Sunday, September 13 – A day in Tarangire….

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Lila breasted roller

Being located in Northern Tanzania and the number one safari site in the world does have its advantages. Our schedule here has always been seeing patients for six days a week and then we have our “Safari Sunday.” It has been my version of “as God would have intended,” and I have stuck with this plan for my entire time here other than the fact that we have somewhat morphed our last weekend into a two-night trip to the Serengeti given the distance and the fact that this is not something to miss. The parks on the Northern Safari Circuit are each very different as they are each based on a different dominating geologic feature that determines their character. Manyara National Park, made famous by Ernest Hemingway’s  The Green Hills of Africa, is dominated by Lake Manyara, a very large lake that sits smack in the Great Rift Valley and is incredibly picturesque with the 2000 foot escarpment of the rift rising from the lake and the park.

A lone wildebeest
Mr. Ostrich
Elephants by the Selela swamp

Tarangire National Park, our subject for today, is dominated by the Tarangire River that runs through it and provides water for all of the migrating animals during the dry season. Ngorongoro Crater is obviously dominated by an enormous caldera that was created with the collapse of a mountain hundreds of thousands of years ago. The crater is 10 miles across and 2000 feet deep with a lake in the bottom and herds of animals that do not have to migrate as they do in the other parks. It has everything other than giraffe and crocodiles, but most importantly is the increasing numbers of the endangered black rhino that are constantly being guarded again poachers. And then there are is the Serengeti. There is little to be said that hasn’t been said before, but it is truly an experience like no other and there will be much more in the future on this. Oh, and one last thing. “Safari” in Swahili actually just means “a journey,” and has absolutely nothing to do with a game drive. A common comment to a traveler here would be, “safari njema,” meaning “safe travels,” for any travel they are doing. When I arrive here, I am always asked, “how was your safari?”

A small group of Cape buffalo
Grabbing for acacia
Satisfaction is some nice acacia

We had elected to travel to Tarangire today which is about an hour and a half drive back past Lake Manyara on the same road we arrived on, except we make a right turn at Makuyuni junction and head southeast to the entrance of Tarangire National Park. As the gates of the park open at 6:30 AM and the animals are always more active in the morning, everyone had elected to leave Karatu at 5:00 AM, meaning that we would be leaving well before sunrise. We had made sandwiches the night before that we’d bring for lunch and had stocked up on water bottles. We were on the road by 5:15 and it was a brisk morning, but everyone was bundled up in Turtle and excited to be on our way. Traveling through Mto wa Mbu, the streets were quiet which is quite different than the normal hustle bustle encountered here. It is a major stop for buses with passengers stocking up on all sorts of fruit, but mostly their bananas that come in all shapes and sizes, and, believe it or not, colors. They are famous here for their red bananas that are advertised through town.

Dusting to stay clean
Baby nursing after a dusting

We left the tarmac at the turn for Tarangire and drove along the very rough and dusty and incredibly “washboarded” road until we reached the main gate where we would check in. Checking in at the gate is always a bit stressful me as I have had troubles with this in the past, though that has mostly occurred at either the Ngorongoro Crater or Serengeti entrances (which are completely separate administrations and each very highly regulated) and for what reason, I’m really never certain other than the fact that I am usually the only private driver there. Today’s entrance went as smoothly as ever, though, and after a few minutes, we had the tops popped on Turtle and were ready to hit the road. One of the only downsides to Tarangire is the fact that it does have a large population of tsetse flies that are typically out in full force and are quite fondly remembered by a number of residents, some of them probably still carrying either the physical or emotional scars of their confrontations with these little beasts.

Dwarf mongooses and their termite mound

The morning remained over cast and cool and seemed to have been ordered just for us. It was probably the most pleasant day I’ve had in the park in regard to the weather which is typically either hot, humid and dusty or more hot, humid and dusty. As we drove along the far side of the river towards the Selela Swamp, where would be having our lunch, there were huge herds of zebra, wildebeest and cape buffalo, many down in the riverbed. We saw herds of eland and the occasional waterbuck, as well as many, many groups of impala – harems with a single male and many female along with the occasional bachelor herds. Giraffe, warthogs and ostrich were all around. Large troops of baboons were everywhere as well as groups of vervet monkeys here and there.

Tarangire hill
Selela swamp

This is the home of the elephants in Tanzania, though, and they did not disappoint in any respect. There were dozens and dozens of families and some were quite large with many babies and adolescents. It was wonderful to sit and watch them, though it is always clear that they are watching us as well, not from a point of fear as it is with other animals, but rather watching to understand and monitor us. On most occasions, we were able to just stop our vehicle nearby and wait for them to come closer while they were grazing, again, always monitoring our location, especially when there are young babies around. After lunch, we drove along the edge of the swamp where there were more elephants, some of who were in the water cooling themselves off despite the fact it wasn’t that hot out.

What we didn’t see today, unfortunately, were the lions. Though it’s really hit or miss, I most often see them here and it was really a shame that we didn’t. It wasn’t for a lack of looking as we scanned every river bank and under every tree looking for them sleeping in the shade, but they were nowhere to be found. The sheer number of prey animals was absolutely incredible, though, and it didn’t take much to imagine that they could have been fully satiated and sleeping the day away after a night’s hunt that would have been very, very successful. Thankfully, Sean had seen plenty of cats in the Serengeti and the Crater and the rest of the team would be heading to both of these places later with more than enough opportunities to see not only lions, but also cheetah.

