I had mentioned in yesterday’s blog that what happens at the Sparrow, stays at the Sparrow and this was no more true than on Friday morning as everyone awakened, in some shape or form from the evening before. What you didn’t see in the photo, as it was just the neuro crew other than Isdori in the back with his victory sign, was that we had also managed to get Elissa, the new peds ID specialist who will spending the next year at FAME, and Leslie, the family practice NP volunteering for her first time at FAME, both out with us for the festivities. Since they weren’t incriminated by the photo, I wanted to also make sure everyone realized that we are an equal opportunity service and will include all who are will to associate with us.

My sleep was a fitful last night and, though I was hoping to get an extra hour or so of sleep in as I didn’t have anything scheduled until around 9:45 am with some meetings and there wasn’t any morning report this morning due to the fact that it was Nyerere Day, my phone began chiming off the hook around 6 am as my son, Daniel, and his wonderful and lovely fiancée, Chloe, decided to send out their wedding “save the date” this morning. My family message group was abound with congratulations from everyone, except me, of course, as I was, shall we say, still hoping for those few extra “z’s” to recover. Once I realized what was going on, though, it was inevitable that I would join in the excitement. Daniel and Chloe live in Boulder, and have planned their wedding in the mountains, which is not at all surprising given their love of the outdoors, near Buena Vista and is one of the Collegiate Peaks. To say we are looking forward to this would be the understatement of the year.

Having recovered from the excitement of the morning with Daniel and Chloe, I was awake now and getting things done prior to my meeting when I received a text from Kitashu that there was a 7-year-old child at the OPD for neurology as we had originally been scheduled to see patients today. While trying to figure out how to see the patient and still catch my ride with Frank and Susan to a meeting, I was hoping that one of the residents would finally emerge from their slumber and poor Ankita was the unlucky one who opened her door first. When I told her the situation, she volunteered immediately to go see the patient without any prompting or bribery, though that may have been helped somewhat by the fact that Kitashu told me they were happy to wait a bit which would allow Ankita to have her morning coffee before heading up to see the patient. I was able to make my meeting at the Lilac downtown, which was an executive committee meeting for FAME Tanzania, which I am not a member of necessarily, but as the board chair for FAME US, I had asked to attend and was allowed to do so. The child Ankita saw was for starring spells and possible seizures, but it didn’t seem consistent at all and there was no need to institute medications so she didn’t have to bother me.

I had mentioned earlier that the reason we had no clinic today was because of the fact that it was Julius Nyerere Day and in memory of the father of the country who died on this day in 1999. He was an amazing man who cobbled together a country from literally nothing and, at times, had to make very difficult decisions that were not always popular, but were important to move the country forward and eventually recognized as being necessary. Several years ago, while preparing for one of our visits to Tanzania which, at the time, required that I FedEx everyone’s passport to the Tanzanian embassy in Washington, D.C., so that our visas could be placed inside the documents. I had apparently forgotten to sign something, or may have even forgotten to enclose the check, but it required that I contact them to straighten things out. I ended up speaking with a very nice and incredibly helpful young woman at the embassy who helped straighten things out and make sure that we received our passports back in time for our upcoming trip. When I was initially speaking with her and was going to need to call back, she told me her name was Julia, but not wanting to have difficulty reaching her, I asked her for her last name upon which she replied, “Nyerere.” I was pretty much speechless and there was a very long pause from me at which point, after finally gathering my senses, I said, “Are you any relation?” She replied, “yes, he was my grandfather.” OK, so this would be the equivalent of reaching George Washington’s granddaughter on the phone if our country were any younger than it is (Tanzania’s independence from Britain occurred in 1961 and its union with Zanzibar was in 1964) and, not wanting to just end the conversation, I told her how incredibly honored I was to be speaking with her at which point we had a short conversation about FAME and what I was doing in Tanzania. I was pretty blown away, to say the least, after the call and am still in awe today that I had a chance to speak with her.

The Lilac Café at FAME was created when the hospital was opened and it became clear that someone would need to feed the patients as well as the families of the patients when they came to visit, which often entails spending days there and sleeping with friends nearby. The food services were contracted out to Nickson Mariki, who had previously run one of the local pubs in town, and he has continued to run the Lilac Café as well as its sister site downtown and also now has one of the newer “high rises” in Karatu, which are no more than 4 stories. Nickson is also on the FAME Tanzania NGO Board of directors. One of his employees, Denis Mcha, is also a wonderful artist who has sold many paintings that he displays at both of the Lilac restaurants and over the years I have also brought him art supplies such as canvas, drawing pencils, a staple gun and similar items for which he has always been incredibly appreciative. For my 60^th birthday, Susan commissioned him to do a portrait of me as a surprise and this painting hangs in my home in Philly.

Once finished with our executive meeting at the Lilac downtown, I made my way back to FAME to pick up the others for we had decided to run down to the African Galleria to pick up some things that everyone had picked out earlier and were being prepared for them. I had strongly considered having my last rice and beans for lunch, but it was an otherwise unanimous decision by the others that we go to the Gallery for lunch as everyone was dreaming of the cheese samosas and I certainly was not about to turn away their scrumptious pumpkin soup. We got to the Galleria, sat down and let Nish know that we were there which the others went inside to pick out their things while the food was being prepared. I will have to say, and I think all of my residents who have been there have also agreed, that the Ol’ Mesera restaurant has the best food in Northern Tanzania by far.

By the time we left the Galleria and made it home, it was now time to go up to Gibb’s Farm for drinks and a later dinner. We had invited Anne, Elisa and Leslie to come with us as well as Dr. Joyce, a fellow long-term volunteer and the person responsible for setting up all of the laboratory services at FAME. Until the pandemic, Joyce had been spending 9 months a year at FAME, though this was obviously interrupted by the difficulties with traveling and the risk of remaining in Tanzania even though she had gotten stuck over there in March 2020, spending about 4 months in seclusion at her volunteer house so as not to risk any exposures to the virus. When it comes to pure beauty and ambience, there is little that can compare to Gibb’s Farm – its gardens are impeccable and the birds on site are absolutely amazing. With their new infinity pool that is not at all overdone and serves as a wonderful location for events like the Tloma Village Choir that we listened to a week or so ago, it has the complete package and serves as a luxurious, yet tasteful representation of Tanzania for those of us from FAME and they are happy to have us come to visit for dinner or lunch given the work we are doing for the community. I have been coming to Gibb’s Farm since 2009 and, even though it has gone through changes, its character has remained unchanged and it continues to be my number one choice of a place to go to relax and to forget all your troubles.

Our dinner was, of course, delicious and the service delightful. They have had much of the same staff for the entire time that I’ve been visiting and having them greet me on arrival is always such a pleasure. We had worked hard over the last weeks and everyone certainly deserved this downtime and a bit of luxury.

Well, the time had finally come for our last day of neurology clinic for our fall season (though, mind you, there is only wet and dry seasons here) of this year. As I have mentioned before, we have now had two groups of residents here rather than one, so for each group, the trip has actually been shorter than it was in the past by week. I have done my best to make each of their experiences equal both to each other’s as well as to what the previous groups have had and, hopefully, it’s been a successful transition, though I guess you would have to query each of the residents on that issue. Interestingly, though it had often seemed much slower for me during the six weeks, we had actually ended up seeing about the same number of patients, and possibly even a few more, during this trip as we have seen on prior visits, so it was just the same number of patients spread out on my days with fewer each day. Though I can’t imagine there are a finite number of neurology patients here in the Karatu district as our limiting factor, so it probably had more to do with the law of averages. I’m looking forward to seeing if this pans out with future trips being a third larger than the current.

For me, it has been the longest time I’ve been in Tanzania in one stretch, though by only a week or ten days. For my patients, I have been covering my in box at Penn if not daily, at least several times a week to field messages from those who have questions, or recent test results perhaps, though most importantly, medication refills. In this day and age of the electronic medical record, including at FAME, the ability to stay on top of things has become seamless, though some might argue that it’s become too invasive and being away for this time I should be focusing on what I’m doing here. The fact of the matter is that I so dislike covering colleagues in boxes that it’s just easier for me to cover my own in box and be done with it. So, there you have my logic and I’m certain not everyone agrees with it, but that’s OK.

With the last day of clinic, though, it is clear that the end of this time in Tanzania is growing nearer and I will soon be traveling home, nearer to close friends and family. I will have to admit that one of the silver linings of the pandemic has been that it forced many of us who hadn’t been overly comfortable in the past with video chats to learn this relatively new technology. In the past, I would do my very best not to answer any FaceTime calls I would randomly receive from family and then call them back at some point to chat on the phone, something that I was equally ill at ease with, though with the pandemic, it has now become an essential part of our lives both personally and professionally. Had it not been for the ultra-quick adoption of “telemedicine” visits right at the beginning of the pandemic and as soon as I returned home early from our March 2020 trip, when the you know what hit the fan, urgent medical care not requiring the emergency room and routine visits would have ground to a halt and there would have likely been more suffering than was already occurring directly related to COVID-19.

Leave it to say that I adopted not only the new telemedicine technology for those patients where it was appropriate, but I also quickly realized that not using the Zoom or similar technologies meant that I would be incredibly isolated from co-workers, those who wished to meet with me, and, perhaps most importantly, family. Had it not been for our weekly family Zooms, I know that I would have gone stir crazy and I’m grateful to my ex-wife, Kim, for having stressed the importance of these sessions as they brought at least some normalcy to what was hopefully the most significant event in our lifetimes. This is all to say that I have now fully embraced this technology and, though it does not in any way replace or even come close to having direct human contact, it does suffice as a substitute for remaining close to those you really care about even though you are literally half a world away. Whether it be Zoom, or WhatsApp video, the technology worked nearly seamlessly and it was something that I looked forward to the entire time I was away, and I say that not having missed even a single day of my time away. Though now it was time to begin the process of looking forward to that personal contact as I was now in the single digits and it didn’t seem so far away.

