Given it was a Thursday, this morning’s lecture was on the examination of the newborn, being given by Mary Ann, a volunteer pediatrician and fellow FAME Board member. There was little question that Gina, our pediatric neurologist, and Megan, our soon to be pediatric neurologist, would be attending the lecture, though I would have to skip it as I had thought Jill would need a ride to the Black Rhino this morning with Pete and Amanda’s car still in the shop. Luckily, it had been fixed in a day with parts being shipped by bus from Arusha and, at the last minute, I was replaced as a chauffeur and Jill caught a lift with Amanda and her son, Ollie. The school is certainly walkable, though not well-advised to do so on your own given the chance that running into a stray buffalo, or even worse, leopard, is not insignificant. Given the fact that I was very interested in keeping Jill around for some time, she took the Amanda option rather than hoofing it on her own.

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It had been intended this morning for the residents and Joe Berger to have had a meeting with Susan (I would also attend) so that she could give them a bit of the FAME mission and philosophy, but as so likely happens here, our schedule was very quickly derailed as morning report went nearly thirty minutes over and there were patients waiting for us in clinic. The purpose of the meeting with Susan was really to just hear from her exactly what FAME was doing here and what we hoped to accomplish. As I had mentioned previously, FAME is current seeing 30,000 patients a year and is providing medical services to a vast population of Northern Tanzania in the Karatu district as well as more remote sites that may be more than a day’s drive and tremendously longer on foot.

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Again, our role here is to assist the Tanzanian caregivers and staff at FAME and not to be the sole provider interacting with the patient. Seeing a patient without a Tanzanian colleague is an opportunity lost for we would leave very little behind. The other issue that is quite significant here, as it is no matter where one is participating in global health, are the unintended consequences that are the result of actions that may seem like the right thing to do, but, in actuality, are not and often create a cascade of events that only complicate matters in the long run. I have numerous examples that I could give, but the one that I usually use to illustrate this exercise is the patient one sees in clinic who cannot afford their medication or treatment. The actual cost of these things in Western terms is very, very small and there is every temptation to reach into one’s pocket and either hand them the necessary money or pay for them at the cashier’s office.

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Though helping this one patient may seem like the right thing to do, you have actually created something of an international event as, despite helping that single patient, they will now go back to their village and tell everyone that if you go to FAME and see the mzungu (meaning stranger, though mostly used in reference to a white person) doctor, they will pay for your care, whether you need that or not. That would certainly be a problem as we are not here as the primary caregiver but are partnered with the Tanzanians to share (often bidirectional) in the care of these patients. And, what’s worse yet, is that by the single act of paying such a small amount for a patient’s care, you’ve just completely alienated the entire Tanzanian staff as they do not have the same ability to reach in their pockets. With a single act of what was thought to be kindness, and certainly the well-meaning intention was there, you have created a situation that will now require a significant amount of finesse to undo, and, in doing so, may limit your effectiveness in the future.

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That is not to say that patients here who are unable to pay for their care are not treated, but rather we have well-trained social workers (Kitashu and Angel) who will assess the situation and determine what the best option is going forward. It is inherent that they are involved before any decisions are made or before any unintended consequences might occur. There are creative ways for us to be certain that those in need are cared for and it must seemingly come from anonymous sources that do not involve the volunteers at FAME. It is not enough to be well-intentioned in this world and acts of kindness must be well-thought out and planned, or inevitably things can go awry.

In the end, our meeting with Susan had to be cancelled given how late it was after morning report. We will meet sometime next week after our mobile clinics so that she can hear from the residents. Perhaps, with more time under their belts, they will have more insight and opinions to share with her. Either way, postponing the meeting will not deter our work in any way.

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As for patients today, it seemed as though someone had advertised that there was a blue light special on psychiatric disease. Seeing psychiatry for us is not at all unusual, as there are few psychiatrists just as there are few neurologists, but it was the volume that we saw today that was perhaps a bit surprising. In the population of patients that we are seeing on a regular basis, that is, they are returning every six months to see us, we have many with various psychiatric illness including bipolar disease, schizophrenia, and depression. Most of these are doing incredibly well on the medications we have prescribed and, except for periods of non-compliance, often from running out of medication due to cost, they are well-controlled and very functional. To be honest, I’ve been a bit surprised over time at the number of schizophrenic patients that we’ve seen and followed here, but I have little to compare it to as this isn’t something that we treat at home.

One of the more interesting patients for today was a young woman who had been struck by a motorcycle (or a boda boda as it is referred to here) about a week ago. She had lost consciousness and by report had been out for about two days but had gone to the local hospital in town (Karatu Lutheran Hospital) and was transferred to Mt. Meru Hospital, which is the government hospital outside of Arusha. There, she underwent a CT scan of the brain which she did bring with her today and which we were able to review.

She was now having headaches (not surprisingly), but more importantly, she had a complete left ptosis (her eyelid was completely drooped) and her left eye was “down and out,” meaning that it was fully abducted and depressed. The meaning of this was she appeared to have a third-nerve palsy (less likely entrapment of the muscles given the ptosis), and, with her history of head injury, this was concerning for either a direct injury of the third nerve or for some compression of the nerve due to bleeding or swelling. In reviewing her CT scan, it was very clear she had orbital fractures involving her left orbit with near-complete opacification of her left maxillary sinus as well as some opacification of her ethmoid sinus suggesting a basilar skull component.

We could certainly treat her symptomatically, but what she really needed was to see an ENT specialist for the orbital fractures and the third nerve palsy to see if she needed any procedure or stabilization of the injury. The closest ENT would be at Kilimanjaro Christian Medical Center (KCMC) which was unfortunate as it is very close to Mt. Meru Hospital where she had the CT scan to begin with and could have simply been referred directly to them, rather than having to be sent back from Karatu. She was also complaining of hip pain, so we did get an X-ray of her hip that looked normal to us and certainly did not show any significant fracture or deformity. We made the recommendation for her to be seen at KCMC, which they did seem to indicate they could do, and hopefully she will go.

There is a phenomenon here in Northern Tanzania that has to do with the large population of Maasai in the region and that is the Maasai Market. This is not the Maasai Market that exists in Arusha or other locations for the purpose of selling things to tourists, but rather a market for the Maasai, or any other locals who wish to buy virtually anything that you can thing of. Every village will have a market day either once or twice a month, and the Maasai Market in Karatu is one of the largest around, occurring twice a month, on the 7^th and 25^th of each month. I have experienced the market on several occasions and fondly recall shopping with Jess Weinstein and Jacci Herold back in the spring of 2016, when I watched the two of them happily shopping among the vast piles of second-hand clothes, most of which have come from the US. That was the last time that I enjoyed visiting the market.

Since then, I have driven many groups to the large fairgrounds just outside of Karatu where the market is located twice a month, but I have not gone in myself. Rather, I have sat in my vehicle while the others have spent varying amounts of time sifting through the many vendor’s wares. You can buy vegetables and cooked foods, bulk grains, hemp ropes, livestock, personal items, baskets, pots, or virtually anything else you could possibly imagine. The market is huge, and it is filled with shoppers and vendors, each hoping for a bargain. As I mentioned, though, the market is for locals and there are no mzungu to be found there, other than us, making easy marks for anyone interested in making a good sale of some local piece of handicraft to bring home.

As we drove up, all the while preparing the others for what they soon be experiencing as Jill and I had no plans to stray from our vehicle, a few of the local “entrepreneurs,” one of whom I have known for several years from the streets of Karatu, ambled up hoping that we would be interested in buying something. They quickly suggested acting as guides for our group, which actually seemed like a reasonable thing given the mass of people who were milling through the marketplace, as well as the immensity of the market itself. It would not be difficult to become disoriented and the last thing I wanted was to lose one of the residents in the market and be putting out an APB later for them. All was well, though, and seeing the entire group coming back after less than thirty minutes with everyone accounted for was an excellent sign and a good indication.

