Heading back to Rift Valley Children’s Village is never a disappointment. The success of the village and the Tanzanian Children’s Fund has been nothing less than spectacular on so many different levels, though, first and foremost, the children and the family that has been created there. The other facets of the TCF have been equally impressive and have included their education initiatives, starting with the local primary school, and now including the secondary schools within the Oldeani district, the health initiatives (which is our purpose there), and, finally, the microfinance and financial empowerment of the women’s group in developing and marketing their crafts.

Not to sound like a broken record, but our plan this morning was to arrive early to begin seeing patients and finish at a decent time as we had plans to visit with an old friend, Daniel Tewa, tonight. Once again, best laid plans seemed to dictate the day here as we finally arrived at the village no earlier than we had yesterday, though there was still some hope that we would finish early enough for the residents to get a tour of the village and to shop in the duka. We had left all the medications overnight there in the pharmacy, along with all our supplies in the offices, so there was virtually no set up on our arrival and we were quickly back to seeing the backlog of patients who had shown up to see us that day. With everyone quite familiar now with how this clinic was run, they were ready to begin seeing patients quickly. Amos, one of translators, was unable to make it today as he wasn’t feeling well (since he doesn’t drink, it could not have been from the visit to the Dungu the night before) so we were down one of our team, but given the fact that there are plenty of people at the village who speak Swahili and wonderful English, finding another translator on the spot was not an issue.

It turned out that today was a holiday here in Tanzania. It was Mawlid al-Nabi, celebrating the birth of the prophet Muhammad, though the specific day was a bit of a question as the government here had not quite decided which day it would be until this week, finally announcing it a day or so ago. Having confusion about which day a holiday is going to be observed is just so “Africa” and perhaps one of the first things you learn here, which is to expect the unexpected. As long as you have few plans, then life goes along quite well, and you are seldom disappointed. Making plans and having expectations is a set up for being disappointed. As Frank always says, “TIA,” or “this is Africa.”

Our lunch today was again a wonderful feast with cheeseburgers and rolls, sliced tomatoes, pickles, and other condiments to place on top. Delicious French fries that several of us took full advantage of (I won’t mention any names) along with salad and fresh fruit on the side. Scrumptious and certainly satisfied my need for a good burger for at least until I get home. After lunch, it was time to visit the duka and do some shopping for gifts. The Woman’s Group here has always made incredible things and has continually branched out to new designs – batik jackets, bathrobes, computer sleeves, shoulder bags, wine bags, glass holders, and more – all very well made and very affordable. What began as a very small operation making only a few tchotchkes has now grown into a much broader selection of items and is being sold through a number of lodges and other partners throughout Tanzania, all being promoted with help from the TCF along with their microfinance opportunities.

We did seem to have a rather short afternoon after all, which allowed for the residents to have a nice tour of the Children’s Village that was led by our translator Nuru, who had grown up here in the village and has now graduated from college as a pharmacy technician and is in the job market, so biding her time and gaining some experience by helping out at FAME. She has worked with us numerous times in the past over the last years and has always been a welcome guest to join us anywhere and everywhere given her incredible personality and willingness to be a part of our team. The very first time she had worked with us at Oldeani, when she was still in secondary school and at the time thinking about becoming a physical therapist, she wrote me the sweetest note thanking me for allowing her to join us. Nothing could have been further from the truth for it was us who should have been thanking Nuru.

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The tour took a bit longer than I had anticipated, though we were able to send the other car containing most of the FAME personnel on their way home given the night before we had been so delayed in getting home. When they finally finished, we loaded everyone up in the stretch Land Rover and were on our way back to Karatu in now time, again taking my preferred alternate route home through the fields and then down into one of the valleys while avoiding the African massage road all together. We were still running later than I had anticipated, so it was decided that we would just go straight to Daniel Tewa’s rather than home first, though did have to pick up Judith, another FAME volunteer, who was going to join us for our visit. Judith is a surgeon from Germany who is transitioning her life to Tanzania and working here at FAME for a short while until she decides on a more permanent position. I had invited her to come with us to Daniel’s for the evening.