Thursday mornings are education days and yesterday, Dr. Ken, who is in charge of the education lectures, approached me asking if the residents could do another lecture for the Tanzanian doctors, which of course they agreed to do, and it was decided that the talk would be on dementia. Though the talk would primarily cover the different types of dementia and how to tell them apart, mostly with the patient’s presentation and symptoms rather than testing, which is good here since testing is so limited here, and expensive comparatively. And furthermore, testing here, similar to at home, would rarely, if ever change the treatment that we have for patients in the long run as the symptomatic treatments are based solely on the clinical issues and do not rely on any testing results. This does, of course, exclude the rapidly progressive dementias, that group of disorders we sometimes see in which the clinical presentation has been less than six months and we become concerned for Jakob-Creutzfeldt disease, an insidious disorder caused by a prion, or a precursor to viruses that is uniformly fatal. This is an important group as there are also mimics of this condition that that are treatable and, therefore, must be ruled out.

This is all to say, that unfortunately there is little to do here just as there is very little to do at home for these patients, though, there is plenty of research and trials going on. At the moment, though, Alzheimer’s disease (the most common of the dementias) or the mixed dementias, as very often there are several contributors to the patient’s underlying cognitive decline. The biggest thing that we can do in these situations, both here and back home, is to reassure the family that there is nothing else going on to them begin to educate them on what will happen in the future and to set expectations. There are no nursing homes here in Tanzania, or at least none that I am aware and certainly none that would be available to the primary population of patients that we care for in the Karatu district where family incomes may be $250 per year or less, so it is even more imperative that families understand what to expect. One of the most significant things that we can do for patients and families with dementia is to offer medications for significant agitation that may occur in the setting of moderate dementias, more so than in mild or advanced dementias. We do see quite a few patients presenting with chronic dementia, so this will absolutely be something that the doctors here at FAME will see in our absence, so it was very helpful to have gone through all of this with them and the residents covered it brilliantly.

At the end of lecture, since there would be no morning report tomorrow with the holiday and this was our last day, they asked each of the residents to say something about their experience at FAME, as well as myself, though they have gotten to hear from for the last twelve years so it is very much more important to hear from the residents. We received the customary three claps from the group and I’m sure that it was a special moment for each of the residents given the fact that there are so few similar situations to being at FAME, where you begin to become a part of the community, both as a caregiver and someone who also deeply cares about the well-being of all those who reside here.

It was our last day for Pilau with meat and, as usual, Charlie and Meow enjoyed it as much as we did, though, thankfully, we don’t have to share any of the pili pili with them as we have become very possessive of that condiment and maintain very close tabs on its supply and whether there becomes any need to ration it going forward for the thought of eating here without it is hard to imagine.

Right after lunch, everyone was called quickly to the emergency room where there a young man who had fallen into some type of a large hole in the ground, striking his head and neck. He had reportedly had loss of consciousness at the time of the fall and, in the emergency room, remained mostly unresponsive to voice and painful stimuli and didn’t seem to be moving one side of his body well. There had been no seizures reported and the presentation was certainly concerning for type of head injury, so, after placement of a cervical collar to protect his cervical spine in case there had been any type trauma to that region given the lack of exam, he was heading off the CT scan to look at his brain and spine to decide if he needed any treatment which would very likely require that he be transferred.

His returned from the CT scanner in very short order and it was reported not to demonstrate any concerning signs of trauma, either an intracranial hemorrhage or spinal abnormality, and sometime later that afternoon, he began to slowly wake up and move. He was admitted to the ward for the night just given how profound his presentation had been, though the following morning, he was asking to be discharged from the hospital, and, with nothing else for us to do clinically for him in the setting of a normal examination, he was released home and told not to fall in any more holes.

Given it was one of our last nights at FAME, everyone wanted to head out to the Golden Sparrow later this evening to spend time together and let off some steam. This has been a tradition here in Karatu, even in its older configuration, which was called Carnivore, as it’s allows fun to do some dancing out with the local population despite the fact this is something I do on a very limited basis back home, usually only on the occasion of the resident graduation after after party (there were two “afters” there intentionally as you might imagine). Carnivore was a tiny pub that served only roasted chicken, chipsi (French fries), and drinks, but had a tiny dance floor that we could use that had mostly an earthen floor, or at least it seemed so, and could accommodate only perhaps six dancing comfortably, though there were always many multiples of that dancing on good nights. The owner of the Carnivore then opened Golden Sparrow, a much fancier and larger place with a formal dance hall and closed the former. The Sparrow, as it is affectionately known in Karatu, has just completely upgraded their dance hall, doubling in size, and to something that now approximates a legitimate dance club. We all had a wonderful time with many of the local Tanzanians who had worked with us for the neuro clinic having joined us for the evening, though any of the details will have to go undocumented for “what happens at the Sparrow, stays at the Sparrow.”

With no lecture this morning, everyone seemed to very much enjoy the extra 30 minutes of sleep and the house was quiet. My routine has been to get up every morning by 6 am for several reasons. Bedtime here is usually much earlier for me than it is at home given the sun setting at 6 pm and the fact that there are no bright lights in the house whatsoever to delay the release of your natural melatonin and staying awake is much more difficult. Another reason is that I love the mornings here as the birds begin their chatter and singing well before sunrise and they are right outside my window, so sitting at my desk and getting work done in the mornings is just the most pleasant and invigorating experience. And the last reason is that 6 am here is 11 pm the night prior on the east coast and a perfect time to video chat with anyone there you’d like to say “lala salama” (sleep safely) to before they are going to bed. “Usiku mwema” in KiSwahili actually means good night, but I so much prefer the other.

At morning report, we were told about an interesting patient who had come in the night before with new onset of a focal seizure and had left sided weakness that had persisted. He was a 62-year-old gentleman with no significant past medical history, but had apparently complained of a right sided headache several weeks prior and had been treated with antibiotics for an ear infection. With this information, the differential was completely wide open – the headache and ear infection might well have been completely unrelated, though it was certainly an enticing connection given the focality of the seizure and the current neurologic deficit, both of which would have lined up with the laterality of presentation. There would have been a number of other things that could have also come to mind with his presentation, such as a simple stroke, which can often present with seizures, or some type of a mass lesion that may have been present to have produced both his focal seizure and weakness.

He had a CT scan had been done the night before after having presented, and despite the fact that as neurologists, we prefer to evaluate the patient first rather than their scans ( I was always taught that was the difference between a neurologist and a neurosurgeon12), we all trekked over to the radiology suite to have them pull up the study for us to review. It hadn’t been read by our radiologist yet as he is in NY and he time difference, but the offending lesion could easily be seen in the right posterior parietal lobe. It didn’t look like a stroke, though, and made us concerned about the possibility of an infectious process. On the contrasted scan, there was no evidence whatsoever of an enhancing mass, like a tumor, nor abscess, and, in the end, we were all much more convinced that we were looking at a localized infection of the brain, or cerebritis, a much less common process than any of the others that were being considered. Given the history of the possible ear infection weeks before, this also significantly raised our concern for an infectious process.

After looking at the CT scan, Taha volunteered to go evaluate the patient in the ward with Amos, one of our Tanzanian translators who had been working with us since we had started back in September, and who was also himself a clinical officer student in Dodoma with only about six months left until he was to graduate. Amos, as well as Hussein, have been an absolute pleasure to work with since starting here nearly six weeks ago and I’m hopeful that each has learned a good dear of neurology during their time working with us as that wouldn’t have been something they would have picked up in school or clinical rotations even if they had wished to do so as there are simply no neurologists here to work with.

On their return, Taha and Amos reported that the patient did not have a history of seizures and was, in fact, still having focal twitching of his left side along with continued weakness and that he was poorly responsive. With no real intravenous antiseizure medication to use here other than phenobarbital, which, for an adult, would be a mess as a loading does would likely cause them to stop breathing and, not having an ICU nor a ventilator here to use, that would not be a good thing. We decided to put an NG tube in the patient and that we would load him enterally with 2000 mg of levetiracetam as well as place him antibiotics that would cover the most likely suspects involved. Unfortunately, we have just recently started running cultures at FAME, so we would not have these to help us in the future with antibiotic selection or narrowing the medications that he was on.  .

The patient continued to have minor focal seizures through the day and we had a contingency plan to add a second agent, though thankfully, his seizures abated in the evening just about the time we were getting ready to pull the trigger. Over the course of the next several days, the patient began to slowly wake up and by the time we were leaving on Saturday, his neurologic examination went from having a fairly dense hemiparesis to being essentially normal and having had no seizures since being started on the levetiracetam, which, as you may know from previous blogs, is in very short supply here and, when available, tends to be very expensive. Thankfully, we had Elissa here who, even though she’s a pediatrician, is also an infectious disease specialist and could help us come up with an appropriate therapeutic plan despite the fact that we didn’t have the luxury of repeating imaging studies to judge the patient’s response to therapy.

In the end, we left FAME several days after the patient had been admitted in focal status epilepticus with a life-threatening brain infection and he was now awake and pretty much normal neurologically, though would require an course of long term antibiotics for at least several weeks and we would have to come up with a plan of how exactly to assess his response, likely a repeat CT scan, or just take him off his antibiotics and hope for the best, not always the most comfortable position, but sometimes necessary. As for how long to continue his antiseizure medications, we chose to phone a friend (actually an email to Mike Gelfand at Penn who is an excellent epileptologist and I knew would get back to me quickly) , mostly knowing that there was no right answer, but at least I would check. We decided to convert him to carbamazepine and continue it until our return in six months.

I know this is a bit more medical detail that I normally give, but I felt that this case would give even those non-medical readers a chance to experience the medical decision making that occurs at FAME and what makes it such an excellent clinical experience and very different than what goes on at home. Had we been at Penn, it would have been MRIs instead of the CT and he would have likely undergone a dozen of them before he left the hospital.

Meanwhile, it was again my favorite lunch of the week, rice, beans and mchicha, though I must admit that the ugali and nyama (beef) from yesterday was giving this lunch a run for its money and I might just have to reconsider things going forward. Though the pilau was also quite excellent, it just didn’t seem to have the pizzazz (or maybe it just didn’t quite mix as well as the others with the spoonfuls of pili pili that put on everything) as the other two dishes, at least for me. Either way, the lunches here continue to be my favorite meal of the day save for dinners at the Galleria or at Gibb’s Farm.