All in all, it was a fantastic day, but very exhausting and especially for me as I had been behind the wheel continuously since 5:00 AM with most of it on the dirt and gravel roads of the park. When driving, you are constantly watching the road in front of you as well as the bush on either side looking for animals. In addition, since everyone is standing in the back with their heads poking out, I have to monitor any branches hanging over the road to make sure that none of them smack into the top of the vehicle and strike one of my passengers. The branches are almost exclusively acacia trees with various sized prickly spines protracting from the branches and something that you’d rather not have grab ahold of you while moving. This is perhaps what I enjoy the most about being here in East Africa, though. Had you told me as a child or young adult, back when I was reading stories about Louis Leakey and Jane Goodall and others who explored this region many years ago, that I would be driving a Land Rover in the wilds of East Africa, I would never have believed you. But yet, here I am doing just that. And even greater is the fact that I have been given the opportunity to come here and work among these wonderful people who have taught me much more than I could have ever taught them. For this I am forever grateful.

Elephants in front of Selela lake

We arrived back in Karatu at sunset, tired, hungry, thirsty and filthy. We had arranged to have hot water for the evening at our houses, but needed to feed ourselves first before having showers and so pulled into Patamu, the little pub on the FAME road to order dinners. The cold Safari beer was incredibly fulfilling after spending the day in the car and hit the spot. Like most pubs here, though, dinner was at least 45 minutes away, but well worth waiting for as we were all starving. We arrived home, emptying Turtle, showered, and called it a day. An amazingly full day, at that.

A family drinking (iPhone photo through binoculars)

Saturday, September 11 – A visit to the African Galleria…

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This was obviously a day of remembrance and an important anniversary for a day that none of us living at the time will ever forget. I can remember exactly where I was when I heard the news that President Kennedy had been assassinated despite the fact that I was only 7 ½ years old at the time. I recall listening live to Apollo 11 landing on the moon and remember where I was standing when I learned of the Challenger disaster. On September 11, 2001, though, our world had changed and would never again return to what it once had been. The horrible scenes of that day were forever burned into our memories and will never be forgotten for as long as we grace this earth with our presence. We can only hope that those memories will somehow serve to prevent a similar disaster from ever happening again.

Saturdays are quite typically slower than the other days of the week here at FAME and though we used to be open seven days a week, over the last several years, Sundays have been reserved for urgent or emergent visits only by enforcing a surcharge to be seen on these days. Anticipating the lower volume of patients for the day, we thought it might a good time to arrange a visit to the African Galleria later in the afternoon. The African Galleria is a wonderful shop that has everything one could ever imagine buying here in Tanzania as a gift for someone back home. Nish and his brother, Punit, own and run the African Galleria, and I have been bringing groups there for a number of years now to shop. In addition to the standard Tanzania crafts that are quite spectacular, Nish also does an incredible business in gemstones – specifically Tanzanite and Tsavorite, or green garnet, both of which can only be found here in Tanzania or East Africa. They are both spectacular, with the Tanzanite having a very wide range of the deepest blues and almost purple at times with tons of sparkle. The Tsavorite, or green garnet, is the most sparkly green you could ever imagine and has the hardness of a diamond. The garnet is significantly rarer then the Tanzanite and priced accordingly.

Nish’s gallery had opened shortly after I began coming to Tanzania on a regular basis and it has continued to grow over the years to include more and more artwork and even antiques. There has always been a small snack bar there,  but about two years ago, he and his brother decided to begin constructing a somewhat more formal restaurant as well as place for safari guests to sit and eat their lunch boxes while traveling between Tarangire National Park and Lake Manyara National Park on their way to Ngorongoro Crater and the Serengeti that lays beyond. Unfortunately, this massive design and construction project was completed almost to the day that the pandemic first arrived here in Tanzania which essentially shut down the entire tourist industry overnight. Tour operators, safari guides, hotels, and virtually anyone related to the incoming tourist traffic in Northern Tanzania, which meant everyone, found themselves with nothing to do and a tremendous amount of very valuable equipment just sitting.

On my previous visits over the last year and a half of the pandemic, the African Galleria has mostly been closed, though did open on a more regular basis beginning in March which was great to see. Finding out that they had expanded their food services even more and now even had nyamachoma (barbecue) available on their menu was incredibly exciting as it now meant that we could couple our shopping trip with a good meal since we don’t receive dinner at the house on either Saturday or Sunday. With this in mind along with the typically lower volume, I had made arrangements for all of us including Sean and Kerry to go to the Galleria for a late lunch/early dinner. As is typical here, though, best laid plans will often go awry and, as our mission here is to see patients and teach rather than eat and shop, clinic will take priority over our extra-curricular activities.

The morning seemed to be going along quite smoothly and we had three stations for the patients to be seen, allowing us to get through the numbers of those here to see us in a more efficient manner. There were our typical smattering of epilepsy patients and some MSK (musculoskeletal) pain patients as well as one gentleman who presented with a history and findings concerning for a thoracic cord compression. He would have to obtain an MRI of thoracic spine in Arusha and return next week to see of with the images. The clinical situation didn’t suggest to us anything that would be seen on a CT scan whether it was contrasted or not. Hopefully, he would get this done as he did report to us that he was financially able to cover the cost of the scan, but you never know what he would decide after going home and thinking about it. Without the scan, though, we had little other way to determine what might truly be causing his trouble.