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Daniel is a very special friend, though he would tell you up front that we are not friends, but rather family. I first met Daniel in 2009 on my very first visit to Tanzania with my two children and while volunteering for a few days at a local school that just happened to be in his village. As one of the elders, Daniel worked with us while painting and then invited us to visit his home. He is a very unique individual as he is so incredibly well-read and well informed on world events and locations yet has never left his home country of Tanzania. He is the local historian of anything related to Iraqw tribe, Tanzania, East Africa, and beyond. He continually amazes me with his knowledge of the world, yet has no interest in traveling for, as he once told me, “how would it benefit my family?”

The Iraqw tribe was at odds with the Maasai, particularly over the ownership of their cattle. The Maasai believe that all cattle are theirs and that taking cattle owned by someone else is merely returning the cattle to their rightful owner. Because of this, the Iraqw began to build houses that were mostly underground though with a domed roof and had room for all their livestock to live inside at night, safe from the Maasai. Anyone walking across the roof of one of these houses would be immediately discovered and chased away as a thief, or worse, attacked. When Tanganyika joined with Zanzibar in 1964 to become Tanzania, Nyerere and the government realized that the only way to build a country and create any infrastructure was to move everyone into villages together and to ban the use of any unique features such as the Iraqw underground home. Daniel had spent the first twenty years of his life in such a house, or tembe in Kiswahili, and, after telling his children about them and having them think he was crazy, finally decided to build an example on his property, not to live in, but rather to educate others about the history of the Iraqw.

In the early 1990s, Daniel began to build a small, though completely accurate and authentic, Iraqw underground tembe. Today, it stands as perhaps one of the only authentic Iraqw houses in existence and stands as a memorial to his culture’s history. It is visited by many scholars and students who wish to learn about the history of the Iraqw for Daniel could spend many hours on end describing how the Iraqw have lived in this region of Tanzania after coming from the north several millennia ago. Having visited his home on countless occasions, I have come to learn a tremendous amount about this amazing tribe and feel very fortunate to have had such a teacher. As Julius Nyerere, the father of Tanzania, was known as Mwalimu, or teacher, to his country, Daniel Tewa has been my mwalimu for all things Tanzanian and Iraqw.

I have brought every group of residents to visit Daniel and to have either a meal or coffee. With the pandemic, it has been coffee more often now, but sitting out in his yard and sharing his African coffee (boiling milk and coffee together) is more than a wonderful experience. He tells stories of Iraqw culture and amazes everyone with his knowledge of US and world geography and politics. Having the ability to visit friends and family here with the residents has truly enabled this to be more than just a medical rotation for them and, though perhaps a bit less than cultural immersion, has allowed them to feel a part of the community, even if for a shorter period of time than they would have liked.

We visited Daniel’s traditional underground Iraqw house, though by the time we visited after several cups of coffee, it was rather dark. Lit only by our iPhone flashlights, it was probably more realistic than any of us would have guessed. Daniel proceeded to describe how everyone slept in the house, men on one side, women and children on the other, and animals in the back in a small corral that housed them during the night. Afterwards, we all gathered in the small living room of his standard Bantu house that he had built years ago and where I have shared many meals with him. When I had first visited him in 2009, he was entirely off the grid, using methane gas produced onsite from a mixture of cow dung, cow urine, and water for heat, light, and cooking. Though he now has electricity connected to his home, he continues to produce methane from his cows and uses it for cooking.

Everyone left Daniel’s home that evening a bit richer for what we had learned from him and what we had seen. Relationships such as this are rarities in this world, and we should cherish them. Tomorrow morning we will all be departing for the Serengeti and two nights in the park. Everyone will be going to sleep tonight with thoughts of the migration and big cats.

It was not an accident or unintentional that FAME came to be in Karatu. Rift Valley Children’s Village and the Tanzanian Children’s Fund, TCF, is an institution that was founded some 20 years ago by a remarkable individual, India Howell, who, like many of the ex-pats living here now, came to Tanzania originally for travel and fell in love with the country. Recognizing the need to provide for those children who had been orphaned, or whose families were unable to care for them, she created the Children’s Village, along with her business partner, Peter Mmassy, and then proceeded to adopt her children rather than having them remain as orphans. From that humble beginning, TCF has now become a multifaceted organization that is not only home to over 100 children who are a family, but it also has partnered with the local education system to provide better and safer schools, has empowered women in their region to develop and maintain businesses which they help promote, and has provided for the health of the local population.

