felt it was really unlikely that sending her to the neurosurgeon in Arusha would change the eventual outcome as I didn’t think she would survive either way. I verified that he was quite comfortable with the information I had given him and was also comfortable conveying that to the patient’s family. I went back to evaluating our outpatients when, sometime later, our FAME ambulance pulled up to the loading area just outside the night office where we were seeing patients and my presumption that it was for this patient with the subdural was correct. Apparently, the family had decided that they wished to do everything possible despite the fact that it would almost certainly be futile to do so. I heard later, that the patient did have surgery and her hematoma evacuated, but that she had not survived the ordeal after all. Though it had been clear to me that it was unlikely she would survive based on her exam and CT scan, the family had apparently wanted to make an attempt as unlikely it was that she would survive. That is the prerogative of the family in this situation and certainly not something that we can decide for them as long as they have a clear understanding of the likelihood of success.

The other case we saw was equally interesting and had a far better outcome than the previous one. In the afternoon and, in fact, in the middle of dealing with our ward patient, we saw a young man in his mid-thirties with a seven year history of diabetes that was most likely adult onset and not juvenile. He had been blind for a few years secondary to diabetic retinopathy and had not been walking for nearly a year with symptoms of neuropathy in his legs, though his weakness didn’t seem to be from a severe length depended neuropathy and very likely from another diabetic related process such as a diabetic amyotrophy, which is a more proximal process with muscle wasting, though he did not have the classic pain I’d expect from this disorder. He was in a wheelchair when he came into the room and had his head down and was very quiet overall. He had been seen at FAME about a month ago for his diabetes and at the time had a Hgb1c that was simply listed as “>14.5,” which is dramatically high (it should be under 6 in a normal person and perhaps around 7 in a well-controlled diabetic) and clearly indicated that he was in dire need of better glucose control. He was put on insulin at that time and had been using it since.

As the visit progressed and we were able to get him up onto the table to examine him, he seemed to be less and less engaged with the questions that were being asked of him and had difficulty even following directions during the examination. As I was typing my notes for the visit while the others were questioning him and examining him, I think it dawned on all of us at the same to time that he was getting more and more hypoglycemic before our eyes. As Adam ran to get a glucometer, we were told that his blood sugar had been 72 that morning and that he had taken his morning insulin rather than adjusting the dose. When we checked his blood sugar it was 50, which is exceedingly low for a diabetic and we were worried that he was still dropping. We threw him back into his wheelchair and around the corner into the ER where we put an IV catheter into him and immediately started a glucose drip. He was admitted to the ward as we weren’t about to send him home given this experience and he clearly needed some serious education regarding insulin and his blood sugars. No necessarily a neurological problem, but we were able to intervene and very likely saved him from any more serious injury from becoming even more hypoglycemic than he turned out to be in the end. Unfortunately, he later went home from the ward without us actually having a chance to fully examine him regarding his weakness, but given the story, I was fairly certain this was going to be a diabetic related issue and that the treatment would be control of his blood sugar in the end.

With all of our excitement, the day went long and I had been invited to Abdulhamid’s aunt’s home for a visit after work. This was where I should have used my instincts and knowledge of their hospitality here when I asked Abdulhamid whether this was for dinner or not and he had told that it wasn’t. I had a nice dinner of spaghetti and vegetables that Samwell had prepared for dinner and then picked up Abdulhamid at the tarmac junction to drive him to his aunts as no one at her home spoke English. As I have mentioned before, Asha, his aunt, has been head of housekeeping at FAME for many years and it was really through her that he and I had been introduced in the first place. I recall when we were making the plans for his trip to Philadelphia how appreciative she had been and I despite the language barrier, I just know how she felt. Not only was she incredibly proud of her nephew, but she was incredibly grateful for the opportunity that had presented itself through FAME.

So, as you might have guessed, he and I sat in the living room of her wonderfully remodeled house, while she worked in the kitchen for what I knew was soon to come. It was quite clear to me that I was now going to be expected to eat my second dinner that evening and it was not long at all before this premonition came to fruition. Asha’s son was also home to join us at her dinner table, which is unusual in most small Tanzanian homes were dinner is usually served on the low table that serves alternatively as a coffee table in front of the couch. I will have to admit, though, that I did not have trouble with my second dinner as Asha is a wonderful cook and her roasted chicken was absolutely delicious, so much so that I know I had a second, and quite possibly a third, helping of the chicken along with ugali and watermelon. It was a great way to end the evening with a dinner from a very gracious and thankful host who has been a part of the FAME family for many years. I know that she is very well respected in her position there and, as I have mentioned before, though it may have been an honor for her to have me here for dinner, the real honor was truly mine as I have been taken in here as family and am forever grateful for these opportunities I’ve been given.