The bar at the Ol Mesera restaurant

Akash later saw a three month old child whose parents brought the baby in because they were concerned about limb abnormalities and the fact that when they moved the baby’s limbs they hear a cracking noise. On examination, the child was completely missing the proximal upper limbs and there were only several fingers on each of her hands. Additionally, her legs had a significant length discrepancy. On further history, the mother had been on several medications that have been associated with congenital limb abnormalities including chlorpheniramine and doxycycline. It appeared the child had phocomelia, quite likely associated with her medication use during pregnancy.

A scene at the Ol Mesera restaurant

Things were looking very good for an early departure from clinic, including Kitashu who was planning to travel home into the conservation area this afternoon, when a young child and his mother showed up much to our dismay. It turned out that they had been sitting on the other side of the OPD (outpatient department) and had not checked in with us as they weren’t aware they had to do so. We were already past the time I had told Nish we’d be leaving, but there was no way we were turning this child away from being seen, especially after his mother began to tear up and that was more than any of us could tolerate. Akash agreed to see the child, who had epilepsy, as did his mother, and was seeing us for the very first time. The child also had developmental delay, but the epilepsy appeared to be very likely genetic and primary generalized. Valproic acid was prescribed and the child will follow up in several months.

While Akash was seeing the young boy with epilepsy, the other residents and Phillip ran home to change as we were hoping to hit the road as soon as we were done. Sitting at my desk, a middle aged gentleman who had not yet registered strolled up to my desk to tell me that he had just driven in from Arusha (two hours away) and had been delayed by car trouble. I’m sure that he could see the disappointment on my face as we were already quite late for our departure. When I asked him what his problem was (I could not remember him from March), he told me that he had tingling in his extremities and our prior evaluation had not discovered a cause, but he was really just coming for a refill of his medication as it was working very well and nothing really had changed since the spring. As much as he would have recognized my earlier disappointment, I’m sure he would have noticed the relief in my face when I realized that he was only coming in for the medication. Dr. Anne was more than willing to take care of this as well as giving him an antihypertensive medication as, when he checked in, his pressure was quite high. I ran home to change and Akash followed soon after. We were on our way to the African Galleria at last and had plans for a late lunch and some shopping afterwards as the gallery closed shortly after 5:00 PM.

Dining at the Ol Mesera restaurant

The drive to the Galleria is probably about 25 minutes as it sits just outside of the village of Manyara that sits on top of the escarpment with the expanse of Lake Manyara and the Rift Valley some 2000 feet below. What was once a tiny storefront is now nearly 40,000 square foot that includes an outdoor restaurant and dining area for safari groups to stop on the way to the Crater or returning, an outdoor art gallery, and a shop that includes virtually any craft that has been made in Africa. Their Makonde carvings are incredible and outside they are working on carving large portions of ebony trees in trees of life, a classic carving of many people intertwined and hollowed out in the center. In the middle of the shop, sits their jewelry, which again is pretty spectacular considering the extensive amount of Tanzanite, Tsavorite and other rare stones they have on hand at all times.

Pleasant company

In addition to the opportunity to pick up gifts for those back home, though, the African Galleria now offers a solid menu of food for lunch and early dinner. There was so much that we really couldn’t decide just what to order, so Nish volunteered to order for the table and have us eat family style, sharing all of the dishes. There were two vegetarians among us (Cat and Akash), so he made sure to include enough for them to eat, though the rest of came for the nyamachoma that he had raved about before our arrival. Well, the dishes kept coming and coming and were all amazing. I wish I could remember all the names of the dishes, but for the first course, we had a pumpkin coconut soup that was out of this world. Had they served me a huge bowl of that soup alone for my meal, I would have been totally satisfied and left happy. (I should mention that the homemade soups in Tanzania, especially those while glamping in the Serengeti, are always amazing). The nyamachoma was incredible as was the fried ugali sticks. There were so many other scrumptious dishes that I can’t even remember them all, but leave it to say that when we later left the Galleria after shopping we were all quite full and couldn’t even think of eating anything later that night. We were leaving early in the morning for Tarangire to go on a game drive, and I’m sure that everyone that much better that night with full bellies. Moreover, the entire experience was just perfect – Nish sat with us for the entire meal and made sure to tell us about each of the dishes while the service was just impeccable. There is no question now that the African Galleria should be on everyone’s list of fine dining here in the Karatu district which already has a number of incredible places to dine. Nish has outdone himself.

Lots of food

We ended up shopping until well after the normal close of the shop, but there were other groups there as well which was great to see as it meant that the economy here was on the rebound if even still only a fraction of what it was in the pre-pandemic days. Hopefully, as more are vaccinated here, things will continue to improve. We can only hope. We drove home through the most beautiful countryside one could ever imagine in the waning daylight as the sun slowly set over the distant hills of the nearby Ngorongoro Conservation Area. It’s still hard for me to imagine that I’m here after my 24th trip and I’m sure it’s even harder for those who have come for the first time to experience this truly magical place.

Friday, September 10 – A busy day in clinic and Gibb’s Farm for dinner…

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The weather here has been surprising cool, dropping down into the 50s at night getting only into the upper 70s during the daytime with very brisk mornings on our walk to clinic. I have rarely used any type of sweater here and find now that I’m wearing a fleece vest or else I’m sitting with a chill well until lunchtime. I can’t help thinking that it’s just another worrisome sign of global climate change such as we’ve seen with the storms and fires in the US over the last year. Watching Al Roker cover the recent hurricane Ida coming ashore in Louisiana as a category 4 after she had massively intensified over the warmer than usual gulf waters would have been enough to convince anyone. His comment of, “for those of you who don’t believe in climate change, this is climate change personified,” certainly rang true to me and now with the unseasonably cool weather here, it certainly makes me worry more than I had already been. Climbing to the top of Mt. Kilimanjaro six years ago in an unusual blizzard and viewing the wonderful glaciers that have existed there over millions of years that are now slowly disappearing just as those elsewhere in the world along with the polar ice caps, are also grim reminders of the mess that we are leaving for our children’s children.