It is that latter function that has involved FAME since it’s creation. The Children’s Village is in the district of Oldeani, an interesting village that has a unique history that is for another blog, that is only 45 minutes away from Karatu and is the reason that FAME exists where it is. When Frank and Susan were researching a location for their dream of creating a health facility, it was Mama India who suggested coming to Karatu, for, in addition to its close proximity to Oldeani and the Children’s Village, Karatu sits on the main, and technically only, road to Ngorongoro Crater, the Conservation Area, and the Serengeti, meaning that every safari vehicle and every tourist has to pass through this town. Though FAME’s mission is to improve the health of the Tanzanian residents of the Karatu district, it has also become the main health facility for any tourist traveling the Northern Safari Circuit, certainly improving the exposure of FAME as a non-profit, charity hospital to greater funding opportunities.

FAME has always provided the care for Mama India’s children, initially with medical clinics held onsite for the children and the Oldeani villagers, though over the last five years or so, patients are now brought to FAME for their treatment, which has proven to be more efficient and economical. When I started doing mobile clinics back in 2011, though, and especially when I began bringing residents in 2013, it was decided that we would run a separate neurology mobile clinic there at the same time and have continued to do so even after the FAME clinic there was discontinued. We now provide two full days of mobile clinic twice a year at the village, seeing both India’s children as well as the residents from Oldeani with neurologic disorders. Outside of these two clinics, though, patients continue to come see us at FAME as there are cars coming from the Children’s Village continuously throughout the day so that accessibility is not an issue.

Early on, Rift Valley Children’s Village employed a nurse practitioner to staff the medical dispensary at the village for both their children and the Oldeani residents. I’m fairly certain that all the nurses were from the US, that is until several years ago when they hired Africanus John, a clinical officer who had volunteered at FAME and had worked with our neurology clinic as a translator initially and was then hired by FAME as a clinical officer. When the Children’s Village needed a new medical officer, they hired Africanus, with FAME’s blessing, of course, and I could not think of a more qualified or perfect person for the job. Not only is he a great clinician, having taught him neurology and then worked with him when he was a clinical officer for FAME, he is an amazing administrator, having now fully organized the dispensary so that it is operating smoothly. Africanus frequently contacts me in the US when he has questions about our patients in between visits and occasionally about new neurology patients that have come his way. Having Africanus there to help manage our patients has made our job tremendously easier than in the past and we look forward to having him around for as long as possible.

Today we were heading to the Children’s Village for the first of two days of our fall neurology clinic there. I hadn’t mentioned before, but I now have the use of two Land Rovers, one stretch (i.e., a safari vehicle) and the other a stock version of the Land Rover Defender 110. In the past for our mobile clinics, given the number of residents and interpreters we have, I’ve had to rent a safari vehicle from the Kudu Lodge to use alongside my stretch Land Rover as we could not all fit in one vehicle and there were no spare vehicles at FAME. We can all fit in our two Land Rovers now including our medications and other supplies that are necessary for the day of seeing patients. Though our plan had been to depart at 8:30 am, one always must remember that this is Africa (or TIA as Frank always reminds me) and time moves at a much different pace than we are used to back home. There are a lot of moving pieces involved that includes coordinating the two vehicles and the fact that half of our neurology group (mainly our interpreters) live downtown and, therefore, have little need to travel all the way up to FAME when only be passing by the junction with the main road on our way. And a stop at the junction to pick up people usually involves a visit to Mushrooms Café, one of the local hangouts for a quick Tanzanian breakfast or to grab good take-out goodies for the road.

