Thankfully, it was a morning to sleep in by an extra 30 minutes and I think everyone in our group took advantage of the extra minutes of slumber. It only takes five minutes to walk up to FAME from the volunteer housing and it’s always interesting to see what the normal morning schedule is for each of the travelers with me. I’m typically an early riser (which doesn’t work well considering I get my best work done late at night), but others seem to roll out of bed with just enough time to pour a cup of tea or coffee, often though unable to finish it. Regardless, we all seem to make it in time. Phillip has had the luxury of taking most mornings to do his work on the database at the Lilac Café where he can order breakfast and a coffee or cappuccino for the morning while working on the internet to enter data and take care of his emails. Sitting out in front of the Lilac with a nice cup of Joe is probably one of the most relaxing things I could ever imagine doing. I dream of this when I’m back home in the US.

We learned at morning report that our seizure inpatient had done well overnight with no further seizures on the increased dose of valproic acid 1000 mg twice daily. He was awake and seemed better than before so the decision was to send him home on the higher dose of medication and have him come back to see us in clinic the last week that we’d be here with the hope that he would remain seizure-free and that his exam would be non-focal. Our hope was to hold off making any long term decisions as long as he remained seizure free and regained his prior functional status. The decision of whether or when to reimage him would really depend on his clinical status going forward and whether his exam changed or whether he begins to have more seizures. For now, though, we would simply maintain him on his current medications.

Our Sydenham’s patient returned for his echocardiogram that demonstrated evidence of inflammation and would determine the length of antibiotic prophylaxis that we would recommend. Based on the current recommendations, given the evidence of carditis, or inflammation seen on echo, he would require IM or PO penicillin for 10 years! I can’t recall whether I had mentioned it yesterday or not, but we would also place him on a fairly long course of oral steroids as an immunosuppressant to decrease the movements over time and hopefully hasten their resolution. Most often, the movements will completely resolve over time, but it can take many months or even years and having them resolve just a bit sooner I am sure would be very much appreciated. After initiating his medications and giving the family all of the necessary information, he was sent out with instructions to return in several months to see Dr. Anne and then in March to see us on our return. Again, Sydenham’s chorea is such a classic illness and so rarely seen in the US, it was great to have all of the residents, Phillip and even Sean and Kerry see him. Once you’ve seen an adolescent present with these movements, you will never forget the diagnosis.

Another young boy who we saw today was brought for evaluation of two months of mid back pain that had been bothering him significantly. These types of complaints wouldn’t normally be seen by us as a neurologic problem, but the family had come from Arusha to see us specifically. Our neurology clinics are subsidized for several reasons, but the most important perhaps is to allow patients to come see us without worry about the cost of medications or diagnostic labs. We charge patients a flat rate of 5000 Tanzanian shillings (slightly over two dollars) for a visit that includes at least a month’s worth of medication (I am often asked to approve a two or even three month supply of medications due the distance a patient may live or their ability to pay for refills) and it may be often that patients are not even able to pay that amount. Because of the flat rate, though, many patients may come to our clinic to seek care for other conditions (most often muscle or joint pain) and, despite our best efforts to make it clear on our announcements to the community and to triage patients in clinic, we have routinely had to categorize some patients as “non-neurologic” or “MSK pain” for our clinics.

Given that back pain in a twelve-year-old is that unusual, though, we felt it reasonable to have Akash evaluate him and make some recommendations. In the end, we were quite thankful that we did so, as it was not only the back pain that worried us, but also his abnormal neurologic findings that revealed some mild weakness present in his lower extremities. This combination of history and abnormal examination required that we refer him for advanced imagining (which would have to be done in Arusha or further away) and would need to be done sooner than later so that we could also review the studies before our departure.