Teddy, the seamstress here in Karatu who has been making clothes for the residents out of the colorful and beautiful kitenge and kanga cloth for the last several years, had come in last night in preparation for a scheduled C-section today. Everything had gone incredibly well, thankfully, and she ended up with a very lovely, though quite large, baby boy weighing in at over 9.5 lbs. who we each got to hold when we visited. His name was Ivan and he seemed to be ever so cozy in all of his blankets as we passed him from person to person and he didn’t make a peep. Teddy looked wonderful and happy and was, of course, all smiles as she normally is at her shop when she greets us with a plate of candies every time.

Tomorrow would be our last day in clinic as this Friday will be an official holiday, Nyerere Day, in honor of the country’s founder and first president, Julius Nyerere. Though we all love to keep working and see more patients, we have to be sensitive to those Tanzanians who we are working with and who have been absolutely essential to anything we do here as they may wish to have the day off and be respectful rather than working in clinic with us. It was a quiet day after work today and everyone settled in to begin the mental and logistical process of leaving FAME which I have found is not always an easy thing for the residents, though, for me, I never have to say goodbye, just “see you in six months.”

“If it’s Tuesday, this my lecture day.” I’ve made reference to this corny, class B 1960s movie numerous times in the past, but for those of us from a certain generation, “If It’s Tuesday, This Must Be Belgium,” became a saying oft used, though I’m sure only a small portion of those reading this blog will have any idea that this movie existed nor the actors who were in it. Suzanne Pleshette was probably who most remember, or at least me, and the saying has stuck in my brain since my teenage years, which is some time ago.

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The residents chose to provide a case based lecture on outpatient management of epilepsy today to compliment the lecture given by the previous group on in hospital management of status epilepticus. Given that epilepsy is the second most common diagnosis that we see here and the incidence of this condition being so high in Sub-Saharan African, and all low to middle income countries, for that matter, it was very appropriate. It is always a huge dilemma of how to treat this illness as it is very often a life-long condition and with medications being required for that long, the expense of this therapy becomes completely prohibitive in the majority, if not all, of the cases we see here.

The WHO has considered phenobarbital as the first line antiseizure medication (ASM) for the planet due to its cost and availability, but it is also a medication that has many, many issues with its long-term use such as cognitive side effects and bone health as well as interactions with other medications. We rarely use it in the US or the Western Countries, but it is often the only thing available in most low to middle income countries where the majority of epilepsy exists in the world. The newer medications that exist elsewhere are not necessarily tremendously more effective, but they have far fewer side effects and medications such as levetiracetam, which is a broad spectrum ASM, are tremendously easier to use as they are more forgiving and cause a fraction of the side effects of not only phenobarbital, but also the older medications such as carbamazepine, phenytoin and valproic acid.

Unfortunately, phenobarbital, which is available for free from the government in many locations, or cost literally pennies, is a fraction of the cost of levetiracetam, or even the other three older medications available here. An average month’s cost of carbamazepine is 18,000 TSh, or approximately $7.80, which is as much or more than many families make in an entire month here. Though we may encounter these issues at home on occasion, it is the norm here and greatly impacts our decision-making and the long-term benefits of the care that we provide here. Too give the impression that our mere presence will fix things would be entirely misleading and much still needs to be done to correct the inequities that exist in this world.

I had left out one interesting patient that Ankita had seen yesterday and wanted to include them in today’s blog. A middle-aged gentleman came to see us for a second opinion regarding an episode he had two weeks prior. He had a sudden loss of consciousness and awakened with a severe headache and vomiting and had gone immediately to a local hospital where he was then taken to NSK in Arusha to obtain an emergent CT scan. Based on those findings, which demonstrated a very significant subarachnoid hemorrhage in the left sylvian fissure and essentially throughout subarachnoid space over the left hemisphere, this was most likely an aneurysmal bleed that needed to be further evaluated and treated. He was seen by the neurosurgeon in Moshi at Kilimanjaro Christian Medical Center and recommended to go to Dar es Salaam to have this done. This didn’t happen and he came to see us to ask if we agreed with these recommendations and brought along a single sheet of X-ray film from his CT scan which I photographed and have presented here. Amazingly, considering the extensive nature of his subarachnoid that had only been two weeks prior, he was completely neurologically intact and without any further symptoms from his hemorrhage, which was part of the problem as he felt that it was no longer an issue for him since he felt so well. Though Ankita knew exactly what to tell him, I gave her a bit more ammunition to use with him. I told her to tell him that he was the luckiest man alive at the present time and if he wished to remain so, he should get himself right to Dar es Salaam to be evaluated and treated as soon as possible. And, oh yes, we also made certain that his blood pressure was under good control.

Another very fascinating patient that actually came in today, was a young man who had come to see us about a month ago with a very interesting story and examination. He was complaining of headache that had been present for some months as well as a strange phenomenon in which he would, for long periods of time, develop a bulging on his forehead that would protrude more when he would Valsalva (bear down). Sure enough, he could make this region of his forehead bulge out and then flatten at will. Concerned that this was some type of vascular malformation that could also involve intracranial structures, we obtained a CT scan of the brain with and without contrast that did demonstrate a vascular appearing structure on the exterior of his skull without anything intracranial and a very normal appearing brain.

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As his headaches were vascular sounding, we placed him on verapamil for them, and when he returned, he reported that his headaches were actually improved, but he was still concerned about the bulge in his forehead and very much wanted to know exactly what it was. Without doing a more formal angiogram, which we do not have here at FAME, it was impossible for us to tell the exact nature of the lesion, but I did send off the images and a brief video to Dr. Carrie Kovarik at Penn, who has provided consultations for us before and is a dermatopathologist with a tremendous amount of global experience. Sure enough, with the help of colleagues at the Children’s Hospital of Philadelphia, they turned up a case report that was identical to this patient and suggested that this was a venous varix, or essentially an enlargement of the veins in this region. Whether there is anything further that is necessary to done or not, or whether it could even be done here, remains unclear, but at least we have some answer to give the patient and to start a discussion.

Just before lunchtime today, I was called emergently to the CT scanner for a 2+-year-old child who was still in the scanner and had been involved in a motorcycle accident having suffered significant head trauma. The child was awake and crying, but tolerated having the CT scan done which demonstrated a very severe facial fracture (a Le Fort 3 per Dan Licht) that also included his frontal sinus with a small amount of intracranial blood and some pneumocephaly (air intracranially). The child was actually intact neurologically from what I could tell in the scanner room and his brain looked otherwise OK, but it was urgent that he be transferred to a center who could deal surgically with his facial fractures and he would absolutely need an ICU. I had immediately sent images to our peds neurology and neurosurgery colleagues in the US and, thankfully, heard back from them rather quickly as this was not something that I wanted to be dealing with alone.

It was ugali and nyama (beef) day once again which is always a happy day for Charlie and Meow as they get to have the reject chunks of meat, mostly from the mzungu volunteers who aren’t as adept with the chewing and pulling that is often required to eat them. This doesn’t seem to both either of the FAME pets in the very least. I’ll have to admit, though, that I took a particular liking to today’s ugali, which had a bit of a grainier texture to it and more “palenta-like” than usual which was quite tasty. Or perhaps it’s just that I’m becoming more African? I did eat it with a spoon, though, as opposed to the proper way which is with the hand. Taha, on the other hand (no pun intended), was being traditional and forewent using his spoon so at least there was some representation by our team.

I had on our agenda of cultural immersion for the evening a visit with Daniel Tewa. We had also invited one of the other FAME volunteers, Leslie, a family medicine nurse practitioner from Washington, D.C., to come along with us, so there were a total of five visitors to the Tewa residence that day. I had forgotten that drinking African coffee is one of the activities as Taha does do any hot drinks and I hadn’t realized that Leslie avoids caffeine, so the three remaining of us were obligated to drink the entire batch of coffee that they had prepared for us. The coffee is rich and amazing as it is boiled with fresh milk from their cows and tastes fantastic with just a touch of brown sugar in it. As soon as Daniel sees that your cup is empty, he immediately refills it so by the time we left that evening, I was pretty well wired with all the caffeine as I had three cups of his coffee and was wondering if I would sleep that night.

After sitting around having our coffee, Daniel took everyone for a tour of his authentic Iraqw home that is underground and which he built in 1992 as an example of what he spent the first twenty years of his life living in and to prove to his children that his stories of childhood were not crazy. The house now serves as a resource that is studied by many students here in Tanzania as well as other historians of the culture. Their houses were underground mostly for protection for their cattle, who also slept in the houses, from the Maasai who would steal the livestock at night as they believed that all cattle were rightfully theirs and, as Daniel would say, they felt they were not stealing but only taking back what was rightfully theirs. The Iraqw and the Maasai were at odds over this issue until an agreement was finally signed in 1986 officially ending this dispute.

After our tour of the underground house, Daniel took us back to his home where he had the women try on the traditional wedding skirts that his wife, Elizabeth, makes out of goatskin and colorful beads in many meaningful designs to signify marriage and life. The skirts are beautiful and are still used for their wedding ceremonies today with each bride’s mother making her a special skirt. We didn’t get home until after 8 pm and there had been plans to go to the Golden Sparrow tonight at 9 pm, so we ate dinner quickly and I dropped Taha and Ankita off at the Sparrow while Sara and I decided to stay home and relax. They caught a taxi home later as I was not about to drive back and pick them up given the time it would be. They arrived safely at home well after my bedtime.

It had been a pretty incredible visit to the Serengeti over the weekend and it was now back to work at FAME for our last week here as we would all be leaving Saturday in one way or another. Sara and Ankita had planned for a week-long vacation beginning with some hiking around the lower altitudes of Kilimanjaro followed by five nights in Zanzibar, while Taha will be leaving back to the US Saturday night. I’ll be staying in Arusha with friends for two nights to do some visiting and will then be heading back home on Monday night, arriving to Philadelphia on Tuesday afternoon given the 7-hour time difference in our favor and the very short layovers in Dar es Salaam and Doha. I’ll have to admit that I’m ready to be back in Philly after six weeks in Tanzania, though I suspect I could “tough” it out much longer here if I didn’t have other reasons for returning.

