Tuesday, September 27 – First full day of clinic for the residents and an interesting education session…

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Alicia teaching reading fetal monitoring strips

As it was Alicia’s last full day at FAME after her 2 month stint here as part of her global OB/Gyn fellowship program with Creighton University, she was giving this morning’s education session that was to more of a practical, hands on exercise in how to read fetal monitoring strips. I certainly planned to attend as I feel compelled to do so as a board member for FAME and wanting to support the other volunteers regardless of their expertise, though I did tell the residents that given the fact they would never really be looking at fetal monitoring strips in their career, they were welcome to get an extra ½ hour of sleep for the morning.

I did find the lecture interesting, as I do any medical lecture to be honest, but when it came to the practical portion of the teaching session, I decided to sit back and take photos instead. The residents had arrived before Alicia distributed the strips to be read and, so, they gladly joined forces with the FAME doctors to weigh in on their interpretation of the strips and they each participated with one of the several teams. The take home message for me was how to report the information from the strips (which I will never have the chance to use) and that obtaining monitoring strips in an otherwise normal pregnancy only serves to increase the number of caesarian sections and does not improve outcome at all. Meanwhile, the other take home message I got was that Dr. Anne really knows her obstetrics as she was answering all the questions from the quiz correctly and, eventually, had be to asked not to answer any further questions and to give some of the others an opportunity. If I were here having a baby being delivered, I would certainly be asking for her. Somehow, though all of this, I couldn’t help comparing the two channels of these strips to the tremendously more that we read on an EEG at one time. Then again, it’s all a matter of one’s perspective.


We went to see our little seizing baby again who was still in the ward and the child, though having had some recent seizures this morning, was bright and alert and acting normally. At the end of the visit, though, he preceded to have another seizure that was very typical of what we had seen in the past – the baby began to stare blankly without response and stiffened it’s arms and legs with some very subtle jerking movements of its face, mouth and eye in a rather rhythmic in nature including his tongue. This lasted less than a minute and stopped. We had started the topiramate over the weekend and I decided to try increasing the topiramate as I was reluctant to put him back on phenobarbital given the three other medications we already had him on. We crossed our fingers and doubled the topiramate as it was at a very low dose currently. We would check back later in the afternoon/evening to see how things were going.

FAME has always depended on its volunteer program which is how I was first introduced – having visited here in 2009 while on safari with my children, and having had neurology cases run by me by Dr. Frank and Dr. Mshana, I was asked if I could come back sometime. Here I am 13 years and 26 trips later, now having a full neurology program here with residents volunteering as part of their training and the benefits of this philosophy have become crystal clear to me and every other volunteer who has visited since its inception in 2008.

Ankita eating the ugali properly

FAME’s mission is not to develop a patient centered healthcare facility that is dependent on Western volunteers for the care of its patients, but rather, quite the opposite. FAME is fully staffed and run by an all Tanzanian staff comprised of doctors, clinical officers, nurses, lab techs, radiology techs, housekeepers, groundskeepers, drivers, kitchen staff, administrators, and many others who, on a daily basis, keep FAME running seamlessly. This was no more evident during the pandemic of the last several years when there were essentially no volunteers here other than myself, and later some of my neurology residents, and yet FAME continued to function, providing the same high quality healthcare that it has been known for since opening back in 2008.

Volunteers coming to FAME and working side by side with the Tanzanian staff have the opportunity to participate in a unique bidirectional educational process that provides not only a tremendous benefit to the population of Tanzania, but also cannot fail to leave a lasting effect and incredibly valuable impression on those volunteers that will stay with them for the rest of their career and make them not only better doctors for their patients, but better human beings. For the residents who I have brought here over the past decade, their experiences have been only uniformly positive and, for many, life changing.

A photo shoot with Turtle

Our lunch today (always on Tuesday) was comprised of a classic staple here in East Africa, that of ugali and meat with a side of mchicha. Ugali can be best described as a stiff porridge that is somewhere between corn mush and cornbread and is made from either maize or cassava, with that eaten here of the former. It is made in a huge cooking pot that requires constant stirring until it completely sets and is then scooped out with a large spoon onto each plate. On top of this is placed chunks of beef and sauce and then the mchicha. Though many of us eat the ugali with a spoon, it is truly meant to be eaten with your fingers, typically rolling it into a ball that you then put in your mouth along with a piece of beef or vegetables. Most of us also dump the appropriate portion of pili pili on top. For many, this is their favorite lunch here at FAME, though for me, it is still the rice, beans and mchicha. For Charlie, FAME’s resident dog, today is absolutely his favorite lunch, along with Thursday’s Pilau which is also served with beef, as he is the benefactor of all those chunks of meat that are less palatable for those of us who are used to more lean cuts of meat. Though Charlie is by far the biggest benefactor, and I say that both literally and figuratively, Meow does also partake in some lunchtime snacking on these days.

Today, I did have to be back at the house by 5 pm as there was a FAME Board update call scheduled and I would need to be available for this. We now have the luxury of having WiFi available in volunteer houses, as well as throughout the FAME campus, that has made life much more livable for everyone as previously, we would hotspot one of our phones, though it never worked very well. Having a working WiFi, though, is predicated on having power, and that has been on ongoing battle with Tanesco, the power company here in Tanzania. Frequently through the evening, our power will go out briefly, or for longer periods, and when this happens, the router and modem will suddenly kick off and often it will take up to five minutes for the modem to recycle and come back to life.

Thankfully, the power lasted throughout my board update call, but immediately afterward, while on a video call with a close friend in the US, the power cut out and remained out for probably 30 minutes until I was finally able to call back and finish our conversation. These little interruptions in the power are certainly manageable, though in the past we’ve experienced more extensive rolling brown outs that thankfully have not been nearly as common in the recent years. I remember arriving in Arusha to the Temba’s home out of power on my phone and computer and all set to charge everything, only to learn that the power was out for the remainder of the day. Those instances have been far less common in the recent years, thankfully.

Ankita, Taha and Sara out for a walk

Earlier in the day, we were approached about seeing a group of patients from a nearby village that we used to go to for a mobile clinic, though have not been there in several years. The patients all have a neurologic issue and had either been seen by us before or not, but were all appropriate for us to see. There was some question, though regarding how they were going to get to us as even the cost of transportation to FAME can be very prohibitive for many of our patients. There is always a fine line regarding how much assistance is appropriate for us to provide for patients to be seen as the clinic is already heavily subsidized as far as the cost that is paid to be seen by neurology – patients coming to our neurology clinic receive their office visit, any appropriate labs that need to be drawn and a month’s worth of medication, or often several months, all for 5000 TSh, which, at the current conversion rate, is less than $2.25. Providing transportation for some patients and not for others, has always been a dilemma for us when it is on top of the subsidy that is already being provided.

This has been our model from the very beginning of the neurology clinic here and though it has served its purpose in regard to making more patients, and healthcare workers, aware of not only the nature of neurologic illness, but also the fact that they are often very treatable. This model, though, has not come without its logistical issues as there needs to be some very robust social services input into this process regarding patient’s ability to continue the treatment that we’ve recommended. Making a diagnosis of epilepsy in a patient and recommending a medication to a patient confers a lifelong commitment very often to continuing this therapy. Starting a therapy that changes someone’s life by completely controlling their seizures only to have them unable to continue the therapy due to cost provides no long term benefit to the patient or to the community.

These are factors that we have continued to monitor and have also analyzed the cost to provide these therapies to our patients on an annual basis. The good news is that for the vast majority of medications needed for these patients, it is extremely cost efficient in terms of the big picture (we analyzed the annual cost to provide the annual care including medications for the cohort of 405 neurology patients that were seen during our September 2019 visit and it was less than $36,000, magnitudes less than what that would cost in the US), though unfortunately, this will require additional funding dedicated to provide this continued care for this often most vulnerable group of patients. Creating a lasting system capable of the sustainable provision of these services must be our ultimate goal and something for which we will continue to strive.

Our ongoing WhatsApp discussion regarding our young seizure child

I finished my evening with a very vigorous discussion on WhatsApp with the FAME Peds Neuro Consult Group – a group comprised of numerous individuals who have been to FAME in the past and who contribute on a regular basis to the care of patients here throughout the year. With the seven time difference (or as someone constantly reminds me, “I am the future”), the late afternoon and evenings are by far the best time for these discussions, and it took no time for me to receive a great deal of help concerning our little seizing baby on the ward. The decision in the end was to put the baby back on phenobarbitone, the medication that we had originally used and had then abandoned in lieu of the levetiracetam and valproic acid, and also continue him on the other current medications he was on. Having the ability to rely on my pediatric colleagues in the US in this manner as well as having them constantly available through the year is a truly a God send and is what makes FAME so remarkable. These loyal resources and the tremendous team of Tanzanian caregivers here on the ground year round are why FAME will continue well into the future.

Monday, September 26 – Our first day of the second session of neuro clinic….

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I’m sure that it had been an exhausting day yesterday for everyone – the residents having just traveled half-way around the world to reach Tanzania and my having driven to and from Arusha over the weekend and twice to the airport. Just to familiarize everyone with the enormity of the African continent, it is further from West Africa to East Africa than it is from east coast of the US to West Africa, a fact I learned traveling here during the Ebola outbreak in West Africa and peoples fear of traveling to FAME at that time. We were further from Ebola here at FAME than those who were on the east coast of United States during that time. Though the Ebola outbreak was a very scary time here in Africa, particularly, it was managed to be contained through the efforts of an international force and specifically those lead by Partners in Health and Paul Farmer. Interestingly, the Ebola outbreak ended up being only a minor dress rehearsal for the COVID-19 pandemic that has ravaged the planet over the last two plus years and continues to create problems despite the fact that life has returned to some sense of normalcy in many areas.

Bringing a new team to morning report is always an exciting time for not only are they introduced in some fashion to what they will be doing over the next several weeks, but it is also the time that they are introduced to the FAME staff who they will be working with going forward. Though morning report is primarily directed at the inpatient and maternity wards, giving report on each in-patient that also includes the many neonates, some of who may be quite premature, we can also discuss interesting outpatients who were seen overnight or the day before. One patient, who had come in over the weekend while I was away, was incredibly sick and very interesting.