This morning, I also had to make a deposit to the bank for our upcoming trip to the Serengeti and the bank opened at 8:30 am, which was perfect timing as I thought I could get in early and take care of the transaction quickly. I asked one of the bank employees which line I should stand in and he asked me if I had filled out a deposit slip or not, which I hadn’t. He pointed out the slip I needed to fill out and I asked him specifically how to list the actual bills as they had shillings on the form rather than US dollars, though he said that was perfectly fine. I waited in the line he said I should use and, when I arrived at the teller, of course she told me that I hadn’t filled out the right form. A bit frustrated and in a hurry, I just stood there and told her that I filled out the form I was told to fill out and didn’t show any interest in stepping out of line to get the correct form off the counter, if it was even there. Eventually, she excused herself for a moment to retrieve the correct form for USD and I filled out the correct form after she returned while I still stood at the window. Having eventually taken care of the deposit, I left the bank, hoped back in the vehicle, and we were off for the junction, and Mushrooms Café, where we had planned to meet.

By the time we had gathered everyone together and seating was finally sorted out as to who was going to ride in which vehicle (we had our four translators squished into my back seat, so we were now 10 in Turtle), it was after 9 am and we were finally under way to the Rift Valley Children’s Village, a drive of about 45 minutes or so. Leaving Karatu behind us, we headed in the direction of the Conservation Area gate, though left the tarmac just short of it on a road marked, “Crater Forest Tented Camp, African Massage Road,” giving one a bit of a hint as to what the drive ahead is like. Though the remainder of the drive to the village isn’t the roughest of roads, it is somewhat bumpy as I’m sure the residents who have been before and those with me now will without doubt attest. Thankfully, it is also a gorgeous drive along a ridge between plowed fields of grain that are now golden post-harvest. The farmer’s homes are typically just off the road on the downhill side looking down into a lovely valley with more golden terraced fiends until we reach the end of the ridge and need to descend a somewhat steep path leading to the bottom. In addition to the natural bumps in the road, there are carved drainage ditches that angle across the road at varying frequency, dug there to direct the heavy rains off the roadway when they come.

I have driven this road in all weather, including heavy downpours, and it is very treacherous, making me thankful for my four-wheel drive as well my low range on the transfer case. Driving down the steep inclines in the mud requires the willpower not to touch your brakes, for doing so will undoubtedly put you into an immediately slide. The low range on the transfer case allows you to use the engine to brake the vehicle and to maintain the correct direction of the vehicle. I the heaviest of downpours, I’ve used the alternate road through Oldeani going home as these roads become nearly impassable, yet the staff village drivers will do this multiple times a day fearlessly. The Land Rover is absolutely the vehicle of choice for these roads given its wider stance and lower center of gravity, along with its fulltime four-wheel drive compared to the Land Cruiser. The Land Rover is nearly impossible to get stuck, though I have done it once a number of years ago and learned my lesson.

The final incline up to the village, and the coffee plantation that surrounds it, is even extra bumpy just to remind everyone that we are in Africa and in the bush. We reach the gate of the village after passing by the primary school that is adjacent and the abandoned coffee pickers village (the workers were moved to other housing, though there are still a few squatters living there) and arrive to the gate. Passing through the gate, one enters what can truly be described as Shangri-La, for it is another world all together with all the children playing and their houses where they live, for this is their home and not an orphanage. The village is home to over one hundred total children, most of who live inside the village itself, while the older children attending college or returning home to visit have houses just outside, but still part of the compound. Each of the houses for the younger children, divided now by sex and age, has a house mama to provide their daily care and upbringing. Children going to primary school access the school next door, while most the older children attend one of the secondary schools in Oldeani before eventually leaving for college. Regardless, Rift Valley Children’s Village remains their home forever and Mama India their mother.