After leaving the market, we still had plenty of daylight left and decided that we would visit Phillipo and his wife, Fausta, our coffee source. We stumbled upon Phillipo and his family about two years ago while walking towards Gibb’s Farm. His neighbor, the wood carver, who I have also known for several years, suggested that I meet his neighbor, and we’ve been friends ever since. Phillipo is a second-generation coffee grower who has a small farm that he runs with his family and caters mainly to locals and other guests lucky enough to know him. He is the loveliest person and each time we visit, we are treated to small cups of coffee to taste as well as spoons of honey from his small stingless bees that inhabit his numerous hives hanging in his yard and around his house.

It wasn’t the right season, but he demonstrated how he processes the coffee beans, first by removing the outer shell in a manual hulling machine, then drying out the beans and pounding them in a pestle with large mortars to remove the inner shells. Once they are winnowed to remove the chaff, the beans are then ready for roasting which is done by hand over hot coals, constantly turning for 45 minutes to prevent any burning of the beans. They are then placed in a cooling bin where the beans are left for about 30 minutes after which they are ready to bag into half kilo portions, either whole or ground, or to enjoy immediately. Though we typically bring only whole beans back with us (we’re purists, of course), we don’t have a grinder here, so buy the ground beans for the house.

It was a wonderful evening and a gorgeous sunset. We departed Phillipo’s home for our home away from home as our dinners were waiting for us. Life is good in Karatu.

As first days go, yesterday was pretty brutal for everyone considering we were all still a bit jet lagged from our long journey here. Despite that, I think it had been a very exiting day with lots of good patients needing neurologic care and opportunities to teach the FAME staff about neurologic illnesses, the entire reason that we’re here in the first place. I should also mention that there are other volunteers here with us, for FAME is not just a neurology center, but rather provides full medical care to the entire community of Karatu and for miles around. Our catchment area is roughly 2.9 million individuals, and patients may often travel for days to reach us here.

The volunteer program has been one of the central tenants of FAME (only one aspect of the education piece with the other being sponsoring nurses and doctors going back to school) since its inception, and the infrastructure to support volunteers have included not only a volunteer coordinator, who takes care of necessary medical licensing and other paperwork, but also housing. When I first arrived here in 2010, we had two houses, each of which had two bedrooms with two beds each, and over the years, there have been two additional houses built along with a small duplex that is used for long-term volunteers, those staying for six months or more. One of the newer houses was funded by a donor who has followed our neurology work here from the beginning and wanted to build a place where we could all stay together, so it has four rooms and houses 8 people.

The other volunteers currently here at FAME include two fellow board members, Mary Ann Zetes and Barbara Dehn. Mary Ann is a recently retired Stanford pediatrician who first came to volunteer several years ago and now returns at least annually to assist with our pediatric programs here at FAME that are quite robust. Barb, who is a close friend of Mary Ann’s and has traveled here with her to volunteer also for several years, is a nurse practitioner who specializes in woman’s health issues and spends most of her time in our maternity ward and with the RCH (reproductive and child health) program. A close friend of their, Sari Levine, is also here for several weeks and was first here last year to volunteer. She is a urologist and not only assists with patients and surgeries in her area of specialty, but also works closely with the surgeons.

Two other volunteers, who are long-term and here with their young children, are Pete and Amanda. They are Australian and have been funded by an Australian non-profit to spend a full year here at FAME. Amanda is an ER physician who has been tasked with bringing our new emergency room here at FAME up to speed, and Pete is a pediatrician who has assisted in general pediatrics while here. They have been here since last August with plans to spend the year, though are already looking into the possibility of staying on longer, especially given the significant need here for both an emergency medicine physician and a pediatrician.

And last, but by no means the least, we have Elissa Zirinsky here, who is a pediatric infectious disease specialist, and is now halfway into her second year at FAME this time around. She has a long history with FAME as she was originally connected with Rift Valley Children’s Village through her aunt who is on the board. Having spent time at RVCV as a volunteer, she was eventually introduced to Frank and Susan and the work they were doing which was a huge factor in her eventual decision to go into medicine. Coming back to Tanzania to practice at FAME has always been a dream of hers and has now become a reality.

Working at FAME is completely a shared experience, and as much as we are bit secluded seeing neurology patients all day, it is often very important for us to be involved with other aspects of patient care here. Seeing babies with hypoxic-ischemic encephalopathy (HIE) or women with pre-eclampsia in the maternity ward are easy examples of the overlap of specialties, but it’s also necessary for us to be involved in morning report, where all the ward patients are discussed, and morning rounds, where the inpatient team will go over patients’ clinical history and course in further detail. During our last visit here in October, while rounding with the medical team on a patient that hadn’t been billed as a neurology patient, LJ heard something that had raised her concern for something neurologic going on and, sure enough, it turned out the patient had suffered a stroke which greatly affected the necessary care to be provided.

Having someone from our team round with the inpatient doctors not only gives the residents a better appreciation of what the doctors and nurses are dealing with on a daily basis here and also allows a contribution to even non-neurologic cases in the ward. It was decided that Joe and Leah would round on the ward service today and there were several patients for them to see, one of which was an unfortunate young boy who had been admitted for the last 6+ weeks with a history of Tb meningitis that had been diagnosed based on response to therapy as opposed to the normal CSF analysis. They had obtained CT scans back in January that were available for our review and, based on those images, they were certainly consistent with that diagnosis and the child looked very, very ill.

As can be seen by the CT scans, there is a significant inflammatory response and diffuse meningitis filling all the sulci and the basal cisterns, with enlargement of the ventricles concerning for hydrocephalus. Though the child was on therapy for their TB, whether they improve from a neurologic standpoint remains unclear at this time. TB meningitis is a basilar meningitis that is often associated with increased intracranial pressure and a high risk of hydrocephalus. It is most often associated with immunosuppression and patients with HIV have a much higher risk of having TB meningitis in the setting of TB than do patients without HIV. This child was not HIV positive.

Later in the day, Gina was evaluating a 10-month-old child with developmental delay and no clear history of HIE or anything else that would suggest a cause for the delay. Given that, we had decided to obtain a CT scan of the brain and quickly discovered the reason for the child’s delay. Her ventricles were huge, and it was clear that she had a communicating hydrocephalus that was significant enough to require placement of a VP shunt, and better sooner than later. At home, VP shunts in children are placed by pediatric neurosurgeons, though that’s not possible here and they are typically placed in Arusha by pediatric general surgeons. There is a single neurosurgeon who is now in Moshi at Kilimanjaro Christian Medical Center (KCMC), and I suspect that she now places many of these as well, but it really depends on availability.

Obtaining an accurate history from patients here can often be quite challenging and it is not only because of the language barrier, though that is also challenging in its own right even with our interpreters. There are over 120 tribes in Tanzania, all of which speak their own language and there can be little similarity between them as many of the tribes, such as the Maasai and the Iraqw, both of which migrated to this region from different areas. Older patients will often have never left their villages and may speak only their native tongue. Even the younger Maasai women may not speak Swahili as they have never left their families boma to travel to the Market where Swahili is spoken. In these situations, it’s required that we have a translator from the local language to Swahili and then from Swahili to English. Kitashu, our social worker who is also Maasai will often serve as a translator for Maa (Maasai means speakers of Maa), and since he knows English well, it removes the need for another translator.

The other reason it’s often difficult to obtain an accurate history, though, is much more of a cultural nature. Most often, when questioning a patient and trying to determine what specific disease process is occurring, it requires a meticulous recounting of the timing of events, often over a course of years. Unfortunately, time in Africa doesn’t carry the same significance as it does in the Western World and the ability for a patient here to give a good timeline of events is often virtually nil. They can recall specific events, but often not in what specific order they may have occurred and rarely exactly how long they have occurred. Though health literacy here is clearly less than it is at home, and health literacy at home varies significantly on its own, the difficulty with obtaining a history is not related to this in any manner. It merely relates to how time is perceived in one’s culture to what importance we place on it.