It was a young Maasai girl who had come in with severe lymphadnopathy on one side of her neck, but by the next morning, her entire neck was terribly swollen and there was concern for her airway. She was still breathing fine and her O2 sats were perfect, but the decision was made to send her to Arusha Lutheran Medical Center (ALMC) where they would be able to intubate her if necessary and ventilate her as well. The concern here was for diphtheria, as many children here are not vaccinated, and it was felt that she may have had a pseudo membrane visible, a defining feature of that disorder. There was also a concern for anthrax as the history came out that she had eaten a dead animal about a week prior, a behavior that is high risk for acquiring this disorder here – I have seen two prior cases of cutaneous anthrax while working here at FAME and it is not very pretty. Both had come from eating dead carcasses that had been laying on the ground where the anthrax spores remain dormant for many years and are fairly ubiquitous in the environment. Unfortunately, we received word later in the day that the young girl had died even though she had been intubated. There was also no clear diagnosis that had been obtained meaning that those caretakers who had significant exposure to the young girl would need to receive the appropriate prophylaxis for the suspected diagnoses.

A Maasai missing his two bottom front teeth

Also ubiquitous in the soil here are tetanus spores, and though they are perhaps less infectious than anthrax requiring an inoculation or entrance wound to gain access to the victim (cutaneous anthrax requires only a scrape or a mucosal surface, if I’m not mistaken) it is still a relatively common diagnosis here where it is almost never seen in the US for reasons of vaccination. In fact, it is so common among the Maasai, and especially those living in the Ngorongoro Conservation Area, that they very commonly remove their two center bottom teeth so that they can be feed liquids in the event they contract tetanus. I specifically recall one young boy who came in with tetanus that he had developed after having had soil placed in traditional cuts over his abdomen that had been made by a local healer when he was being treated for abdominal pain. The boy came in with horrible spasms throughout his body and in tremendous pain. We didn’t have the tetanus immunoglobulin here at the time, so the treatment was solely benzodiazepines and keeping him in a dark room with absolutely no stimulation. Having never seen a patient with tetanus before, it was quite impressive and once you see it, it is not something that you will soon forget.

Having been fully introduced to the staff at FAME and morning report now complete, it was now time for the residents to get their formal orientation to FAME and to learn how to use the new EMR here. Having an Electronic Medical Record, or EMR, had been a goal for FAME for a number of years and it finally came to fruition in September 2020 after months and months of incremental implementation. It was the height of the pandemic and I had traveled here on my own despite the fact that there was a complete travel ban being imposed by the University of Pennsylvania. I appealed the travel ban on the grounds that I had been visiting FAME every six months for ten years and that there were patients expecting to be seen in follow up. After having gained the trust of FAME and the community by returning every six months, pandemic or not, I was not about to let them down and not show up. The reception I received from everyone here was heartwarming and absolutely worth any risk that I had taken, though I didn’t perceive there to be one, and the reassurance that was given by my presence was considerable.

The young Maasai boy with tetanus

Having originally hoped that I would be long retired by the time EMRs became the norm, and realizing that battle had been lost long ago, I eventually accepted the fact that this was an inevitability and made peace with the EMRs I have come to know. The EMR at FAME is very basic and serves the basic purposes that are necessary here. I did learn the basics of FAME’s EMR and, more importantly, the residents, incredibly quick to pick up these new technologies, as opposed to an old fart like me, took no time at all to learn the ins and outs of the system here. It is actually a pretty clunky EMR, but gets the job done and this morning, both Dr. Anne and our IT person, Valence, had set aside time to go over the specifics so they could all get comfortable seeing patients for the second half of the day and documenting them appropriately. The other thing the EMR does help with is our database of neurology patients that we have been accumulating now since 2015, and has made their information now incredibly more accessible for everyone, and though we still have full access to the EMR while on FAME’s campus, accessing it from back home is another matter and a bit more complicated requiring a VPN and lots of prayer.

Once having taken the complete tour of the entire FAME campus, which is tremendously larger than it was back in 2010 when I had originally come to volunteer, there only existing the single OPD, or outpatient department, at that time, the residents were now ready start seeing patients. We had several patients who had come early, but as there are no appointments here and most patients who come are willing to spend most of the day to be seen, it wasn’t an issue to have them wait. There were only three residents this session, so they set up shop in three of the cubicles, again outside, which is a tremendous advantage for us given the open air and sunshine that exists here in the dry season, though it also works out quite well in the wet season of the spring. We had plenty of translators to go around as there were several clinical officers (similar to our nurse practitioners or physician assistants) volunteering at FAME who would be helping us and Nuruanna, a pharmacy student from Rift Valley Children’s Village, who has been working with us over the last several years.

Both MDs and COs (clinical officers) will often have a difficult time finding jobs in Tanzania once they have graduated from school and will volunteer at facilities both with the hope of obtaining employment, as well as also hoping to gain some valuable experience along the way that would serve to make them more valuable when they move on to a new position. Both MDs and COs are also often employed by the government, the latter commonly being placed in very remote regions of Tanzania in health dispensaries such as the one we visited several weeks ago at Kambi ya Simba. In these settings, a CO will take care of all medical issues in an unsupervised setting, but considering the environment and remoteness, this is most often quite satisfactory.

Thankfully, there were a steady number of neurology patients needing to be evaluated throughout the late morning and afternoon, though none of them were particularly remarkable to be honest. Lunch may have been the highlight of the day for the residents since it was their first introduction to more traditional Tanzanian cuisine and my favorite lunch here, rice and beans with some mchicha (African spinach) on the side and lots of the pili pili that I’ve spoken about so often. We finished seeing patients around 4 pm which is pretty typical for us, and made our way back to the house for a nice quite evening of relaxation and finally our dinner.

Sunday, September 25 – The new group arrives and it’s back to FAME…

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Having dropped the first group off at the airport last night without a hitch, other than the fact that they were griping about having to wait for the ticket counter to open, and getting back to the Temba’s home in Arusha, mostly exhausted after a day of shuttling everyone, I had to do it all over again. The new team would be arriving into Kilimanjaro International Airport first thing in the morning at 7:35 am, which meant that I would have leave around 6 am to get there in time and just in case they arrived earlier than scheduled. The drive was surprisingly pleasant as it was early on a Sunday morning meaning that the traffic was sparse and the number of trucks on the road was far less than normal. The issue with the trucks here is two-fold – first, the roads were never really graded properly meaning that there are steeper inclines than there should be and, second, the trucks here are typically heavily loaded, ginormous, and have the acceleration of a particularly slow snail. It is not at all uncommon for several trucks in a row to be driving 10 or 20 kph up a long hill with a tremendous line of vehicles behind that are unable to pass safely. Add to that the many buses, both large and small, who will attempt to pass regardless of whether it’s safe or not so as to remain on schedule and, hence, the many, many accidents that occur here on the highways day or night. Driving here is not only challenging, but is downright dangerous.

Ankita, Sara and Taha having just arrived

I drove to the soothing sounds of Vivaldi’s Four Seasons playing through the speakers I had specifically installed for this reason and the stereo head unit that allows us to play our iPhones through it. Typically, I don’t have the luxury of controlling what is being played when the residents are along as they have their own music, which is fine both from the standpoint that I can tolerate their music as well as the fact that I’m completely deaf in my left ear and, when driving a right-hand drive vehicle, it’s the one that’s facing into the car. Vivaldi lasted just the right amount of time for my drive and pulling up in the parking lot, I was able to watch as the Qatar Airways jet carrying the new team had just landed and was taxiing to the terminal. KIA, or Kilimanjaro International Airport is a tiny airport that twice each day is inundated with arriving passengers who had traveled here either with Qatar Airways or KLM, which are the only two airlines traveling here from off the continent.

I received a text from Taha that they were in the immigration line waiting to get their passports stamped with their business visas that would allow them to “work” at FAME for the next three weeks. It is always a mob scene outside the arrivals side of the terminal as there are dozens and dozens of guides waiting to pick up their clients, all holding up signs with their names on them, and the passengers exiting out into the bright sunlight, scanning the crowd of safari guides looking for the one holding a sign with their name and, when they do, greeting the person who they will be spending the next weeks with. There seemed to be an inordinate number of visitors with backpacks and climbing shoes who were clearly planning to climb Kilimanjaro over the next week which, in addition to the Serengeti, is one of the main reasons that people travel here.

Our summit morning on Kilimanjaro in a blizzard

I had done this back in 2015 with a group of five of us – Danielle Becker, Lindsay Ferrero, my brother, Jeff, and his son, Nick. We had hiked the Lemosho route which we did over seven days – 5 ½ up and 1 ½ down – as it has one of the very best success rates of summiting, though the main issue we had wasn’t the altitude, but rather the rare blizzard that occurred the night we reached the top. Having to wipe the snow from the sign confirming our success, it certainly spoke to the added challenge and significance of our achievement, though it did not make our descent any easier considering the slippery ice and snow that covered the entire top of the mountain. It was an achievement that none of us would never forget.

Watching what seemed like at least ¾ of the passengers having already exited and met with their guides, I began to worry a bit about the residents and whether they had run into a snag somewhere along the way, either in immigration or customs. They finally surfaced, telling me they had just picked the wrong line to stand in, though Ankita did comment that she was asked a number of questions about what she was planning to do here when going through immigration, always a bit of stressful time as we are visitors here and they are typically expecting tourists rather than volunteers. They all had their luggage, which is always a very good sign, and we proceeded to load everything into Turtle, a bit of déjà vu as I had just done this yesterday with the previous group’s bags. Once loaded, we began our journey back to the Temba’s home as Pendo was preparing a nice breakfast for everyone.

The Land Rover County that Leonard and I rebuiding

The boys were unfortunately already heading back to Nairobi for school, but their two younger children, Gabrielle and Gabriel, were both home to greet the residents. Having been flying for over a day, the residents were pretty exhausted, but despite this, managed to play with the children and keep them busy. Pendo had prepared another amazing breakfast for everyone – fresh beet/watermelon juice, tea masala, chicken and vegetables, omelettes, toast, pancakes, sweet potatoes, mangos, pineapple, and watermelon. Oh yes, and fresh brewed coffee. After breakfast, I did have an errand to run as Leonard and I have been working on a project together rebuilding an older Land Rover and I would be seeing it at the shop for the very first time. It would very difficult for me to truly convey my love affair with the Land Rover, and specifically here in East Africa, but leave it to say that from my early childhood, I have dreamed of being here, in this exact place, doing exactly what I am doing, and in a Land Rover. The progress on our vehicle has been impressive and it should be ready for the road sometime soon and hopefully before I head home in three weeks, but if it isn’t, I’ll see it in the spring.