We finished our clinic a bit early this afternoon and everyone had been wanting to take a hike around the area since we’d arrived. The red clay in the Karatu district is remarkably perfect for brick making and there are community brick quarries located throughout the region, but one of the larger ones just happens to be down below FAME. Walking through the quarry and up the other side of the ravine takes you onto a small road that leads to the town of Tloma, an Iraqw community where many of our patients come from and a stone’s throw from the entrance to Gibb’s Farm. Everyone chose to tag along so it was the neuro team along with Kerry, Sean and Revo. Leaving from the main gate of FAME, it’s just a short distance across the main road to reach the trail that descends into the ravine where we’d find the quarry and the trail up the other side. The trail that descends is also used for cow and goat herds, so one must do their very best to avoid  these booby traps, though they’re fairly obvious. As we got the very bottom of  the ravine, there was a small stream that hadn’t been there in the past, or at least I couldn’t recall. The braver half crossed as we first encountered the stream, though those of who were a bit more interested in remaining dry chose to scout out a better crossing point and found one close by.

Having now all successfully navigated the stream, we walked through the quarry where there were several workers processing bricks and a number of children working on piles of broken bricks turning them into gravel with clubs, a very labor intensive job for certain. The bricks are first formed and then stacked into very large, perhaps 10 feet tall, towers with cavities in the bottom where wood is placed and eventually lit to fire the bricks. The finished product is used for building all of the structures in the region that are not otherwise built of wood branches and mud. Once out of the quarry and onto the road above we encountered lots of children who were playing on the many properties that we passed on our way to Tloma Village. There are also a number of nice lodges here that are older and have high walls that surround them. We finally intersected the Gibb’s Farm road which is the center of Tloma Village and begins the countless rows of coffee bushes that form the Gibb’s Farm coffee plantation.

As we were walking past one of the remaining shops of wood carvers, we heard a “hey Dr. Mike.” Though I hadn’t been up there in several years, an old friend, Mbuga, had recognized as we were walking past. He is one of the remaining Makonde wood carvers in the village where before there had been dozens and had entertained residents in the past by demonstrating and then instructing them in the fine art of wood carving. In addition to the wood carvings that were more than plentiful in his shop, he also had many pieces of art that were mostly in the Maasai or Tinga tradition. Several of our group spent a good amount of time shopping there and when we were almost all finished, Mbuga told me that he wanted to bring me next door to meet a friend of his who was serving coffee. Our little impromptu visit to the house next door turned into the most amazing and pleasant of experiences.

Next door to Mbuga’s wood carving shop lived a family of coffee farmers who had been in the area for at least two generations and not only grew their own coffee beans on the five acres of land they owned, but also processed and roasted their beans for sale to the public. There resided Philippo, his wife, Fausta, and their four children, all of whom helped with harvesting and processing the coffee beans. There were no other visitors when we arrived, so we had he place to ourselves and Philippo proceeded to not only give us a guided tour of the farm, but he also delivered an incredibly detailed explanation of each of the various steps in bringing the coffee from plant to bean to cup. The beans are shelled with a grinder and then pounded by hand before they are then winnowed to remove all of the chaff. Philippo and Mbuga gave us a demonstration of pounding the beans, singing “Twanga, Twanga….Twanga, Kahawa, Twanga” as the did. Then they Cat and Denise a turn at the pounding that was pretty impressive. Once the beans are dried, they are then put into a canister and roasted over coals while turning by hand for approximately 40 minutes to achieve a perfect medium roast.

Philippo was one of the most patient and warm individuals, answering all of our questions along the way and then some, and after all was done, we sat down for a cup of his freshly brewed coffee that was truly amazing and served by his wife. In addition to his coffee, he also had many bee hives as the bees were necessary for pollinating his coffee plants. He told us that he had recently harvested his honey and didn’t have any left over for sale at the moment. When I asked about purchasing some of the honey from him, he did promise to save his next batch for me as soon as he had more to sell. Both Phillip and Sean turned out to be closet bee keepers and were enthralled by Philippo’s hives there were the home to a species of small stingless bees. He opened one of the hives for them that was handy so we could all look inside and actually scooped out some of the existing honey for us to taste. It was a very thin, sweet, coffee-tasking honey that was really out of this world. I sure hoped that he would come up with some extra bottles before I left.