Showing up for morning report after being gone for three days is always a bit exciting as we get to find out what cases had come in over the weekend and may still be in the ward for us to see, or not if they had been severely ill and passed away or had been transferred out. There had been a tourist admitted last night after falling in their lodge and suffering a fractured hip who would need transfer back to the US that was being worked on by Dr. Gabriel and Prosper given all of the paperwork that needed to be supplied to the insurance company for the necessary air evacuation as they would need to be taken down to the airport in Manyara first and transported to Kilimanjaro or Nairobi by Flying Doctors, the in country evacuation service that we all register for when coming here, and would then be flown to the US on a larger medical air transport. One should always make sure you have good evacuation insurance when traveling to low resource settings which is why we all have both Flying Doctors and International SOS, the latter a company that Penn subscribes to and supplies not only the evacuation insurance, but also health insurance should we need medical services here.

I had forgotten that today was the day the group from Tarangire had told us they were going to come visit us. Chief Lobulo is the village leader from just near the entrance of Tarangire National Park who had brought several patients to see us a few years ago and recognized at that time that there were many of his villagers who were appropriate to see and could be helped. Shortly after that very first visit, he showed up with a van full of neurology patients who were all completely appropriate to see us with disorders such as epilepsy, developmental delays secondary to birth injuries, and a number Down syndrome patients. Since then, he has continued to bring us patients, all of who have definite neurologic problems and all of who are entirely appropriate for us to see given their diagnoses. He has also continually asked for us to have a clinic in their area, but unfortunately, they are outside the Karatu district and it would require permission from the district and regional health officers, so for now, we have decided to assist them with transportation rather than having a mobile clinic go to their village. Chief Lobulo is an incredibly caring individual who has taken it upon himself to see the best of medical care for his villagers and I have always felt a debt of gratitude to him for having pursued this possibility.

About two years ago, he had brought two adolescent Down syndrome boys to see us, both of who were pretty high functioning and delightful to meet. Neither had any serious neurologic issues or deficits other than the obvious intellectual issues, and neither of them had been to school due to their condition, which was a real tragedy as their hope for any sense of self-sufficiency in the future was severely limited. I had recognized that in these two boys, there was still significant hope for us to find some reasonable solution to this dilemma, and one that would allow them to learn specific skills which they could use going forward to help support themselves in a community. With Kitashu’s tireless efforts and amazing research, he was able to locate a vocational rehab facility in Usa River on the other side of Arusha that would be perfectly appropriate for them and, after each of them visited the school with one choosing to be a tailor and the other choosing to become a welder, we arranged for them to attend the school for two and three years, respectively. With the help of generous donors and a GoFundMe site (https://gofund.me/9d3e6a7b), I was able to raise the necessary funds to get them started and to continue their school, though they will always be able to use additional money for incidentals while away at school, transportation, and hopefully a good start for their new lives. Though Tajiri and Amani will soon be finished with their schooling and have been doing incredibly well with their vocations, I hope to help other similar children who are in need of such assistance that their families are completely unable to provide and for which absolutely no public programs exist here.

The patients that Chief Lobulo brought to see us today were very challenging, as they very often are, and one of the first we saw was a 9-year-old boy with a history of hydrocephalus and difficulty walking. He had undergone a ventriculoperitoneal shunt at 2 years of age and his mother reported that he has no progression to his walking difficulty over time. His head was normal size suggesting that his shunt had worked well and as there was no report of recent decline, there was no reason to think that his shunt wasn’t working. He had no weakness in his legs, but when he walked, he seemed to lock his knees as if he had proximal leg weakness, but was able to squat and then raise back up without difficulty and muscle testing of his legs did not reveal any weakness. With outstretched hands he also had some pseudoathetosis and he was somewhat ataxic in his gait. Given the fact that there was no progression of his condition, it was our feeling that this was most likely something that had been acquired early in life and there was little need for a CT scan of his brain and, thankfully, we were able to reach out to our ace pediatric neurology team for their thoughts, hearing back first from Dan Licht, who has been to FAME on several occasions, with a likely diagnosis of a cerebellar germinal matrix bleed at birth which would explain his constellation of deficits and his early hydrocephalus. This type of help from our colleagues is priceless as I was having significant difficulty localizing this patient’s problem.

We did see another Down syndrome patient today, who was a 14-year-old girl with very obvious physical stigmata of Down syndrome, or trisomy-21, but had never been diagnosed by anyone in the past or at least it had never been explained to the family she seemed so delayed and had not gone to school. When Marissa Anto had been here several years ago, she had written a short piece about the lack of a word in Swahili for Down syndrome (https://fameafrica.org/journal/2019/10/4/theres-no-word-for-downs-syndrome-in-my-language) which she discovered when explaining to the mother of a young six-week-old child whose mother had brought her in because she had noticed that her tone was low. The family of the child we were seeing today had been completely unaware of the cause of their child’s disabilities or of the special needs she had in the past or going forward. We checked her thyroid status as these patients will commonly have problems with hypothyroidism, but there are also other conditions that are typically monitored for (congenital heart disease, cervical instability and leukemia) and, thankfully, this patient did not appear to have any of these issues, but would need to be followed going forward to monitor for them. There was little for us to do at the moment other than labs, but we did educate the family to make them more aware of these special needs.

One of our other cases was quite sad and, unfortunately, something that is seen throughout the world quite unnecessarily. A 22-year-old woman was brought to see us from Tarangire to assess her neurologically for she had severe intellectual impairment that had been present since birth. She was accompanied only by her sister and, therefore, we had no birth history whatsoever as this would have been very helpful with our assessment. She was significantly microcephalic with a very “syndromic” appearance and had no expressive language function. Her comprehensive language function was very difficult to assess and she mostly sat looking at her examiners during the entire visit while her sister did her best to fill in any of the details that she could.

Then at some point, when her sister was asked about how she was functioning at home, it became evident that the patient had a two-year-old child at home that she was apparently caring for. It was not entirely clear to us what her actual abilities were to care for her child, but it was very obvious that they had to be very limited at best and we had difficulty imagining just home much further she would be successful in raising this child which we went on to explain to her sister. As for any therapy that we could provide in regard to her neurologic status, there was very little as she was not agitated and required no treatment for any behavioral issues, but we could counsel her family immediately on the incredibly important need to place her on effective birth control. Given her very severe degree of intellectual impairment, she was not competent to make any decisions for herself nor did she have the ability to give consent for any therapy, let alone to have ever consented for sexual intercourse. The fact that she had already become pregnant and given birth to a child was extremely tragic and was not something that I wished to see repeated if at all possible. We expressed our concern to her sister and recommended that she speak with her family by phone to obtain consent for the patient to hopefully receive a progesterone implant today that would last three years or more and prevent another incredibly unfortunate event such as this from occurring. As I mentioned earlier, instances such as these are not limited to low resources settings such as Tanzania, but occur worldwide including the United States.

We were able to finish in clinic early enough for us to consider taking a walk down to the brick quarry and up to Tloma Village near Gibb’s Farm. The walk is great not only for the exercise, but also for a way to view the very important process for producing bricks that are used in most of the buildings here in Tanzania. The quarries, which are located in areas where the dense clay is easy to mine, are privately owned and workers will dig for the clay which is then formed into the bricks, but are not ready to be used until they are fired as they would dissolve with the first heavy rains and everyone would be unhappy. After the bricks are formed, they are then stacked into tall structures with a small amount of space between the bricks and one or two openings in the bottom where firewood could be placed and completing what is essentially a kiln. The entire stack is then covered with cow dung to further contain the heat inside. Once fired, the bricks are then ready to be purchased and used for building.

From the brick quarry, we continued walking on the Tloma Village Road that heads uphill to eventually intersect with the Gibb’s Farm Road in the center of Tloma Village. Along the road, we passed by numerous homes and several lodges, one of which, The Tloma Mountain Lodge, is quite beautiful inside and one of the older, well-known lodges here. Tloma village is large Iraqw cultural area and nearly all of the employees at Gibb’s Farm are from the village. A few yards from where these roads intersect is where Athumani, the artist, shows his work and there was a gorgeous piece that I hadn’t seen the other day and pictured women with baskets of fish on their heads walking through the water that so reminded me of my time at Ushongo Beach on the Indian Ocean watching the boats come in from fishing all night and the women would unload the first and bring them ashore. Athumani was grateful when I purchased the painting, telling me how much he appreciated my supporting him. What he didn’t realize, though, was actually just how very grateful I was to have been given the honor of supporting him and that it may have meant more to me than to him.

We walked home in the waning light as the sun was setting and as we climbed up from the quarry to FAME, I think each of us were quite thankful for the time we’ve spent here and the opportunities that we’ve been given.

It was another very comfortable night sleeping at camp with lots of animal sounds overnight that somehow here seem not to really disturb you. At home, living on the Schuylkill River in downtown Philadelphia, the trains come through every night with the clang of metal and the occasional blare of their horn, but never seem to disrupt my sleep having gotten used to it over the last seven years. Perhaps it’s the same in the Serengeti given the amount of time I’ve spent there over the last thirteen years? You may recall, though, that on my last trip, I did have a very loud hyena that sounded like it was inches from my head wake me up one night, but that was a different matter altogether.

I was up very early once again, well before sunrise, as I had wanted to get down to the main tent to post a blog and to chat with that special person back in Philly. This is by far my favorite time of the day for so many reason. Going from the pitch black of the night with so little stirring, the world just seems to come alive at a very slow pace as the horizon begins its soft glow of orange with the knowledge that the sun is already up somewhere, but it is just hinting at it here. The birds begin to sing with their morning chatter to announce the coming sunrise and you can just make out the distant plain in front of you extending into forever. There were herds of zebra this morning passing by on their way to some far off watering hole, hoping to evade those ever present predators that stand in their way. The world is coming alive in slow motion and there is some sense of gratitude for having experienced this as it has been for millions of years before.

If you haven’t listened to Ferde Grofé’s Grand Canyon Suite, and its opening Sunrise, it is the closest thing that captures this moment that occurs throughout the world, every day, but sitting in nature, it is so entirely different. One has to go back to nature, wherever that may be, every so often to experience this wonder and to rekindle or rejuvenate that sense of mystery in the universe that should exist in us all. We are merely another living thing on this planet and with that comes a responsibility to love and respect all others.