We heard back from Prosper who, by now had made his way to Arusha by bus, and would be meeting us very close by at the Njiro Cinema where we could then jump on the bypass and be on the road to Karatu. Everyone was incredibly tired at the start of the drive so it didn’t take very long for everyone to begin to doze given the circumstances. I think Ankita may have slept all the way to Mto wa Mbu with Sara and Taha dozing more intermittently along the way. We spotted a small group of baboons as we passed by the entrance to Manyara National Park and then began our climb up the escarpment with Lake Manyara stretching out for miles in front of us. I made the compulsory stop at the overlook so that everyone could get out of the car and take photos and we then made our way to the African Galleria for some cold drinks before the final leg of our drive to Karatu.

Overlooking Lake Manyara

We arrived before sunset and everyone was introduced to the Raynes House. With only three residents, each of them would have their own room for the next three weeks and I allowed them to choose which room they would take going forward. Ankita was somehow placed into Alex’s old room which was unfortunate for her as both Moira and Alana had apparently stripped and made the beds in each of their own rooms, but not only had Alex not done this, he had also left his bathroom in rather poor shape, much to Ankita’s chagrin, though she braved the dirty shower as she was pretty desperate, and dirty, considering all the flights and the long dusty drive. She will just have to find a way to pay back Alex in the future. We had decided to just have peanut butter and jelly sandwiches for dinner as everyone was far too tired to go back out. Tomorrow morning would be their orientation to FAME and the EMR here and we’d get started with clinic before lunch. I knew that everyone was very excited to begin their work here, but for now it would be a good night’s sleep and perhaps a Malarone dream or two.

Saturday, September 24 – A relaxing morning, lunch at the African Galleria and a jaunt to the airport…

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With the first three weeks, or the first half, of this season’s neurology clinic now complete, it was time to transition the two teams of residents. The second team was already en route, having left from Philadelphia last night on their long flight to Doha and then their long layover prior to boarding their second flight at midnight, arriving at Kilimanjaro International Airport Sunday morning. These were exactly the same flights that we had taken three weeks ago coming here and it is really a fairly long haul even flying on one of the best airlines (all economy, mind you).

As I had mentioned previously, it had been the decision of the current group that this would be a quiet morning at the house prior to our departure for the airport, though they had somehow still decided to get up earlier than I had expected so they could exercise, Moira (aka gazelle) doing her usual morning run and Alana and Alex something else that was at least energetic enough for Alex to complain about his “gluts” afterwards. My plan had been to continue working on the blog and some other necessary work and to definitely NOT do any exercise this morning 😀

Lunch at the African Galleria with Prosper and the departing residents

Doing a switch over of the rooms on the weekend, though mundane, did present a few logistical issues that were slightly more than insignificant. For whatever reason, our trash hadn’t been emptied yesterday and, with all the packing and moving, it was overflowing onto the flow and not a pretty sight. We have an incinerator here at FAME, so all the composting goes into a 5-gallon bucket with lid and all the trash into another container. The houses are also not insect-proof and, in fact, seem at times to be more havens for bugs. There are screens on the windows that are open, but the outside doors are far from airtight letting most of the creepy crawly critters easy access.

The tarantula that decided to come in our volunteer house several years ago was a bit on the exciting side for Dr. Joyce (lab Joyce) as we were staying in the same house at the time. I thought I had seen some movement out of the corner of my eye and that it was likely a mouse or a gecko, but it turned out to be a very, very large hairy spider and not something that Joyce was thrilled about. I grabbed a paper bag to collect it in, but it ran under the bookcase and required a bit more finagling to coax it out from under before collecting it up and depositing it outside. Frank’s story of perhaps ten or so years ago of a pit viper in his pantry would have raised just a bit more concern on my part as well, but thankfully I haven’t seen one of those on campus yet.

Our babies CT scan

Meanwhile, housekeeping here usually prepares the rooms for the incoming volunteers which, if the volunteer is coming on the weekend such as this time, would be taken care of on the Friday before. But the outgoing residents were staying in their rooms on Friday night and housekeeping doesn’t work on the weekends. The trash posed no issue for Prosper just had someone from maintenance come and empty it, but I don’t think they were interested in changing the sheets and towels and cleaning the rooms. The plan would be that housekeeping would leave us fresh sheets and towels on Friday and then we would take care of changing over the linens ourselves. That all seemed like a pretty simple solution to a simple problem.

The morning seemed to drag on a bit as none of us really knew what to do with all that extra time on our hands. It certainly was nice to sit and relax, though I think everyone was ready to get the show on the road given their upcoming flights that evening. They weren’t flying until 9:30 pm and didn’t really have to get there until 2-3 hours prior to their flight, but I had the constraint of not wanting to drive on the treacherous highway back from the airport in the dark. My plan had been to try and get them there at 5 pm which would allow me enough light to get back to Arusha. Prosper, whose family lives in Moshi, which is on the far side of the airport, was going to travel with us and catch a bus from the airport junction once we were there so he could see his kids tonight and then catch a ride back with us tomorrow.

The second team arriving in Doha before their departure for Kilimanjaro

We packed Turtle with everyone’s luggage, once again fitting everything into the boot like playing a game of Tetris. Once completely loaded and including Prosper, we were on our way down the road to Manyara to stop for lunch at the Galleria for those wonderful cheese samosas that are so scrumptious, though there seemed to be a great deal more ordered from the menu than I had anticipated. Ironically, Susan, Mary Ann and Alicia had already beat us there for lunch and had taken a taxi – if we had known, they could have just as easily ridden with us and taken a taxi home. Lunch was really delicious and one of the new dishes that I had never tried before, the grilled paneer with beets, was simply out of this world and will absolutely be on my list of things to order there in the future.

At some point during the drive, we began to receive calls regarding the young baby who had been having seizures all along, notifying us that he was again seizing. There were still questions about whether the baby should be transferred to KCMC, though I was certain that they would not have anything to offer the baby other than what we were doing. We had more than half a dozen pediatric neurologists on the case, several of who were epileptologists and this was probably more clinical knowledge than was present in all of East Africa, let alone Tanzania. We decided to do a CT scan on the baby just to reassure everyone that there wasn’t any acute going on and, sure enough, the scan didn’t show us any surprises. After extensive consultation throughout the group, we added topiramate to the babies medication regimen and it eventually stopped seizing and began to wake up.

Pouting residents on the floor at the Kili airport – boo hoo

We started our long journey back to Arusha after lunch, first descending the escarpment into Mto wa Mbu, then passing the “scene of the crime” from Thursday at the Maasai Market with all of us cringing as we drove by, and then on to Makuyuni which lays at the junction with the main highway traveling to Tarangire to the right and Arusha to the left. Given that it is the dry season now, the landscape was brown and incredibly arid as opposed the green grass of the wet season, and huge dust devils arose in the distance, visible every several miles that we traveled. Mt. Meru, standing at 15,000 feet, rose in front of us, though was mostly covered by clouds, obscuring all but the lower slopes feeding down into Arushatown and its surrounding suburbs.

We had one last bit of shopping to do as everyone wanted to stop at the Shanga Shop on our way to the airport. The Shanga Shop is located at the Arusha Coffee Lodge near the Arusha airport and has lots of artistic blown glass and textiles that are all made by workers with disabilities through a non-profit that had been created a number of years ago. I think everyone found a little something that would still fit in their luggage and once we were done, we were back on the road, taking the bypass around Arusha to avoid the horrible traffic that exists in the center of town. The bypass was completed about 4 years ago and allows one to completely avoid the hustle bustle of the city center, though now with the expansion and construction that is occurring along the bypass, it is creating its own congestion. Adding to that the fact that the speed limit varies between 50 and 80 kph intermittently on the bypass with the traffic police now cracking down with every chance possible, they somehow clocked me driving 66 kph on a downhill stretch of road where it was a 50 kph limit. The fine isn’t necessarily onerous, only 30,000 Tsh, or about $13, but it was the fact that I have been trying my hardest to always stay within the limit, knowing that they are looking for speeding.

Now happy residents (and one snarky resident) with food at the Kili airport

We arrived at the airport at around 5:15 pm after dropping off Prosper at the junction for his trip to Moshi by bus, which wasn’t bad planning considering we had traveled all the way from Karatu, had lunch, shopped at Shanga shop, gotten a ticket, and fought the traffic on the Moshi road. We said our goodbyes and the three travelers made their way towards security to enter the airport and check in for their flight. Shortly thereafter, I received a text with them pouting while sitting on the floor of the airport, so I could only presume that the ticket counter hadn’t yet opened for them to check in, meaning that they couldn’t yet make it to the airport lounge. I had suspected that this might happen, though I really had no choice as it was already later than I had anticipated driving home and, sure enough, the last 20 minutes of my drive was with very poor visibility on the incredibly dark roads and every vehicle seeming to have misaligned headlights shining right into my eyes. Finally arriving to the Temba’s, I found their two older boys, Lenox and Lee, still home from school, but leaving in the morning. It is always great to see them as I’ve watched them grow into fine young men over the last 12 years. I was home at last as this and FAME have become my Tanzanian homes and both, my Tanzanian families.

Friday, September 23 – Cara departs for the Serengeti and we hike through the brick quarry….

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In the history of our neurology program here, we have very often been without a child neurologist and even though I have taken care of children for my entire career, I will be the first to admit that I am not a child neurologist and that evaluating neonates or floppy infants is certainly not my forte. Having trained in a program where our pediatric exposure was very broad, I have always been comfortable with pediatric headaches, seizures, Tourette syndrome, or even a bit of ADHD, but evaluating neonates with hypoxic-ischemic encephalopathy or metabolic disorders would cause any adult neurologist to run for the hills or cry uncle in short order. So, having our only pediatric neurologist, Cara, depart this morning for some well-deserved time with her boyfriend wasn’t something that I was necessarily looking forward to for today or the next three weeks as she wasn’t going to be replaced with the new group coming in.

Me petting Gary (our new name), one the two cats at the volunteer houses

The rest of us went to morning report and upon showing up for clinic, which was not incredibly busy, decided that it would be reasonable to make the clinic a half day so everyone could pack as they were departing tomorrow for the airport while I would be staying here for another three weeks with the new group. As luck would have it, of course, almost immediately following Cara’s departure from FAME around 10 am, the little baby who had presented earlier with status epilepticus decided that he would come back after again going into status despite having taken all of his medicines while home. Alana and Anne decided to head over to the ward to handle the situation with the child who was actively seizing at the moment. After loading with more levetiracetam and still having seizures, we made the decision to give the child a valproate load which he promptly vomited, but we were able to get him to hold down a second dose by adding some ondansetron. That stayed down and at that point it was a bit of wait and see strategy, though I’m not certain that any of us were entirely confident of the situation.