Phillip in the morning at the Lilac Cafe – “really, I’m working.”

Despite our world as we know it slowly disappearing (I say that only half sarcastically), we arose for clinic with an extra half hour of time as there was no education lecture this morning and only morning report that begins at a more humane (and not surgical) 8:00 AM. I should have also mentioned earlier that most of the local population here goes by Swahili time which starts at our 6:00 AM and counts up from there. Our 8:00 AM would be 2:00 in Swahili time. There is no AM or PM typically attached to that and it has forever baffled me how one would tell daytime from nighttime, but be that as it may, our clinic runs from 2:30 to 10:30 in Swahili time which is what the sign says at reception and what most of our patients have on their cell phones. That’s another topic for discussion, in case anyone was wondering, but everyone here has cell phones. Most of the Maasai use the older type, non-smartphones, that they carry in a small pouch around their necks as the shukas (plaid cotton blankets) that are wrapped around them in traditional style don’t have pockets and, although the men usually have a belt they wear, that is for their traditional knife they carry. Charging of their phones is typically done via either small solar panels on the roof of their hut as their bomas do not have electricity, or by utilizing a power outlet wherever they find one, such as clinic. For Maasai that live in town, that is obviously less of an issue as they would typically have power in their homes.

Matilda at her best…sleeping

Morning report today included a small child who had hit their head and was having repeated vomiting overnight and into the morning. Though that would be something we would normally deal with here, I was more than happy to turn it over Kerry and Sean since it was much more in their bailiwick than ours and it’s been such a pleasure to have them here for these kinds of things. Over the years, we’ve had neurosurgical cases that I’ve had to deal with, but as long as the time permits, I’ve always utilized Sean for necessary clinic questions. I recall several skull fractures in adolescents that we’ve seen here and he has come through every time in guiding us to the proper decision of whether it’s been something that we can just watch here or would have to refer on to Arusha to see the neurosurgeon there (who’s only been available to us over the last few years). Akash got report on the young baby with the hypoxic ischemic encephalopathy who seemed to be holding their own for the moment and we were otherwise free to start our clinic at 8:30 (2:30 Swahili time) as we had plans for dinner tonight at Gibb’s Farm and wanted to make sure that we were finished in time for sunset which is typically gorgeous there and not to be missed if possible.

Various stages of explosion from the freezer. Oops…

Our clinic began rather slowly, but began to pick up through the day with a smattering of epilepsy patient that were great for Cat and Emily as well as enough pediatric cases to keep Akash in his comfort zone (and the rest in theirs). Denise, our budding neurohospitalist, would have to be happy seeing everything, which is certainly what she’ll be doing in the future, albeit on the inpatient rather than outpatient side of things. The epilepsy cases were all excellent and continued to reinforce the need for our work here for these patients in particular. I’ve spoken about this repeatedly, and it is one of the main focuses of the education we are providing here to both the patients and the doctors. 90% of the world’s epilepsy occurs in low to middle income countries and the reasons are many. The increased incidence of childhood infections including cerebral malaria, traumatic head injuries and perinatal injuries are the main reasons for this increased prevalence of epilepsy.

Experimenting with beer in the freezer overnight. Do not try this at home.

Most worrisome is the fact that epilepsy is also occurring more frequently in exactly the places where there are no neurologists or any expertise to treat it so that it either goes unrecognized, untreated, or treated incorrectly, all of which result in the same thing – poorly controlled seizures that can be life threatening in and of themselves as well as with the risk of injury during the seizures. In the rural communities, as well as the big cities, most Tanzanians cook over open fires or using propane tanks that rest on the floor. Adults and children having seizures and falling into flames sustain horrendous burns that can lead to death or a disfiguring injury. It is not uncommon for us to have several patients, more often children, with severe burns in the ward when we arrive or during our time here. Also, children with recurring seizures are, most often, not allowed to attend school, which is another tragic consequence of this very treatable disorder. Since 2010, we have encountered children, adolescents and adults with epilepsy whose lives have benefited greatly with improved seizure control meaning that the impact of treating this single problem has made perhaps the greatest difference for the patients who we treat.

The view out the bathroom window at Gibb’s Farm

In addition to monitoring the basic demographics of the patients seen by us, we have been keeping a separate database of our epilepsy patients in order to drill down on the effect we’ve had providing this care by recording such variables as adherence on medications (compliance) as well as seizure frequency and quality of life issues. We have also looked at the characteristics of those patients who return to see us versus those who are new and seeing us for the first time. In September 2019, Leah Zuroff (medical student then and now second year neurology resident at Penn) crunched the numbers to compare these rates of return vs new by diagnosis and discovered that epilepsy patients were 3X more likely to return for a visit than headache patients. We had truly made a difference for these patients and they were returning to see us. FAME shot a video last fall with an interview of one of my patients who I’ve cared for since 2011, and her mother. She had a perinatal injury with a hemiparesis and was having frequent focal seizures that precluded her from going to school. It was merely a matter of putting her on the right medication and maximizing her dosing regimen such that she has now had no seizures in many years, completed primary school and has advanced to secondary school where she is totally thriving. It is success stories like these that really make all of this worth it and keeps us coming back again and again.