After our tour was through, everyone put their orders in for bags of coffee as we didn’t want to have to carry them back with us on the walk home. We had a half day of work on Saturday and planned to return on that day after our work was done. Before we left, though, we did make sure to pick up a 500 gram bag of ground coffee, which Philippo proceeded to freshly grind for us with his mechanical disk hand crank grinder. We all said our good byes to Philippo and his wonderful family. Their home, their lifestyle and their hospitality were all idyllic and, as a group, we all agreed that our visit was incredible and that none of us could wait until we visited with Philippo and his family once again. We trekked home into the setting sun, down into the quarry and back up the other side until we reached FAME once again. We all met on the veranda for dinner in the gentle darkness that is Africa, lit only by the waxing moon and our little solar powered blow up lantern.

Later that night, I did run up to the clinic as I was asked to check in on a tourist of one of the tour companies who had been admitted for the night, though she had been put in the isolation ward due to some low oxygen levels and concern over COVID. I wasn’t able to see them as they were isolation, but did follow up the next day. It was not a neurologic case, so I had little to offer medically over the doctors here at FAME, but I was happy to help out with communications. On my way back to the house, I marveled at our migrating ants who had creating quite a sight and worthy of a photo.

Educational lectures occur every Tuesday and Thursday at 7:30 AM and are typically given by visiting volunteers of which there have been few over the last year and a half of the pandemic. We, meaning the neurology team, had been here in March 2020 when everything hit the fan and we had to scramble home in a rush before the borders closed. Despite having been safer in Tanzania than it was at home, the State Department announced that anyone overseas had to either return home or shelter in place, which really wasn’t an option for our team. The airlines had immediately cancelled everyone’s flights at the announcement meaning that we all had to rebook with some of the team having to pay exorbitant amounts for their new tickets. Worse yet, all the new flights flew directly into NYC, ground zero for the outbreak, at a time when there were very few restrictions in regard to personal protection. On arrival, we were all led through immigration in long lines with very little spacing and no one wearing masks. How we all made it back to Philadelphia with contracting COVID is pretty remarkable.

I was back by myself in September/October of last year as the residents still were not allowed to travel and then we all returned last March as the first group of volunteers since the beginning of the pandemic. We were able to do some lectures then, but they were still restricting gatherings at that time. For this trip, though, now that everyone has been vaccinated including all of the fame staff after vaccinations finally reached Tanzania last month, we have been able to meet, albeit masked, for our normal educational lectures. Dr. Kerry’s lecture this morning dealt with the assessment and management of babies born with hypoxic-ischemic encephalopathy, or HIE, a common problem here for a number of reasons.

Babies with HIE are typically very developmentally delayed and may often be dependent for life, something that must always be considered prior to beginning resuscitative efforts on these children. The long term prognosis is an issue given the lack of social services and support for these families beyond simple rehab which doesn’t really affect their overall outlook, but rather helps with managing problems rather than resolving the underlying issue at hand. Jumping in without having considered all of the ramifications of your actions and potential unintended consequences can often do more harm than good.

After Kerry’s lecture, we learned that our patient who had presented with seizures and had also raised concern for COVID, had several more seizures overnight and into the morning. We were unable to fully evaluate him yesterday due to the COVID concern, but had asked that he be loaded on valproic acid, a common antiepileptic that we use here. Despite the load we had given him yesterday, he had continued having seizures. As most of the team began seeing our neurology clinic patients, a few went into the ward once it was determined that we didn’t have to worry about COVID and he was transferred to Ward 1. At that point, he was observed to have focal seizures of his left face and arm with minor suppression in his level of consciousness.

His CT scan that was done the day before did demonstrate some extremely subtle fullness of the right parietal lobe with some cortical hyper density and it was difficult to tell whether this was a primary problem or something related to his seizures. We decided to repeat his valproic acid loads over the remainder of the day (we only have oral and no IV) and considered a benzodiazepine challenge as he was initially felt to be sedated and we wanted to rule out subclinical status epilepticus. When they went to do the challenge, though, he had improved and we held off. Overnight, his seizures stopped and by the following day, he thankfully remained seizure free on the higher valproate dosing. Unfortunately, we had no real explanation for his having seizures, and, given the clear focality of the episodes, this raised even greater concern for an irritable focus such as a tumor, infection or stroke. His original CT scan, though not entirely convincing, did have some subtle findings that were not unequivocally abnormal which left us a little bit in the lurch as how to proceed. In the end, his examination was entirely normal  from a neurologic standpoint making the issue a bit less urgent and we ultimately decided to discharge him home on valproic acid have him follow up with us in several months. Dr. Anne would see him and do a detailed neurologic exam at which point she could let us know her thoughts and we could always decide on whether to repeat a contrasted CT scan or try to get an MRI in Arusha, not always the easiest thing to do for many respects.