The rest of the morning was spent seeing the few stragglers that we had asked to come in the last day, but we hadn’t made this a fully scheduled clinic day to begin with so that we could wrap things up without having to scramble at the last minute for everyone to pack. They all enjoyed their last serving of beans, rice and mchicha with a pili pili on the side, although for Alana, it was again more like a lot of pili pili with rice, beans and mchicha on the side. If there such a thing as a pili pili bush, Alana would wish for acres of them. After lunch, everyone decided to head back to the house to relax and back while I was hoping to get the rear door latch fixed on Turtle as it had been acting difficult for the entire trip, not wanting to latch shut until I finagled with it for several minutes, splashed some water on it, and finally said a few curse words, whereupon it would finally decide to shut.

The brick quarry

I drove the vehicle down to see if Soja, the mechanic in town I’ve used for years and who also fixes all of FAME’s vehicles, was in and could possibly work on it. A teenage boy came out of Soja’s home and upon seeing me, came over to the workshop where I had parked. Without speaking any English at all and my few words of Swahili, I was able to explain to him what the problem was and he was intent on fixing the problem for me. Over the next 1 ½ hours, he took removed the entire latch and lock assembly, opened the latch box ,which had been riveted shut and had to be drilled out to open, cleaned everything meticulously with gas and solvent, then oiled the mechanisms and rebuilt the latch assembly, finally reinstalling everything in excellent working order. When I finally asked him what I owed him, he said 10,000 TSh, or about $4.30! Arguably, there were no new parts that were involved along with their cost, but he had spent at least 1 ½ hours of time working on this problem and knew exactly what he was doing the entire time. I thanked him profusely and gladly gave him 20,000 TSh, even still with the feeling that I was somehow underpaying him for the service that he had provided.

I arrived home to find everyone having mostly taken care of their packing and were now in the hammocks relaxing and reading their books. The weather was again gorgeous today and we had finally decided to take a nice walk through down through the brick quarry that sits below FAME and then up the other side. The quarry, which has been a steady fixture here since the very beginning of FAME, is one of the many quarries in the area where workers dig the clay, form the bricks, stack them, fire them and then sell them throughout the community. It’s a slow process that is done continuously as there are bricks that are always in various stages of the process lying about throughout the quarry, the most noticeable of these being the very tall stacks of unfired bricks with the openings at the bottom for the wood to be placed. I’m certain that this is an incredibly ancient process that has been carried out in exactly the same manner for thousands of years and has become no more mechanized now than in the past.

Cara’s gift to us upon her departure

We descended the steep trail that is heavily trafficked by man and beast and leads from the road just below the FAME entrance gate down to the quarry. In the dry season now, it is incredibly dusty and the creek at the bottom that must be crossed to reach the larger part of the quarry was bone dry. During the wet season, though, the creek is often very full and can be a challenge to get across at times. I remember Danielle Becker and I climbing up the trail in the wet season and finding the trail to be incredibly slippery, especially in the rubber rain boots we were wearing to save our shoes from the mud. There were workers attending to the various stages of the brick making process as we passed through and for those close, I gave a “pole kwa kazi” to which means “sorry for your work,” and is the polite thing to say to someone who is in the process of working as you pass by.

On the far side of the quarry was the Tloma Village Road that would lead us in the direction towards the village of the same name, with a steady incline as we seemed to attract the local school children wanting to walk with us for a ways, then finally departing. Tloma Village is one of the main Iraqw centers here and where many of our patients come from. As we reached the Gibb’s road, we had the choice of continuing on to Gibb’s Farm or turning around and heading back the same direction. As it was getting late, we chose the latter and made our way back in the direction of the quarry and finally back up the steep other side on our way home to FAME. We had a group of young boys following us up out of the quarry who were laughing and joking, all of which was our expense I believe, but there were no worries.

The new crew en route

We were almost home now and it was this teams last night. I would be staying on another three weeks with the new team coming on Sunday. The request for tomorrow morning by the team was to sleep in and given there was no morning report on Saturday, this would not be a problem. We had no morning report, no clinic, no patients and not a worry in the world. My only responsibility now was to get them to the airport tomorrow night for their flights home and then pick up the next team the following morning. We planned to leave FAME around noontime, stopping by the African Galleria for lunch to have their wonderful cheese samosas on our way to Arusha and one last stop at the Shanga Shop before making our way to the airport. Alex, Moira and Alana enjoyed their continued game of Bananagrams while I sat blogging. It was a very relaxing last evening for them and a wonderful end to their three weeks here, at least from my perspective. By the next morning, I received notice that the new team had successfully departed Philadelphia and were on their way.

Thursday, September 22 – A visit to the Majengo Children’s Home in Mto wa Mbu and Cara’s last day…

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Our original plan had been to finish our Cara’s time at FAME today as she would be leaving tomorrow on safari with her boyfriend, but earlier in the trip, we had been approached by another children’s home in Mto wa Mbu to provide a neurology clinic for them. We had been asked in the past to work there, which is in another district, but for various reasons, it hadn’t worked out. The Majengo Children’s Home (https://majengo.org), though, had already done all of the leg work on speaking with the District Health Officer there as they had also had a cardiology clinic earlier this year with Dr. Reed, a cardiologist and long-time volunteer at FAME, who screened children throughout the village for rheumatic heart disease (much more common here than in the US). He had seen hundreds of local children for this purpose and it was initially thought that we could do something similar, but I explained that we would be happy to see children that had already been screened and there were concerns for neurologic disease or a previous diagnosis which is really what we do here rather than the initial screening.

Taking our tour of Majengo Children’s Home

Though the opportunity to provide this care was appreciated, we could provide these services just about anywhere in Tanzania, to be honest, but that is not what FAME’s mission really is which is to improve the health of patients in the Karatu District Community. Nor would it be sustainable without the funding necessary to provide the continued care for these patients and that would need to come from elsewhere as it would not be a project FAME could take on with its current obligations here in Karatu. Over the years, our mobile clinics have all been within the district and with the budgeting that we knew would be necessary to provide these services on a continuous basis. Well-known projects such as surgical programs, whether it be for cleft lips and palates, or for cataracts are those that can “fix” the problem and, if for some reason, the funding ended, those patients who had already been helped would not necessarily require continued care. Making diagnosis such as epilepsy, for example, requires life-long treatment very often and without the sustainability piece for us (neurology), it doesn’t really make sense to start if you can continue it.

So, after making sure that everyone had the same understanding and expectations, it was agreed that we would travel to Mto wa Mbu for the day and evaluate those children at the Majengo Children’s Home who needed our services and we would make recommendations for treatment. It was also convenient that Majengo had their own nurse, similar in a way to Rift Valley Children’s Village with their clinical officer, Africanus, as our recommendations and prescriptions for medications could be carried out in between our visits by the nurse and, if need be, they could also speak with Dr. Anne here at FAME if there were any concerns. We traveled down to Mto wa Mbu on the tarmac until we need to turn on Majengo Road and drive another several kilometers on a very dusty and bumpy road eventually leading us to their site.

Our clinic set up at Majengo

Joseph, the director at Majengo, took us on a tour of the facility where the children live and go to school with a number of other at risk children from the community. Majengo takes in children from families who can no longer care for them, but unlike RVCV, these children continue to maintain a strong relationship with their family, or at least as much as is practical, that is facilitated by Majengo. Many of the children who we saw later had come from homes where severe malnutrition and alcoholism had been the norm such that the only chance the child had for success, or sometimes remaining alive, was for Majengo to take them in. If possible, the children go back to their families for the holidays and, eventually, at age 17, they are returned to their families or their community which is what is required by law. The children there are incredibly well cared for and the information we received from the nurse and psychologist at the school about each of the children we saw clearly indicated their deep devotion to every child’s well-being both emotionally and physically.

There was also a group of children that had been brought to Majengo this morning for us to see who had come from another nearby home, The Tumaini Home (https://tumaini-home.no/about-us), who we have worked with for a number of years. Tumaini Home takes in many children with neurologic disorders and is a Norwegian based non-profit run by Ståle Ande, an incredibly lovely man who, for many years, has brought children to see us at FAME for our assessments. Most of these were young boys with muscular dystrophies, but there were also children with other disorders who would come. He would always drive up in his Land Rover with wheelchairs strapped to the roof and as many children (some of them actually being young adults) stuffed in the inside of the vehicle. Despite their often incredibly limiting deficits and the likelihood that they would not be living much longer as many of them had already lost siblings to this horrible genetic disorder, they were always all smiles and I don’t think that I ever really heard a complaint from one of them to be honest.

The residents ready for work

Unfortunately, Ståle had to return to Norway at the beginning of the pandemic and I don’t believe that he has returned since. Though I clearly missed seeing him again this time, it was so reassuring to see these children after not having done so over the last two years and I was glad that we were here to do so even though there was very little that we had to offer them other than compassion as most of them were in the later stages of their disease and were non-ambulatory. As time goes on, I know that I will not be seeing these exact children any longer, but hopefully we will have the opportunity to see others like them along the way so that we can offer at least so assistance in their early management.

The setting at Majengo was just idea for us to work in as they had four stations with desks and chairs already set up for us to begin seeing the patients. The one limiting factor that we did have was that we had a limited number of informants both from the Tumaini Home and Majengo which meant that we couldn’t really proceed at our normal rapid pace given that constraint as the children were too young to supple each of their histories and the boys from Tumaini were also unable to do so. Be that as it may, we were able to get through all the children they had asked us to see from both homes a bit before 4 pm. Before we started, though, we were served a breakfast of juice, hard boiled eggs and butter sandwiches. The residents were most interested in getting started so it didn’t take long for them to get the show on the road and begin seeing patients.

Interestingly, we really didn’t have anyone with epilepsy to see here which was surprising as that is our second most common diagnosis here at FAME. We saw a number of children with very classic migraine headaches, which, for those of you who are not aware, is really a childhood diagnosis. Seeing a child with an intermittent, pounding, throbbing headache associated with photophobia, nausea and occasional vomiting and a normal examination is actually very reassuring as it is so common, typically presents in a very common manner and is also very responsive to treatment whether it be symptomatic for each headache with non-steroidal anti-inflammatory medications or a preventive with medications such as propranolol or amitriptyline. Patients coming in at age 40 or 50 with no history of headaches and new onset of even rather classic sounding migraines, make us feel a bit more unsettled and those patients will usually end up with an MRI scan of the brain back home.