One of our last patients of the day was a middle-aged woman who came to see us for headache, but it was also noted that she had weakness and atrophy of her right leg as well as some abnormal posturing of her right foot. The initial history that was obtained was that her leg problems had all occurred over the course of the last year and made us most concerned for some process involving her motor neurons. She had no other signs to suggest ALS, though this was in the differential, of course. After she was presented and Joe had a chance to examine her, it was decided that she would go for an MRI scan in Arusha as a CT scan would not be very helpful. After some time, though, and more questioning as to the onset of the leg symptoms, it finally came out that her leg had been like that since she was two years of age, easily clarifying her diagnosis for the withered leg as being polio, which made absolute sense. It had just taken asking her numerous times about the history and mainly about the time course and when the symptoms had begun. Thankfully for her, she did not have a recent motor neuron issue, nor did she require any additional testing for her leg. We offered her treatment for headache and called it a day.

It was another late evening seeing patient, though we had time enough before sunset to have a round of my special gin and tonics made by adding a splash of mango juice. They were absolutely delicious, though of course their main purpose was solely medicinal to further prevent malaria with the tonic water. Or at least that was our excuse.

Build it and they will come. Not only does this describe the history of FAME, but equally so our neurology clinic. In a country with so few neurologists, or for that matter, specialists in general, having an incredibly efficient team of outreach coordinators who scour the local villages to make announcements of our arrival means that you will never want for patients. No matter how I make the schedule for our first day of clinic, hoping to limit the number of patients as we are all still jet lagged and the residents need to be given an orientation on the EMR (electronic medical record), it never seems to make a difference. With the schedule clearly stating that we would be seeing patients beginning at noon today, there were patients lined up waiting to be seen almost before we arrive.

The neurology clinic here tends to be a microcosm of what’s happening out front at the general OPD, and today was no different. Tying to limit the number of patients in a manner that would actually allow us to get everything finished that was necessary is very often akin to a salmon swimming upstream – not only exhausting, but often feeling as though it will end in death. Mondays are always the busiest day of the week, and the reception/waiting area of FAME will look as though there’s a run on the bank or it’s the best blue light special ever offered. As FAME typically sees around 30,000 patients a year with the average number in a day nearing 100, it’s not difficult to realize that on Mondays, the OPD can be seeing far in excess of that number. And on top of that, we’re adding in the neurology patients when we’re here visiting. Needless to say, the reception area can become a very crowded area with little notice.

Though our plan had been to start working at noon, we started earlier than that as the patients were already here waiting for us, and the volume was only building. Seeing neurology patients typically takes far more time than seeing most of the other outpatients here as it requires obtaining a very detailed history, not the easiest when exclusively using a translator, or sometimes two when the patient only speaks their tribal language, and there is a detailed neurologic examination. This is not unique to practicing neurology here in Tanzania, for the same situation exists back at home when seeing patients, absent the translator most of the time, of course, but not the detailed history and examination. Not wishing to sound condescending, practicing neurology is often far different than most other specialties as it requires far more detective work and is often what one would refer to as very “touchy feely” and very intuitive.

We had a full complement of translators, who, for the most part, are all clinical officers, which is the equivalent of nurse practitioner back home. Most of medicine in Africa is practiced independently by clinical officers, or COs, as they staff nearly all of the government health dispensaries throughout the countryside and see patients routinely on their own. Some of the clinical officers work here at FAME, and others will volunteer here, hoping to gain valuable experience to possibly be hired by FAME, but if not, obtain a good letter of recommendation to be hired elsewhere. For the most part, they are all amazing and motivated.

Dr. Anne, who is an assistant medical office, or AMO, a position no longer offered in Tanzania, but had required her to go to school for an additional two years after becoming a CO, will be with us for half days as she is still on partial leave after having a baby. Anne has worked with me for over ten years and is our neurologist on the ground here. Elibariki is a CO who I have worked with in the past and is a FAME employee who has been a delight to work with and train. Hussein is a CO who is volunteering with us and hoping to gain more experience, though is very, very good at this point in his career and will have no trouble adapting to any position. Emanuel is a clinical officer who I have not worked with before, but has already shown that he can fit in without an issue. Nuru is a pharmacy tech who has worked with us for several years and, even though she is not a clinician, is incredibly helpful and energetic, and has always been a pleasure to have working with us.

This is the contingent that will be working with us over the next six weeks and who we will be spending every day with, and even some evenings. Kitashu and Angel are our absolutely amazing social workers who organize and run our clinics for us in addition to doing all of the outreach work in the communities, notifying patients of clinic and making certain that we’re seeing appropriate neurology patients. If it were not for the two of them, none of this work, though there is also plenty of behind the scenes planning that goes into making all of this work smoothly.

While sitting in clinic this morning and leaning back in my chair against the wall behind me, Hussein suddenly warned me to be careful of the insect that was not very far from me. It was a very harmless looking insect that was perhaps ½ an inch long and red and black in color, but unfortunately, it packs a punch, not by it’s bite or sting, but rather from a compound that it releases and causes severe burns. It’s known as a Nairobi fly, but, in actuality, is a small beetle of the genus paederus which is found throughout East Africa. Any contact or disturbing it in any way will cause it to release a very nasty chemical called pederin that will cause a significant burn that is both very painful and also causes a severe inflammatory reaction. Needless to say, it’s not something very pleasant and best to avoid at all costs. Unfortunately, they often show up in unexpected places and before you realize what you’re brushing off your arm or face, it’s too late.

Shortly before lunch, the skies began to darken and the rain began to fall. At first, it was a light steady rain, but then began to come down a bit heavier, though not the deluge that can often happen here, when there are virtually rivers in the streets and the rain coming off the roof becomes as thick as curtains that are difficult to see through. Loud booms of thunder became more frequent and we could even see a few flashes of lightening from underneath the overhanging roof of our outdoor clinic. It was still raining as we went to lunch, making the seating a bit tight for everyone, but we all squeezed in. The lunch menu had changed for the first time in years and the rice, beans and mchicha that has always been my favorite lunch was no longer being served on Mondays. Today, it was to be ugali (a stiff corn meal dish) and a stew made from the tiny sardine-like fish that are harvested from the local lakes in the region. It was also served with mchicha, a dark green vegetable similar to spinach. I opted to have beans with my ugali rather than the fish stew, but Gina and Megan said they both enjoyed the stew.

There were two patients in the ward to be seen in consultation, so both Joe and Leah went together with Hussein to see the patients. One was a young boy with neurofibromatosis who had a chest wall resection of a probably neurofibroma, but after surgery, had been noted to be complaining of painful weakness in his legs and difficulty walking. After obtaining a more thorough history, though, it seems that he had some of these symptoms before surgery and was also significantly malnourished, raising the concern for some nutritional causes of what appeared to be a painful neuropathy.

There was also another case for them in the ward which they were able to see, though they were both soon back to neurology clinic to help with the outpatient load. The patients just kept showing up and even after reaching our maximum, we were still being asked to add more patients. An elderly gentleman who was being seen by surgery for urinary incontinence and a prostate problem but had also been noted to have problems with ambulation. He was referred our way and was sitting out in our waiting room in a wheelchair, but it took only a quick glance from me to know what his diagnosis was. He had the classic masked facies, decreased blink rate, bradykinesia, and drooling of parkinsonism and, most likely, Parkinson’s disease.

