Saturday, October 10 – And we’re off for Tanga…at least I thought so

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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.

My final memory of a wonderful surprise of a hotel

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 Pare Mountains

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.

A view of the distant Pare mountains

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.

The North and South Pare Mountains with sisal farms dominating the horizon

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.

Rows of sisal by the side of the road

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.

A view from the patio of the service area

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.

Three master Land Rover mechanics working on our vehicle with sisal in the background

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.

The mighty Usumbara Mountains

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.

This is a photograph and not a painting of one of the mountain ranges from inside our vehicle

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.

The Usumbara Mountains

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.

The ferry landing in Pangani

Our ferry before boarding

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.

Looking west up the Pangani River at sunset

Our road illuminated only by our headlights

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.

Leonard, behind the bar, and Simon relaxing after dinner in our little restaurant

Thursday and Friday, October 8 and 9 – Moshi and the Keys Hotel….

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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.

A delicious plate of kuku choma

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.

The pool at the Keys Hotel

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.

The back deck of the Keys Hotel

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.

Out in front of the Keys Hotel, a beautiful view of Mt. Kilimanjaro

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.

 

 

 

Wednesday, October 7 – A day to finish charts and documentation…

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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.

Monday and Tuesday, October 5 and 6 – Wrap up days for our FAME Neurology Clinic….

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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.

A scenic view of the kuni boiler

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.

The working end of the kuni boiler

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.

Three partners in crime – Dr. James, Christopher and Dr. Adam (l to r)

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.

Dr. Adam testing his pediatric skills

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.

Dr. Adam examining a young patient

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.

Patient and his mother

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.

Abdulhamid doing a pupillary exam

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.

My little black kitty friend escaping the heat outside of the cantina (or catina)

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.

 

 

Sunday, October 5 – FAME Safari No. 2, a trip to Tarangire….

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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.

Our crew at the entry gate

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.

Mother giraffe and baby

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.

Zebra at the watering hole

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.

Thirsty zebra

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 wake 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, to right behind my front seat, clearly for the effect of getting me to listen as quickly as possible.

All lined up quenching their thirst

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 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 video 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 one’s intention never to stress or threaten these animals I any way and I felt as though it was a failure on my part 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.

Thirsty zebra

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.

Our lunch spot overlooking Selela Swamp with distant fires burning

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.

A reedbuck in the swamp

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.

A pregnant lioness on the far river bank

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.

Young male lion with a full belly

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.

Walking to his kill