The other group of children who we saw and were asked to evaluate, were those with various behavioral issues and difficulty in school. A number of them had significant anxiety and had come from very difficult home situations. Counseling, the most effective treatment for this is difficult obtaining here for obvious reasons and, therefore, we had to rely more on medications unfortunately. Placing a child on an SSRI medication is often necessary if the anxiety is such that it is interfering with their happiness and school performance. Attention Deficit Hyperactivity Disorder, or ADHD, is an entirely different matter as it also responds to medications, but we have no stimulant medications here in Tanzania for obvious reasons. There is a very basic medication, though, that we will try early on to see if they have benefit to it and that medication is clonidine. It is often used for milder cases in the US, but to be honest, most patients will eventually end up on a stimulant just because of the overwhelming effectiveness.

Some of the children who we were evaluating for ADHD and were of the inattentive type, rather than the hyperactive type, also were described as having staring spells which always invokes the concern about whether they are having absence seizures. Having no EEG here at FAME or a practical way of obtaining one, it makes the history that much more important and that is often much easier said than done. The other manner we have here is during the examination, we can try hyperventilating the child to see if we can induce a seizure which, if they do have a primary generalized epilepsy and absence seizures, will cause the child to have a brief period of staring and often blinking representing a seizure. We have recorded a number of these here in children with primary generalized epilepsy and getting them on medications is always quite rewarding as they are very, very responsive to treatment. None of our patients today had convincing episodes, so none of them were placed on anti-seizure medication.

After we had seen all of the patients, we then grouped around a big conference table and each of the residents presented one of their patients at a time with the team from Majengo as far as what our concerns were and what the recommended plan would be. It was like a multidisciplinary meeting at a school in which each party would give some input into the care of a child to come up with a comprehensive plan. I felt that the staff at Majengo were incredibly well prepared and voiced what concerns they had about each child so that we could then discuss our assessment and then our recommendations. Though this isn’t something that the adult residents were particularly familiar with, I knew that Cara would totally comfortable with this style of meeting and she was. We didn’t have all the medications necessary with us, but would send the rest down from FAME which would not be an issue. We ended our visit at Majengo with very positive feelings about the impact that we had made during this visit and about going forward with this clinic on a regular basis in the future as long as everything continued to work out. It was very much a Mission Accomplished moment, though I say that not at all in a GW Bush manner, but rather in a sense of true accomplishment on so many levels.

Having left Majengo a bit before 4 pm, it allowed me to keep my promise to Anne who had asked to stop at the Maasai market for some nyama choma (barbecue) and other supplies before heading back up to Karatu. Every town or village will have their Maasai Market either once or twice a month and they are very typically big affairs where you can purchase anything from food supplies to clothing to livestock and people travel from far and wide to stock up. The markets in Karatu are on the 7th and the 25th of the month and I can honestly say that having visited it once was more than enough for me for it is mass hysteria as far as I’m concerned. If you have any issues with social anxiety or claustrophobia, this is not the place to come. That being said, I have had many residents who have enjoyed going to the market just to walk around and I’ve told them that I’m happy to drop them off and pick them up, but don’t expect me to join them. Just driving up to the edge of the market and seeing the mass of humanity spread out over the many acres is enough to give me the heebie-jeebies in very short order.

Abbie and Moira attempting to hyperventilate a young patient

So, it is with this preface that I tell you this story. After driving the few minutes in the opposite direction from Karatu to find the market, which wasn’t difficult as the closer you get the more bijajis and boda bodas begin to swarm around on the road in every direction transporting people to and from the hive of activity that is the market. I found an initial parking place in some shade as Anne, Angel, Nuru, Abbie and Cara jumped out of the vehicle to do some shopping. The last thing I heard from them was that they would be a few minutes to pick up some things. It took all of about 10 seconds for several of the local youth to realize we were there and begin to ask for money. As the majority of vehicles that look like Turtle traveling through this area are filled with tourists on safari, this is the typical behavior and was not unexpected, though I was quite tired and they were overly persistent. I chose to move the car to what I thought might be a quieter spot, though was sadly disappointed.

Alana and Hussein evaluating a patients gait

For the next 45 minutes, I sat in the driver’s seat of our vehicle trying not to be rude to an older Maasai man who just wouldn’t take no for an answer and proceeded to continually try to ask me for things that I tried to politely decline and not be offensive. It was really a very laughable situation and I know that Alana and Alex were getting a kick out of it even if I wasn’t. At some point, Cara texted me to tell me that they had been separate in the market and to let her know if the others returned. Eventually, a few of them returned and then Angel decided to buy some jewelry out of the back window of the car which then made it clear to the surrounding merchants that we were actively purchasing things which only increased the activity around our vehicle.

The others eventually returned and the Maasai man who had been harassing me for the entire time was now actually leaning his head in the car to talk to others. I had enough of the situation and started the vehicle engine figuring that this would be a fairly reasonable indication that we were planning to leave and that if wasn’t interested in losing his head, he should probably take it out. Apparently, my message had been too subtle and it took more than a gentle persuasion by the Tanzanians in the car to get him to remove his head, still on his shoulders thankfully, from the car. Finally, fully unencumbered, I started the car rolling in the direction of home, never happier than this to begin the short drive back up escarpment towards Karatu and never wishing to see another Maasai Market again, at least for the near future. For the next several days of their visit, the mere mention of revisiting the Maasai Market was enough to make the point that whatever was being discussed was not an option.

Wednesday, September 21 – A visit with Phillipo and dinner at Gibb’s Farm…

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Patch Adams

I think everyone was still reveling in their visit to Daniel Tewa’s home last night as it has always been one of the favorite activities here. As you may have guessed by now, in addition to the work we are all doing at FAME in running our twice annual neurology clinic, as well as visits in between by other faculty from Penn, I have always tried to make this visit one of a more cultural nature so that everyone can get a good sense of the community here which is always so important in better knowing your patients.

Our waiting room before opening on a cool morning

Years ago, I had the privilege of meeting and spending time with the real Patch Adams, who was made famous by the movie of the same name where he was played by Robin Williams. He had come to my children’s school to speak and spend time with the kids through the help of their school’s educational foundation. He is an incredibly remarkable person whose activism in so many areas has brought benefit to people’s lives, one of which is through his clowning school where he brings his students from around the world to war torn and impoverished regions throughout the planet to spread joy and hope. The reason I bring him up here though, is for something he said to me, and which I will always remember, during the small cocktail gathering we had prior to his speaking to the entire community.

Kizito, FAME’s head of nursing, and me discussing Epic (Penn’s EMR) and FAME’s EMR

He told me that whenever he saw a new patient, he went to their home for several hours so that he could better know the living environment of the patient he was about to treat for how could a doctor think that he really knew a patient or the challenges that the patient may be facing without first doing this. As incredibly impractical as this may sound, and there would be no way to implement this in our current health care system in the US, which is already broken, by the way, it does make a lot of sense on so many levels. How can one really provide all of the necessary care for a patient if they have little understanding of the patient’s cultural make-up, their beliefs, their resources, their understanding, or their living environment. I would be the first to say that this would be virtually impossible to implement in our current system, but perhaps there are ways we could do better and I am always hopeful that there are some simple things that each of us can do towards meeting this challenge part-way.

Cara super exciting as we’re departing from FAME for coffee and Gibb’s Farm

Bringing the residents from the US to come here and work with patients who come from an entirely different cultural background that is half-way around the world and asking them to even begin to understand these differences may actually be the first step towards solving this dilemma for when they return home after this experience, my hope is that they will have an increased awareness and sensitivity to these subtle, or often not so subtle, challenges. Working in a country with a completely different language and with patients whose culture and living environment are so vastly different than ours clearly accentuates this conundrum far beyond what we are normally dealing with at home, but yet it is also very similar.

Even when both parties are speaking English, there is quite often a difference in understanding that may go far beyond any benefit that speaking the same language may provide. And then there are the issues of health literacy that bring us the next level in this discussion. The residents visit homes of Tanzanians from various cultures and levels of social status and work with Tanzanian healthcare providers who also help to provide additional insight and, through all of this, will gain a better appreciation of the patient that will hopefully make them better, more compassionate, and more understanding physicians who will be able to provide their patients better care through having come here.

There was no educational lecture this morning, so once again, everyone appreciated the extra half hour of sleep. There was also plenty of time after morning report for the group to make a trip to the Lilac Café where they could focus on their need for caffeination. I will have to admit, though, that I have also benefited from their habit as I’ve enjoyed this morning cup of Joe along with them, something that I haven’t done at home for several years. I still don’t feel the urge, so I am confident that once home, I’ll revert back to my previous schedule. Clinic today was not overly busy and Cara got to see her normal share of children with delayed development, who by the way, will be coming over the next three weeks even though we are going to lose our child neurologist when she leaves at the end of the week. I’ve been doing it for twelve years, often without the benefit of a pediatrician, so we will make do.

Lunch today was once again our favorite, beans and rice with mchicha and lots and lots of pili pili. Even though we have all enjoyed the pili pili here, it has been Alana who has taken to it the most and I often think that her portions of this delicious Tanzanian salsa exceed that of the rice and beans. She will frequently go back to put more on her dish and we’ve now come to ask Samwell if we can have his fresh pili pili at the house for dinner rather than using the bottled variety. I think we go through over half a small jar of this for each dinner and God help the individual who uses up the last drop if Alana hasn’t gotten her aliquot that night (maybe that’s a bit of an exaggeration, but she is totally i love with the stuff!).

The afternoon was running a bit slow and we were able to slip out of clinic at a decent time so that in addition to our dinner plans at Gibb’s, we would have time to visit with Phillipo and his family, our coffee supplier. We had found Phillipo a year ago while on a walk to Tloma Village and the Makunde wood carver who I knew. While there, he invited us to visit his friend next door who is a small coffee grower and what was initially an impromptu visit, turning into an hour long tour of his coffee making operation including enjoying some of his fresh pressed coffee that his wife brewed up for us. Phillipo has about five acres of coffee bushes that he grows and harvests and then processes and roasts. The land was passed down from his father who is also the one who taught him how to grow and process the coffee.