His history was such that he had been having ambulatory dysfunction for about two years and progressive cognitive dysfunction for the last year. The reason for his urinary incontinence was, in addition to his prostate, the fact that he could not communicate to others that he needed to use the bathroom and was immobilized so that he could not get there on his own. He was our last patient of the day and it was appropriate to place him on a carbidopa-levodopa trial, though the only formulation that we had in the pharmacy was a 25-250 strength and far too much for him to start on. Thankfully, I had brought a supply of the lower strength of this medication that much more appropriate for the initiation of therapy in a new patient. Patients with idiopathic Parkinson’s disease are so responsive to carbidopa-levodopa (otherwise known as Sinemet) that we often use it as a test which is diagnostic. Not responding to therapy is usually a sign that the patient is not suffering from Parkinson’s disease.

We had ended up with more patients than we had anticipated for the day and clinic had now run long past our normal stopping time. As much as all of us would love to keep seeing patients, we have to keep in mind that the staff we’re working with have families at home and other limitations such that they do not have the same freedom that we have here. We ended up seeing patients until well after 6 pm which was a significant issue for the translators as they all depended on taking the staff bus home at the end of the day and that had departed long ago. Walking was an option, but it was still raining intermittently and having a downpour on the way home would have been very unfortunate. They ended up catching a ride from Dr. Anne, who had stuck around just for that purpose.

Everyone was more than exhausted after such a long day, but not only had we seen many patients, we had seen those in whom we could make a difference and, for that, I think everyone felt that they had accomplished something.

The photos today are predominantly those taken by Kelly on one of her early morning runs. I’m not sure that I can give an actual count of how many times she was accompanied on her runs (though I do know that it was absolutely zero times by me), but I can saw that she was the most dedicated to some form of exercise during her time here out of all the residents. She was up before dawn every day and out the door in time for sunrise. Today, though, her photos were particularly informative of the sights surrounding FAME, and of the Black Rhino Academy.

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I’ve mentioned the Black Rhino International Academy many times in the blog, and it has become no less impressive since its conception several years ago. It had been the long-time dream of Caroline Epe to open a school in Tanzania ever since she had arrived on the continent well over a decade ago and, after being a work in progress for several years, it has now become one of the pre-eminent learning institutions in Northern Tanzania with levels (grades) covering all primary school and the recent addition of early childhood learning. Caroline has been a fixture at FAME since just after it opened in 2008 and was actually the volunteer coordinator when I first arrived in 2010, though has moved well beyond that position, now being the primary development person on the Tanzanian side, though on a part-time basis given her involvement with the Black Rhino. One of the other unique features of the Black Rhino, though, is its sports facility and its incredible football pitch (field) which is one of the finest in all of Tanzania that even hosts training sessions for the national football team.

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Even though no one had been out extraordinarily late at the Sparrow last night, I’m sure the extra half hour of sleep with no educational lecture this morning was much appreciated by all those who had not chosen to run this morning. Our days at FAME for this session were winding down as we had only one more full clinic day after this and a half day on Friday as we had plans for an early dinner at the African Galleria for our last night in town. We would all be departing on Saturday evening, with everyone, including me, taking the same flight to Doha, though I would be heading on to Barcelona to meet Jill for a week or vacation, and the others would be heading to Washington, D.C, as Qatar Airways was no longer flying directly into Philadelphia.

Having flown the first several years out of Newark or JFK on KLM (which had been the only airline with flights from outside the African continent to fly to Kilimanjaro), it had been a blessing when Qatar first announced that they would be flying direct from Philly to Doha given both the huge benefit of not having to drive up to or near NYC, and the fact that Qatar is hands down one of the best airlines operating at the present time. How things will play out going forward remains to be seen and we will have to reassess the situation based on cost and convenience.

We were planning to visit Daniel’s home for the second time this visit as the current group had not yet had the pleasure of a visit with that remarkable man. With plans for a visit, though, it meant that we did have an early target time to leave, hopefully well before sunset, as it’s best to see his home in the daylight, and though it can be done after dark, the effect is just not the same. Of the patients that stood out for the day, there were two.

The first was a young patient who had come in with their family and, as I was sitting right next door to them, I could hear all the conversation after they arrived, which made it very clear to me early on what type of matter we were going to be dealing with. Kelly’s interest not only in epilepsy, but also functional disorders (those without a physical cause) would clearly play a role in the management of this child. The unfortunate part, though, was that the patient had been taken by the family to be seen all over, including Muhimbili University in Dar es Salaam, as well as India. The symptom complex was really all over the place and within several minutes of listening to their discussion, I had simply asked Kelly if this was someone in her area of expertise, to which she had given me a simple “yes.”

In addition to an extensive GI workup that had already been done with lots of testing and records that were contained in several shopping bags and all of which had been stone cold normal, they had also been having episodes of unresponsiveness or loss of consciousness for which they had undergone an EEG. This was, of course, also normal, though it is important to point out that a normal EEG does not, in and of itself, come close to ruling out epilepsy in the right clinical setting. The neurologists in Dar had noted that in the EEG read in their clinical notes (which is standard), though had decided to place the patient on sodium valproate to see if that would, in some way, affect the frequency and nature of the episodes. There was some suggestion by the father that the medication had, in fact, helped a “little,” but the episodes were still occurring and, given the fact that they sounded definitely very functional to us, we were not at all convinced that it had helped.

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In the end, the family was very accepting that the diagnosis was most likely functional neurologic disorder, and it was then a matter of figuring out how to find some type of therapist who could help with the situation considering we were literally in the middle of a therapy desert. Amazingly, though, I had been contacted by someone at Kilimanjaro Christian Medical Center while we were in the Serengeti last weekend who is a neuropsychologist and was also interested in collaborating with patients. We put them in touch with each other and, hopefully, they will be able to begin some type of therapy soon.

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The other patient was a young Maasai boy from the Loliondo area (seven hours away by way of the Lake Natron Road) who was seen by Dennis and was clearly not acting himself. The history that was given to us was that he had fallen off the back of a boda boda (motorcycle) within the week and several days before coming to see us, had what was very well described to us as a focal seizure. They had also reported that the boy had been febrile. The boy was encephalopathic and unsteady on his feet which, given the history of the fall and seizure, made us very concerned about a subdural hematoma following a traumatic brain injury meaning that it was imperative that the boy have a CT scan as soon as possible, though this would not explain his fever.

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We were able to arrange the CT scan perhaps quicker than most and, when it was completed, it turned out to be normal (it was also done with contrast as I had some concerns about the history not being as simple as billed which is often the case here), meaning that there was no intracranial bleed or other abnormality that we could see to explain the presentation. Being that histories here are quite often not always as simple as they seem, the concern now was that the boy could have a meningoencephalitis, such as herpes simplex, given its common presentation with encephalopathy and focatl seizure. He was admitted to the hospital and placed on antibiotics, as well as an antiviral agent, with plans to do a lumbar puncture for more information, though given that we are not able to do cultures at FAME, we would be limited to cell counts, gram stain, glucose, and protein.

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Lumbar punctures, though quite simple to perform, do have significant cultural bias here in Africa for several reasons, with a big one being the history on this continent of HIV and patients coming to the hospital on death’s doorstep, having a lumbar puncture done as part of their evaluation, and then dying, with the perception by the public that their death was in some way contributed to by the procedure. Thankfully, having Kitashu here to help explain the need for the test and, in fact, that it is not at all dangerous, helps immensely in these situations. The family consented and we were able to do the LP with no trouble. The boy would be kept on his antibiotics and antiviral agents at least until we had the results of the spinal fluid either later that night or the following morning.

Having to deal with the young boy, though not complicated, did set us just a bit behind schedule having to make all the arrangements for the spinal tap and the admission, but it was finally all taken care of allowing us to depart at a reasonable time for Daniel’s house. We loaded in Myrtle and made our way towards to the Gibb’s Farm Road where Daniel lives, near the Ganako Secondary School and the village of Ayalabe, where I had first met him in 2009 while volunteering at the primary school there with my children. As an elder of the village, Daniel was there to help us with the painting we were doing and to act as a liaison for the community. He later invited us to come to his home, meet his wife, Elizabeth, and share with us the history of the Iraqw tribe. Now, fourteen years later, Daniel continues to host my teams for similar stories of the Iraqw tribe and culture and considers me part of his family. I have worked with several of his younger children (he and Elizabeth have twelve, eleven of their own and one adopted whose mother was a neighbor and died in childbirth).