We did not have a predawn departure scheduled for the day, but Vitalis had wanted everyone to breakfast at 6:30 am for an early 7:00 am departure, which was still a bit too early for what some had wished for, though it did seem to work out, sort of. As I have mentioned, I had been up well before dawn and working in the main tent for the WiFi and Taha had come and joined me, also early, to check his emails. Apparently, not wishing to be late, Sara and Ankita had gone directly to the dining tent a few minutes before our appointed breakfast time and had eaten breakfast already, not knowing that we were relaxing in the other tent and in no rush to find them. They were not at all amused as we finally strolled over to the dining tent wondering just where they were, while they were wondering the same about us, having thought that we were late. Despite the miscommunication, breakfast was quite tasty and included freshly made to order omelettes, bacon, sausage, French toast and fruit. And, of course, lots of coffee.

One we had eaten breakfast, it was time to depart and say our goodbyes to the camp crew who had taken such excellent care of us over the last two days. The camp had been full both nights, but they had provided wonderful service with no complaints on our part and I would recommend this camp to anyone wishing to have a pleasant experience while enjoying their game view here in the Serengeti. Sure, there are more luxurious camps and, even more so, lodges that are here, but at some point, it can become a bit of overkill. At Tanzania Bush Camps, we were incredibly comfortable, safe, well-fed and well taken care of.

We departed camp and drove west over the same ridge that our camp was sitting on, through a woodlands area where a few intrepid tsetse flies found us, but weren’t a bother as they were slow and ineffective in the coolness of the morning. We were in an area where only three weeks ago there were thousands and thousands of wildebeest gathered as part of the migration, but now, they had all moved on to another location. Knowing Vitalis’s route through this region, we headed next to drive along the Seronera River and would follow it back towards the visitor center area with the hope of finding some good wildlife. Our first encounter was with a huge family of elephants at the river, mostly munching on the greenest grass clinging to the river banks, many of them leaning forward over the edge for a chance to enjoy this prime food while seeming like they could fall in or the river bank would collapse under their weight.

Moving along, we came across a very large herd of Cape buffalo with many of them crossing the road to reach the river for a cool drink. As we drove up, though, it was clear that the buffalo were very alert to some danger in the area and, looking across the river, it was very clear as to why that way.  Sitting just across the river, and very, very close, was probably one of the largest prides of lions that I have ever seen – once tallied, there at least sixteen lions, mostly adult females with some adolescents, and nearly all were very alert and paying very close attention to the buffalos. Most were in a single group, but we then spotted the alpha female, some yards away and looking very intently in a different direction where there some impala and where we had seen a group of zebra earlier as we passed by.

After some time, the larger group of lions began to move towards the alpha female and were clearly in hunting mode, though they didn’t seem to have an interest in the buffalo, and probably for good reason considering the size of the herd and the fact that these animals can easily kill a lion with their horns (which is why they are one of the Big Five). Cape buffaloes are very protective of their weak and young, forming defensive lines that are impenetrable and manned by the larger males who are frightening enough when they are causally grazing and even more so when in a group shoulder to shoulder and angry to boot. Four weeks ago, while in Ngorongoro Crater, we watched a group of lions chased by only two adult buffalo who were doing their best to protect a weak calf and, though they were ultimately unsuccessful, the lions were giving a very wide berth so as to prevent injury or death. Unfortunately, at least for those of us who wished to see some action, the lions had little interest in tangling with the buffalo and were soon heading away from us across the river to an area that we couldn’t access and were unable to follow them. They were definitely in the hunting mode, but would finding their victims far from our watchful eyes.

From the river, we made our way past the Seronera Airport, where there many giraffe just outside the fence line and we imaging those visitors getting off a plane for the first time visiting and seeing these animals as they first drove out the gate. We then proceeded to make the long trek to the Maasai Kopjes where we had seen the leopard the night before. Most of the carcass that had been in the tree had been eaten, though there was still some of it remaining. Just a bit further ahead, though, one of the two leopards sat resting on top of a rock trying to get as much of the warmth from the stone as they could while still surveying the surrounding landscape for any potential prey. There were several vehicles already there including two that were with a photography safari as each photographer had a massive lens sitting atop their custom bean bags that sat in their custom windows and on top of the vehicle. I’m sure they were getting some great shots and perhaps someday I’ll be lucky enough to own one of these lenses, but for now, I feel quite lucky to be shooting what I am and having the opportunity to be here seeing what I am.

From the Maasai Kopjes, it was now just a matter of heading south past the Seven Hills in the direction of Naabi Hill and we’d be having lunch. We were still in search of more game on the way, though, and just couldn’t help but find more and more lions along the way as we traveled slowly in the direction of the gate. They just seemed to be everywhere and by the time we reached the Naabi Hill, we had seen at least 32 lions for the morning, a number that I can’t recall ever having seen in one day. We didn’t make the Big Five today, though the consolation seemed to be a reasonable trade. And to add to the wonderful number of cats that we had seen for the weekend, we spotted two cheetah sisters (siblings of the same sex will hunt together) traveling in our direction and clearly hunting. There were no prey that were visible to us within range, so it was clear that they would be traveling far to locate their lunch, something that would not be on our agenda since we need to leave the park by lunchtime or shortly thereafter not only because our permit was ending 48 hours after we arrived, but also because we had a date with Kitashu’s boma and his family this afternoon.   

Arriving to Naabi Gate, we had beat the crowds that gather here crossing into and out of the Serengeti, those entering with the excitement of what is too come and those leaving with the memories that will last forever. We easily found a table and brought along our lunch boxes and Vitalis brought his picnic coffee setup that had gone over so well all weekend. Though we were now leaving the park, or would shortly when we crossed the office border, we had a long, dusty and bumpy drive back to the Loduare Gate and Karatu. It would be at least two hours before we reached Kitashu’s family’s boma where we were to visit for a bit before continuing on. I had told him not to roast a goat for us, his usual gesture of appreciation for us, as he had just done that three weeks ago with the other group and goats are precious to the Maasai.

The drive was uneventful (no rocks to the windshield this time!) and I texted Kitashu to let him know when just when we’d arrive as it would be a bit earlier than normal. On the last trip, we had gotten stuck at Naabi Gate waiting to pay for the transit, delaying us at least an hour and we had already been running a bit late. The problem occurs when leaving the boma as it’s about 40 minutes to the Loduare Gate that we need to be through by 6:00 pm, otherwise we can look forward to spending the night in the Conservation Area which would not be a happy situation as it would either be spent uncomfortably in the car or in a lodge for a significant cost. And either way, they would charge you for another day spent in the Conservation Area.

Once in the boma, the residents were treated to a tour of Kitashu’s home, meeting his wife and then being placed in ceremonial robes to enjoy some traditional dances and singing. Having done this several times before, I now stay outside with Vitalis handing out the “pipi,” or candy to the children, or at least taking photos and videos of Vitalis doing this. Given the number of children in the boma, it becomes a bit of mass hysteria when the candy is taken out of the box of gifts that we have brought for the boma, though Vitalis has done well training the children to listen to him and stand in a line to receive their treats. In addition to the candy, we have brought the traditional gifts that one brings when visiting someone’s home here – rice, sugar, tea, and soap among other things. Everyone got a chance to dance with the woman singing and jumping and Taha doing his best to jump as high as the other men and, though not doing too bad of a job, just didn’t get quite as high. The men also demonstrated for us how they make fire using a piece of flat acacia and a wooden rod that is spun between your hands to cause the friction necessary to create a spark and a glowing tinder.

Once finished with your visit, we packed everyone back up in Turtle including Kitashu, who was hitching a ride with us back to Karatu as we’d all be at work again tomorrow, or “kesho,” for our last week at FAME. We would be having clinic each day and trying to fit in some fun activities in the evenings, not that every day in Africa isn’t already incredibly fun. We rolled into Karatu with plenty of daylight, though everyone was exhausted from the weekend that had been incredibly successful on every level. I’m sure it was a trip that would not soon be forgotten by those that were present. We unloaded Turtle and as I drove Vitalis back to town and to his guest house for the night, the others ordered food from the Lilac Café for our dinners with the knowledge that it would take well over an hour for our food to arrive from just across campus. But then again, this is Africa after all.

The night had been lovely and cool in the tent and perfect for sleeping given the luxurious beds and linens at the camp. I have always liked staying in the camps tremendously better than staying in a lodge for the reason that you hear all the animals at night, some closer than others, and it is about as far from roughing it as one could possibly get. Tanzania Bush Camps have really upped their game substantially as far as both their main tents and the sleeping tents without going too much overboard and the amenities have made it incredibly comfortable here.

Vitalis had recommended that we depart prior to sunrise for today’s game drive and have both breakfast and lunch prepared for us to eat in the bush, giving us the best flexibility to not only get out into the bush when the animals are most active, but also to follow wherever the animals take us rather than having to be tied to a schedule. We would depart the camp at 6 am and would plan to return at the end of the day to enjoy the sunset hour in camp. This has always been my preference when traveling to the Serengeti as our time here in the park is rather short and I’ve always felt it best to get as much time seeing the animals and the landscape rather than relaxing at camp as nice as that sounds. When doing longer safaris of a week or more, then having some down time in camp is almost a necessity as the days can be grueling and even more so for your guide.

I had gotten up extra early to video chat with someone special at home and went to the main tent where the WiFi reception would be best. Sitting outside on the deck in the cool morning darkness with the soft light of the sun approaching the horizon from below was just magical and despite having experienced this many times before, it never gets old. The birds were just beginning their morning activities with their constant chirping and there were animal sounds on the plain just in front and only a short distance away. I was able to share most of it on the video call, though I must admit that the birds did seem to drown out most of the other sounds which was fine since they were so beautiful. Thankfully, the coffee had been ready early and I had my cup in hand, ready for the day ahead. Ankita and Sara had requested a coffee wakeup call in their tent and were enjoying their coffee in bed prior to our departure.

We loaded up in Turtle, Ankita and Sara in the second row, Taha in the third, and me occupying the fourth and final row with all of my camera equipment spread out across the three seats essentially akin to having a full row on an airplane to yourself. Everyone was quite happy with their spots which was perfect for me as I prefer having the room in the back and essentially never sit down during the game drives as I love spotting for things. Standing this morning absolutely required my fleece sweater as the air was very brisk and as none of the others were standing, I had no one to block the wind. We had barely gotten under way when we spotted a leopard just walking along with what appeared to be somewhere to go, though they were walking in a direction that didn’t allow us to follow as in the Serengeti, we are restricted to traveling only on existing roads that may be as little as two tire tracks, but at least there has to be something. In the Conservation Area, there is no such restriction and one can follow animals wherever it is possible for the vehicle to pass.

