After the exhausting adventure we had yesterday, it was up early for our educational lecture today and then back on the road to Mang’ola and the village of Mbuga Nyekundu. This morning lecture was given by Mary Ann and had to do with abnormalities you visually note in babies at birth and what they may or may not indicate as far as an underlying defect. Though most are totally benign, others are significant enough observations to suggest obtaining a CT scan of the brain (for example, excessive or multiple hair whorls may indicate abnormal brain development).

Our drive for the day was essentially the same as yesterday, though we would turn off earlier before cresting over into Barazani and, instead, travel more inland from the lake towards the hills. We had actually driven this same route when returning last night from Pendo’s home, Majiyamoto, though given the darkness that had quickly enveloped us, none of my passengers would have known that we already driven this road. Once again, a long and terribly dusty drive on the heavily rutted, or “washboarded,” road that makes you feel as though all of your fillings will soon fall out if it persists. Thankfully, everyone’s dental work remained completely intact as the road continued on an on until we finally reached the village of Mbuga Nyekundu that sits in the foothills far above Barazani in the distance.

We had started visiting this clinic at a similar time as we had Barazani, though the number of patients here have always seemed to lag behind a bit, most likely a factor of the size of the village and the population. They have been enlarging the clinic, though, over the time we’ve come and though we were still in the same building we had used six months ago, which was new for us at the time, they already have another large clinic building under construction. The area itself is incredibly windy and throughout the day, it continued to howl excessively.

Patients were here early waiting for us and continued to accumulate throughout the day, but we were never swamped. There was one child who had traveled from Barazani as they had showed up late for yesterday’s clinic and there was some debate over what had been promised to them. Kitashu, who had been able to attend only the last part of yesterday’s clinic had spoken with the mom of this child, but there was a difference of opinion regarding what had been said between them. Mom was adamant that Kitashu had promised round trip transportation, but the driver of our other vehicle recalled only that we were responsible for trip to the clinic and not the return. I really wasn’t certain what the issue really was considering the other vehicle and driver were essentially leased for the day to bring us there and back and in between was pretty much down time. In the end, we were able to resolve the issue and the child was transported home with his mother and the crisis was averted.

Most often the one to resolve these issues, Kitashu was not with us today, nor was Angel, our other social worker, so those duties were left to Dr. Anne who handled them seamlessly, though not without some friction as happened with the child’s mom above. Kitashu was enlisted to help with the group that was going out to find the family of the young boy who had died of rabies as the other family members were desperately in need of getting vaccinated as quickly as possible given their exposure to the boy prior to his coming to FAME. There was also the report that a sibling of the boy had also been bitten by the same rapid dog and now showing symptoms. Finally, when the family was found, the sibling was evaluated and, thankfully, not felt to be symptomatic so they received the vaccine in the same fashion as the rest of the family. Had they been symptomatic, there would have been little purpose in supplying the vaccine or immunoglobulin as neither would have provided any benefit. The entire family and anyone else who had come in contact with the child who had died was vaccinated. Though this will end the issue with this incident, there is little question that the problem will persist and there will be further exposures in the future.

Encountering a case of rabies in the US would be exceedingly rare for any of us given the rarity of the condition back at home, though they do occur from time to time. There was a case in the ICU at Penn within the last few years, though again, this is something that most physicians will never see in their career. Unfortunately, for Africa and other regions that are similarly depressed economically, rabies is far more common than it need be and is a significant public health problem. Dogs account for 99% of all human exposures to rabies worldwide and, therefore, aggressive campaigns for dog vaccination will ultimately reduce the risk of exposure for humans. Unfortunately, the same countries where these campaigns are most needed are those who are the least able to enact them due their economic issues.

The region of Tanzania where we had spent yesterday as well as today seeing patients, and especially last evening visiting Pendo in her home, is a very culturally interesting area for the diversity of tribes that inhabit it. This is the Lake Eyasi region that is very remote and definitely feels like you’re traveling back in time. The most unique of the tribes that live in this region is the Hadza, or the Hadzabe, who are the last hunter gatherers in Tanzania and also speak one of the click languages known mainly in South and East Africa as well as Asia. I had spent a significant amount of time with the Hadza during our larger mobile clinics in 2010 and 2011 and, during that time, found their language to be truly intriguing. On one occasion, I had accompanied Amir Bakari, a wonderful colleague who was working for another NGO, to visit a distant village during the rainy season to let them know the FAME bus could not make it to them due to the flooding of the roads. Two Hadza men had asked us for a ride to the other village which wasn’t at a problem other than the fact that they were both a bit intoxicated and, when they spotted a small flock of guinea fowl, decided both to shoot their bows and arrows out the open side windows of the vehicle. Given their state, they both missed the birds badly and then had to run outside to retrieve their arrows. What I remember most, though, was their laughing and cackling in the back of the Land Rover, all the time speaking click. I have videos of the drive focusing on the horrible roads we were driving, but the sound track is primarily these two Hadza in the back seat conversing.

What’s truly sad about the Hadza, though, is the fact that there are probably only 1000 of their tribe still living in the area and remaining true to their culture such that they are marrying within their own tribe and raising Hadza families. Their numbers have been reduced over time by the typical pressures that are placed on such small groups of people, but in this case, it is also the fact that their homesteads have been encroached upon by surrounding tribes, and mostly the Datoga who grave their animals through the Hadza region, running off the typical game the Hadza hunt. What has been left for them to hunt are small birds, dik dik and baboons as all the larger prey have been reduced by this encroachment. I recall hunting early in the morning with a group of teenage boys a number of years ago and being amazed by their accuracy in hunting small birds in the trees, but, in the end, coming home with a string of small birds to feed a small family isn’t something that is sustainable. I came away with an entirely greater appreciation not only for what it takes to “eat what you kill,” but also for the fact that the Hadza are a dying tribe and that both their language and their incredible uniqueness will soon be gone to this world. There are a number of groups working to save the Hadza, but it is unclear if these efforts will be successful or not.

One of the other unusual features of this area of the Karatu District and, perhaps, Northern Tanzania, is that there is an amazing amount of agriculture that goes on here, but they specifically grow huge crops of onions primarily and, for this reason, many of FAME employees who accompany us here will plan to stop on their way home to buy large amounts of onions. Dr. Anne and several of the others quite early announced their intention to stop on our return trip to get a 20 kg bag of onions for something like $3 USD if I remember correctly. No matter how you cut it, that’s a ridiculously small amount of money for a very large amount of onions.

We left in advance of the other vehicle which was carrying all of the Tanzanians except for Nuruana and Amos as they had elected to travel home with us. It was a much better drive for me than the one the night before that had been done in darkness and when we returned home, it was decided that we would take it easy for the evening considering the busy days we had over the last two.

In our previous configuration of having a single team of residents with me for four weeks, it had been convenient for us to schedule our mobile clinics in a single week, though now, with the two groups each for three weeks and trying my best to make the experience similar, we’ve split the mobile clinics up so that each group could participate. I have been doing mobile clinics, in which we bring a team from FAME to a number of the more remote villages within the Karatu district to provide the same neurologic evaluation that we do here on campus, since 2011, the year after I began our neurology program here. We have now provided these services every six months to a number of villages where we will follow patients and see new ones as needed.