Our clinic space at the village has for years been the dispensary office that is attached to all the administrative offices, but on arriving, Africanus led us to their brand-new health facility that was recently built to house his office, a number of exam rooms, a minor procedure room, a pharmacy room, and a laboratory room. The center is located just outside the village now and is attached to the duka, or store, where the Rift Valley Women’s Group merchandise is sold, which is always one of the highlights of a visit here. It is also closer to where the older children’s homes are and has plenty of room for patients to sit out in front while waiting to be seen. Africanus has triaged all the patients and we have written charts already pulled for patients who have been seen by us before and sheets of paper to write on for those who have not. Writing notes is a new thing for the residents and only done in the mobile clinics as FAME’s EMR is on the intranet and not available off the FAME campus. Charts are also divided into two stacks – children and adults – and the number of children here is typically higher than we see at FAME making Whitney quite happy. We had four examination rooms set up, and at some point, the residents decided to have five rooms with Fien there to help, making my job a bit more hectic with five residents to staff. Thankfully, it isn’t required for me to see the patients here myself as that is mainly a Medicare requirement at home. Should there be a question about the patient, or an exam finding in question, I’ll join them, but given the excellent residents I’m working with, that’s rarely a question, and when there is one, it’s appropriate.

Lunchtime here is a bit earlier than at FAME and lunch is served to us in the volunteer kitchen where a fresh lunch is made every day for the volunteers. Though I can’t say enough good things about the lunches we eat at FAME, especially the rice and beans, that are made for the entire staff, volunteers and Tanzanians alike, I’ll have to admit that the lunches at the village are particularly good and a bit more home like. Everything is grown there, and the salads are delicious. We had a wonderful chicken salad with freshly made bread, couscous, coleslaw, and fresh fruit. What more can I say?

The residents had hoped to visit the duka today, but clinic went on for longer than expected and we didn’t end up getting out until after 5 pm. Unfortunately, the person who runs the duka had left for the day, so it was an activity that would have to be done tomorrow when we would be back for day two of the clinic. One the way home, by a slightly different and even more beautiful route, the residents decided to go out with the translators, all of whom had recommended a new location (rather than the Golden Sparrow which is a dance club) that is a mobile bar fashioned out of an old safari camp supply truck. The “Dunga” was created by Nixon, who has played a large role at FAME and owns and runs the Lilac cafés, is pretty much like a food truck that is equipped with a bar as well as the ability to cook food.

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Later in the evening, we drove into town, where we picked up the translators and then drove in the direction of Rhotia. Just before the incline, there was an old, abandoned structure that was primarily some walls and piles of sand, and I was told to turn in there. As we got closer, sure enough, there was the dunga, parked inside the walls with chairs set out and a bonfire in the middle. Denis, an old friend and artist, was manning the dunga, which was very reassuring to me as I was planning to drop everyone off and head home and the whole thing was just a little bit sketchy to me. In the end, they had a wonderful time and I drove back later that night to pick everyone up as Wajiha had texted me that they were all going to take bijajis home, which I didn’t think was safe that late at night. My only requirement is that they all are able to get up for clinic the next morning, and they were, so all was good.

Our very first neurology mobile clinic occurred in 2011 and was in Kambi ya Simba, where we’ll be heading today. I never would have imagined on that very first clinic that I would still be traveling to the same village after a dozen years, yet here I am. What was a tiny dispensary back when we started visiting this village has now turned into a health center that was actually visited by the President of the country several years ago and is one of the health ministry’s flagship centers.

Kambi ya Simba, literally meaning Lion’s Camp, is in the Mbulumbulu region of the Karatu District and sits along the escarpment of the Great Rift Valley just northeast of the village of Rhotia that is on the main highway to the Serengeti. This is a highly volcanic region (Ol Doinyo Lengai, a nearby volcano, last erupted in 2008) and, as such, is incredibly fertile and the entire area surround Kambi ya Simba is made of fields of crops that are grown by the Iraqw, who settled in the area. As you travel further north along the escarpment, towards the village of Upper Kitete, where we used to have another clinic, the area between the mountains to the west and the drop off into the Rift Valley becomes narrower and narrower until you finally reach the 2000-foot drop into the valley below. I have posted many photos of our visits to the overlook which is one of most amazing views up and down the Rift Valley.

I was also contacted several years ago by someone who had run across this blog and had been volunteering in this region back in the 1970s, just after independence, and sent me lots of photos that he had taken back when the new government was active here with their socialist plans for work camps and such. One of these camps still stands as a memorial just outside of Upper Kitete and is a reminder to the roots of a brand-new country that only came into existence in 1964 with the merger of Tanganyika and Zanzibar (Tanganyika had gained independence from the British in 1961).