In an area of enormous coffee plantations and one of the world’s best coffee growing regions, Phillipo is a small grower and family run operation with his wife, his father and his two small children all participating in the various processes of growing, drying, shelling, fermenting, roasting and bagging the coffee for sale. In addition to the coffee, though, he also has dozens of beehives around the property for the small stingless bees that fertilize his coffee plants. They produce honey that is heavily coffee flavored and really wonderful. I had tried to bring several bottles home last year, but they didn’t last for whatever reason and I suspect have to be consumed much faster than I had anticipated.

Relaxing on the veranda at Gibb’s Farm

As we arrived, we were greeted by the entire family. We had called ahead, not only with an order of coffee as everyone was buying some, but also to let him know to prepare our order if possible so we could pick it up and bring it home with the departing residents. His wife was sitting at her sewing machine, busily stitching bags out of kanga cloth of different designs that her children then thread the tie through on the top. His father was cranking the coffee roaster by hand and, when that batch of coffee had finished roasting, it was dumped into an open container with a screen bottom for the coffee to cool and be ready to either be packaged whole or then ground, also by hand. The entire process was demonstrated, including the shelling of the coffee and removing the chaff, again, all by hand.

Quite happy at Gibb’s Farm

During all of this, his wife also brewed us a fresh batch of coffee in a large French press that was delicious and meaningful, as were all siting there in the midst of this coffee operation drinking the product incredibly fresh. Their two children are lovely and I will enjoy watching them grow over the years as I plan to visit Phillip and his family on every trip as it was again something very much appreciated by the residents and another example of visiting people’s homes to better understand the culture here. I think we could have remained at Phillipo’s forever, but eventually another large group showed up from a nearby lodge, having walked there, and I felt it would be appropriate for us to move on and let his focus on these new clients, who I am sure were going to buy coffee from him as well. It’s so rewarding to see how successful he is as he and his family deserve it.

Dinner at Gibb’s with Nish at the far end

We had made reservations at Gibb’s Farm for dinner tonight and getting there early and well before sunset is always a major advantage as their veranda overlooking the entire valley to the west, with the endless coffee fields below and the incredible foliage around the main farmhouse, is an incomparable setting as are their cocktails while enjoying this view. Sitting in these lounge chairs with a drink in hand and taking in the surroundings, it is impossible for one to have a care in the world and the well over-used phrase “life is good” comes to mind, but one knows that it was really created for these moments alone for there is simply nothing better than this.

Our menu at Gibb’s

I have been visiting the Gibb’s Farm since I first came to Tanzania and for that entire time, it has been a sanctuary among sanctuaries and a place that one visits to cleanse their mind and body. Driving through their gate, or even writing this blog and thinking about it as I am doing currently, will cause a general decrease in your blood pressure and heart rate and your stress level begins to precipitously drop. Tonight, there was also going to be a performance of the Tloma Village Choir, a choir from the village here, that would be singing traditional Iraqw and Tanzanian songs around the pool. Their pool area also has an equally incredible view as the veranda and listening to the group with this wonderful backdrop was stunning. All of the other guests of the lodge were there for the same experience and the fact that we had been invited was another benefit of volunteering at FAME as they are happy to have us come and enjoy ourselves for the work we do for the community.


After the choir finished, we sat down at our dinner table in the farmhouse and proceeded to enjoy an incredibly delicious dinner that was mostly farm to table. Nish had come up to join us and we had Dr. Anne with us as well and it was a relaxing and fun dinner with lots of conversation and camaraderie. I have known all of the staff at Gibb’s for many years, many of who have come to see me or have brought their families to see us and we always receive a warm welcome from them as one can imagine. Being here to provide the services we do at FAME and for the Karatu district is something that is highly valued by the community and they are always incredibly appreciative when we visit anywhere. The personal rewards that one receives from volunteering anywhere is impossible to measure by any standard means.

Tuesday, September 20 – An acute stroke in a resource limited setting and a visit to Daniel Tewa’s home…

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Tuesday morning’s educational lecture was given this morning by Alicia Wiley on electronic fetal monitoring, something that I had not really contemplated for nearly 40 years since graduating medical school, that is, except for those of my own two children 33 and 30 years ago, respectively. We all attended, though, as we always do to be respectful to every volunteer that comes here to provide this necessary education in such an amazing atmosphere. It also helps, to be honest, given that we listen every morning to the report from the maternity ward along with the medical ward and this gives us some additional perspective on what is being discussed.

Alana staffing a patient with me

After lecture, during report, we gave the updates on our little seizing baby, who was just now receiving their first dose of levetiracetam through their NG tube and was on his way to improving significantly over the next days. As we were just preparing for another day in clinic, I was summoned to reception for a call from radiology, which is never a good sign here, and then asked to come down to the radiology building for a patient there. Entering the front door of the suite, I was met by Jafar, one of our radiology techs, and Dr. Josephat, who had apparently been working overnight and evaluated a patient who had reportedly fallen several days ago and had not regained consciousness after the fall. The patient was on the CT scan gurney and had just had their scan completed and they had the scan all teed up on the computer for me to view.

CT scan with hypertensive hemorrhage, ventricular extensions, and hydrocephalus

What was on the screen after my several clicks of the page up button was not a subtle finding and several things were immediately clear. The patient’s problem had not come from their fall, but rather had caused their fall, and it was highly likely that the patient was not going to survive their injury. There was a very large area of hemorrhage in the right basal ganglia with blood in the ventricles, very significant midline shift and compression that was causing hydrocephalus. These findings were consistent with a hypertensive hemorrhage in a patient who most likely had a past history of hypertension and, unfortunately, she was in the process of dying. There was little for me to do at the moment and she did not require any immediate management other than getting her to a bed in the ward where we could make her comfortable so I asked to get to the wfard and I would have one of the residents come down to fully evaluate her.

Walking back to our clinic space where everyone was just getting started seeing patients, the choice of resident was clear since Moira would be starting a stroke fellowship in July and she was clearly excited to head off to see this patient even though it was quite likely there was very little to do. After a little while, she came back to present the patient to me and to give her recommendations on what should be done. Hypertension is a very significant problem here in Sub-Saharan Africa and the percentage of hemorrhagic versus ischemic strokes is much higher as a result of this. Though it most accurate to determine whether a patient has suffered a hemorrhagic stroke rather than an ischemic one by using a CT scan, there are often clinical symptoms that will help as CT scans are not only unavailable throughout most of East Africa except in the larger cities where medical centers exist, but they are very costly if the patient were to have to pay for it themselves, which is often the case. In the end, since thrombolytic medications (clot busters) are not available here for a number of reasons (cost, necessity of using them with hours), the vast majority of stroke patients can be managed safely without a CT scan. When your clinical examination is very limited, though, as in our patient who is unresponsive, it can be helpful to have an imaging study available for management.


Our patient, who by the way was around 80 years old, had a very large hemorrhage that was causing significant mass effect and hydrocephalus. Had we been at home in the US and this patient had come into the emergency room, it is very likely that the most that would have been done for her would have been to insert an extra-ventricular drain, or EVD, that would have relieved that pressure intracranially resulting from the hydrocephalus, but not that from the hemorrhage itself which was causing the midline shift and resulting in the majority of her impaired consciousness. She was not a candidate for any other therapy such as evacuation of her hemorrhage as it would not have improved her functional outcome at this point. We also did not have the capability of placing an EVD here at FAME nor placing her in a neuro-ICU which would have also been necessary to manage a patient with an EVD.

The cutest little baby in the world and, fortunately, not our patient

So, Moira proceeded to have the very same discussion with the family that she would have had back home at Penn or anywhere else for that matter. Though there were procedures that could possibly be life-saving, they would not improve her functional outcome nor would she ever awaken to have any sense of a quality of life to interact with her family or others. These decisions, as tough as there are, are always those that must be tackled at the front end of any clinical relationship as it is entirely necessary that the correct expectations be set on both sides very early to avoid any misunderstandings.


Moira’s initial assessment that she sent to me on WhatsApp was very telling in regard to this patient’s prognosis. “GCS 3, patient has fixed dilated pupils, negative VOR, negative corneal. Does have some respiratory function but satting 77.” Shortly after, she came back to clinic and we all discussed the situation, the patient’s prognosis, what should be done and what we were going to communicate to the family. The patient was going to die regardless of what anyone tried at this point and, other than giving her some hypertonic saline or mannitol, neither of which would really make a difference, but might make her more comfortable, we would tell the family that she was going to pass away and we recommended only comfort measures. We heard shortly after that the family had discussed among themselves possibly transferring her to KCMC, though the FAME staff were able to convince them that this would not change anything and it was very likely that the patient would not survive the transport, regardless.

Eventually, they agreed to remain here , though later that night, opted to take her home to die peacefully with her family. In the US, we may well have contacted hospice services to assist the family in bringing her home and provide some support in doing so, but the fact of the matter is that this would probably not have occurred. Here, there are no hospice services, nor any social or home services, though families are comfortable bringing their loved ones home in these situations. Having the ability to participate in a patient’s care in this setting, though perhaps not life-saving, remains life-reaffirming and fulfilling for us as providing comfort to patients and families in these times of need are essential.

Daniel Tewa’s traditional underground Iraqw house

We finished out clinic for the day and had plans to visit my good friend, Daniel Tewa, for coffee that evening. Daniel is a wonderful person who I first met in 2009 during our first visit to Karatu when my children and I were spending several days volunteering at the Ayalabe School where Daniel was one the village elders. We spent several days together, painting at the school, and quickly became good friends during that time, but it was a year later when I returned that our true bonding occurred. I reached out to Daniel a full year after having visited with him on that first trip, and his first question to me was “how are Anna and Daniel?” Not only had he remembered me, but he also remembered my kids and their names!

The residents with Renata Tewa in Daniel’s house

When I visited with him that very next trip, he insisted that I stay for dinner as he told me that it was impolite here to ever have a guest leave without having eaten. I sat in the family room of his small house to eat a traditional Tanzanian meal of ugali, chicken and vegetables. His granddaughter, Renata, who was only 6 or 7 at the time, helped with some of the serving, but I was distinctly taken and incredibly impressed by the fact that she sat quietly throughout our dinner and did not speak or attract any attention until Daniel and I were both finished with our dinners. At that point, she was quietly given her grandfather’s plate and his leftovers and I was told that this was an honor for her to be given this. I could not imagine a similar situation such as this ever occurring in the United States.