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This began in Kambi ya Simba in the Mbulumbulu region and we have continued to provide these services there in addition to the Rift Valley Children’s Village. Other villages, such as Upper Kitete and Qaru became less necessary over time for various reasons of either low volume or perhaps patient’s ability to be seen at other clinics. Several years ago, we began attending two clinics in the Mang’ola region on Lake Eyasi which is a fairly remote group of villages inhabited by the Iraqw, Datoga and Hadza, the latter being the last hunter gatherers in Tanzania still hunting with bows and arrows and speaking click language. Barazani, where we will be today, is the largest of the villages in this region, and Mbuga Nyekundu is another village somewhat smaller and further inland from the lake. Medical services are very minimal here and, therefore, our clinics are typically very busy.

Given the time it takes to get to Mang’ola, that being typically over an hour, as well as the size of the clinic, we typically try to leave a bit earlier than we do for the other mobile clinics. We had decided to leave at 8 am which meant missing out on morning report and learning about any new patients that needed to be seen or follow up on patients already in the ward. Heading up to the outpatient looking for the doctor on call to speak with, I discovered that our young rabies patient had passed away around 4:30 am and was, thankfully, comfortable at the end. Ankita and Taha had gone up the night before and were pretty certain that the end was near as he had very agonal respirations despite still being awake and somewhat responsive.

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It was an incredibly tragic case for such a young boy to have died of a disease that was potentially preventable on so many levels, the first of which is vaccinating the dogs, while the second is the public awareness campaign to get vaccinated immediately after any exposure to a potentially rabid animal. There was still a need to confirm the boy’s diagnosis, though, and this would require a limited autopsy, something that is not easy to obtain anywhere, but even more so in a country with a tremendous diversity of cultural beliefs. Thankfully, after everything was fully explained to his family, they consented to the procedure such that we would very likely have that information after several days.

Luckily, I have known the road to the Mang’ola region since my very first visits here as this is the area where the larger monthly FAME mobile clinics took place, though a bit further down Lake Eyasi and more into the Hadza, or Hadzabe, community. These were week-long clinics that involved a large number of caregivers and support staff traveling in an all-wheel drive bus outfitted with a lab and solar power along with several Land Rovers as support, one of which would be driven by me. The road to Barazani in those days was a bit treacherous, but nothing like the drive from Barazani to Gitamilanda, the village we were working out of, which was essentially off road for most of way and what roads existed were very often washed away by the rains or impassable due to mud. Needless to say, it was very exciting.

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Today, the road to Barazani has been widened and graded, but still presents driving challenge as it is loose rock for the entire way, passing through numerous washes or ravines that become raging rivers in the rainy season. And then there is the dust. Every vehicle puts up a massive cloud of red dust that stays in the air forever and creates an essential smoke screen making it difficult to see for some moments as you pass. To prevent the dust from getting into our vehicle, we are constantly rolling the windows up and down in the front doors and those in the back are sliding their windows closed for the same reason. For the driver, this is all done while driving 60-80 kph, staying hyper focused on the road to look for larger rocks and/or potholes, meanwhile shifting through the gears on the frequent uphill and downhill portions of the road. Needless to say, the drive is not only a challenge for the driver, but also for the passengers.

We arrived at the Health Center in Barazani, a location that I know well from having been there over the last several years and were greeted by their clinical officer and nurses who had most of the rooms already set up for us and our patients were already waiting to be registered and seen. Dr. Anne did her pre-clinic triage speech about what types of disorders and symptoms we see as it is not our interest to provide medical care for things other than neurology. The clinical officer there is fully capable of doing this and it has never been our intention to alienate any other health care provider as that is not the best way to develop and good relationship and be invited back each time. Six months ago, I had also assisted in providing some necessary furniture for the health center and they were very grateful for that – desks, chairs and benches that would allow our clinic to run more smoothly and would be something they would benefit from in between our visits.

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The residents worked at a quick pace evaluating patients with the full spectrum of neurologic and psychiatric diseases, both return patients and follow up, but no matter how quickly they were seeing patient, they continued to accumulate. At some point after lunch, I recall going out front to see where things stood as far as patient numbers and remember that we had 28 patients in the register with an additional four patients who had yet to be registered. 32 patients for the day with three residents seemed like a pretty full day to me and I went back to my staffing duties in the back hallway. Sometime thereafter, it became apparent that we had exceeded that total number of patient and were already at 39 with several patients still wishing to be seen. It was now approaching 5 pm when we should have been on the road at least an hour prior to that. There were just that many patients who needed to be seen and we could do very little about. Thankfully, we were able to have the additional several patients come to the clinic the following day that would be in another village, but we would arrange their transport.

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One of the significant issues we had today was that we had agreed to go out into the bush to visit a young patient, Pendo (which means “love” in Swahili), that Dan Licht and Marin Jacobwitz had seen back in June while here and were working on sponsoring her in school as she had been disabled for over a year with bilateral lower extremity paralysis and had been unable to attend school. She lived somewhere far beyond Barazani in an area that I had driven through years ago on our other mobile clinics, but the landscape is every changing due to the rains. Kitashu knew where she lived apparently and had it not been for him directing us, there would have been no way whatsoever that we would have found her home.

We drove along minor roads and/or trails, through tiny villages and in between homes with the residents wondering what a Land Rover filled with mostly mzungu, and, even more so, a mzungu driving, was doing way out in the middle of nowhere. There were massive river beds that were dry, thankfully, and needed to be crossed at just the right place so as not to high center Turtle, which has a very long wheelbase and can be prone to this. For me, it was incredibly exciting and there could be nothing more than I would rather be doing than this, but I suspect for the others in the vehicle, it was all a bit questionable to them. One of the funniest things, though, and I kick myself for not getting a photo of this, was the fact that there were street signs out in the middle of nowhere indicating the names of what appeared to be livestock trails. The country just decided to put up street signs in over the last six months as they were not here during my last trip. I did like in the past when people asked me what street someone lived on here and I would say I have absolutely no idea since there are no street signs. I can’t say that any longer.

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We were essentially driving through perhaps the most remote landscape one could imagine, with home which were very small structures of one or two rooms made out of clay and branches and surrounded by brush fences to form enclosures for their livestock. These were the Datoga, who are pastoralists similar to the Maasai, and had no fields or agriculture to speak of. The homes were in small groups that formed more of an enclave than a village as there no structures other than these living units. We stopped at several and asked people we would come across where the family of this young girl were located and, thankfully, were able to finally find her home. Pendo lived in the village of Majiyamoto (which means “hot water” and named for the hot springs nearby), though calling it a village is really a misnomer as the distance between homes was incredibly vast.