We sat on the stoop of the new house his children are building so they have a place to stay when visiting, as Daniel still lives in the small three-room Bantu house that he built in 1973 when he first settled on this property. We shared his wonderful African coffee, boiled with fresh milk from his cows, and enjoyed fresh (and amazingly delicious) cakes that he had purchased in town just for the occasion. After giving everyone U.S. geography lessons on their home states (when they joined the union, capitols, square miles, important facts) that none of them knew, we finally walked over to visit his unique underground Iraqw house that he built in 1993 to prove to his children that he his stories of his childhood were true and that he wasn’t crazy. The houses were built underground to protect their cows from the Maasai who believed that all cows were theirs and they were only stealing what was rightfully theirs. Daniel grew up in a house like this for the first twenty years of his life, defending their livestock and listening for intruders who would walk on top of their houses at night. The Iraqw and the Maasai continued to fight until a treaty was finally signed, but not until 1986.

What stood out the most to me tonight, though, was just how vast the differences were in our cultures and in the technology that we all took for granted. Dennis had brought his drone with him and, though he was keen to fly it and take some nice aerial photographs, I was also excited to share it with Daniel. Yes, we all had our smartphones and computers, but here was also something very physical and real, a drone that took off at our feet, flew miles away, and then returned, taking video the whole while, with the final images of our little group, including Daniel. A man who grew up in an underground house, using spears and clubs to defend himself, goatskin wraps to dress with, and, all the while, teaching us facts about the United States that he learned in school (he only went to the 8^th grade) and that none of us had known ourselves. The significance of the moment was just beyond comprehension.

It was up early again for a 7:30 educational lecture, though this time, it was not our group giving the lecture. Even though twice a year, a large neuro team descends on FAME, there are still other volunteers that come during our time there and it’s often a bit of a struggle to decide who gets the privilege of presenting. Dr. Ken has overseen determining who will be giving the lectures and we are always happy to share the spotlight with the others. This morning, Dr. Josie, a medical hospitalist originally from Cameroon, though now living in Los Angeles, gave this morning’s lecture on hyponatremia (low serum sodium), a topic that is near and dear to the hearts of neurologists due to a very well-recognized complication that can occur when it is corrected too quickly.

In that setting (overcorrection of their hyponatremia), patients develop a condition that was originally called Central Pontine Myelinolysis (CPM) that would have a delayed onset and cause considerable and irreversible damage to primarily the motor portions of the brainstem, and particularly the pons. More recently, it has become clear that this condition actually often involves other areas outside of the brainstem such that it is now referred to as Osmotic Demyelination Syndrome and can affect many areas of the brain. The condition can be easily avoided if one recognizes that the sodium must be corrected very slowly and over days. These patients are most often managed in the ICU in the US, and they have very frequent labs to follow the correction of the sodium, though this is quite difficult here as we don’t have an ICU and checking labs as frequently as we do at home is not the norm. Merely recognizing the risk, though, goes a long way to prevent the situation and you can worry less about the neurologic complication.

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We’ve continued to have one of the residents rounding with the FAME doctors in the morning, primarily on the Ward 1, which is the medical ward, but also on the surgical ward on occasion and, when Dennis is the resident, even in maternity where he can check on the babies. Doing so has gone a long way to helping the residents understand just what it is that the FAME doctors do here, which is quite a lot, and has also helped when input has been needed on neurologic patients. In the case of LJ before she left, she picked up significant neurologic issue on one patient that had gone unrecognized and clearly needed to be managed.

The morning was slow and, when that happens, especially on the days when there is an early morning lecture and it’s quite likely that not everyone has eaten breakfast (that usually means me), we put an order in from the Lilac Café for some breakfast munchies and coffee. Their beef samosas are just delicious with mango chutney and having two for breakfast is quite filling for me along with a small cup of their French press coffee. Even better, we can put the order by phone, and they will deliver it to us just in case patients start to show up while we’re waiting. The Lilac also has wonderful full breakfasts, but to that usually takes more time than we have too spare.

The Lilac Café first opened around 2012 along with the hospital as it was recognized that FAME needed a different kitchen than our canteen to make meals for the patients and, they would also need a place for families to eat while they were visiting their relatives who were in the hospital. The Lilac has become a quant café for a coffee, a cold drink, or dinner on the weekend when we’re on our own.

Caroline had an interesting patient come in to see us who was complaining of frequent right ear infections for many years, decreased hearing on the same side, and, lastly, right sided headaches that seemed to correspond to her ear infections. Though she had been treated many times with antibiotics, no one had ever really investigated why she was having the frequent infections and she had never had any imaging. I guess this would have been more interesting if you were an ENT specialist but given the fact, she had come to see us, we felt compelled to get some answers for her, and recommended a CT scan of the head with and without contrast. After speaking with the patient, she agreed to have the CT scan, which of course would be costly, but after doing all our research on UpToDate (our bible, so to speak), it was clear that she needed one to determine the proper therapy going forward. Unfortunately, she would have to come back on Thursday to get the scan, so we put her on oral antibiotics for the time being since she wasn’t febrile and didn’t look particularly sick. We’d have to wait a few days before we could make our final recommendations.

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Clinic was over at a reasonable time and the residents had decided to take everyone working with us out to the Golden Sparrow later in the evening. Though I did have work to do that night, I had pretty much already decided to forego the Sparrow this trip and thought that it might be nice for all the younger people to have fun together without Babu (Grandfather in Swahili and what Teddy has always called me) tagging along. The Golden Sparrow, which had become a tradition over the years, had really started as the Carnivore, a tiny bar with dirt floor except for an even smaller dance floor that served barbecued chicken, chips, and beer. I had first gone with Kelley Humbert and Laurita Mainardi in October of 2016, but the next year, the owner had decided to expand, and had built the Sparrow.

The Golden Sparrow is a much more sophisticated establishment than the Carnivore as it has a large outdoor dining area with a much larger menu (though still includes their delicious, barbecued chicken), and the dancing is now inside a proper dance club with a DJ and disco lights. I will have to admit that there has been a fair share of dancing on the tables in the past (I will mention no names, though I will remind everyone that I have incriminating videos), but with remodeling over the years, the tables are such that it is now impossible to dance on them with a significant risk of harm. The DJ takes requests, and the dancing doesn’t get started until after 9 pm most nights.

All the translators had joined them as well as some of the other support staff and, from what is reported to me was that everyone had an excellent time and that no one had drank too much, if at all (and I have no reason to doubt it as several people who were there don’t drink). They had all enjoyed dancing and being together with little in the way of alcohol which is always a good thing considering that I wanted to make sure everyone was up the following morning for work. To be honest, I had gotten into bed just before they arrived home, though I was a bit parental in that I was happy to hear all their voices when they came in. Despite the videos that I mentioned earlier, I have often said “what happens at the Sparrow, stays at the sparrow,” and I have done my best to honor that in the more recent years.

Having come home from the Serengeti last night, we were all still on a bit of a high from the adventure that we’d all experienced. Having spent well over fifty nights in that remarkable place since I’ve been coming to Tanzania, I can honestly say that I have never tired of it. Not even of that long and dusty road, though I will admit that I much prefer the Endulen road given its scenery.  I attended morning report with one of the residents as we hadn’t been here for three days, and I didn’t want them to get swamped if there had been a number of neurology patients over the weekend. Thankfully, there had not been and the patient who had suffered the head injury the day before we left was doing better as far as his mental status, though unfortunately, he was still not moving his right side.