We also saw two patients today with idiopathic Parkinson’s disease, a disorder that is made entirely on a clinical basis and without any testing, which is certainly a blessing considering that we’re very limited on testing here either based on the cost or availability. Though we do have a CT scanner here at FAME, the cost for the patient of doing one can be prohibitive even though it is far less expensive than what one would pay at home. A non-contrast CT scan here may only cost 200,000 TSh, or approximately $90, which would be a bargain in the US, though in a region where the annual income may be only $250/year, that amount is out of the question for most. Thankfully, the culture in East Africa is predominantly communal, meaning that a patient can go back to their family, their village or their community to obtain the funds necessary for something like this. MRI scans are only available in Arusha at one facility and are probably double the price of the CT scan. Something so specialized as a DaTscan which is performed primarily for helpful when evaluating patients in whom Parkinson’s disease is a concern are not even a consideration here. Thankfully, since Parkinson’s disease is primarily a clinical diagnosis and carbidopa/levodopa, or Sinemet, is a medication that is so effective as to be considered a diagnostic test and is available here, we can easily diagnose and treat this common disorder without the need for any expensive or unavailable testing.

The view from the veranda

Some stories, of course, are not so easy to sort out and treat. Histories are quite often very difficult to obtain despite the wonderful assistance we have from the doctors and translators who work with us here. Patients may have been treated at other facilities and have no inkling as to what was done and medical records are rarely available for us to review. Cultural differences that determine just how one relates historical events is often very great, effecting just want facts a patient or family may relate to the condition they’re being seen for. We commonly hear things such as a psychiatric disorder that may begin if a snake crosses in front of the patient or even the name for seizure here which is degedege and that dege means large bird, often linking the superstition that seizures happen because a bird flew over the house. Trying to back up to obtain the necessary information for us to build a good timeline and make a diagnosis can be very difficult in these situations requiring us at times to decide just what the most plausible explanation for a patient’s condition is and go with that. This certainly happens at home as well, but just seems to be that much more prevalent over here.

A walkway at Gibb’s with the night sky in the background

We had hoped to leave for Gibb’s Farm at a decent time, but our clinic turned to be far busier than we had anticipated, seeing, in the end, 28 patients total for the day. Dr. Anne would be coming with us as well which meant that she would need to run home to change and we would pick her up in town where our road met the tarmac. By the time we left FAME, picked up Anne and then drove up the road to Gibb’s Farm, the sun had mostly set, though it was still light enough to enjoy the loveliness and serenity of this place. The view from the veranda is spectacular and no matter how often I return, I never get tired of relaxing atmosphere and tradition that is Gibb’s Farm.

The afterglow of sunset at Gibb’s (photo courtesy of Akash)

The farm was very different when I first visited in 2009 as it was still in its original configuration when owned earlier by the Gibbs family and run as a self-sufficient village where there was a dairy, gardens and a shop for making all of their own furniture. There was also a free-standing clinic, the Osero Clinic, that was run by Dr. Labiki, a Maasai healer, who had his various herbs and natural products that he prescribed for patients, but clearly knew when it was appropriate to send patients to FAME. When I first came, Labiki took me and my kids on a walk through the woods surrounding Gibbs to identify various leaves and bark that were used by traditional healers. He had completed a manuscript along with an ethnobotanist in Nairobi that compared the chemical makeup of the commonly used plants to the medications used in the western world and looking for any similarities. They obviously found many. Labiki remained at Gibb’s and the Osero clinic for several years and I would visit him frequently, but he later left and moved back to Arusha to work with his brother in their own clinic there.

Our dinner table (missing Kerry and me)

Later, there were many renovations done to the farm, all for the best, as it is now a destination resort, but with the old appeal of the original Gibb’s Farm. The main building now has a wonderful dining area that accommodates both inside and outside dining and the veranda and front are wonderful for having drinks while watching the sunset. I have known a number of the staff at Gibb’s for many years and am always greeted with such warm friendship there that it is impossible not to want to remain there for as long as possible. Dinner was once again the incredible affair that it has always been such that Gibb’s remains one of my favorite places to visit here or, for that matter, anywhere in the world. I think we probably spent just short of three hours for dinner, yet the evening seemed timeless as it was spent among friends, both those at the table, as well as those serving.

Thursday, September 9 – Our first day of neuro clinic….

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Having arrived the evening before and fully moved into the Raynes House, everyone settled into life here. The Raynes House was built several years ago, through the generosity of Stephen and Lisbeth Raynes, as the fourth and final volunteer house on FAME’s campus and a home for the Penn Neurology team during our time at FAME. The house would be used by other volunteers at times that we’re not here, but will always be reserved by us during the months of March and September, as well as other months that Penn faculty and residents may come. The house is incredibly comfortable with four bedrooms (three double and one single, the latter for me), each with its own bathroom. We have a large living area centrally and a kitchen with the best view in the world looking out over the coffee fields to the west to watch the wonderful sunsets here. We have a small veranda in front of the kitchen windows with a beautiful garden courtesy of Annie Birch, a long time ex-pat resident here and jack of all trades. I have three hammocks set up across the front of the house for that occasional day we get back to the house early to enjoy the evenings. As I mentioned before, life is good.