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As it was Tuesday morning, our education lecture today was given by Dr. Judith, who is a volunteer surgeon working here for a bit and helping with our surgical program. Her talk was on peritonitis, something that we don’t deal with on a regular basis in neurology, but she covered the basics and, as would be expected given how far I am from my basic medical training, I did learn a few things during her half hour talk. A rather brief morning report followed her talk which allowed us to get prepared for our mobile clinic a few minutes early, and it wasn’t long before we had the stretch Land Rover filled with neurologists (there were probably more neurologists in our vehicle than there may be in the rest of the country!) and on our way into town to meet up with the other vehicle that was transporting our translators, social worker and nurse to dispense medications.

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To reach Kambi ya Simba and the Mbulumbulu region, we head east out of Karatu and up the big hill towards Rhotia. This steep hill was the site of a horrible school bus accident back in 2017, in which over 30 children died when their bus lost control heading down the hill and fell into a ravine after leaving the road. Once in Rhotia, we leave the tarmac and head northeast past beautiful farms and small enclaves of houses. Some of the fields are tilled by hand and others are lucky enough to have a tractor to do the work. One the way home in the late afternoon or early evening, we typically pass large groups of school children, all dressed the same in their individual school uniforms that is a standard practice throughout the country. There are lots of vehicles coming and going along this road, some being larger buses on a schedule, and others that are older Land Rovers completely packed inside and out with as many bodies as possible and then some. Their tops are stacked with more supplies than one could ever imagine and then there are usually several individuals sitting on top plus one hanging off the back. With their high center of gravity, they sway from side to side so that I’m always very careful when they pass for fear they might lose control.

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Once we reach the village of Kambi ya Simba, it is a short drive uphill and out of town to reach their health center and three are usually lots of patients waiting for us on the benches outside the rooms we use as interview rooms. Today, though, there were fewer patients than normal, and we later found out that it was market day for the village which means that many of our patients were very likely attending the market as this is very often a vital part of people’s lives here for it can be their main source of commerce and, occasionally, income. It did turn out, though, that our clinic also coincided with their RCH clinic meaning that there were lots of mamas with their little babies, each with their own little harnesses for weighing them on the grocery scale as it is done all over. This is a tradition here and something that is done at all the villages and even in the RCH clinic at FAME.

The health center at Kambi ya Simba consists of many buildings, a far cry from what it was when I first came here and held the clinic outside in front of their wood and stick church building. There is still a very rustic feel, though, and the several chickens running around in the courtyard grass certainly would attest to that fact. Even more so, though, was the incredibly loud and large rooster keeping watch over his many hens. If there was anyone to “rule the roost,” he looked the part.

Our clinic was in one of the outbuildings where we were able to find four rooms to use, though one of them had an outer door that was missing its handle and hasn’t opened in several years. Thankfully, the room on the other side of the stuck door was fully accessible from another one of our rooms, so other than the fact that you had to escort your patient through a room in use, it worked quite well. Their RCH clinic was in the same building, so all the babies seeing the nurse for their well-baby visits were there for us to gawk at and pour over.

With the fewer number of patients present due to it being market day, everyone was able to take a bit of a breather and things were less rushed for us. There were the typical number of new and follow up patients for us to see with the more common diagnoses that we see here such as epilepsy, headache, neck and back pain, and neuropathy. We don’t have access to labs here, so if patients require them, they are sent to FAME to have them done. The other issue we have is that we only come here every six months which can be a long time for a follow up visit, especially if the medications require either a titration or an assessment as to whether to adjust or discontinue.

We had brought box lunches with us from the Golden Sparrow, though had forgotten to tell Kitashu that we had two vegetarians with us. There was a reasonable amount of food in each box that was still edible for them, so it was not a huge catastrophe. Whenever we’re on mobile clinic and at one of the villages, we never eat in front of our patients or the workers as it is quite possible, and very likely for that matter, that they have a significant food insecurity and may not have had a meal for some time, so instead, we eat in the car most of the time or find an out of the way place somewhere in the shade to eat. Kitashu will most often also hand out any extra food from the lunch boxes or extra drinks to the local children or others from the village. I remember years ago, attending a soccer match with Leonard that was high up on the slopes of Mt. Meru outside of Arusha, where the soccer teams supplied all the ingredients for a massive pot of rice, vegetables and chicken that was distributed to all the villagers. Everyone was so happy and joyous that they were having a full meal as that is not often the case. In a similar manner, I am always amazed at the amount of food that many of the FAME employees take for the communal lunch that is served there. It makes perfect sense, though, if you realize that it may be the only complete meal they are receiving for the entire day.