Since shortly after we arrived at FAME, one of the neurology residents has rounded with the ward team to help not only with continuity of care for the neurology patients, but also to help the residents understand just what the doctors here must do as far as their schedule and the various types of patients that each of them must see. It is quite often that the doctor covering the ward may also be first call for maternity and tied up doing a C-section. Not quite what we do back home in our super specialized medical society that we have. There are so few generalists left these days, which is really a shame and a loss to patient care.

As you may have gathered from the photos that picture either me or Vitalis driving, is that it is the British system here, driving on the left, or wrong, side of the road as most Americans think of it. This is from Tanzania having been a British colony, or actually protectorate, in past prior to its independence in 1961 when it became Tanganyika, and subsequently joined Zanzibar in 1964 to become Tanzania. But one of the interesting features that follows this phenomenon (of driving on the left) and which I had never really recognized in the past, is that pedestrians also “drive” on the left here. Walking anywhere around FAME, I am constantly surprised about just how apparent this distinction is for I am always running into people on the “wrong” side when walking through the halls and corridors here for the first few weeks until it finally sinks into my brain that I need to make a conscious effort to walk on the other side. I know that it sounds like a small thing, but it is very reproducible and recurring. Thankfully, this has never been a problem for me on the road as I have never had a problem switching back and forth between driving here and at home.

We had a steady number of patients for the day that included two with idiopathic Parkinson’s disease (PD) currently on carbidopa-levodopa and doing reasonably well on their medications. Unfortunately, we do not have some of the other adjunctive medications that are used in this condition and that can make patients much more functional as the disease progresses. Treating this condition is always a bit tricky regarding how to explain it to patients as there are no therapies that improve the underlying condition itself, only the symptoms and functional status. Off medications, the patients return to whatever their baseline was or perhaps worse if they progressed some. Also, the carbidopa-levodopa comes in a number of different ratios between the two ingredients and the one that is most often available here is not the normal starting formulation (25/100), but rather the stronger (25/250) that is typically used for more advanced patients. I have brought large bottles of the 25/100 dosing in the past, especially when Whitley Aamodt and Meredith Spindler were here, as we were hoping to see all our PD patients in follow up that visit.

There were a good number of epilepsy patients that were coming both for follow up and as new patients including a few who had been started on medications with the last group a month ago and were now checking in with us. Unfortunately, without a patient portal (a means for a patient to communicate with their doctor online in the EMR), the only way to adjust these medications here is to have patients come back to see us and to decide whether their therapy needs to be changed.

One of the biggest issues we have here in caring for our epilepsy patients, as well as many of our other neurology patients, has to do with communicating instructions. In a culture where chronic medications are not the norm, the health literacy in that regard is not very good causing patients to either stop their medication when it runs out or to not understand titration schedules even if they are written in Swahili and explained to them in detail. Anti-seizure medications often need to be cross titrated, meaning titrating a new medication until it’s therapeutic at which point you then begin to taper the older medication you’re planning to discontinue. This is not an easy concept to explain to patients with some experience in this process let alone ones who have no experience whatsoever with daily medications.

Once we had finished with our patients for the afternoon, Kelly came to me asking about walking to visit my artist friend, Athumani, from whom many residents have purchased artwork in the past. He used to be an artist in residence at Gibb’s Farm, where I had first met him, though is now showing his artwork just down the road from Gibb’s, next to the woodcarver and Phillipo’s home where we visit to buy coffee. It’s about a 30-minute walk down through the brick quarry and up the Tloma Village Road and, in very short order, she had enlisted the remainder of our group, plus Leslie, to go with her on the journey. I reached out to Athumani to let him know they were coming and, off they went. I stayed home as I had other work to do and had been there to visit him with the last group of residents when several of them had purchased artwork from him. In the end, Dennis purchased a piece from him, but Kelly did not.

The group made it home sooner than I had thought they would, and the remainder of the evening was quite restful with our roasted chicken and potato dinner that comes every Monday. Except, of course, Kelly, who is a vegetarian.

Everyone was up, bright and early with the anticipation of finding our shy leopard still in his tree, hopefully enjoying his breakfast of day-old Thompson gazelle. We loaded into Turtle and made our way to the same tree in the chilled morning air, everyone excited with anticipation for what we may find when we arrived. But first, it would require a drive of perhaps 20 minutes through the valley where our camp sits, not too far from the Sopa Lodge, for those who may be familiar with this part of the Serengeti. The roads were still wet and muddy as the sun had not yet risen to dry the previous night’s rainfall, though the large herds of wildebeest and zebra residing here for the moment were quite happy with the wet grasses that would supply their daily need for water. As we rounded the edge of the small mountains that defined the valley, and were now pointing east, the sky began to lighten with only a hint of the coming sunrise.

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Traveling further on and nearing the tree in which we had seen the leopard last night, the sun finally peeked over the horizon with its strong rays of light that shone intensely through the acacia trees that abound here. This is what everyone imagines that sunrise should look like in the Serengeti, and exactly what Dennis and the others had been waiting for all along. As the cameras clicked away to capture the scene unfolding before us, it was truly the mental imagery for me as there is little that can match seeing this in person.

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As we arrived at the leopard tree, it was clear that the gazelle kill had been partially eaten, but looking up into the tree, the leopard was nowhere to be found. Or so we thought. As we circled the tree, the leopard suddenly sprang up from where it had been resting before our arrival and began to run seemingly as far away from us as he could. I’m not certain who was more startled by the sudden movement, us, or the leopard, though Dennis clearly had his wits about him as I could hear his camera clicking off some shots of the running cat. We drove a short distance in the same direction as the fleeing animal, though he quickly settled under another tree to gather his thoughts as I’m sure we had frightened him as much as he had us.

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At the same time as everything was unfolding, Vitalis spotted a male lion who was not far at all from where we had first spotted the leopard. We drove to where the lion was slowly walking across the grassy area between the trees as he occasionally stopped to let out his low rumble of a roar in search of the females of his pride. He was obviously unhurried and heading nowhere in particular for he eventually found himself a comfortable place to rest and made himself at home.

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It was very odd to see both the leopard and the lion in such proximity as all the cats are mortal enemies competing for the same prey. From where we sat, each of them was quite visible to the naked eye, yet neither was paying much attention to the other. Had they decided otherwise, the lion easily outweighed the leopard by a factor of two and would have overpowered the smaller, more agile, animal had it come to a show down. Perhaps it was the beauty of the gorgeous sunrise we had just witness and what the lion also seemed to be taking in, though I think not. It was merely that neither was interested in the other for the sake of conservation of energy as there would have been no benefit to either of them to have tangled with each other.

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Shortly after the leopard had vacated his tree, along with the Thompson gazelle that he had been snacking on overnight, a tawny eagle decided to take advantage of the situation and settled themself down on top of the reasonably fresh kill and began tearing at the carcass, enjoying his unfettered meal with a clear sense of accomplishment. As I had mentioned previously, the eagle would not have had to worry about competition from any of the vultures as the prey had been hidden very well by the leopard and out of sight of the scavenger air force.

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Having enjoyed a perfect sunrise and found our leopard as well as the bonus discovery of the male lion and the tawny eagle, it was time for us to make our way back to camp for breakfast. I cannot think of a more perfect morning and the day had not even started yet. The crew had been waiting for us at the Dancing Duma and we were back at the specified time, which is never the case here. As we relaxed at breakfast with our fresh brewed coffees, we reminisced on all the amazing things we had seen already this day and wondered what more there could possibly be in store for us.

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It was time for to depart camp after breakfast and, once again, the entire camp crew came out to say goodbye and bid us farewell. I had seen them only three weeks ago and knew that I’d be back soon, but this time, it would not be for another six months. With our lunch boxes packed in the vehicle and our luggage secured in the boot, we were once again ready to explore on our way back to Karatu, though we had more adventures in front of us.