Once we found the correct home, Pendo’s brother, who was home at the time as her mother was not, directed us to the front door where we found young Pendo sitting on the ground on a cloth, with her legs folded underneath here. After speaking with Marin, who had evaluated Pendo at the last clinic in Barazani, she had lost the use of her legs about a year earlier and on examination had a T12 spinal level. There had been no x-rays taken or any other tests as it was unclear how that would have changed her management, though at some point, I suspect we will try to obtain more information so as to know exactly was caused her condition. Her legs are severely contracted and unable to be extended in any fashion and the only means for her to move around at present is to scoot along the ground using her arms and to carry her body forward with her legs remaining folded beneath her. She briefly demonstrated this to us and it was very tragic to see.

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The reason for our visit was that Marin found Pendo to a bright young child with absolutely no future unless she could get to school and then some type of vocation rehabilitation. Unfortunately, she is too young to go to the vocational rehab center we had sent the two Maasai Down syndrome boys to a year or so ago, but Kitashu miraculously found a school for children with disabilities that she could go to until she is old enough to go to the vocational rehab center. Marin is in the process of raising money for this to occur and Pendo will be going to the school in Moshi shortly for a visit to see if it is the right fit for her. We can only hope that this will work out as it would be life changing for her to get to school and later, vocational rehab.

Meanwhile, it was now sunset and we were in the middle of essentially nowhere with the light quickly fading. Kitashu felt that it would be best for us to take a different route, or really just a different direction, to get back to main road that would take us home, but the problem was there were really no roads to speak of and we would have to cross several deep river beds along the way. We made several tries to find a route to cross the dry rivers with no success as they were rather steep banks that were completely unpassable to us. We eventually made it across one, but were still somewhat lost in regard to finding anything that resembled a road or even a viable trail. We spotted a Datoga man walking some distance in front of us and eventually caught up with him to ask for directions. He spoke with Kitashu for some time and, the next thing I knew, the man was climbing into our vehicle to show us the way himself which I was glad he did as it was not an easy path, either to find or to drive. We eventually came upon a major graded road that was clearly our way home and the man hoped out of the car with a tremendous debt of gratitude from us and countless thank yous in Swahili.

By now it was dark and time for headlights which is never a thrilling idea as the headlights on vehicles here are not well leveled and driving in the dark is treacherous. Any oncoming vehicle is blinding and then there is the dust cloud that follows. With my bright lights on, I could just about see my way, but with all of the oncoming motorcycles, whose headlights were worse than the cars, along with the cars and trucks, I was constantly turning my bright lights on and off throughout the drive. Maintaining one’s focus on these roads is essential in the daylight and, in the dark, is a matter of making it home safely or not. Thankfully, we arrived home in one piece, though all a bit frazzled. It had been an epic adventure and, coming from me, that’s saying a lot considering some of the crazy travel incidents I’ve had in the past here in Africa. After arriving home, I made my special gin and tonics with mango juice for everyone and they were more than well deserved. Not only had it been an epic adventure, but it was day that none of us will soon forget.

Awakening in the predawn darkness here in Africa is far different than back home for so many reasons, but the obvious one can best be summed up by a question. Just how dark is dark? Both because we are so close to the equator, where the sun both rises and sets very quickly and completely, and there is far less ambient light here in Northern Tanzania by magnitudes of difference from most anywhere on the East Coast of the US. We were scheduled today to once again travel back in time to a place that has changed little in the several million years since it was first formed.

Ngorongoro Crater, which is actually a caldera, or the remnant of a collapsed volcano, is actually the largest dry caldera in the world and is a remarkable geographic landmark that is considered one of the eight natural wonders of the world and is a UNESCO World Heritage Site. It is unique among most parks in Tanzania as the animals are resident and do not migrate with the other herds that are so famous for their other wonder of the world, the Great Migration of the wildebeest and zebra. The crater contains all the animals of the other nearby parks except for the giraffe, as it is too steep for them to descend from the crater rim, and the Nile crocodile, as there are no flowing rivers within the crater itself. The one animal that is best known here within the crater are the black rhinos that now number somewhere around 30 and are heavily protected as they had been hunted to near extinction. There are also black rhinos in the Serengeti in such places as the Moru Kopjes, the Western Corridor and the Northern region near the Mara river and Kenya.

We had planned to leave the house at around 5:50 am so we would arrive to the gate shortly after it opened at 6 am. We had also invited Amos, a clinical officer student who has been volunteering and working with us for the last month. He is a terrific translator and is going to make a great clinician and has never been on a game drive in the past to any of the parks which is quite common for most of the Tanzanians here. Though the entrance into the parks is negligible for East Africans, the cost of a vehicle and driver, the limiting factor, is not. He was waiting for us at the junction of the FAME road and the tarmac and was there early as I suspected he would be given the incredibly prompt and respectful person he is. The residents had made lunch for him as well, so we were all set for what would hopefully be a wonderful day in the crater.

The Loduare Gate, the entrance to begin the drive up to the rim, is also the only way to get into the Ngorongoro Conservation Area and on to the Serengeti and then to the west side of Tanzania, so not only is it the only way for every safari vehicle to get in, it is also the only way for the trucks plying this route to get in and travel to Mwanza and other cities to the west. Two weeks ago, there had been over fifty safari vehicles here, but that was later in the morning and, thankfully, most tourists like to have their breakfasts before traveling. We had beaten nearly every safari vehicle to the gate, but I still had to wait in line for the truck drivers that were at the registration window waiting to do their paperwork and pay their fees for entrance and transit. I finally reached the window and again found the process to work perfectly smoothly like it had when I was here three weeks ago – we had our paperwork in hand and were ready to begin one of my favorite drives in the world.

Driving up the crater rim is an experience like no other. You ascend about 2000 feet in a very short distance up a very windy dirt road with hairpin turn after turn and a sharp drop off to the one side. Primordial trees and vines line the road on both sides and at the exposed cliffs on the uphill side, the elephants have left their marks where, using their tusks, they mine for minerals in the soil that they then eat for their nutritional value. Occasionally, you may run into elephants or some stray Cape buffalos crossing the road in front of you on their morning constitutional. On a rare occasions, you can come across a leopard using the road for transit as we have several times. I’ll never forget when Jess Weinstein, one of my former residents, slept through a leopard sighting on the road, though then again, she slept through much of our safari that weekend.

It was a pretty overcast morning so I was suspecting that we would be in the clouds on the rim, and, sure enough, we were in the incredibly dense cloud cover even before reaching the rim road such that the overlook for the crater looked like you were standing on the edge of an ocean. Worse yet, we were driving through pea soup thick fog or clouds once we started our way around and it was very difficult to see anything through both the moisture and the dust that was being kicked up by the vehicles. There was a safari vehicle in front of me that was helpful as I could see his brake lights in the distance, but there was a sweet spot for the distance behind him between the clouds and the dust that I had to manage in addition to not being able to see much of the road with its ruts and bumps, not to mention that there were vehicles also heading in the other direction. Thankfully, we encountered some blue sky peeking through on the far side of the crater and, by the time we were overlooking the road heading off to the Serengeti and the lovely valley that exists there, there was open sky above us. The one-way descent road was just in front of us with its gate to check in to the crater for there is a separate fee that is paid to visit it, which we had taken care of at the main gate, and after a bathroom break and popping the tops, we were ready to descend to the floor far below.