The remainder of the day was spent seeing our routine smattering of patients that also included someone with suspect occipital neuralgia. We see this often at home and mainly in patients that have chronic headaches associated with cervicalgia, or neck pain. This is often referred to or described as a “rams horn” headache as it radiates from the occipital region up and over the top of the head unilaterally or bilaterally at times. One therapy that has worked very well for these patients, both here and at home is an occipital block, something very simple to perform and will often resolve their symptoms for months, years, or even indefinitely in some cases. This is something we teach the residents to do back at home and have been doing here at FAME since we’ve been coming. I’m convinced that there is a tremendous amount of cervical pathology here that very likely stems from the culture of carrying heavy loads on their heads, whether it be to bring goods to the market, or carrying 5-gal buckets of cement on their heads when working hard labor. Overall, this contributes to their neck pain and headaches and keeps us quite busy with our neuro clinics in this regard. Job security 😉

As is often the case, our most interesting patients will come late in the day and today was no exception. A 17-year-old boy with a history of predominantly motor cerebral palsy secondary to a birth injury who was otherwise cognitively intact and had successfully attended school presented with abnormal movements that had begun several months ago. The movements came on rather abruptly and were there throughout the day, but went away during the night. There were very disturbing for him and something they had never noticed before during his life. There was no history of infection or fever that they could remember and he had no other symptoms such as shortness of breath to suggest any cardiac involvement. When I went to look at the boy, he had very classic movements of his limbs and face that was essentially constant and something that I had seen here on two prior occasions. The movements were choreiform and, given his age and the sudden onset of the movements, quite classic for Sydenham’s chorea, a movement disorder occurring primarily in late childhood and adolescence and related to a Group A Streptococcal infection and often rheumatic fever, causing inflammation of the heart or damage to the heart valves. Cases of Sydenham’s chorea, though, may often occur in the absence of any clinical manifestations of an earlier infection, but the presumption is that one had occurred.

Other than his choreiform movements that were again, constant, and his motor findings consistent with his prior diagnosis of  CP, his exam was unrevealing for any other pathology. All patients with Sydenham’s should have an echocardiogram to rule out any cardiac involvement, despite a lack of symptoms or history, as the major complication for this disorder is cardiac in nature with patients often requiring heart valve surgery or replacement. We were able to set him up for an echocardiogram the following morning, which did demonstrate some mild carditis, indicating inflammation of the heart and would impact our recommendations for antibiotic treatment. His erythrocyte sedimentation was normal, suggesting against any active infection, though the current recommendations were still to treat with 10 years of penicillin and using the monthly IM formulation to assure compliance. The purpose of continuing the antibiotics is to reduce the risk of recurrence with potential cardiac complications or recurrent chorea. The treatment of the movements, on the other hand, when necessary can be by either using steroids to treat the underlying autoimmune process or possibly other medications commonly used in the treatment of movement disorders.

Sydenham’s chorea is no longer commonly seen in the United States, mainly due to the prompt, or often excessive, use of antibiotics in the western world. This was the third case that I’ve seen here at FAME. The first case that we saw was in 2013 when we (Danielle Becker and I, quite independently I should add) first diagnosed it by seeing a video of the patient, immediately recognizing the movements and history and then traveling here several months later to meet Roza, the young girl who we had seen in the video. She had an active infection and some valvular damage, but thankfully didn’t require anything more significant from a cardiac standpoint. It is a fascinating condition, both historically in the world of neurology and in regard to its crossing over into many specialties with neurologic, cardiac, infectious disease and even psychiatric manifestations that are possible. It is a diagnosis that many learn about in medical school, but never have a chance to see it in real life. Once you see it, though, you will never forget it.