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Leaving camp, we were heading south in the direction of Moru Kopjes, where we hoped to spot a rhino, though knew that it would be a stretch considering their scarcity and lack of interest in being out in the open. On our way at the river crossing, there were many giraffes and a large herd of zebra, the latter nervously approaching the watering hole, knowing that if a surprise attack by lions was to take place, it would occur here more than anywhere else. Having seen this occur many times, I could easily sense their anxiety and luckily for them, today was not the day for this to occur. As we watched the constant jockeying for position, a savannah monitor that was several feet long decided to appear on the opposite end of the bridge. It continued to sit there until we finally approached it on our way across and it slithered quickly into the riverbed below.

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On the way to the Moru Kopjes, we suddenly came upon another leopard, the second of the morning, running along the road holding something in its mouth that looked like a meal. It was hard to make out exactly what it was holding, but it was certainly not entirely happy to have seen us as it scooted quickly into the grass and up a distant tree that was far enough off the road that weren’t able to get close enough to see it well, unfortunately. Regardless, it was amazing to see another leopard on the ground so soon after the other as they are normally only spotted in the trees and sleeping sprawled on a branch. The leopard is a normally shy and solitary cat that prefers to remain far out of site and when it hunts, it does so stealthily such that its prey is completely unaware of its presence until it’s too late to escape. There is rarely a chase involved and the prey, regardless of its size is then dragged into a nearby tree to avoid any challenges that might arise from hyenas or lions.

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As we drove through the rhino sanctuary at Moru Kopjes, we kept our eyes peeled for the elusive rhino, that you wouldn’t imagine was that hard to find given its size but failed to spot any. We stopped at the rhino research station where all the black rhinos living in this region of the Serengeti are monitored on a continuous basis. The station continues to be funded by the Frankfurt Zoological Society who had originally done most of the research here and the structures that housed the research teams still remain. The black rhino was nearly poached into extinction through the 1970s and remained decimated until the 1990s when efforts were successful to protect the three remaining individuals in the Serengeti and by the late 1990s, the species began to recover. Today, they are aggressively protected by the park rangers and the numbers have massively increased despite our failure today to find one.

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From the Moru Kopjes, we continued south in the Kusini region of the Southern Serengeti, a completely different landscape than what we had seen throughout the Central and Western regions that we’d been to over the last days. The migration comes through here in April and May on their way to the Central after leaving the Ndutu region, so now there are very few wildebeest to be seen. The non-migratory animals, though, such as the impala in the woodlands, and the Thompson and Grant’s gazelle in the plains remain here. We checked out of the Serengeti at the Kusini ranger station at the airstrip to avoid the crowds at Naabi Gate and continued to Lake Ndutu where we would then check into the Ngorongoro Conservation Area for our transit back to Karatu. The parks are all separate requiring that you have permits to each even though they are contiguous. Here, though, the ranger stations for each are far apart as opposed to Naabi Gate where they are side by side.

Leaving the woodlands of Kusini and traveling across the vast flat plains that lead to Lake Ndutu, a small figure is visible far in the distance atop one of the many termite mounds that can be seen scattered throughout the landscape. As we come closer, a lone female cheetah is sitting quietly, scanning the distance to decide where to go for her prey. We sat and watched her for a short while when, somewhat unannounced, she began to chirp like a bird, which is the sound that cheetahs make (they don’t growl or roar) when they are calling for each other. It was clear that she was calling for her cubs that were hidden somewhere in the area. After several minutes, two, tiny cheetah cubs crawled out of the long grass and up the termite hill to be with their mother.

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Shortly thereafter, the mother cheetah climbed down from the mound with her two little cubs in tow behind here and continued to walk some distance in the direction of a Thompson gazelle herd that we could barely see without our binoculars, though she knew exactly where she was heading. At some point, the mother signaled her cubs to remain hidden in the grass while she continued sizing up the gazelle for her attack. She sat in the grass for the longest time, with the two cubs still hidden, and eventually started to move forward in what must have been a low crouch as the gazelle still hadn’t seen her. It was very difficult for us to see her at this point, but through the binoculars and long camera lenses, we could see her suddenly take off in a cloud of dust, though it was difficult to tell just where she was in relation to the gazelle due to the perspective that we had. It looked to us that she should have been successful, but when we drove to where we expected to find her with a kill, it took us some time to actually locate her and when we did, she had come up empty. Though we would have liked to have continued following her, we were already running behind schedule and needed to move on.

Lake Ndutu is another of the saline lakes in this region and one of the homes for the many flocks of flamingoes that exist in the area. There were many on the lake to be seen, but little in the way of larger animals as the migration will not be here until March when nearly all the several million wildebeest congregate here for the lush grasses of the rainy season. Now, all that can be seen of the migration are the thousands of bones of the animals that either succumbed to the predators or were trampled to death during one of the lake or river crossings that are many.

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We left Ndutu and eventually met up with the new Endulen road that bypassed the terribly rocky and dusty main road that 99% of the vehicles take to get to the Serengeti. The Endulen road, which we had taken three weeks ago is absolutely gorgeous and travels through the most beautiful parts of the conservation area where most of the Maasai are now living. The scenery was just stunning and continued as we climbed higher and higher into the Ngorongoro Highlands and then eventually arrive at Kitashu’s boma, though it was again too late for us to share in the traditional dancing and singing that we normally do with his family. We were again running quite late for the Loduare Gate, which closes at 6 pm, though I think they took pity on us once again and let us through. Either that, or they are beginning to recognize us and expecting our late arrival. We pulled into FAME, and all felt happy to finally be home, though badly missing the incredible scenery of the Serengeti.

Spending the night in the Serengeti is just magical. The nights are cool, though even with the tent flaps open, the soft billowing of the fabric and subtle breeze running through lulls me to a sound sleep beneath the cozy comforter. The zebra herd just outside my tent continued with their commotions, mostly eating, but occasionally braying, barely disturbed my slumber at first and was then a distant sound as I slept through the night. There were other sounds, of course. The frequent whooping of the hyena and honking of the wildebeest herds further down by the river. The laughing sound that the hippos make both in the river and during their nighttime excursions grazing in the grass, often a mile or more from their home. I didn’t hear the elephants, though, who apparently visited our camp during the night, one of them deciding to puncture the water tank with its tusk. Elephants can be troublemakers and are very aware that they are doing something they shouldn’t be doing. The low growl of the male lion, searching for the females of his pride during the night, sounds as though they are right outside, though I know their calls can travel a great distance. It is all a movie soundtrack, but one that you’re in and living through real-time.

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Having worked with Vitalis over the last seven years, I know the typical schedule that he likes. Saturday is for our long drive, and we don’t return to camp until dinnertime. The kitchen prepares us both a picnic breakfast and lunch and we plan to depart camp at 6 am sharp after a quick cup of coffee and cookies. The sun isn’t up yet and as we drive through the valley where our camp is located, the line of sunlight on the hillsides slowly descends towards us until the we finally encounter the sunrise through the trees with its initial soft glow and then the intense warmth that follows. It’s quite cool before the sun comes up, especially standing in the vehicle as we all are to get the best view of the amazing scenery unfolding before our eyes. Everyone is wearing a light jacket or sweater to stay warm.

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Before we know it, we spot four cheetahs walking across the plain and it’s immediately apparent that these are the same four individuals that we had seen three weeks ago when they made a kill right in front of us. It’s a mother with her three grown offspring that she has continued to train to ensure their survival. Having successfully raised these three cubs is a miracle for the life of the cheetah can be very tenuous at times. They are not aggressive like the leopard or lion and are unable to defend their kills from their larger cousins or from the hyena, who will often steal their prey after it’s been caught.