Spotting a leopard on the ground walking, not the most common of sights, was an incredibly auspicious start to our day and produced excitement. We watched it walking slowly into the distance while constantly checking to the horizon to make certain there were none of its mortal enemies, primarily lions, anywhere around. It will most likely set up to hunt wherever it’s going, though that will most likely be at night as the leopard is a stealth hunter, sneaking right up to its prey so that it’s essentially on top of them before they even realize that it’s there. How exciting it was for us to have seen one first thing in the morning without having expected it.

Driving through the Serengeti is an experience unlike any other, for the word in KiMaa (the language of the Maasai) means, “endless plain,” and this is almost an understatement for every hill you crest, there are three others in the distance and more beyond that. It is quite simply infinite. At one point, on perhaps one of the furthest hills we could see, Vitalis somehow spotted a family of cheetahs enjoying the high grass and running back and forth playing. With our binoculars, you could easily see them, but they were too far for me to photograph unfortunately. It was till great to be watching them frolicking with each other on the hill side, seemingly without a care in the world. We watched the cats for some time before moving on and it was getting time for our breakfast picnic soon.

Vitalis knew a very nice spot that sits up high on a hill above the luxury Lamela Camp and a spot where they have their “sundowner’s party,” as it has an expansive view of the surrounding landscape. As we would not be running across any bathroom facilities during the day (there are very few in the Serengeti), this spot would serve first for everyone to relieve themselves after the earlier coffee of the morning. I believe that this may have been a new experience for some who will go nameless, but, thankfully, everyone performed like a champ and we were soon free to roam around the site without risk of embarrassment.  But before we could even begin to break out our breakfast boxes and prepare the coffee, Vitalis spotted two rhinos far in the distance that were very likely the two we had seen three weeks ago when the other group was here with me. It was a very lucky break for us as we never expected to have seen more of these very rare and magnificent animals over the weekend and this was such a treat for us. It also once again gave the opportunity to see the Big Five in one day as all we were missing at this point was to see some lions as we had already run across the elephant, Cape buffalo, and leopard and, now with the rhino, we had seen four of the five.

We finished breakfast along with Vitalis’s fine coffee in the French press and were back on our way, now looking for some lions which are normally quite easy to find here in the Central Serengeti on most occasions. Though we had found the more difficult animals and quite early in the day, we were now on the hunt for our feline friends. We traveled a bit through some other beautiful areas without initial success, but then ran across some very nice lions sitting on top of a termite mound posing for us! It was noon on the nose which meant that we had once again seen the Big Five before noon in the Central Serengeti and, coupled with our accomplishment last night of seeing the Big Five within two hours of entering the park, had really hit a grand slam.

The cheetahs that we had seen earlier, though, were in the far distance and could only be made out with our binoculars, so we were still hoping to see some cheetahs closer up sometime today. We eventually stopped for our lunch under a nice Acacia as the sun was intense even though the air temperature was delightful. After lunch we spent several hours searching high and low for the cheetahs or anything else of a similar nature, but other than the absolutely spectacular scenery and gorgeous weather, we could turn up little else. Eventually turning back in the direction of the Maasai Kopjes, though, Vitalis spotted a cheetah in the very far distance standing on a termite mound that, when we looked closer with our binoculars, turned out to have at least two cubs with her! There were significant enough tracks that we were able to get out closer to the mother cheetah and her two young cubs until they decided to climb down and began to walk towards some bushes to shelter from the sun. The little cubs were particularly cute as they still had their downy fir on their backs. We didn’t hear them chirp, but the sound they make is just like a little bird having heard it several times in the past. Ten years ago, Leonard and I had come across a mother cheetah and five of her cubs who were just a bit younger, but their chirps still resonate in my brain as it was just so out of character to see a cat chirp.

Heading off to the Maasai Kopjes, named as they are very large and one of the more prominent in the Central Serengeti here, we spotted a number of vehicles sitting adjacent to some of the larger rocks on one end. I have seen many leopards over the years at the Maasai Kopjes and seeing this many vehicles in one spot makes you immediately think of a leopard or a large pride of lions. As we pulled up some distance behind the other vehicles, a gorgeous leopard began to descend from the rocks above and was heading straight for our vehicle. Unfortunately, as he came closer to us, several of the other vehicles began to back up or turn around so they could get closer, but instead scared the leopard who then turned around and headed back up into the rocks. I had been able to get a number of good shots, though, prior to him turning around. He was a beautiful animal that appeared quite healthy and his coat was bright and perfect. What a powerful animal.

We eventually left the spot and proceeded to drive around the kopjes, only to find a second leopard sitting up in the tree with its prey hanging in a nearby branch, partially eaten. This leopard was far too close to the other as they are very territorial and, therefore, they were most likely a mating couple as the other in the rocks was a male. A female may allow one her offspring to remain nearby for a time, but an adult male would never be so hospitable to an offspring or to another adult unless they were mating.

The mating theme seemed to continue during the remainder of our safari as we slowly meandered along the Seronera River in the direction of our camp. During drive, we came upon a mating pair of lions who were initially resting along the roadside, but as they mate every 30 minutes for at least 48 hours, the alarm clock happened to go off while we were sitting there and it was time for them to mate though it is an incredibly brief encounter. The reason for the frequency of this of two days is to ensure that the female is impregnated and the pair will usually wander off from the pride for this entire time, forgoing hunting or eating until the ritual is over.

Tearing ourselves away from the mating lions, we proceeded to the filling station (there are two in the Central Serengeti) to top off our tank, though we could have very likely driven home on the same tank as fuel efficient as the Land Rover is compared to the Land Cruiser. Fuel prices in Tanzania have increased by 50% from what they were in the spring on our last trip, mainly due to the war in the Ukraine and the instability of the oil markets at the present time. As fuel prices go up here, so does everything else, unfortunately.

Since mating animals seemed to be the theme for the day, we did run across a pair of mating giraffe on our way home from the fuel station and despite the encouragement we were providing by watching them from the road with bated breath, nothing seemed to happen after numerous advances by the male with the female each time taking a step or two forward and spoiling his plans. We continued to watch for another 10 or 15 minutes, but remained equally disappointed as was the male giraffe in the females reluctance despite her apparent interest. It was a matter of continuing to sit there watching versus driving on towards camp and very likely cold drink, and we chose the latter for good reason.

It had been an incredible day of game viewing for us having spotted the Big Five in short order for the second day in a row, an accomplishment that was quite unexpected before we had arrived here. We got to camp early enough for both showers and drinks before dinner and it was nice evening to go back over the day and reminisce. We would be departing midday tomorrow after a morning game drive, but it was all icing on the cake as we had seen so much already.

Having been out last night to the African Galleria, everyone was a bit slow this morning, though thankfully, our departure for the Serengeti wasn’t scheduled until 8 am (still a tad early for Ankita, I think). For me, it was my second attempt at Anna’s birthday zoom that was scheduled at 6 am my time (now October 7, but the rest of my family was still enjoying the waning hours of October 6) and it did take just a bit more for me to get out of bed this morning than it had yesterday. At least I wouldn’t be doing the driving to the Serengeti, a task that Vitalis would be handling for the weekend.

We had originally planned to make our own lunches for tomorrow, but Vitalis had suggested that we instead stop at one of the markets in town that has good pastry type things and samosas that would work not only for our lunches, but also for a breakfast snack for those of us eating (recall, I’m still trying to operate on my intermittent fasting and not eating anything until noontime). Everyone picked out a bunch of little things to eat later as did Vitalis and we also stocked up on smaller bottles of water along with a few frozen bottles that would all fit into the cooler he had brought with him from Arusha. Once raiding the market of most of its baked goods and tanking Turtle up with fuel given the distances we would be driving over the weekend, we were ready to depart Karatu for our weekend of game driving in the Serengeti.

Driving up to the Loduare Gate and the entrance to the Ngorongoro Conservation Area, it seemed like everyone had decided to drive to the crater or the Serengeti this weekend – safari vehicles were lined up side by side on the road even before we had arrived to the parking area one normally uses when going in to get your permits processed. After a few minutes slowly moving towards the gate, Vitalis parked Turtle on the side of the road and left to go to the office to get our permit processed. I jumped into the driver’s seat to keep us moving in a forward direction given the large number of vehicles and, at one point, an MP who clearly had things under control, waved us over to a parking spot where we could sit until we were ready to go through the gate. Vitalis came back moments later saying that he had already taken care of everything, clearly related to the fact that we had put everything through the reservations system this time rather than trying to pay with my credit card at the office gate. It also turned out that there was an international meeting in Arusha for travel companies and agents and they had apparently taken this Friday off to take trips to the crater. How lucky for us. Miraculously, though, we were through the gate quite quickly and on our way back up the crater rim once again, one of my favorite drives in the world as I have previously mentioned and, this time, I would enjoy it as a passenger for the weekend.

Our next stop would be to Oldupai Gorge and a visit with Professor Masaki and the museum there. I had met him about five years ago during a visit here with a close friend and he had taken us to the Leakey’s camp, which at the time had been closed to the public and used for fossil storage. I can still recall him taking me through the small warehouse where the original artifacts were and taking a several-million-year-old mammoth tusk off the shelf and letting me hold it. Since that time, I have continued to maintain my contact with Masaki and have tried to visit him every trip here with the residents, all of who have found a visit to this miraculous place well worth the time. When I first visited Oldupai in 2009 with my kids, the museum had been comprised of two small rooms with some makeshift signs and a few fossils that had been put together many years ago by Mary Leakey. Since them, a new museum has been constructed that is incredibly wonderful – it was built in a circular fashion starting with the oldest fossils here of Zinjanthropus and is divided into four sections with each one being closer to the present as you proceed. The last exhibits cover the modern day tribes here.

Since our first visit, the site has been transformed into a true destination, though I am still amazed at the hundreds of vehicles that pass by every day with only a small fraction of them stopping to visit the gorge and its museums. The Leakey camp has recently been opened to the public as the Mary Leakey Living Museum, and though I’ve yet to visit it, I plan to do so soon. For those of you who are not familiar with Oldupai Gorge or the Leakeys, it is essentially ground zero not only for much of what we know about oldest man, but it is also considered to be the cradle of mankind, for the fossils here tell the story of man’s evolution, the parts of our ancestral tree that made it and those not so lucky, and it was the Leakeys, both Louis and Mary, as well as their children, who were the ones that shared this story with the world. Standing at the overlook with Dr. Masaki telling the story of Oldupai, spread out in front of us in all its glory, one can’t help but feel as though a significant part of our history is still being written in our presence.