We had asked Teddy, the seamstress we have used the last several years, to come up to FAME to do all of the fittings for all those who wanted clothes made. That included everyone except Akash and me. Even Dr. Grady had wanted to have a bowtie made. In addition to the fabric that everyone had purchased in town the day before, Teddy brought quite a number of additional fabrics to choose from. The many colors and designs of the typical Tanzanian fabrics are absolutely incredible, much as they are in many of the other East and West African countries. Teddy worked with each of the residents, Kerry and Sean individually, taking many, many measurements along the way and figuring out how many and what types of pieces to be made from each of the fabric pieces based on their design and size. She would write everything down in her notebook and attach a very small piece of fabric to remember given the number of pieces she would be working on for the group. Kerry would be leaving the coming weekend, as would Sean, so she would need to have their pieces ready before then, while there was no rush on the others items as we’d still be here for over two weeks.

It took well over an hour for Teddy to complete all of the ordering and get packed up. Dr. Anne had remained for the entire time to help out as Teddy doesn’t speak English well and I thought it only proper to offer the two of them a drive into town rather than having to call for their own driver which would have meant a bijaji or a bota bota and it was late. We hadn’t eaten dinner either and everyone was starving in addition to me. I drove them down to the junction at the tarmac where they each had a driver waiting for them, but the rides would be much shorter from there. As I drove back up the FAME road to my home away from home, I once again realized how fortunate we all are to be here, helping others and ourselves at the same time. Though Akash was still in Dar tonight, he would be getting his passport tomorrow and catching a flight back to Kilimanjaro where he’d have to spend the night at the KIA Lodge at the airport since his flight home would arriving after dark and the drive to Karatu is too dangerous at that time. We would hopefully have him back for clinic by Thursday morning as they were picking him up at 6:00 AM and everyone was looking forward to having our pediatric neurologist back with us as soon as possible.

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.

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?”

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 24^th trip and I’m sure it’s even harder for those who have come for the first time to experience this truly magical place.

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.

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.

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.

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.

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.

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.

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.

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 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.

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.

Preparing for my trips to Tanzania have become pretty routine considering this will be my 24^th trip there since 2009. That being said , traveling in the time of this pandemic has become just a bit more complicated than one can imagine. The weekend before my departure, I had come down with what I was pretty sure was just a common head cold, but given the current environment, I was convinced to report my symptoms to the hospital, necessitating that I get a COVID test first thing Monday morning and wait to report to work until the following day. It was, of course, negative, proving once again my incredibly powers of diagnosis in the world of infectious disease – please know that I am kidding with all my heart as those who know me would be more than happy to attest. I stick to neurology. Given my upcoming flight on Friday, though, I knew that I would need to have another COVID test done within 72 hours of my flying. So, I arranged to have another test on Wednesday midday, knowing that it would result in plenty of time for my flight.

Meanwhile, Mother Nature decided to add just a little bit of spice to the Philadelphia region during the middle of the week with Hurricane Ida, now only a tropical depression making its way up to the Mid-Atlantic coast prior to heading up through New England. The forecast was certainly for lots of rain, but what I’ve come to learn living on a river is that it is not only important just how much it rains where you live, but is equally, or even more, important just how much it rains upstream. That’s exactly what happened with the Schuylkill River as the storm came through and sat over the counties north and west of us such that the river swelled to a near record flood stage of over 16 feet. Now, that would be really exciting if it wasn’t for the fact that my apartment buildings lobby sits lower than that as does the garage of my building. We were awakened at 5:45 AM with the building flooding and had to evacuate out the back of the building since the front was now submerged and cars parked on the street in front were also under water. For all of the damage that others suffered in the flood, though, ours was minor and living on the sixth floor was also a bit of a saving grace, though the elevators were out for several days, meaning I had to walk up and down six flights of stairs several times a day. I moved my car out of the garage and to higher ground before the water started coming in and other than slogging through the water to get my bike out of the bike room (yes, I rode to work each day just like I normally do) I came away pretty much unscathed.