As I had mentioned before, the herds of animals here are resident animals, meaning that they do not migrate in or out of the crater, but will remain here their entire lives. As we had seen previously, there were huge herds of zebra, wildebeest and Cape buffalo all throughout the crater floor and, given that it was morning, most were slowly heading out of the surrounding hills and towards the sources of water at the center of the crater. Lake Magadi is the large lake at the center, but there are also large sources of water in many other areas making it impossible to drive in many places due to the swamps that are created by the water sources there. The other common animals that are seen on the floor include Thompson gazelles, Grant gazelles, hyenas, jackals, elephants, eland, hippos, and, of course, the many cats that include lions, cheetahs, serval, caracal and leopards. The cheetahs have been difficult to see here for the last several years and I have never seen a leopard on the crater floor, only the rim. I apologize in advance to the hundreds of bird species here that are truly spectacular, but are far too many to name. The elusive rhino (it took until my third visit here to see one) is what most people are here to see, do not like to come out on windy days as they rely tremendously on their hearing for defense as they have incredibly poor eyesight.

By lunch time, we had seen all of the more common animals, but we hadn’t seen a lion or rhino yet. We were using our short wave radio to listen for any spottings by the other drivers which is all in Swahili, but, as Taha reminded me, we had Amos in the car who could listen and translate for me. After a nice lunch that included ice cream from the snack truck that sits there every day, we took off in search of the things we hadn’t seen so far. I had spoken with a guide when we were at lunch, and he had not yet seen a rhino or lion either, so it didn’t look hopeful. Suddenly on the radio, there was mention of both animals and in a location that was not too distant as nothing really is in the crater.d

The lion turned out to be a solitary cat sleeping under a bush in some distance, but at least they could see it through their binoculars. The rhino was even more distant, though that is not at all unusual given their elusiveness, and the line of vehicles was entirely commensurate with the sighting. With binoculars, the shape of the rhino was easily evident and, as it moved through the high grass and brush, one could make out its distinctive horns, the unfortunate feature that led to its near extinction over the last century. Thanks to the conservation efforts of the Tanzanian government, though, with near militaristic enforcement and protection of the animals, they are once again thriving despite their rather slow reproductive rate. They are an incredibly awkward looking animal that is beyond shy and, despite this, they still manage to strike fear for their sometimes aggressive behavior when forced to protect themselves or when there is a calf somewhere around. When hunted, though, these large and unwieldy animals can use their large horns quite effectively when defending themselves and there are plenty of stories of hunters who have succumbed to their attacks. This is why they are one of the Big Five animals along with the lion, elephant, leopard and Cape buffalo, all of who are equally dangerous when being hunted. Thankfully, they are not threatened by our long camera lenses.

Now that we had seen the lion and the rhino, and with no further radio traffic regarding other sightings, it was time to drive by the hippo pool and then the Lerai Forest on our way out of the crater. I had spoken with my friend, Ladislaus, at the Ngorongoro Crater Lodge about having us stop by for a tour and some coffee or drinks before departing the crater and the NCA. He is always so gracious and was happy to have us come by which is always such a treat for everyone, given the fact that it is one of the most luxurious lodges not only in Tanzania, but probably in all of Africa.

Arriving to the lodge in Turtle, so incredibly dusty adlong with the rest of us, I always seem to feel a bit self-conscious walking into a main house for one of the three villages there as everything is so very clean and immaculate. It’s easy to forget that we’re in Africa, though considering the views of the crater from every single window, the sight quickly reminds you of where you are. Ladislaus has great stories that he tells us of the history of the lodge and his journey to get there and become one of the village managers for the camp. There are also some resident animals at the lodge and, as we arrived, zebra were wondering around the lodge in small groups. There was also an older Cape buffalo, normally a very feared animal, snacking on some of the bushes outside of one of the rooms that didn’t seem to mind our presence, even though Taha seemed to get just a little closer than Ladislaus wanted when trying to get his own photo with the beast. Thankfully, he survived the encounter. After using the restroom, Ankita came running out to tell us that there was an elephant outside. Sure enough, an elephant was crossing the grounds directly in front and was the closest view of these great animals that we had all day.

They took us to a few rooms to check them out, one in the Tree Village that was a bit smaller and let luxurious, and the other at South Village that was much larger and far more luxurious. All of the rooms have incredible views of the crater not only from their deck, but also from their toilets, bathtubs and bedroom. Once finished with our tours, it was time for us to depart as I had to be back to FAME by 6 pm for a meeting with two members of a company that aligns philanthropic clients with non-profits looking for funding. We rushed around the rim and then back down the main road descending to the Loduare Gate and then on to Karatu for my meeting at FAME. We arrived at 6 on the nose, and I had to run in, jump in the shower to clean all the filth and dust off of me from the day and then run next door to Joyce’s house where we were having our meeting.

Afterwards, Susan invited me to accompany the two advisors who I had met with earlier, she and Mary Ann for dinner at the Lilac Café in town. With everyone pretty hungry and me exhausted from an entire day of driving in the crater, it took well over an hour to get our food, but, then again, this is Africa! Too my incredible pleasure, though, while waiting for our dinners, in strolled, or, more accurately, waddled, one of the cutest animals in all of Africa right at our feet – a hedgehog, who had come in from the street probably looking for warmth. He seemed to be heading towards the kitchen, though there would be no food for it there considering their diet consists mainly of insects and occasional small reptiles. I followed him in and one of the kitchen workers picked him up and handed him to me. He squealed and twitched about a bit, but was as cute as advertised. I set him back down on the floor at which point he promptly waddled away seemingly quite happy and in search of some juicy bugs. Thus, I happily added yet another animal to my list for day and my long list of animals seen over the last thirteen years. Life is good….

It had been an interesting day and evening yesterday as they had been so very different for us – the tremendous diversity of the clinical problems we had seen, some neurologic and some not, that had really run the full gamut of emotions, though unfortunately more that were incredibly trying rather than hopeful unless you count the gentleman with the brainstem hemorrhage who could have looked much worse than he did. The little baby who everyone had worked so hard to keep alive and even beat the odds, eventually did not, but more from cultural issues than medical. The young boy with what we believed to be rabies and, if so, the only thing to offer would be comfort care. Of the bunch, our real hope for a good outcome would have to rely on the mother who was 25 weeks pregnant and was transferred to ALMC – there was still a reasonable chance that either her pregnancy could be extended or, if she delivered, that the baby would survive against all odds as they often do here given the resilience of the patients and people living here in this often harsh environment.

Meanwhile, I had spent the night at Rift Valley Children’s Village in some luxury given the lovely dinner and lodging we had there as guests and board members of FAME. I had a tiny bit of angst over having left the residents on their own for the night, but in the end, they had enjoyed themselves at the Highview Lodge and despite several messages that I sent this morning, they went unanswered as the entire group had slept in quite late and hadn’t seen them. I wasn’t really worried, though, as I knew if anything seriously wrong had occurred, I’m certain that I would have heard about it.