The first day of school – Emily, Denise, Phillip, Cat, and Akash (left to right)
An ant colony on the move

Our daily schedule here is clinic from 8:30 AM through 4:30 PM with tea time at around 10:30 AM (a British colonial holdover) and lunch usually around 1:30 PM. Lunch is made by the kitchen for all the workers at FAME who eat together, though now it is outside during the pandemic where it used to be inside the small cantina at picnic tables. We have rice and beans complimented by mchicha (a spinach like vegetable) on every day but Tuesday, when we have ugali and meat plus mchicha, and on Thursday, rice pilau with beef (most everyone’s favorite, though I am partial to the rice and beans). Lunch is served seven days a week for anyone on campus. The kitchen prepares dinner for us on Monday through Friday, serving it in hot pot containers, one for each of us. The dinners are basic, though adequate, and after a long day at the clinic, we’re usually so tired that the dinners more than suffice. There are lots of vegetables, prepared in every way imaginable, with a smattering of beef or chicken complimented by occasional chapati. We are on our for breakfast, but are supplied all the basic groceries such as cereal, eggs, bread, veggies and fruit. Trust me, we are never wanting for something to eat here, that is for certain.

Akash and Cat evaluating a child
A good view of our outdoor clinic
Revo and Emily

For our first dinner here, they had unfortunately shorted us on dinner, which was not a major problem as it included meat sauce and Akash is a strict vegetarian. Sean and Kerry came to the rescue, though, as they had been here for a few days and had some salad fixings that worked just fine for Akash. We all sat out on the next door veranda (Joyce’s house) which is much larger than ours and in between our house and the one Sean and Kerry are staying in. Thankfully, they also had some beer and wine to bring which made dinner that much more enjoyable.

Morning lecture on chronic subdural hematomas and burr holes
Dr. Sean demonstrating on wood

Perhaps it would helpful for me to introduce the cast of characters for this trip as that might be helpful for those of you who are not family members or unfamiliar with the group. The neuro team consists of three adult neurology residents – Cat (Catherine here as the nickname Cat is not well understood), who will be going into epilepsy; Emily, who will also be going into epilepsy; and Denise, who will be pursuing training as a neurohospitalist. Our pediatric neurology resident is Akash, who will certainly discover how indispensable he is, though we would never tell him that 😉. Phillip is our medical student, whose role it is to keep our database of patients current and, when he’s not doing that, work with us in clinic to observe as he’s not allowed to officially offer any treatment or touch a patient, a common rule for medical students going to foreign countries and imposed mostly by the home institution, in this case Penn, rather than the host country.

Dr. Ken and Dr. Sean

Sean (Dr. Sean Grady) and Kerry (Dr. Kerry Vaughan) represent an entirely new effort here at FAME and that is neurosurgery. Not to bring highly technical procedures to FAME, but rather to train the surgeons here how to do a rather simple, lifesaving procedure to treat a very commonly seen problem here in East Africa and other parts of Africa. Traumatic head injuries are significantly more common here in Africa (and all low to middle income countries) and often result in bleeding outside of the brain called a subdural hematoma, or, less commonly, an epidural hematoma. Having a CT scan available here at FAME, we’re easily able to identify when these events occur, but we have no mechanism to treat them effectively other than giving some medicine to reduce intracranial pressure and shipping them off to Arusha for a burr hole or craniotomy to remove the blood and relieve the pressure. The problem is that time is of the essence, as one can certainly imagine, and very often the patient may suffer significant injury or death prior to or en route to Arusha, where there is a single neurosurgeon.

Kerry preparing the femur

Sean has accomplished similar efforts in the past during his time in Seattle, Washington, where he trained general surgeons in lower Alaska how to do these procedures successfully so that these patients could be treated on site rather than having to be shipping down to Seattle with many of them suffering complications along the way. Kerry, who is actually a pediatric neurosurgeon and just about to start a new job after her fellowship training, trained at Penn under Sean and has done extensive global health work in many locations, including nearby Uganda. We are so excited to have them here with us and this will be a huge new step for FAME, equipping them to deal with these neurosurgical emergencies in the appropriate time to save lives. They will be here for two weeks and, though it would be an excellent opportunity if one of these patients presented during our time here, it is not entirely necessary as they will prepare the surgeons and the operating rooms either way.

Gabriel saving a femur’s life

Sean and Kerry had arranged to give the educational lecture today which would be an introduction to the hand drills that were brought here to use for this procedure. Not having a ready, or willing, volunteer to undergo a burr hole (essentially the same as trephination that was practiced by many cultures in both prehistoric and ancient historic times), they had arranged for Dr. Ken to boil down a few cow femurs to remove all the soft tissue and these would serve as surrogate skulls to provide the feel of drilling through the two layers of the skull – the harder outer and inner tables and the softer cancellous bone center. After some introductory slides for orientation, the practical exercises began and our two neurosurgeons instructing the FAME doctors on the fine points of using a hand drill, or brace, to bore a hole through the two layers and note the feel of the drill bit as it was about to perforate each of the harder layers, the outer leading to the cancellous center, and the inner leading to the cranial vault with the brain and the fluid collection that was the target.