Alana and Cara wearing traditional Iraqw wedding skirts with Daniel

That simple meeting began a long standing relationship with Daniel and I have never failed during a single visit here to spend time with him at his house, initially with just me during my first visits, then with one or two residents during my subsequent visits, and finally with our entire team of residents, medical students and accompanying faculty on more recent visits. He would always insist on having us for an entire dinner, eventually moving to his daughter, Isabella’s, home for the benefit of greater space, and it was typically one of the highlights of everyone’s visit here to Karatu. Unfortunately, for safety’s sake, we have limited our meetings with Daniel to being outdoors and enjoying his delicious African coffee – boiled coffee and milk – that is simply amazing.

Daniel is a local Iraqw villager and cultural historian whose knowledge of everything Tanzania is impeccable and his knowledge of most everything else is equally impressive. He loves to quote everyone’s home state’s capital, square miles, when they joined the union and much more. His grasp of world politics is far better than any of us would hope to have. And this is from a man who only finished the equivalent of middle school for when he was a child, there was a single secondary school (high school) in all of Northern Tanzania. Daniel and his wife, Elizabeth, have 11 of their own children, all of who had attended university, and a 12th child, Stanley, they adopted when his mother died during childbirth. Several years ago, Danielle Becker and I probably saved Stanley’s leg when we stopped at their home to say goodbye only to find him with a horrible knee infection and probable osteomyelitis that had been treated at the local hospital less than optimally. We got him right to FAME for IV antibiotics and he is walking normally today.

Daniel, me and Renata in Daniel’s home

As part of his love of history and to help his kids understand the Iraqw culture better, he built a replica of the type of traditional Iraqw house which he grew up in, but were outlawed in the 1970’s when it was required that all Tanzanians move into villages together (there are total of 128 distinctly separate ethnic tribes in Tanzania) so an infrastructure for the country could be developed. The traditional Iraqw house was built mostly underground with a large dome over the top that was covered with dirt and grass. Having their homes underground were to provide protection from the Maasai, who were their principle enemies in a long-standing dispute as the Maasai in those days felt that all cows were their gift from God meaning that they could recover their property. The Iraqw would store their livestock in their homes at night, which is when the Maasai would come to get them and this continued until a truce was finally signed between the two tribes in 1986. Daniel’s traditional Iraqw home is one of the only ones in existence and scholars from all over come to see it and study it.

When I had first visited Daniel in 2009, he had no electricity to his home and all of the lighting and cooking was done with methane gas obtained through an ingenious system in which urine and feces from three cows was drained into a large underground domed tank, fermented and then the gas collected and run to his home. The exhausted excrements were then forced out of the tank by the pressure of the gas and flowed into his fields as fertilizer, helping to grown more crops and enable to feed the corn shucks to the cows, thus perpetuating the process. It was only several years ago that he had power run to his home, but has continued to use the methane for cooking, and also now has a solar panel on his roof with solar bulbs outside and inside for additional lighting.

Enjoying some time together

We had a wonderful evening with Daniel and everyone enjoyed seeing his home and listening to his stories. We bad him farewell, though I’m sure I’ll see him again shortly with the new group next week as well as with my future groups of residents.

Monday, September 19 – A seizing child overnight and a quiet clinic back at FAME…

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We had arrived home last evening after an incredibly dusty day traveling all the way back from the Central Serengeti by way of Katashu’s boma, all with the constant worry that our windshield could collapse or shatter with one wrong bump (and these roads are the bumpiest you could possibly imagine) or another ill-timed rock kicked up by a passing vehicle. Amazingly, the windshield somehow held up and Turtle got us home, though Vitalis would have to make the long drive back to Arusha tonight so that the vehicle could be repaired and returned to us by tomorrow as had daily plans for the coming week including a trip to Mto wa Mbu on Thursday for another mobile clinic. As is usually the situation, Vitalis would hopefully drive it back to us in the morning, but as it turned out, it was not a standard windshield and took several tries to get one fit installed after which it had to be tested to make sure it was watertight. Having expected the vehicle back in the morning, it was not until almost 9 pm that he made it back to us meaning that he would have to spend the night and head back to Arusha the following morning by bus.

Meanwhile, having arrived home last night and arranged to have hot water available in the kuni boiler for us all to take showers, with plans to spend a quiet evening after all of the excitement of the Serengeti, with me hopefully catching up on this blog, we received a phone call regarding a child in the ward who was having seizures. We now have phones in all of the volunteer houses making us that much more available, which can be, of course, a double-edged sword. So once Cara was dressed and more respectable, the two of us began our stroll up the ward to see this young child who turned out to be a bit more complex than we had hoped for.

He was a 9-month-old twin whose mother was with him and he was definitely developmentally delayed as he was not yet sitting or crawling, both of which his twin was actively doing. He had apparently been seen previously at Kilimanjaro Christian Medical Center (KCMC) at 3 months of age for seizures and had been placed at one point on lamotrigine and carbamazepine, though his mother had reported having stopped them a month or so ago as she thought the medications were making him worse. The child had come in earlier that day and had already been given a loading dose of phenobarbital, which, as many of you including the non-neurologists are likely aware, will suppress someone’s respiratory drive and, given the lack of ventilators here, is not a happy situation to be in.

Everyone attending to our seizing baby late at night

What was readily apparent to both Cara and myself as we walked in the room was that the child looked syndromic, meaning that he may have a genetic syndrome causing dysmorphic features, but could also explain his seizures. We also immediately noticed that he was having recurrent episodes of impaired awareness and abnormal movements of his extremities that were clearly seizures meaning that he was essentially in non-convulsive status epilepticus and very likely had been for some time. More so, this was on top of the phenobarbital load that he had already been given earlier in the day and had also been repeated once with continued seizures. On examination, when he wasn’t seizing, he did seem to track some with his eyes, though he had some asymmetric motor tone giving us the impression overall that we were clearly dealing with a young child who did not have “normal brain.” The significance of this fact was specifically how it related to the reason we were now seeing the patient, that being uncontrolled seizures.

He had already been given some good doses of phenobarbital and was continuing to have seizures despite very generous doses of the medication and anything of this very sedating drug would cause him stop breathing and that would be adding insult to injury and would be a problem neither of us were interested in dealing with at the moment. The fact that we had no intravenous antiseizure medications remaining was clearly going to be an issue in trying to manage this patients continuing seizures, so we began to look at what else we had available and could put down a nasogastric tube once one was placed.

The availability of medications in Tanzania has always been a bit of mixed bag as there are several factors that are involved – first, a medication has to be registered with the Tanzanian Medicines and Medical Devices Authority, or TMDA, which is the equivalent of the FDA in the United States and decides which medications and medical devices can be used in this country and which cannot. Using a medication not registered can be a significant issue for any facility and merely having an unregistered medication on the shelf in your pharmacy is an infraction. Considering the TDA stops by for unannounced visits from time to time simply enforces this standard which is entirely reasonable and if one wishes to have a medication registered, you must go through the normal process of doing so. Secondly, there are issues of availability and supply chain issues that can affect that. Having a steady supply of a medication that patients use on a regular basis is an essential consideration before prescribing a medication and, even more so, for medications such as antiseizure medications where discontinuing the medication can have grave consequences for the patient. And lastly, there is the cost of the medication. Placing patients on a medication they unable to conceivably afford in the future serves absolutely no purpose and can, in fact, cause more harm.

This is why phenobarbital is considered to the first line antiseizure medication for the world – it is inexpensive, easily affordable and readily available. Unfortunately, though, phenobarbital has some very significant downsides to its long term use, first and foremost being those of cognitive impairment and delayed development. That being said, it is still a medication that can used in children at a very early age, but you just have to remember to switch over to another long term medication at some point. I won’t go into all the aspects of how we decide which antiseizure medication to use in which situation as that would probably bore the majority of you, but leave it to say there are a number of interdependent factors that go into this decision once one has elected to start a medication for this purpose.

So, back to your young child in the ward with seizures. Unfortunately, the medication that Cara most wanted for the child, levetiracetam, a very broad spectrum antiseizure medication that can be easily loaded, doesn’t suppress a patient’s mental status or respiratory drive and mixes well with other medications, was unavailable here at FAME due to supply chain issues. Given that, our other choices were to use phenytoin, and older medication that can at least be loaded quickly, and valproate, which can also be loaded quickly, but we were concerned about its safety for this patient due to his developmental delay and the fact that valproate can cause serious problems in patients with metabolic disorders. We chose to give him a phenytoin load, but the other issue with phenytoin, which is usually loaded intravenously, is that it is very lipophilic and would stick to the NG tube, lessening the amount of medication that would get into the patient. Since it’s usually given IV, this is not ordinarily a problem.

After an hour or so in the ward, Cara and I walked home, though she returned immediately to continue working with the child who continued to seize despite receiving the phenytoin on top of the phenobarbital and was now looking just a bit encephalopathic by the morning when we looked in on him again. Amazingly, though also a bit frustrating, someone found a bottle with just 11 tablets of 500 mg levetiracetam, with one tablet being a perfect loading dose for this young child and enough to allow up to continue it for at least a short period. The child received his first loading dose of the levetiracetam and within a short period of time, his seizure frequency lessened dramatically. And, after his second loading dose of levetiracetam several hours later, his seizures stopped altogether and, over the next day or so, his encephalopathy improved and he was slowly back to his baseline with no further seizures.

Even without the ability to provide IV antiseizure medications in this setting, it can make a great difference just having the right oral medications to administer and, in the case of levetiracetam, having it readily available, though, at times a challenge, was life saving for this young child. Our hope will be to have enough of it now to send him home on it which I do think will be possible going forward. It was a real challenge, but putting all of our knowledge and resources together, along with finding that bottle of levetiracetam, truly made a difference.

Considering Cara got very little sleep last night having made several trips to the ward for our seizing baby, it was helpful that things were a bit slower in clinic today as it gave everyone time to recover from our trip home from the Serengeti as well as the late night in the ward. During morning report, we were able to catch up on everything from the weekend and, thankfully, there were no neurology patients that had been admitted over the weekend who required our attention other than our little baby with the seizures. We were without our beloved Turtle since it wasn’t home and, therefore, we were stuck at home in the early afternoon, though no one minded the extra downtime and a chance to catch up. It had been an exciting weekend and we were all able relax and consider all the amazing things we had seen – Oldupai Gorge, Shifting Sands, Cara and Alana’s balloon ride, our wonderful camp, the amazing cheetah hunt, and the Big Five before noon on Saturday.