It was another group affair at India’s for breakfast with the large group of older kids home from school sitting at her very long dining table having cereal and friend and Kahawa, or coffee. I broke down and had a bowl of granola, corn flakes, blue berries and yoghurt, even though I’ve been amazingly firm about sticking to my intermittent fasting that I started several months ago. I don’t eat until noon and finish by 8 pm and I’ve felt great with this regimen that fits perfectly with my schedule both here and at home. We left RVCV by around 11 am and were home before noon, back to FAME and a quiet schedule for a rare day off for us. The clinic had slowed up during the week and Anne, who is a Seventh Day Adventist and whose sabbath falls on Saturday meaning that she will typically take these days off when we’re not around, but will graciously work them during the time that we’re here. Given that we expected very low numbers of patients for the day, both for us and the OPD, and the fact that Anne has been working most Saturdays, we decided not to schedule clinic for the day, but to remain available should there be any inpatients for us to see or should a straggler happen to wonder into clinic needing to be seen by us.

We had also planned to have dinner at Gibb’s Farm tonight which we would have done for no good reason, though we could also celebrate both Ankita and Taha’s birthdays at the same time. With the plans for dinner and an early arrival at Gibb’s, we could try to finish up any business at the clinic early and be on our way at a reasonable time. Depending on the weather, we would also plan for a possible swim in their pool.

The young boy with presumed rabies was still in the ward and, even though there was really nothing to offer in regard to treatment of his underlying condition, we were providing him with comfort care measures, meaning any sedation or muscle relaxation that would make him more comfortable. Taha and I made our way over to the ward to discover that he had been moved to the isolation ward that had been created with the pandemic, and now was to be turned into a surgical ward for post op patients as FAME was working on beefing up their surgical program as part of our new five-year strategic plan.

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The boy had been on standard isolation precautions previously, meaning only gloves, masks and eye protection, though the main issue was really to avoid any secretions, but primarily his saliva. I had mentioned previously that there has never been a case of human to human transmission of the virus, other than through organ or cataract donation, but given the consequences of contracting the virus and becoming symptomatic, meaning certain death, doing everything possible to prevent its transmission seems pretty reasonable. The boys older brother remained at his bedside and the boy was certainly quieter than he had been the previous day, likely the effect of the standing haloperidol and as needed lorazepam that he was now receiving. We had his brother conversing with him while we stood mostly in the doorway so as not to risk exposure and it was clear that the boy remained severely encephalopathic and, by the way he was handling his secretions, it was also obvious that he was unable to swallow. He was refusing to drink any water per his brother and, very shortly upon our watching him, began to launch streams of his saliva across the room in a spitting action that was very impressive and very dangerous for those of us in his vicinity. He wasn’t screaming any longer, but was babbling on and on about which I had no idea, nor do I believe did his brother. It was very, very sad to see this young man in his current condition, but there was absolutely nothing to do for him other than provide compassion.

We walked over to the OPD to find the doctor who was covering the ward for the day just to discuss this case as well as the gentleman with the brainstem hemorrhage. The timing was good as they were just about to order rabies immunoglobulin for the boy, but this had been discussed the night before with folks from a Tanzanian NGO team as well as an ID consultant back home and it was very clear that once a patient is symptomatic, neither the immunoglobulin nor the vaccine will provide any benefit. It would be a waste of a very precious resources and, thankfully, our timing was perfect as we were able to intervene and prevent the immunoglobulin from being administered. At the same time, we were also able to pass on the news that they could discharge the man with the brainstem hemorrhage as he continued to do well and was surprisingly ambulatory.

With our work at the clinic complete and any cloud cover having broken up, it was time to consider heading to Gibb’s Farm. The others had decided that they would like to check out the pool, though neither Mary Ann nor I were up for that. We made it there by late afternoon and the weather was spectacular with bright equatorial sun and plenty of necessary shade throughout provided by their magnificent trees and landscaping. Sally, their general manager, just happened to meet us at the front entrance of the property and invited us to join them at the poolside at 5:30 pm for the local Tloma Village Choir which I had seen several weeks ago, but ended up equally entertaining as they had been the first time. She also invited the residents to enjoy the pool as much as they wished which was a real treat for them.

It was a lovely late afternoon and evening with the residents swimming and Mary Ann and I sitting in the shade and just enjoying the peace and quiet that is Gibb’s. At around 5:45, the choir came marching in and gave a very nice performance of song and dance and then it was time for dinner. They did have drinks at the poolside during the choir performance that I believe we all took advantage of, and then it was time for dinner, which, of course, was amazing as usual. I had told them of Taha and Ankita’s birthdays, so, come dessert time, the waiters and kitchen staff came out with two plates, each containing a personal chocolate cake, candle and decoration with their names. They all same “Jambo Bwana” first followed by “Happy Birthday” twice, once for Ankita and another for Taha. It was tremendous fun.

We drove home at a reasonable time given the fact that we were leaving for Ngorongoro Crater quite early the following morning and still had to prepare our lunches, which the residents were going to do, and I would gather up all the additional supplies necessary for the trip that included most camera equipment and binoculars. I have two cameras, one for me and one for the residents to use, both with longer telephoto lenses and perfect for shooting photos of the animals. They were all incredibly excited to be going tomorrow.

Today, we were very busy on numerous fronts and it all seem too start with morning report. But first, Mary Ann had wanted to cover a topic that was very dear to her heart, and ours as well – child development – in about 10 minutes at the beginning of report. She had some very tables and graphs that were simple and easy to remember and would help to identify whether a child was meeting their developmental milestones or not. There is certainly a wide range on when a baby reaches of these milestones, but at least this gives one a ballpark for reassuring parents. Not every child is spot on with their dates, and reassuring families is often the most important thing. The charts Mary Ann presented to help with these determinations were very simple to understand and would also be very easy to put in one’s iPhone for future use, especially by those adult neurologists of us seeing these children when we don’t have a pediatrician or pediatric neurology around. It was also Ankita’s birthday today, so everyone sang Happy Birthday to her at Morning report, but then we had another surprise for her that she would receive at lunchtime along with Taha, whose birthday was coming on Sunday.

There were two patients in the ward that were both concerning from a neurologic standpoint and would each need our attention sooner or later. The first, was a gentleman in his 50s who came to FAME after drinking and then developed nausea, unsteadiness, right sided weakness and diplopia. We were clearly worried that he had a brainstem event and, since Ankita is planning to go into stroke, she was more than happy to go see this patient and to check out the situation. The patient looked much better than anticipated given the story we had heard, though he continued to have excessively high blood pressures, probably a manifestation his chronic hypertension which had unfortunately not been adequately controlled previously. The patient went for a CT scan of the brain at some point that morning that demonstrated a very significant brainstem hemorrhage that should have caused far greater deficits than he had, which was certainly good for him considering that there was very little we had to offer him other than restricting him from any antiplatelet agents and managing his hypertension going forward.