Gabriel working with the drill

After the educational exercises, we had a brief morning report to go over the inpatients and any new patients that might need our expertise, as well as the maternity patients. There was also one patient in the COVID isolation ward that was being taken care of. Once finished with morning report, the first piece of business for us to take care of would be for everyone to be instructed on the reasonable new EMR used at FAME. This is a rather bare bones system designed to primarily capture the necessary data on patients, as well as to track medications and payments. In addition to orienting everyone on the EMR, they were oriented on the work flow of the clinic and introduced to our translators. Revocatus, or Revo, who has worked with us on multiple occasions previously, is a medical intern at Kilimanjaro Christian Medical Center and is a superstar. He is a fantastic clinician who has learned a tremendous amount about neurology working with us. He has reinforced the power of our program in regard to training those frontline clinicians who will go on to care for their patients now armed with a full complement of the knowledge necessary to provide basic neurologic care where there was little before. Dr. Anne would, of course, be working with us again as she has for the last eight or so years. She is FAME’s neurology provider in our absence and has done a remarkable job of this over the years. She works with us for the entire month each time that we’re here. Dr. Leeyan, who is Maasai and a relative of Kitashu’s, is new to our clinic and working at FAME for the first time. We will give him time to get up to speed and make sure everyone is comfortable as working as a translator is not always the easiest job.

Dr. Sean instructing Dr. Ivan

By the time we were finished with orientation for everyone, it was already tea time, and this is not something that is taken lightly here. The wonderful African tea, or tea masala, is served as well as coffee and bread. I’ve never totally understood the tradition of eating slices of white bread with margarine, but it seems to be well accepted by everyone here with employees walking from the cantina holding several slices in their hands. In a continent where caloric intake is poor at best, I guess it’s certainly a means of improving that issue, even if it isn’t terribly appetizing to me.

Dr. Sean working one of the FAME doctors

Our clinic began at around 11:00 AM when everyone was finished with their tea since, as I’ve mentioned before, this is not something that we would ever interfere with here. The patients who came today were mostly return patients who had been called by Kitashu or Angel, our clinic coordinators, to come see us for their follow up visits. There were a number of well controlled epilepsy patients on medications that were working well and merely needed to be renewed or a few may have needed lab work to make sure they were having no issues on their medications. There were also a few consults for us. One was a patient with a long history of quadriparesis from what sounded like Pott’s disease (Tb of the spine), though the history was a bit inconsistent and would require a bit more interrogation to make sure we had an accurate story. The other was an unfortunate baby who had a very problematic birth with likely HIE or hypoxic ischemic encephalopathy and then began promptly having seizures. Akash went to evaluate the child who was now very sleepy and on phenobarbital which was very likely contributing to the sedation and they hadn’t seized in some time. We elected to hold the phenobarbital and observe the child to get a better exam on them as far as a prognosis.

Our patient with carpopedal spasm

Just before we were finished for the day, Dr. Anne and Cat ran to the ER to see a very interesting patient for a neurology consult. It was a 28-year-old gentleman who had no past medical history and had been driving their family member to the hospital when he developed a bizarre posturing of his hands and feet that looked dystonic in nature. They brought him to FAME fairly quickly where he continued to have the same posturing that indeed appeared to be a dystonic posturing of the hands with flexion and abduction of the fingers and, to a lesser degree, the feet. He was given some diazepam with eventual resolution of the abnormal posturing. When Cat and Dr. Anne got there, he was back to totally normal with a totally normal examination. Thankfully, they had taken a video of the patient when he had first arrived and they brought this back to show me. The patient was clearly hyperventilating and I took one look at the video and was pretty certain what the diagnosis was. The patient was having carpopedal spasm in the setting of a panic attack! What a great case for the residents.

Meow and Charlie

We gathered for dinner once again on Joyce’s veranda and enjoyed a meal of curried vegetables and chapati. Matilda was once again pestering everyone in constant search of some morsel of food despite the fact that she is fed daily by housekeeping. The sky was quite clear tonight and Akash took some amazing photos of the stars. I was working late only to realize that I had an important Zoom conference scheduled from 11 PM to 12 AM that I had forgotten about. It was with the Center for Global Health at Penn meeting with the director and assistant director as well as others at Penn who are currently doing work in Tanzania. It was great to be on the call considering I was the only one actually in Tanzania at the time, but it was also very late and we had clinic the following morning. Thankfully, we didn’t have a 7:30 AM educational meeting so that I could at least get a few minutes more of sleep.

The heavens above (photo courtesy of Akash)

Wednesday, September 8 – The team arrives to Kilimanjaro

Standard

Having finally made my way to Tanzania and recovered from my jetlag and two sleepless flights, it was now time for me to drive to the Kilimanjaro International Airport to pick up my team of four residents and one medical student who were arriving this morning on the same flight I had taken days before. I had been in touch with them back home to alert them all to the frustrating issue with the COVID test needing to be done within 72 hours of arrival and the timing of getting it tested. It proved to be an issue for one of them, necessitating having a rapid PCR done at the airport for a rather princely sum, though it was all taken in stride and just another reminder of how the pandemic has affected our lives. Thankfully, the five of them were all able to travel on the same flights, making it far easier for me having to make only a single trip to the airport and having a vehicle large enough for all of them and their luggage was equally important.

Success. Everyone made it as did their luggage

I got there shortly after their arrival, but still managed having to wait well over an hour given the many hoops that are now necessary for entry into the country with the pandemic. After leaving the plane, you must first check in to receive your COVID rapid antigen test (which cost only a very reasonable $10) that surely seems superfluous given the requirement for a PCR within 72 hours of arrival and not departure. After that, you must then go through immigration with your online visa paperwork so your passport can be stamped. Once you’re through immigration, then you get your bags, or not, as has happened to us a number of times over the years. Once you have your bags, it is then through customs which requires your bags to go through X-ray to make sure that you’re not bringing in any items that you should have been charged a customs tax for. This is typically a crucial point for me as I am often shuttling supplies for FAME, though the residents were only bringing their own gear which would be permitted without questioning or any further discussion.