Leaving the visitor center and museum, we drove into the gorge, passing by some of the most famous archeological sites in existence, then up the other side and out heading west in the direction of Shifting Sands. This is a remarkable geologic feature that is unique to the Ngorongoro Conservation Area and is the result of an eruption of the sacred Maasai mountain, Ol Doinyo Lengai, which means “Mountain of God,” about 1000 years ago and is composed of black volcanic sand that is magnetized and is slowly being blown west across the grasslands at a speed of about 15 meters per year. The sand stays together due to its magnetic nature and the mound is about 8 meters high and about 20 meters across with a crescent leading edge due to its windblown nature. Both during our last visit and again today, there is a small group of Maasai women who shelter close by during the day, coming out when there is a visitor to sell their beaded jewelry and knick-knacks that are actually quite nice. Living out here in the grasslands must be a very harsh existence and we purchased a number of things from them which was just the right thing to do.

Leaving Shifting Stands, we drove along the smallest of roads heading south towards Naabi Hill and the gate into the Serengeti, though you cross the actually border into the park a bit earlier than the gate. It’s a wonderful drive as we’re off the beaten path and instead of the heavily rutted main road with all its loose and flying rocks (remember our shattered windshield last visit) such that we could enjoy the surroundings more thoroughly without constantly having to slide our windows shut to prevent the dust from coming in. We also enjoyed lunch along the way rather than fighting the crowds at the gate as we had planned and Vitalis won Ankita and Sara’s hearts by having brought thermoses of hot water and a French press to make a picnic pot of coffee that I shared in as well.

We eventually arrived to Naabi Gate and as soon as Vitalis exited the vehicle, the heavy latch to his front door fell off the jamb such that his driver’s door would no longer remain closed properly and was essentially swinging freely. We were now down to one operational door and this one was a problem as both of the bolts had sheared off, with the inner portion remaining in the two holes and no way to fix it without a drill gun to drill them out and replace them. Thankfully, something similar had happened to us in the past and what’s required is that something, either a cord or a rubber strap, is wrapped around the pillar between the driver’s window and the one behind with the only problem that neither could be closed when driving and it had to be removed each time he needed to enter or exit the car. There was the additional problem of not being able to lock up.

Thankfully, there was a repair shop at one of the research garages and Vitalis had repairs done there in the past. We later stopped by the shop and then he brought the car back to them before dinner and we were able to fix the door with no problem. Meanwhile, we began our game drive much earlier than we had three weeks ago, broken door and all, and in short order had pretty much bagged everything necessary for the weekend. I had mentioned previously about the Big Five, those five animals, the elephant, rhino, Cape buffalo, leopard and lion, that were the most dangerous to hunt back in the 20s and 30s when the Great White Hunters were coming to this region, some of who were mortally wounded by their intended victims after they had merely maimed them rather than killing them.

Driving into the park, we encountered the Cape Buffalo, elephant and lion readily, but it is always the rhino and leopard that pose the problem in “bagging” this group. The rhino has been pretty much non-existent here in the Central Serengeti, though we had seen the three of them three weeks ago when we were here and I had little hope of doing so again. Miraculously, Vitalis had heard something on the radio and drive us right to the spot where there were several other vehicles viewing something far off in the distance, but could actually be seen with the naked eye and even more definitively with the binoculars. What we saw was actually a mother and very small calf, clearly not the group from several weeks ago as that group had a nearly full grown calf with them. We watched them for quite some time moving about in the low grass and enjoying themselves.

Now that we had seen four of the five, we were in search of a leopard to complete our quest and didn’t have to wait all that long as we ran across a leopard in a tree along one of the rivers. We still had plenty of sunlight to spare and had found the Big Five in probably a record time of less than two hours after having entered the park. I don’t believe I had ever seen the entire group in a single day until three weeks when we did it before noontime and now we had done it in what seemed like an inordinately small amount of time such that we rolled into our camp knowing that we had really accomplished something significant. It was clearly due to Vitalis’s excellent guiding and perhaps a little help from his fellow guides on the radio, though that is not at all an unusual tool that guides use on a regular basis, sharing information with each other. I just wish that I spoke Swahili if for that reason alone.

We checked into our camp where I had stayed three weeks ago and had a relaxing evening. Vitalis left momentarily to have Turtle fixed and returned in plenty of time for dinner. It was a gorgeous night out and one could hear the sounds of many animals out in front of camp – zebra and hyenas were the loudest, though I believe some lions joined the chorus sometime during the night.

Having spent on average two months out of every year here in Tanzania for the last twelve years does amount to a considerable amount of time out of the country and away from family and friends, but the months I have spent away also account for both my own birthday as well as a considerable number of my daughter, Anna’s, birthdays. Over the last two years, as the pandemic has caused so many the inability to travel and visit family, Zoom has probably saved our sanity on this account and I am sure that many families have resorted to the regular family Zooms as we have. Well, today, or at least I thought, was to have been one of those days that we were all going to get together for Anna’s birthday and, given the time differences between California, where she is currently attending veterinary school at my alma matter, UC Davis, and East Africa, it meant that I would be jumping on the call at 6 am my time, which would be at 8 pm Pacific time the previous day for her. Daniel and his fiancée, Chloe, who live in Denver would be on at 9 pm the prior day and Kim, their mother and my ex, would be on at 11 pm east coast time.

Somehow, it never occurred to me that at 6 am on October 6 East Africa Time (Anna’s birthday is on October 6), would actually be October 5 for everyone else and not her birthday. I had woken up around 5:45 am to be ready for the call and when no one had yet signed in, I reached out to everyone on WhatsApp, only to discover the mistake I had made and that the actual call had been scheduled for tomorrow at 6 am my time, which would be, quite appropriately, still her birthday in the US. Somehow, I had missed that important fact on the message that had been sent to me, though even if the date hadn’t been included in the message, it should have occurred to me that it wasn’t yet her birthday. I would just have to do it all over again tomorrow.

This morning was again an early day for educational lecture and the residents were to give a talk on stroke using a few cases as examples from which to begin their discussion. Dr. Ken has asked that we use cases from which to teach as it seems to work best for them and also allows the talks to be a bit more interactive, though sometimes it’s a bit like pulling teeth to get the team to offer answers and we have to call on them to do so. A stroke talk here is very much different here than it is at home for a number of reasons that mostly have to do with the therapies that are available for the acute treatment of stroke as well as the testing that can done. All of the efforts in the United States and in the west have been to deal with having the public recognize warning signs of stroke so that patients are brought into the emergency room as quickly as possible where, if appropriate, they can receive the miracle drugs such as tPA, or the newer TNK, which are clot busters (thrombolytics) that will break down the offending blood clot to hopefully restore blood flow to parts of the brain. The big limitation with this therapy, though, is that one, it requires a CT scan prior to administering, and two, is required to be administered within hours after the onset of the stroke for reasons of safety. If given “outside the window,” the risk for a hemorrhage outweighs the benefits of the medication.

The availability of CT scanners, and particularly ones that are working as they are frequently down at many sites that have them given the cost to keep one operational, is very poor and it is incredibly unlikely that a patient will be brought to a center with a CT scanner in the short time necessary to do any acute therapy safely. There is also the cost of the CT scan that is involved, and, even if this was possible, the cost of the therapies are very expensive and pretty much unavailable anywhere in the country for stroke. Even if these two technologies (CT and thrombolytics) were readily available and affordable, which they are not, the other matter is the time. Given the difficulty with transportation in the country and the amount of time it takes to get anywhere due to both roads and vehicles (there are no public ambulances or rescue squads here), it would be nearly impossible that anyone would get to a center capable of administering these agents within the several hours from the onset of the stroke necessary to give them safely. And this is not just for places like FAME, but also for centers such as their national hospital in Dar es Salaam. The fact is that patients coming in with stroke, typically arrive to the hospital days after the onset of their symptoms and the stroke has already been completed.

At home, a huge effort is made in the emergency room to determine what is referred to as “LKN,” or last known normal, which is considered the time of onset of the stroke, unless, of course, their LKN was just prior to bedtime in which case the time is onset would technically be unknown. During their talk, the residents mentioned this term several times and I was tempted to say something as it is really not something that is used here for these reasons, but decided not to interrupt their talk as it was otherwise going very well. This is just to say that working here is very, very different than at home where the focus of our efforts is often directed towards providing therapies that are not even conceivable here without first having Herculean changes in their infrastructure both for their healthcare system and for their economy. And my discussion of acute care of stroke didn’t even touch the newer therapy of mechanical thrombectomy, where a catheter is placed in the artery to retrieve the clot and restore blood flow which can be done much later than the thrombolytics, but requires not only the technology of catheter labs, but also those highly trained individuals who provide the therapy, none of which exist in this country outside of heart institute.

So, as you can see, the problem is quite complex. This does not mean, though, that all is lost as we can still do much in regard to not only providing care that can lessen the functional impact of a stroke in the hours or days after it has occurred, but also there is much to be done in the prevention of stroke, or what we call risk reduction. Recognizing the medical conditions that increase the risk of stroke, such as hypertension, diabetes, smoking, lipid management and cardiac arrhythmias, are incredibly important in populations where these conditions often go unrecognized and untreated. Things as simple as taking an aspirin a day can lessen the risk of stroke in the appropriate patient or even given in the aftermath of a stoke can lessen the severity of a stroke. Improving the understanding of the clinicians here at FAME for the general pathophysiology of strokes and their treatment can go a long way and will allow them to be more effective in both treating their patients who have suffered a stroke and those who are at risk to suffer one due to comorbid medical conditions.