Hypertension and stroke occur with a much greater incidence in Sub-Saharan than what we see at home and much has been written about in the countless journals on the subject and numerous studies concerning this matter have also confirmed this additional burden of disease here. Hemorrhagic stroke also occurs at a higher incidence in Sub-Saharan Africa and this is very felt to be due to the excessive amount of undiagnosed and untreated hypertension here where it is always an issue trying to treat chronic disease in culture that still hasn’t fully recognized this entity or the need for chronic medications. Treating an infection with an antibiotic or a case of worms with albendazole requires only a short course of treatment and you’re done. Taking medications for any length of time is something that requires an entire readjustment of the thinking here.

The other case that we had to see in the ward was a 13-year-old Maasai boy who had come in last night and was reported to be confused and was also complaining of pain in his legs. Dr. Jacob, also a Maasai, had conversed with the boy and noted that he wasn’t entirely confused and had mostly been complaining about his leg. Taha had offered to go the ward to see the boy before our clinic, but the true extent of his condition and all its ramifications would not unfold until much later in the day.

When it came time for maternity rounds at morning report, there was very vigorous discuss regarding a woman who was 25-weeks pregnant and had been having significant issues with severe hypertension for several weeks so there was concern over impending pre-eclampsia that would not only risk the life of her child, but hers as well. The problem was that her baby wouldn’t survive being delivered at 25 weeks here in Tanzania and that the closest full neonatal intensive care unit that could deal with a neonate that small was in Arusha at Arusha Lutheran Medical Center, or ALMC.

Initially, there seemed to be the decision that the woman should be advised to deliver her baby, who would not survive here at FAME or, if they did, they would undoubtedly have a tremendous burden of neurologic deficits. If the woman did not wish to proceed in this fashion, then that bridge would be crossed at that time. At this point, Mary Ann weighed in heavily with the recommendation that we should strongly consider transfer to ALMC immediately as was a very difficult situation and, that in her experience, it was much safer transporting the mother and infant still intact before delivery than it would transporting a 25-week premature infant on their own after delivery. In the end, after discussion with ALMC, the director of the hospital agree not only to take the woman and her unborn child, but also committed to covering the cost of their care if the patient and family were unable to do so. Miracles to happen every so often.

When it came to our lunch that day, I had asked Prosper to have a cake made for both Ankita and Taha that could be presented during lunch and all the staff could sing, “happy birthday.” The cake hadn’t quite shown up in time, though I was able to drag my feet long enough for everything to get set, which meant having the cake brought to the kitchen and placed on the counter where our lunch is traditionally served so they would see it immediately upon entering the cantina. Sure enough, they were both entirely shocked, as was I , and I think they were both quite surprised to see such a gorgeous cake here in the middle of Africa and I was equally so. There had been lots of kidding about what they both could expect and Anne had them convinced that they were going to have cold dirty water poured over their heads when they least expected it, though, of course, this was all a rouse and there was no such thing, or at least not that I’ve ever seen. Typically, though, the birthday cake is to be cut in many bite sized pieces and then everyone lines up to have the one whose birthday it is feed them a piece of cake with a toothpick. I had to do this for my 60^th birthday at the Highview Lodge, but for today, it was just a matter of singing “happy birthday” to the two of them while the cake was doled out to everything along with their rice and beans.

Sometime during the afternoon, Mary Ann had brought some sad news to me regarding one of our recent patients, a young 28-week premmie born at FAME earlier in the spring who had actually been discharged home but had been admitted several times in the recent past with complications of her bronchopulmonary dysplasia. She had come back in well over month ago and had been slowly gaining weight and improving, but still required the smallest amount of oxygen otherwise she would desaturate. While the last group was here, Cara had seen this child daily and, on some days, multiple times checking in on her. Apparently, her bebe (grandmother) came in insisting that she be discharged so they could take her to KCMC, though, in the end, that was not their intention. Given her even tiny oxygen requirement, it was not surprising that the child died without it shortly after having been discharged from the hospital. She was a beautiful child who had battled back from incredible odds only to suffer the consequences of a complete lack of understanding despite our best efforts otherwise.

So, now back to our young boy who had been brought in last night with complaints of confusion and leg pain. His vitals were fine and there were no signs of infection or meningitis that we could find, yet he was seeming to worsen with increased confusion and all of his lab work was unremarkable . At some point in the midafternoon, though, it was reported that he was having difficulty swallowing and, upon learning this, Taha because concerned about an infamous disease that is rare at home but not in other parts of the world like Africa and Asia. He quickly asked the boy and his older brother who was also there whether he had been bitten by an animal prior to the current symptoms having started.

Sure enough, the boy related the story that he had been bitten in the heel by a dog that was aggressive and that he and his younger brother had subsequently killed. He also reported that his younger brother had also been bitten by the dog. The boy was encephalopathic and had very rapidly developed severe dysphagia and, shortly thereafter, was documented as having a fear of drinking water, or hydrophobia, when he was offered it. The boy had the hallmark features of rabies and, sadly, now that he was symptomatic, the disease would be 100% fatal with no adequate treatment existing anywhere in the world.

When I arrived later in the evening, the boy was severely agitated and screaming in his bed, confusion and was unable to swallow his own saliva. I will never in my life forget that image of his massively wide eyes and the look of fear or madness in them along with his continued screaming in Maa, the language of the Maasai. At that point, as we had little doubt to the diagnosis, we began treating him with comfort measures to reduce his suffering and first gave him some haloperidol, a strong tranquilizer to calm him down and provide some sedation. I also immediately put into action the network of contacts that had been developed six months ago when another child had presented to FAME and immediately died.

The issue wasn’t in regard to treating a patient currently symptomatic, but rather doing contact tracing for any exposed to the boy who would benefit from receiving rabies vaccination, the current recommendation from the CDC and WHO for the prevention of human to human transmission, though a case of human to human transmission of rabies has never been confirmed outside of organ or corneal transplantation. The matter, though, is one of absolute, 100% safety as there is no room for mistakes when a disease is uniformly fatal and can potentially be prevented by receiving a simple vaccination. Any healthcare worker or family member who had been exposed to the patient’s secretions, a scratch or any other means of possible transmission should receive a vaccination. Taha, who had made the amazing diagnosis to begin with, would be one of those at FAME to receive his vaccinations.

In the midst of all this, a number of us had been invited up to Rift Valley Children’s Village for dinner and to stay the night, Mary Ann and I were to be staying in the Kili House, their accommodations for their own board members when visiting, but given the partnership between Tanzanian Children’s Fund and FAME, the two of us apparently qualified as board members. Frank and Susan stayed at India’s home and Dr. Elissa, a previous volunteer at the RVCV many years ago, found lodging with some of India’s older children. It was a lovely night that followed an incredibly hectic day and it was so good to relax for a moment.

Meanwhile, the residents had decided to visit the Highview Hotel which is next door to FAME as they had a spa with massages, manicures, facials and pedicures, all of which they took advantage of prior to having dinner there as well. The hotel even provided them with a ride home that night which was actually very good considering several days later, there had been a killer bee attack nearby and a local woman died as a result. This was obviously a specific situation in which they were near the bees or working with them and not something remotely likely to happen otherwise. Still, I was quite happy to know that the residents had made it home safe and sound after their night out.