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We finally finished with clinic at Kambi ya Simba and were heading back to Karatu well before sunset which a nice turn as we’re often coming back from mobile clinic late. Last spring, we came back from the Lake Eyasi region clinics well after sunset which is always an issue as driving at night here is not something that’s advisable for a few reasons. First is probably the fact that there are lots of wild animals here that often like to cross the road at night. Secondly, drivers here are not the best. The large buses often drive far too fast to keep on schedule and will frequently crash on their own or would happily involve another vehicle in their mishaps. Vehicles commonly pass in no passing stretches where the visibility is already terrible during the day and is far worse at night. There are no streetlights here, and when the sun goes down, it becomes incredibly dark.

Today, though, we were getting into town early enough for me to drop off the group in the business district of Karatu with our interpreters who could guide them around to see what they wanted. Karatu is a frontier town that exists because of the safari circuit and is the last outpost of civilization on the road to the Serengeti. It is the jumping off point for most trips and there are almost more safari vehicles here than there are people. In the evening time, all the guides are out washing their vehicles and staying in town at the “guesties,” or the inexpensive guest houses while their guests are staying in the more expensive lodges, waiting to be picked up in the morning in a clean and shiny vehicle, only to do it all over again given how dusty it is here right now.

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I left the group off by the Bamprass fuel station in the center of town and was quite comfortable with them walking around town with their escorts. Other than the street vendors trying to see their wares, there was little trouble they could get into here. Karatu has changed, though, over the years. When I first arrived, the only paved road was the one that went through the center of town and there were no buildings over three stories, or maybe even two. Now there are several five plus story hotels in town and there have been paving roads in town so that there are now several of them. Six months ago, I was shocked to see streetlights through the center of town and even though it makes a difference as you drive at night so that instead of seeing dark shadows running across the street in front of you, you actually can see things. Regardless, I do long for the old wild west days of Karatu but am aware that change is inevitable.

Perhaps the most significant thing for today is that it is Fien’s first day with us, and I am happy to say that she required virtually no orientation. She was off and running from the get-go. As I had mentioned, she arrived from Belgium yesterday and will be joining us for three weeks. Fien (whose name is pronounced like the end of “Josephine”) had contacted me almost a year ago inquiring as to whether it might be possible for her to join us sometime on one of our rotations. She is a fourth-year neurology resident in Belgium (the program there is five years compared to our four) who had been listening to BrainWaves, an amazing neurology podcast, that had been created by Jim Siegler, a former Penn resident and fellow, and covered a variety of neurologic topics with each episode featuring a guest who would be interviewed by Jim and would elaborate on whatever topic was being discussed. I have participated in probably half a dozen of these podcasts (which I believe numbered in the 180s when it was finally discontinued only recently) over the years, but very early on, he asked us to do one on our work in Tanzania and global health. An-Thu Vu, one of my former residents who had come to FAME in 2015 and who is now a movement disorder attending at Jefferson in Philadelphia, was interviewed by Jim, as was I.

After listening to the podcast, Fien realized that coming to FAME with us was something that she would love to do. Having volunteered previously in several global health circumstances – Lebanon, Cameroon, Tanzania, Ghana, Croatia, and Albania – she knew exactly what she wanted to do. She searched for me on the internet and, in addition to finding my contact information, also found this blog, which she spent time reviewing, only further confirming her interest in working with us. She contacted me by email and shortly thereafter, we connected on Zoom. It was immediately clear to me that she would fit in with my residents and our program and, furthermore, this would be an experience that she could draw on going forward in her career. Additionally, and somewhat selfishly, I felt that my residents could only benefit from working with someone with a completely different academic and training background such as Fien. There were really no logistical issues on my end, so the only matter that had to be dealt with first was with her training program and to make sure they were OK with her joining us for three weeks. That didn’t seem to be an issue, so the next step was just deciding when she would come, and this time frame worked perfectly for both her and us.