That was on Thursday and my flight was on Friday night. Thankfully, one of the elevators was repaired in time so that I didn’t have to lug my two 50+ lbs. duffel bags down the stairs to get my Uber to the airport. I had everything taken care of in my apartment as I would be gone for the month with Marissa looking after my indoor jungle of houseplants at home. I arrived to the airport over three hours early thinking that I would sit in the American Express lounge after check in and have some dinner before my flight. Recalling my wonderful experience in Chicago last March with the passport issue, I now had my brand new passport in hand with extra pages so I wouldn’t run into that problem again. I handed over all of my paperwork to the gate agent who checked that I had everything necessary. Visa – check. Entry registration for my rapid COVID antigen test in Tanzania upon arrival – check. COVID PCR test here within 72 hours of ARRIVAL? Wait a minute, it had always been within 72 hours of DEPARTURE previously. The agent double checked for me and, in fact, the Tanzanian government had recently changed their rules (unlike nearly all of the other countries) which really made little sense as many of their flights are to distant destinations and often take over 36 hours to arrive and the timing of this requirement would be incredibly difficult.

I’ll have to admit that I was pretty calm about the whole thing as it become clear to me that I wasn’t going to be allowed to fly that night. Shades of Chicago once again. Thankfully, my travel plans this time were flexible by several days as I had planned to spend the weekend with Leonard and Pendo and their kids and would merely have to miss one of those days by rebooking for the next day. The supervisor was incredibly understanding and found me flights the next night that would be the same times. The only inconvenience was really that I would have to pay for another Uber round trip back to my apartment, and that was a small price to pay. So, I lugged my two huge duffels and camera backpack to the Uber pickup and headed home to water my plants which I hadn’t had time to do running out that evening. I would have to get yet another COVID test the next morning and pray that it would be resulted before I needed to check in the following night otherwise that would be a major problem. Things went smoothly, of course, and I was able to get my test done at 7:20 AM the following morning, which was surprisingly negative as were my previous two only days earlier. I arrived back at the airport the following evening, now four hours prior to flight just for safe measure, only to find that the American Express club had closed at 5 PM due to the pandemic. I spent the next several hours sitting at the gate, working on my computer and getting hungrier and hungrier as I was determined not to buy any overpriced food at the airport.

In most situations, that would seem like a rather normal response, but I will have to confess to everyone now that I had actually purchased an upgrade to business class the night before, which they thankfully honored on my newly booked flight. This meant that I would be wined and dined on the entire flight to Doha, Qatar, and would also have the opportunity to sleep in their lay flat bed that would be turned for me by the flight attendant. That is if had actually planned to sleep for I had actually decided to work for the entire flight, save for the time that I would be eating the fancy meals that were served to me and watching a movie or two on the large monitor at each seat. I have often told others that flying business class on Qatar Airways is like its own separate vacation and this upgrade did not disappoint. I had perhaps the best flight ever due to the constant attention of the flight attendants and it proved wonderfully productive as well with the work that I was able to complete. Given the opportunity, I would certainly upgrade again in the same situation.

I would have an eight hour layover in Doha, which for those of you who have not flown through this airport, is an amazing conglomeration of high end duty free shopping for just about whatever you can imagine and lounges that are equally nice as long as you belong to one. Thankfully, due to my frequent flying on Qatar, I have a membership to their business class lounge which means I can continue to enjoy wonderful meals where my flight had left off (see a common theme here?). In addition to the food, there are also showers and business facilities there to pretty much get done whatever you need during transit. With the pandemic, we can no longer leave the airport, where previously, we would visit the Doha Marketplace and spend the night. It’s unfortunately that is no longer available, though the trip is now about eight hours shorter as a result.

The flight to Kilimanjaro departed at the ungodly hour of 1:40 AM, and, despite my best plans to sleep, I could not seem to do so. As such, I landed in Tanzania pretty sleep deprived after two completely sleepless nights and promptly became comatose just afternoon at Leonard’s house, but slept for only three hours. I had planned to spend two days relaxing in Arusha, but I really think it was more recovering from the lack of sleep and didn’t normalize until the following morning when I drove to the airport to pick up the residents, which I’ll pick up on in the next blog.