Though this morning’s lecture, which was given by Mary Ann, our visiting pediatrician and fellow board member, was on the topic of neonatal hyperbilirubinemia, it had quite a bit of relevance to us as neurologists as the significance of this condition is one, that it results in the neurologic syndrome of kernicterus, which produces a condition akin to cerebral palsy, and two, it is completely preventable and often very predictable in certain populations. The incidence of hyperbilirubinemia, and thus, kernicterus, is much higher in patients with glucose-6-phosphate-dehydrogenase deficiency, or G6PD deficiency, an x-linked genetic disorder that is found in a very high incidence in African-American males in the US as well as other regions of the world including Africa. There is also a relationship between G6PD deficiency and sickle-cell trait, both of which will cause hemolytic anemias that, in neonates, will result in hyperbilirubinemia and, if not treated, eventual kernicterus.

Elevated bilirubin occurs in many babies and is most often not harmful and will be cleared on it’s on, but there are many situations in which a babies bilirubin is elevated beyond normal, such as immunologic incompatibilities between the mother and baby, severe bruising of the baby that may have occurred at birth or certain genetic or ethnic factors that may impair clearance of the bilirubin. When the bilirubin reaches severely high levels, it must be treated as an emergency and the babies should be receiving phototherapy immediately for just as in stroke, time is brain. If babies don’t respond to phototherapy in regard to lowering their bilirubin levels, then it may be necessary to perform an exchange transfusion, but this is a life-saving procedure that carries significant risks and is used only in the most severe of cases and those in who the risk of brain injury is immediate.

A number of members of the staff were unable to attend the hyperbilirubinemia lecture as there had been a “mzungu” emergency in the OPD prior to the beginning of the teaching session. A young visiting child from one of the nearby lodges had apparently had something to eat that had caused an allergic reaction with diffuse urticaria and some wheezing, but did not have any significant airway obstruction nor did they have any mucosal involvement to indicated that they were having anaphylaxis. Just the same, no one was really interested in proving the point, so the child was given some steroids and antihistamines just to be safe, but it did require the attendance of several of the doctors right at the point that Mary Ann was giving the talk.

As is usually the case, there was some great discussion on the topic that followed the talk and also some very good questions. One that was asked by Dr. Ken, related to the use of phenobarbitone (phenobarbital) in the baby to help hasten the decrease in the level of bilirubin, something that I had never heard before, nor had Mary Ann, but sure enough, when I did a quick search on the internet during morning report, I found numerous references to both giving the mother prenatally and the baby postnatally the medication. This is not a practice in the United States, but does sound like it is used in some resource limited settings, similar to here at FAME, as the phenobarbitone will induce the liver enzyme pathways to clear the bilirubin quicker. Very ingenious and something that makes a lot of sense once you hear it.

After report, we checked on our little baby with the seizures who was miraculously doing very well and had been seizure-free since noon the prior day and looked very well. We had made some simple adjustments in the baby’s antiseizure medication regimen and the combination was holding – he was still on four medications, but we were weaning one them so he would be going home in a day or two on three medications as long as he continued doing as well as he was now. Again, his mom was incredibly understanding and, though clearly thrilled that he was doing so well, did understand that he was still developmentally delayed and that this was not going to improve necessarily with his seizure control. If his seizure burden prior to coming in to see us had been so excessive that it was limiting his development, though, he could have some subtle improvement and that would be something to hope for, at least.

Our clinic was again rather slow today and though it was not entirely clear as to why, I have seen this in the past typically in times of harvest or the rains, but neither of those were ongoing at present. The effect of the pandemic could certainly be playing a role, though not in the manner most would expect. Tanzania was hit tremendously harder by COVID-19 from a financial aspect than it ever really was from a medical standpoint for as worldwide travel had essentially shut down over the last two years both in regard to the availability of flights and to its safety, the number one industry here, that being the tourist trade, was decimated.

The impact was devastating as the safari companies, the lodges, hotels and restaurants all felt the brunt of the loss of visiting tourists, but also the jobs at these businesses that supported the towns and villages also became non-existent and it was very difficult for people to get by. How a family who had been paying school fees for their children and paying their bills and were just barely making ends meet were going to make do was not entirely clear. Even though over the last several months, the tourist trade has dramatically rebounded and many of these jobs have returned, the financial stability of the country, that is, if one could ever really consider it stable, has not completely returned and many of the businesses that had previously accounted for the job market are not fully up to speed. I’m sure there is also a fear of what would happen if there is again a ban on travel due to a blip in the pandemic – business owners must have this in the back of their minds and are hoping to protect themselves in some manner should it happen again. I am sure that these effects of the pandemic are still in people’s minds after the trauma of the last two years.

Turtle needed some minor repairs and I had wanted to get them taken care of prior to our upcoming trip to Ngorongoro Crater on Sunday, so I drove down to our mechanic’s place in town, though he was unfortunately not in. The young boy who had helped me with the rear door of the vehicle last week was there, though, and proceeded to fashion a gasket for my oil filler cap that had been leaking and at least took care of that problem. Our doors had begun to act up again and we were back to having only two of the four doors working from the outside – these Land Rover conversions to a full on safari vehicle have still not had all the bugs worked out and I wasn’t able to fix that problem today. At least my door and one of the other back doors work and though it’s a pain to lean over and open the doors from the inside, we can do it.

We had dinner on the veranda of Dr. Joyce’s house (the Hoffman House) which is next door to ours and has much more space for us and also has a great view similar to ours. We had wanted to join Mary Ann as she’s staying there by herself and besides, I had promised Joyce when we had built our house that we would continue to have dinners on her veranda as much as possible. The two cats were as annoying as ever despite the fact that our meals were completely vegetarian. I’ve never seen cats who are willing to pounce on chapati, but somehow, these two are more than willing to do so.

After dinner, Mary Ann asked if anyone wanted to play Bananagrams and Taha, Ankita and Sara were up for it, so joined her in the house to play. They came back home later reporting that Mary Ann had won every game and they were very impressed with her skill, which certainly didn’t surprise me at all. I’m just not a game player and will typically do my best to sit out, having been quite successful so far on this trip. After they returned, we decided to watch a movie and everyone decided upon the original Top Gun. Though I had planned to work while watching, I’ll have to admit that I didn’t get much done as it was hard not to pay attention to the movie as we had it playing on quite large on the wall with my inexpensive LCD projector and the sound through a USB speaker which made it quite entertaining.

I did interrupt the movie at one point to share a baby day gecko that I had caught earlier with the others, though I’m not sure how much they appreciated it. They were entirely shocked when I let it go back in the house where I had found it, but given that these little creatures catch the mosquitos, I wasn’t about to put it outside. Later, as everyone was going to bed, I caught another, even smaller, baby gecko and knocked on Taha’s door, though he was again not very appreciative of the gift and wouldn’t let me release it in his room, so it went back to my room in the end. Hopefully, no one had bad Malarone dreams of giant man-eating lizards that night.