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The cheetahs were clearly on the hunt and there was prey virtually everywhere. Similar to what we had witnessed three weeks ago, the mother walked purposefully, constantly studying the nearest herd of Thompson gazelle to select the individual that she would have the best likelihood of running down in a chase. A nearby termite hill served as an excellent base for the four cheetahs during this process. There was little question that she was ready to begin her hunt and expected her children to follow her. We continued to watch intently as the drama unfolded before our eyes.

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In the distance to our right, we were also watching two of the Serengeti balloons in the distance as they were slowly moving in our direction. I have had the good fortune of flying on these balloons twice in the past and it is a remarkable experience. The balloons launch before sunrise and, after a flight of about an hour or so, will come in for a landing on the open plain, where they are met with safari vehicle to pick up the passengers and bring them to a lovely area to enjoy a full breakfast with champaign to toast their successful flight. My two flights in the past were with a good friend of mine who is a pilot for one of the balloon companies, but the balloons that were approaching were from another company.

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The cheetahs remained on the termite hill, continuing to study the gazelle, though it was quickly apparent to us that they were directly in the flight path of one of the balloons as it was attempting to land. The balloon soared silently over the termite hill, clearing it by what seemed like only several feet, but must have been many meters. The balloon’s shadow preceded it and crossed over the termite hill, initially spooking the cheetahs, and completely distracting them from the hunt. When the balloon itself passed over, they had had enough, and were quickly on the run, having abandoned their hunt. Trying to imagine the odds of us having found the same four cheetahs, who were also on the hunt again, only to be foiled by a landing balloon who could have chosen virtually anywhere else in the Serengeti to land this morning, was just a bit mind boggling.

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Disappointed, we watched as the four cheetahs slowly wandered off, their prospect of a hunt having been dashed by the landing balloon, though I’m sure they would pick it up again shortly, but not soon enough for us as we were heading out towards the Western Corridor and needed to move on in that direction. Within minutes, we came upon a large group of vultures sitting around a young wildebeest kill watching a single hyena working tirelessly to devour as much as it could and as quickly as possible for it wouldn’t be long before other hyenas it the area would locate the kill. Hyenas locate their food by smell and sight, but also from watching the sky for the circling vultures. As we watched the hyena slowly dissect the wildebeest, easily identifying the abdominal organs in our binoculars. Within minutes, though, several other hyenas began to descend on the kill, all from different directions, and had soon joined in the dining.

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Having taken in these two scenes of the circle of life, it was now time for us to begin our trek into the Western Corridor. This is a portion of the Serengeti through which the Grumeti River flows and the topography is very different than that of the Central Serengeti as it has rolling hills and is heavily wooded with scrubby trees and bushes. With the woodlands, though, come the tsetse flies with their nasty bites as they look for their blood meals. Thankfully, there is no sleeping sickness, or trypanosomiasis, for the most part here in Tanzania. The tsetse flies can be very stealth, but they are quite slow and easy to swat. Killing them is a different story as they have a very hard exoskeleton and merely slapping them with your hand fails to harm them, immediately bouncing back for another attempt at a meal. They must be crushed, or, as I describe in a more technical term, “smooshed” between your hand and a hard surface or dragged under your hand to make sure they are good and dead. They are nasty, and killing one gives a certain satisfaction of a job well-done.

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The Western Corridor which, for some odd reason, I had never been to in the past, was absolutely spectacular. It follows the Grumeti River, the importance of which has to do with the migration, for when the wildebeest herds are here in huge numbers, result in their crossing the river to head north. The significance of the river crossing has to do with the huge Nile crocodiles who inhabit the river and very much enjoy having wildebeest for breakfast, lunch, or dinner, or even all three. The Grumeti is not as wide as the Mara River, which is on the border between Tanzania and Kenya to the north, where the crossings are much more spectacular as the herd has a long distance to swim, making them tremendously more vulnerable to the crocs. Though there were lots and lots of wildebeest in the Western Corridor, they were not on the move north so there were no crossings that were seen today.

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After several hours of travel to the west, and halfway to Lake Victoria, we arrived at the Grumeti Airstrip, a tiny airport for those travelers who prefer not to endure the bumpy and dusty roads, though I cannot imagine having missed the scenery that we’ve seen so far. As we ate our delicious lunch that had been prepared for us, it was clear that Dennis had one thing on his mind, and that was somehow figuring out how to one day land a plane on this runway. At one point, a plane came in for a landing that was from one of the companies that fly to the more remote places in Tanzania. Though none of us knew anything about the plane, Dennis assured us that it was the nicest, and most expensive, plane of its kind that one would fly here, and we all took his word for it.

Before arriving to the airstrip, we had come across one of the largest groupings of giraffes that I have ever seen and, even more importantly, more baby giraffes than I have ever seen in one location. Baby giraffes are incredibly cute and are just miniature versions of their parents. Giraffes give birth standing up due to the size of the offspring, and though I’ve been told that many babies are injured by the fall, I could not confirm that. The infant mortality from predation, though, is about 50% by one year of age. Having survived the adulthood, the mortality rate for giraffes is very, very low at about 3%.

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At the airstrip, we were a very long way from the Central Serengeti and, rather than taking the same route back, we drove north through the private Grumeti Reserve to exit the park and reach the highway (I say that very liberally as there are no paved roads here) that we’ll take for some time until we reach the gate to re-enter the park once again. Back in the Serengeti, we drove the river circuit just north of Seronera where we found more huge wildebeest herds as well asl elephants and a lion pride. We ended up in the central area Seronera where the fuel station is and Vitalis decided to fill up tonight so that we wouldn’t have to return tomorrow before our departure. They had been out of diesel the day prior, so there was a significant line which took us at least 30 minutes to get through, though the holdup had less to do with line and more to do with the mechanism of pumping fuel here.

As each vehicle’s tank was essentially filled the owner would spend another ten minutes trying to get every last drop into their tank, rocking the vehicle back and forth numerous times in an attempt to get the last few drops that the tank would hold. This was the same for every vehicle that pulled through, including the large bus that took extra-long for this procedure. When we had finally finished getting our fuel and I told the others why the drivers were rocking their vehicles, we all immediately agreed that having done the same thing in Philadelphia, in the same overcrowded situation with people waiting in line, would have likely ended in getting shot by a disgruntled driver waiting in line. Things happen at a much slower pace here and that doesn’t seem to bother anyone. I’m not sure there’s a lesson to be learned there or not, though it’s just an observation rather than a commentary.

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As we were heading back to our camp (some ways from Seronera), we spied two vehicles sitting near a tree that looked like it would be tempting for a leopard. Sure enough, there was a very fresh and barely eaten Thompson gazelle kill that had been dragged into the tree by a leopard. Looking through the branches, though, there was no leopard to be found. That is until someone spotted the leopard sitting way up in the very top branches of tree in what seemed like a very precarious position. Leopards carry their prey into the tree not only to keep it away from hyenas and lions (though lions can climb the tree if their desperate), as well as vultures, who are then unable to spot the kill from the sky.

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The leopard was huge and clearly a male, with massive paws (from what we could see given how hidden he was) and a large, round head. It was getting very dark now and we really needed to make it back to camp soon, so decided that we’d come back first thing in the morning as it was very likely that the leopard would still be in the same tree.

It began to rain on us as we were heading back to camp, and the roads muddied very quickly so that we were slipping and sliding as we went. The visibility was also very poor, though we could see the herds of zebra and wildebeest as we drove by and eventually back to camp. The staff were waiting for us with cool, wet washcloths and hot showers in each of the tents that were very much appreciated. Our dinner that night was of a more African flare as it included ugali, the stiff corn porridge that is a staple here and lots of vegetables. Bolts of lightning flashed in the distance. We were to leave at 5:45 am the following morning in search of our very shy leopard and would then return to camp for breakfast. It was a perfect plan to start our last day.