As we were leaving for the Serengeti tomorrow morning, Turtle was in need of some necessary repairs, as the locking mechanisms in two of the doors were again acting up and there were only two that worked (which thankfully included the driver’s door) so Vitalis was going to come to Karatu early in the day, or so I thought, to get them fixed while we were working. In the end, he didn’t get in town until 2 pm, which did pose a bit of a problem as we had plans to visit Nish’s place, the African Galleria, for dinner tonight which would require transportation. We had also wanted to get there on the earlier side as the others wanted to do some shopping for gifts. Our clinic was going along smoothly and though this didn’t end up keeping us late as the car and Vitalis hadn’t yet arrived, we were delayed by a last minute tourist who had somehow lost their medications and one of them, which was not available in this country, could be replaced by a similar medication we did have, but would require some dosage conversion. Since the medication was one that we do use, we were enlisted to figure this out which did take a bit of time looking things up on the internet and making some assumptions. I the end, we had come up with what I felt was a good solution and we were able to head back to the house.

Vitalis finally arrived, though a bit later than we had hoped, and we all drove down to the Galleria for shopping and dinner. Thankfully, it was crowded at the shop so they stayed open later than normal giving everyone plenty of time to shop. Dinner at the Ol’ Mesara restaurant was again fantastic and Nish ordered plenty of food for everyone. We had brought Vitalis with us, who had never eaten there, and Amos also came along. We did enjoy some of their fancy cocktails before dinner, as well as during and after dinner, and the night was rather long, or at least it seemed so, but in the end, it was only around 8:30 pm when we finally left. I think we tried all of the meat dishes they had, but to be honest, the pumpkin ginger soup and at cheese samosas remain my favorite. The grilled paneer that I had tried for the first time a few weeks ago is also now one of my new favorites. The food seemed to keep coming and never stopped and, for the first time there, we weren’t able to finish everything.

Just before we left, I received a call from Onaely, our radiology tech, that there was a young patient there with a small bleed who had been in a motor vehicle accident earlier in the day and that the ward was requesting a consult from us. Not that any of us was looking forward to seeing a patient that night for obvious reasons, though Sara, who really hadn’t had much too drink, became the one that would do the consult along with Amos who was also feeling fine. We returned home and all went straight to radiology to look at the scans first. Even though the patient had skull fracture with some pneumocephaly (air in the head), the bleed, which looked somewhere between an epidural and subdural hematoma, was quite small and required no immediate treatment which we confirmed with Dr. Grady back at Penn just for reassurance, and the patient was fully intact neurologically when Sara went to evaluate him. In fact, the patient didn’t want to remain in the hospital and it took some convincing by Amos to keep him in the hospital overnight. The eventual recommendations were to repeat a scan in 24 hours and, if there was no change, he would not require any intervention. We were all quite relieved that the patient’s situation didn’t require anything more complex in nature such as an overnight transfer, though I believe that Dr. Thomas would have been willing to provide a burr hole if it had been necessary.

I would be getting up ultra-early tomorrow morning for my redo on the Zoom birthday call with my family for Anna’s “real” birthday and then, we would depart for a weekend in the Serengeti. Everyone was filled with excitement, including me, as it is always a thrill for me to bring the residents there for their very first visit to this truly magical place. No matter how many times I’ve been, and it is many, I always manage to see and experience new things.

Having spent both of the two previous days on the road, I’m not certain that any of us realized just how exhausted we were after all the travel. I’m sure the drives were just as tiring for the others as it was for me, though having driven over an hour each way to Mang’ola both days, and in the dark coming home on Monday, I was more than ready to stay at FAME for the day as I’m sure everyone else was as well. Mang’ola is by far the toughest drive of the mobile clinics for the drives to Kambi ya Simba and Rift Valley Children’s Village, though challenging in a different way, don’t have that draining, high speed pace on bumpy gravel that always seems like you’re just a bit on the edge the entire time. For certain, the roads to the other villages are bumpy, but they just don’t involve the same nerve wracking challenge, unless, of course, it’s raining in which case they are like a slip and slide and that’s an entirely different story. Leave it say that even though the mobile clinics can be a welcome change, it’s always nice to be home.

Angel had started her annual leave, which is why she wasn’t available for us on Monday or Tuesday in Kitashu’s absence, but thankfully he was back with us today so our team was once again fully intact. There was no educational lecture this morning , so it was just morning report at 8:00 am and then our regular neurology clinic. Mary Ann was leaving today, so it was time for everyone at FAME to give her the standard three claps of appreciation always preceded by “pasha, pasha, pasha, choma,” neither of which the translation or custom I am quite certain of. I do like the three claps, though, as it never leaves anyone questioning just how long they should have clapped or feeling as though they may have ended early. I also said something about what a powerhouse Mary Ann is when it comes to fundraising for FAME, something that is absolutely essential and, without the donations that we receive from individuals, FAME would no longer have the ability to provide the life affirming services that it does to the residents of the Karatu District here in Tanzania.

One thing that I was really looking forward to today, of course, was our return to my favorite all time lunch – rice, beans and mchicha. The last two days, we had eaten box lunches that were from the Golden Sparrow and are typically intended for those guests going to the parks and to be eaten on the road. The lunches contained roasted chicken (typically a small piece consisting of a thigh and wing unless you’re lucky enough to score part of a breast), a bun and hot dog, a butter and carrot sandwich, a piece of chocolate, a mango juice box and a hard-boiled egg. Not that there’s anything at all wrong with the box lunch as it was very filling, but I would be willing to take the five day a week FAME lunch of rice, beans and mchicha over just about anything that someone could off to me. Last Saturday, when we had taken the day off, the residents went to the Lilac Café for lunch which I had originally planned to do as well, but just really could pass up the FAME lunch and ended up going with that instead. Somehow, learning how to make the meal at home just doesn’t seem like it would be the same, so I will just have to enjoy it here and know that I’ll have it again when I return.

Our day in clinic was slow but steady and we had actually planned to make a trip in the late afternoon to visit our friend, Phillipo, the coffee grower as everyone wanted to buy coffee to bring home for gifts and we had also wanted to visit another old friend of mine, Athumani Katongo, who is a wonderful artist that I had first met at Gibb’s Farm years ago. His artwork hangs in my office at Penn and over the years, numerous residents have also purchased his works. I had lost touch with him during the pandemic as he had moved from Gibb’s Farm, but I recently learned that he now had his work next door to Phillipo’s at a shop merely known as the “woodcarver’s shop” – also an old acquaintance of mine, Mbuga, who is Makonde from Southern Tanzania famous for their wonderful and very distinctive ebony wood carvings.

I had just recently learned that Amos, the clinical officer who has been working with us over the last weeks, was a very close friend of Athumani’s and also wanted to go to visit him when we did. As the drive to get to the woodcarver’s shop and Phillipo’s would take about 25 minutes, we had hoped to leave clinic a bit early, but as is usually the case, Taha’s last patient was a bit complicated as she was a 40ish year old patient with a complaint of left facial weakness, but also had other cranial nerve involvement in the same vicinity and a headache, all of which was new and made us very concerned for the possibility of a mass lesion causing her problems. She absolutely needed a CT scan of the brain with and without contrast, so both Taha and Dr. Anne proceeded to discuss this with her and the fact that she and her family would have to pay at least part of the cost for the study.

This is always such a difficult situation as FAME does not offer care for free, and even though there is a single charge for the neurology clinic that covers the visit, labs and medicines for at least a month, it does not cover radiology and certainly not CT scans. From the very beginning, it was very clear that FAME would not be able to provide care for no charge from the standpoint of funding and that patients would be charged reasonable and appropriate fees consistent with what was being charged by other healthcare institutions in the country. The benefit of FAME is not that the cost of care is any different, but rather that the quality of care which FAME provides exceeds what is available elsewhere in the country. FAME has succeeded in doing that, but must still charge for the care that patients receive.

Often, though, when patients are unable to afford a procedure or test, they must go back to their family or their village where they will speak with the elders who may then raise the money from the community to provide the necessary care. Unfortunately, when dealing with these situation, you quickly realize that there are always unintended consequences when dealing with these situations – reaching in your pocket to pay for the CT scan may work in the short term, but what if you find the patient has a problem? The expectation at that point is that you are responsible for the patient’s continued care and that is not a viable option. Unintended consequences are often the result of over zealousness and a failure to think things through to their most likely or possible conclusions.

Our patient needing the CT scan initially disappeared for around 15 minutes, but eventually returned and explained that she would be back the following day to obtain the study which, unfortunately, did not happen. In the coming days, we will have to reach out to her to follow up on this and make certain that everyone is on the same page. Somehow, we will try to do what’s best for the patient going forward.

We were eventually able to get away and, even though it was a few minutes later than we had wished, we were able to get there in the daylight so we could spend an adequate amount of time with Athumani’s artwork, which worked well for Sara, who found a wonderful painting of four Tanzanian women carrying fresh fish to the market in baskets that they were carrying on their heads. I loved the painting and, if Sara had not purchased it, I would have in a heartbeat as there was something about it that really characterized the people of Tanzania. He does a lot of very cool stuff with his art work using handmade papers and lots of the colorful cloth here to create a fantastic background on the canvas and then paints on top of that. The painting I have is one of an abstract elephant with an incredibly colorful trunk, but I’ve included one that he did for one my residents, Lindsay Raab, that she ordered specially from him.

We spent some time with Mbuga, the woodcarver, as well, though I’m not certain that we bought to much from him. The real highlight was once again visiting Phillipo and his family. They are such a job and the coffee he produces is the best, much of which is also related to the fact that he processes everything by hand right there on his farm and right in front of us. As we arrived, his father was roasting a fresh batch of coffee beans by hand and, one finished, put onto the cooling rack. We were there for enough time that the beans cooled and we were able to package and purchase that batch which made it all the better. We also spent time watching the stingless bees that pollinate his coffee plants going in and out of their hives. The larger “stinging” bees also try to steal their wax, but the smaller stingless bees have soldiers defending the hives. He also brought out some of the honey for everyone to try as it is equally delicious, but he didn’t have any to sell this visit which was unfortunate as I believe Ankita would have purchased his entire stock had he had any.

All in all, it was another lovely visit with his family. I can’t remember his wife’s name for the life of me, but his children, Elia and Elizabeth, are just fantastic and I’ve watched them grow over the last several years. I always love playing with them while Phillipo is giving his talk on the coffee process to the others. We drove home that evening incredibly satisfied with a boatload of coffee in hand and good sense that we had helped his family specifically by buying his coffee and it couldn’t have been more “direct from the source.”