In addition to discussing our patients, morning report is a time for any announcements to be made and today was Alicia’s last morning at FAME after having been here for two months as part of her global health fellowship. She spent the first month as the only volunteer here at FAME which one might imagine could be rather lonely, though it is also a time where one is forced to become a part of the routine here rather than hanging around with the other volunteers as is sometimes easier than making new friends. In the early years for me here at FAME, there always seemed to be other volunteers that were here at the same time, though it was only one or two at a time. Later, when bringing the residents, my role drastically changed as I was in charge of the group and most of my time was spent making sure that everyone and everything was taken care of and in the right place. During my one visit in the fall 2020, during the height of the pandemic and prior to vaccinations, I was here alone, but by that time I had become a fixture at FAME and everyone knew me, a much different situation than if you were here volunteering for your first time.

So, after morning report, Alicia spoke to the staff about how amazing her time was here at FAME and how much she had learned in addition to how much she had been able to pass on to the staff regarding maternal care. In my role as a board member of FAME, it had been clear to me that the benefits of her involvement had been tremendous, both in regard to deliveries as well as prenatal care, and that her visit would have a lasting effect on the staff and patients here. Having relationships such as these for global health fellows that come on more of a long term basis is extremely important. Alicia had come through a relationship with Creighton University, that had been established several years ago and had previously brought a surgical fellow, Dr. Kelly, for an entire year, and Dr. Alyssa, another OB/Gyn who had come in 2020 prior to the pandemic. Our hope, of course, is that these fellows with eventually also become long term volunteers who will continue to visit FAME in the future, though even if they don’t, their positive impact on the health of the residents of the Karatu district will be long lasting.

We started out work for the day with our little baby in the ward who had been seizing overnight and was now in need of making a change. The decision after last night’s discussion with my peds neuro fundis (experts) was that we would put him back on phenobarbital, but not a loading dose given all the other medications he was on. We spoke with mom, who has actually been incredibly patient with us given the difficulty we’ve had in controlling her son’s seizures, and informed her that we were going back to the phenobarbital and our hope was that he would stop seizing or at least that they would slow down significantly. While seeing the baby this morning, he proceeded to have a seizure for us during rounds just to prove the point that something needed to be done. As he had an IV in, we decided to go with IV phenobarb as that would get on board the quickest. Sure enough, his last seizure of the day was around lunchtime and, after that, they reported no seizures at all to us for the remainder of the day. The baby was sedated throughout the day, of course, but was still arousable and, most importantly, still breathing. Finally, we were making some headway with this child.

The clinic day remained rather slow which allowed a good amount of time for the residents to do some neurology teaching with our translators, who also happened to be clinical officers and could greatly benefit from the additional time for education. Going over such topics as management of headache, and migraine specifically, back pain, epilepsy, and the neurologic examination were all areas that were incredibly helpful for them to work on during these downtimes. Unfortunately, we’ve had more of these lulls in patients than we would like, but there’s very little that we can do to change things and there are times that we wonder whether we’ve actually stamped out neurologic disease in the Karatu District. As quite unlikely as that was, it still crossed our minds.

At one point, Kizitu, who is in charge of all nursing services here at FAME, and is also a Maasai, came by to check on how we were doing and ended up answering questions from the residents as they were curious about his tribe and their culture as they make up a significant portion of who we see here, along with the Iraqw, who are the other tribe that we see in significant numbers here at FAME. Interestingly, it has been these two tribes, the Maasai and the Iraqw who have been at odds in the most recent past, not signing a treaty until 1986 to ensure their continued cooperation. The Maasai are pastoralists, acquiring wealth through there large herds of cattle, goats and sheep, though it is traditionally cattle that are their main source of food, eating the meat, drinking their milk and also their blood on special occasions. This practice (the milk and the meat, not the blood) and the fact that everything is unprocessed, actually exposes the Maasai to an infection that is seen here commonly called brucellosis, though on rare occasions it can actually develop into neurobrucellosis which then becomes much more serious and our problem.

The Maasai are probably the most well-known of the Tanzanian tribes (there 128 culturally distinct tribes in Tanzania) for their colorful dress, their way of life (mud huts grouped into a family unit, or boma) and their warrior reputation, though it is also due to the fact that tourists traveling here have the greatest exposure to them as they live in and around many of the national parks and the game reserves. More recently, there has been tremendous controversy regarding the Maasai living in certain areas and especially the Ngorongoro Conservation Area, where they have become extremely overcrowded over the last thirty years and have greatly encroached on the resident wildlife such that the government has proposed moving them from what they consider are their ancestral lands. This struggle is still ongoing today and a lasting solution is still in the works.

Regardless, the Maasai, who make up a significant portion of those who work and are seen at FAME and also live in the Karatu District, are an extremely proud and culturally profound group of people who I have become very close with during my work here at FAME and have found them to be a both wonderful and unique people. The Maasai range throughout Northern Tanzania and most of Kenya and though most of them speak Swahili, many who are from the more remote areas speak only Maa, their traditional langue, making translation for these patients often a three-way affair.

Once clinic was finished for the day, it was time for me to bring everyone over to Teddy’s shop for them to select fabrics and then decide what each of them would like to have made with them. I had first met Teddy several years ago when I was introduced to her by our former communications director here a FAME who had used her for having clothes made. Teddy’s original shop was just off the road past Carnivore, a local’s bar and restaurant that served only grilled cuckoo (chicken) and chips and had a tiny dance floor – Carnivore has now been replaced by the Golden Sparrow, which was built by the same owner. From the very first time I had met Teddy, I was sure that she was the one who would best take care of my residents going forward and we have never been disappointed.

Teddy has now moved to her very own shop which is in her home on the far side of town and, even though a bit further for us, it is an outing that everyone enjoys. She has a small duka (shop) that carries lots of general supplies for the neighborhood and then also has her fabrics and sewing machines. In the past, we would typically first go to a fabric store to pick out the patterns that everyone liked, but just recently, Teddy has acquired a great number of these incredibly colorful and distinctive fabrics for sale at her own shop, so it was now only a matter of going there rather than having to make two stops.

Everyone found fabrics that they liked and began to give her their patterns for the clothing they wanted made while she diligently began taking everyone’s measurements and putting them down in her notebook with tiny swatches of each fabric she was to use to make the piece of clothing. We had brought Mary Ann with us, and even though she didn’t want anything made as she does all of her own sewing at home, she did find two very nice pieces of cloth that she wanted to bring home and use. For me, I have never really had anything made, and even though I am totally enthralled by the colorful designs of the fabrics, they have just never felt comfortable on me for some reason and having something made that I would never wear just doesn’t seen like a good option. So, I live vicariously, enjoying bringing each group of residents to Teddy’s shop, them thinking it’s an imposition for me, when, in reality, it’s a total joy for me, both watching them go through their process of deciding on fabrics and what to make as well as the joy of bringing someone as deserving as Teddy this steady business for her shop. She takes care of the residents and we take care of her.

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.

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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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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 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.

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.