Sunday, September 18 – Heading home from an amazing weekend and visiting Kitashu’s boma…

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Around the campfire, or what is known as “bush TV,” the night before

It would be incredibly difficult to conceive of anything that would top yesterday in regard to the diversity of experiences that we saw. Even if we had not found the rhinos and completed our Big 5 before noon, it would have still been a truly remarkable day. As I mentioned, Cara and Alana had each decided to go up in the hot air balloons that ply the skies about Seronera this time of year, taking guests on an exciting safari in the sky, launching before sunrise and floating across the sky at altitudes between the treetops and a thousand or more feet to view the wildlife from above. Leonard’s brother has been a balloon pilot now for over ten-years and I had the opportunity to fly with him back in 2014 – it was really an experience and far beyond what I had anticipated, to be honest. With this in mind, Cara and Alana were more than onboard with this once in a lifetime experience. They had to get up very early, though, to be picked up at camp and taken to the launch site well before sunrise. Their ride would meet them at 5:15 am!

Getting ready to take flight

Meanwhile, last night we had a group of hyenas that had come into camp and broken into the kitchen area looking for anything edible they could find. I woke up in the middle of the night to the loudest hyena howl that seemed to be only inches from my head and immediately behind our tent. I reached up quietly to double check that there was some metal of the headboard separating my head from the hyena and thankfully I was reassured that there was indeed a barrier. This went on for several minutes and I swore that I could hear heaving breathing just behind me during the entire episode. The next morning, it seems that everyone, other than Cara, had been awakened by the loud hyenas and had also sworn that they were just outside their tents – either there were a number of hyenas last night, or there was only one and it seemed like they were closer than they actually were. Regardless, they had apparently caused some damages in the kitchen though no more details were available.

After a successful landing

With Cara and Alana having left for the balloon ride, the rest of us (Alex, Moira and me along with Vitalis) had a relaxing breakfast with plans to leave camp at around 7 am. I had gotten up at 5:15 am as I had wanted to do some work with the internet early and enjoyed some coffee at the same time. The sunrise was absolutely spectacular and I shared it with someone back home on a WhatsApp video call as it was around 11 pm on the east coast and a perfect time to share the experience. Alana and Cara had packed completely before they left for the balloon, so it was just a matter for us to check out and pay the bar bill as the rooms had all been paid in advance of our stay. We said goodbye to the Tanzania Bush Camp, though I’d be back in three weeks with my next group and was quite happy for that as this camp had met our expectations and then some without question.

A pair of mating lions

We left heading west over some of the nearby woodlands and very quickly encountered very large herds of wildebeest and zebra that were part of the great migration coming down from the Maasai Mara in Kenya and heading for the Southern Serengeti. The numbers of animals here were really incredible and we encountered ever increasing numbers as we headed further west. In the midst of all this, we spotted a mating pair of lions not far in the distance and were able to get quite close to them only to find that the brother of the male lion of the mating pair was relaxing nearby in the trees in a somewhat voyeuristic position given that lions will mate approximately every thirty minutes for around 48 hours to ensure that the female is impregnated. I’ve seen a mating male with several females before, but never had I seen two males and one female. After the mating, which takes only about 15-20 seconds, the female walked a few feet and then plopped down on her side readying herself for their next interlude which goes on like clockwork for the several days. We decided to give them some privacy and moved on quickly encountering the migration herds that were truly immense. The zebra and the wildebeest migrate together as they both help each other out both from the standpoint of the different grasses that they eat as well as from the standpoint of protection as the zebra have amazing eyesight and can spot predators at a far distance while the wildebeest are good at finding water for the herds during their travels.

A dik dik

Along our drive, we encountered the landing site of the balloon that Cara and Alana were on just after they landed. We could see everyone taking pictures with the pilot and the balloon gondola. Alex was able to get a few shots of them before we drove on and they were heading out for their breakfast in the bush that would be prepared special for them before being brought to the visitor center where we would pick them up. Along one of the rivers as we were circling around back towards the Seronera Village, we encountered a massive group of zebra and a lone lioness that was hunting. She dipped down into the river depression hoping to surprise the zebra, but they unfortunately spotted her and quickly moved away and out of reach for her. A single hunting lioness most often indicates that she has her cubs stored away safely someplace and is hunting for sustenance. It was a loss in more ways than one that the zebra had spotted her for she was going to go hungry and we were deprived of what would have been an excellent opportunity to watch a lion kill.

Secretary bird

Continuing to follow the river, we encountered more of the large zebra herds mingling through the woodlands here with families of giraffes and some incredibly large extended families of elephants. We stopped for fuel to top off Turtle on our way to the visitor center to pick up Alana and Cara – amazingly, we had used only 2/3 of a tank over the last two days of driving and though we probably could have made it home on what remained, running out of fuel on the return drive is not an option as being stranded in the bush does not end your day well. The visitor center at Seronera is the center of activity in the Central Serengeti and where the passengers from the balloon flights all return after their exciting experience.

There are several shops, a restaurant and, most importantly, bathrooms available for the weary travelers in need. The Central Serengeti airport is also not far and is where many guests arrive on a regular basis as many of the tour companies have you drive only one way to the park and fly out to save time. Many flights also depart for Zanzibar and other remote areas in Northern Tanzania. In 2009, while on our original trip here, while flying through this airport from the Northern Serengeti where we had finished our safari, the president of Tanzania had landed briefly to refuel and I remember sitting on the tarmac for some time waiting for his plane to land and then depart. Certainly not unlike Air Force 1 with our president, but the plane was much smaller and was chartered from Air Tanzania.

Reinforcing the windshield for our ride home

Once we had our full contingent intact and everyone had taken care of any essential needs, we were once again ready to hit the road. The drive out was long as we drove first to the Moru Kopjes, the sanctuary for the black rhino here in the Serengeti, though we had our sighting yesterday and for free as it costs an extra $100 to drive through the actual sanctuary in search of the rhino, something that was not at all necessary for us. Lake Magadi is in this region and is one of the larger saline lakes that attracts flocks of flamingoes to this region, though there were only a few to see today. We were now on our way to Naabi Gate and ready to depart the park which meant that we would also have to stop in the NCA office to pay our transit fees to travel back to Karatu. We were also going to have our lunch boxes here and use the facilities before our drive back by the Crater and home. There were many, many vehicles arriving at this time, all with the same plan for lunch, so tables were at a premium, though we found one sufficient for our number and enjoyed our final box lunch from the camp, which was again delicious.

Alex displaying his jumping skills

After lunch, Vitalis and I went up to the office to take care of payment only to find the office packed with guides and a single window available for credit card payment which was my plan given the cost of $60 each for the transit fee. Once again, the system failed us as they were having difficulty with the payment by another private traveler in front of us. While all of the guides proceeded to have their entry permits stamped as they were already in the system, we waited and waited, finally getting taken care of after the office was entirely empty and we were now more than 30 minutes behind schedule. The road back to the Loduare Gate past Oldupai and the Crater was going to be incredibly bumpy so I decided to secure the windshield a bit more before we left, adding just a little extra insurance. Amazingly, the windshield had lasted throughout our game drive the entire weekend, but I was concerned about the rocky drive home. If the windshield decided to let go, there was no way we could have safely driven Turtle as the mere thought of another rock flying into the car would have been enough to have stranded us, not to mention the dust. It was a pretty untenable situation and I’m surprised that this doesn’t happen more often to make it profitable to have a shop in the Serengeti that could replace them if needed. It would take a little of prayer, crossing our fingers and the insurance a bit more duct tape to get us home.

As we were somewhat behind schedule for our visit to Kitashu’s boma where the others would meet his family and we were to have a goat roast, Vitalis was forced to drive a bit faster than I’m sure he wanted, but he did a wonderful job navigating a treacherous road in a wounded vehicle. We made it to Kitashu’s home up on the crater rim with just enough time to enjoy our visit. Kitashu was raised here in this boma and had made his home here, commuting back and forth to Karatu during the week until only recently when he moved his family to town for his son’s education at Tumaini Primary School. He still has to travel back and forth, though, to take care of his herd of cows at the boma and to visit his brothers and sisters.

Their boma sits atop a ridge with a lovely view of the highlands surrounding Ngorongoro Crater which is only a short distance away across the rim road. As a youth, he grazed his animals throughout this region, often traveling many days away in search of the best grazing spots. He knows all the regions of the NCA incredibly well which came in handy last March when he led the search for the surviving boys who had been exposed to two rapid dogs and required prophylactic immunoglobulins. Had we not had him as a resource both for his knowledge of the area and the people it is unlikely that the children would ever have been located and treated.

Kitashu’s family dressed all the residents in their traditional, though more fancy, dress to do some dancing and then we enjoyed eating freshly roasted goat with the most incredible backdrop of scenery, sitting on the ground and doing our best to wash our hands first, while Kitashu and his brothers sliced chunks of goat for us with their long knives freshly “cleaned” with the surrounding grass. The goat quarters sat on the spits it was cooked on with no spices used at all, but the tastiest and most tender meat. Everyone enjoyed partaking in this ceremonial feast, though it was getting late and, if we had any hope of getting out through the gate by 6 pm, we had to leave rather quickly. Vitalis had already distributed the “pipi,” or candy, to the children, so all that was left to do was to give the gifts we had brought for the village to his oldest sister and mother – rice, sugar, tea, soap, flour and other essentials that is traditional here when visiting someone’s home.

We were on the tightest of schedules and Vitalis drove like a banshee to get us to the gate in time and, even though we had Kitashu with us as we were giving him a ride back to Karatu, it was not likely that the guards at the gate would have much sympathy for us if we were late. Amazingly, we arrived at exactly 6 pm to the gate and, using a strategy I knew well from previous times I had cut it this close, we drove to the other side of the gate before stopping to check out. That way, they couldn’t lock the gate in front of us, but rather behind us. Though Kitashu could have just walked through to leave the NCA, we would have been stuck there for a very unpleasant night in the car or an expensive night at one of the lodges back up on the crater rim.

Vitalis handing out pipi to the children

All in all, it had been an incredible weekend in the Serengeti, well worth the time and money for the residents to have experience one of the most remarkable landscapes in the world that has no equal. Our windshield had held, we were all in one piece and we had seen the Big Five in less than six hours yesterday. What more could anyone ask for?