Tetris

The entire group finally emerged from the arrivals hall which is always a hectic scene of almost exclusively safari drivers waiting to pick up their clients, either holding signs with their names high aloft above their heads or against their chest if they’ve been lucky enough to secure one of the front spots and readily visible to exiting passengers. It’s always fun to watch as they exit looking for their names, something I recall quite vividly from my very first visit here in 2009. Meeting your guide and loading your bags into your Land Cruiser or Land Rover is the very first experience you have before heading off into the bush and experiencing this amazing continent and it is a very formative moment.

Cat (upper) and Emily (lower) finding something to do at the Doha airport

After their 24+ hours of flights, they all appeared to have weathered the travel well and were excited to get on the road, though not until I got a picture of the group, their first of many that I would get over the next month. We were soon on our way to Leonard and Pendo’s for a short visit and breakfast, something that has become a tradition for our visits here. They have always been insistent on providing a meal or accommodations for the residents on their arrival as their way of giving something back for the work we’re doing. I have tried time and time again to reimburse them for their troubles and they have refused me every time, simply insisting that they were just doing their part and would think of doing nothing less. That’s the way it is here as the Tanzanians so appreciate the fact that you traveled such a distance to help them because it’s something that you want to do, not something that you have to do. Little do they know, though I’ve told them time and again before, but what we get out of the experience far exceeds anything that we’re providing and is something that gives us some meaning to our lives. That is what it’s all about and why we continue to return year after year.

Breakfast was a wonderful spread of small roasted potatoes, chicken sausage, small pancakes, pineapple, watermelon, fresh watermelon juice and Pendo’s amazing African tea or chai masala, which is a wonderful cacophony of spices including cardamom, ginger, and everything nice. I have attempted this tea at home, but have never been able to perfect it and always dream of my return just for the tea (as well as most everything else I eat here). My Land Rover, named Turtle, had needed a few last minute services performed and so Leonard had taken it, but it was much needed downtime at the house with several of the residents closing their eyes on the couch prior to our departure.

Cat above and Emily below. Not sure whose hand that is 😉

We were finally all packed and had Turtle back from the shop, ready to say our goodbyes to everyone and finally make our way to FAME. With the new bypass, we were thankfully able to avoid driving through Arusha, which was once a sleepy, sprawling town with only one stoplight that has now become a massive tangle of traffic from the moment the sun rises and is worth avoiding at all costs. A quick trip to town during any of the daylight hours is no longer a possibility. The bypass, on the other hand, is not really heavily used and, as a result, we were able to scoot out of town and be on our way heading west in no time. As I’ve mentioned many times, the drive from Arusha to Karatu takes one from the green slopes of Mt. Meru through more arid lands that are occupied primarily by the Maasai and their many boma, eventually arriving to the Great Rift Valley and Lake Manyara. Here is the village of Mto wa Mbu, or Mosquito River, that sits at the entrance to Lake Manyara National Park, the site in the 1930s of Ernest Hemmingway’s hunting trip for rhinos that unfortunately no longer exist from over hunting. From here, we wind up the escarpment of the rift valley that ascends over 2000 feet to the Ngorongoro Highlands, famous for its coffee plantations and the many luxury lodges for those safari goers so inclined.

Matilda, our volunteer house cat, who makes Cat and Emily quite happy. Me, not as much as she constantly meows. Or is that Emily? (photo courtesy of Akash)

Each time I travel here, I am reminded of just how truly lucky I am to have found this place. Even during the current dry season, traveling out of the valley and up onto the escarpment with its vibrant and lush vegetation makes one realize just diverse the ecology is here. As we reach the highest point of our drive, at Rhotia, its valley below of fertile fields stretch before us and high on the opposite side sits our destination, Karatutown, where FAME has existed since 2008 and I have been coming since 2009.

Karatu is frontier town, the final stop on the tarmac, or paved road, before the gate to the Ngorongoro Conservation Area, the Crater, and the Serengeti. If one is planning to get to the Serengeti, you must travel through Karatu unless, of course, you’ve chosen to fly between location, which, in my mind, defeats the entire purpose on traveling to this amazing country. At one point, there had been plans to build a paved highway across the entire Serengeti to allow trucking to make the journey more easily at the expense of the wildlife there including the potential disruption of the wildebeest and their great migration. Thankfully, environmentalists rose to the occasion and blocked the continuation of the project which fizzled out without much fanfare.

I’m sure that traveling up the FAME road must have been incredibly exciting for the neuro team and they were probably also wondering what to expect at the end of this incredibly bumpy and dusty road. FAME is about three kilometers out of town and up a few hills, but you reach it, you know that you are home and have arrived. It is a place of great goodness and the nearby coffee plantation by the name of Shangri-La seems to say it all. The smiling faces and shouts of “Karibu” from all who see us driving through the gate and up to the administration building are all that it takes to wipe away any stress or troubles that you’ve brought with you to this wonderful place. We met up with Prosper, our volunteer coordinator, who gave the team their tour of FAME, then headed off to the Raynes House, our home for the next month. If the expression “Life is Good” ever had a more appropriate place to use, I can’t think of it.