The residents spent some time with Fien last night as far as orientation on the EMR (electronic medical record) and Wajiha brought her to morning report where she was able to introduce her to the FAME staff as a new addition to the neuro team. Our clinic began at 8:30 am as usual and Fien fit right in such that she was seeing patients on her own (with an interpreter, of course) and presenting them in exactly the same fashion as if she had been training with us all along. If there had been any concerns whatsoever from my standpoint, they had been immediately quelled.

Given the problem we were having with Turtle (having the rear door swing open constantly on a bumpy road was just not a tolerable situation, especially as we needed to use the vehicle for our mobile clinics over the next three days, and then to the Serengeti on Friday morning), I was having two mechanics come from Arusha to work on it today. I had hoped that they would arrive early, but having waited all day for them to arrive, it was not until about 3 pm that they eventually landed at FAME (causing much angst on my part given that if we could not get Turtle repaired today, I would need to rent a stretch vehicle from Kudu Lodge to make it through the mobile clinics this week, something I would hate to do given the cost), meaning that the any repairs would likely go well into the night and I wouldn’t have an update until very late.

Perhaps the most interesting patient of the day was a gentleman in his 50s who had a lesion on his skull, but it was not just any lesion. Dr. Manjiro, FAME’s surgeon, had brough the patient to me asking if we could possibly see him and, despite that fact that his primary problem wasn’t very likely going to be neurologic in nature, he still needed to have a good neurologic assessment based on a CT scan of his head that he underwent earlier in the day. His history was such that he had been seen in Arusha earlier in the year and had the mass at least biopsied, and quite possibly resected, though it had grown back and was now much larger. They had been told that it was a lipoma, which is a benign fatty tumor, though the appearance on the new CT scan done today was anything but benign.

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The patient was also complaining of right-sided weakness that had started more recently, but on examination, this seemed to be related to a mass in his right upper arm or axilla rather than being of a central origin. Given that the largest mass on the right side of his head, it would not have made sense for him to have right sided weakness that was related. Unfortunately, there was another large intracranial mass that had eroded much of the left sphenoid wing and was also beginning to invade the left orbit. All in all, this was a very bad situation and not something that could really be handled at FAME given the extent of the disease. We could have potentially biopsied something superficial, which may have given us some answer, but it would not have helped from a treatment standpoint. I contacted the neurosurgeon at KCMC, asking her to see the patient, which she could do in the next several days, but after hearing back later that morning from our neuroradiologist that he felt the scan was most consistent with a plasmacytoma secondary to multiple myeloma, it was clear that the patient would absolutely require an oncologist for treatment. Seeing a patient with advanced disease to this extent was something we would rarely run across in the US.

Our patients from Tarangire eventually arrived in the late morning, but we were sad to see that there were on about 12 patients as opposed to our normal 18-20 patients from this region outside of the Karatu District.  I can’t recall exactly how this relationship with the Tarangire folks began, though it has been a very rewarding one over the last several years. I believe that their “chief” had heard of our clinic and, on his own initiative, brought some patients to FAME for us to evaluate. After identifying several epilepsy patients and treating them with appropriate medicines and having them improve, he has continued to bring us more and more patients to be seen. All the patients have been more than appropriate for us to see and other than helping with the cost of their transportation to and from FAME, which is quite inexpensive, we have tried not to provide any additional services that are not available to other FAME patients. The chief has done a great job in making sure that the patients who need to see us are brought, though we have had some issues with patients running out of medications and will continue to work on that aspect of their care in conjunction with Kitashu as they are all Maasai, which allows him to have a greater appreciation for their cultural needs.

At some point in the morning, a young man was brought to FAME with an altered sensorium and a history of having another similar episode several days prior. The episodes had been precipitated by stress or anxiety, including the episode today, and his examination was most consistent with a functional disorder, meaning that it was not organic (i.e., physical). It was reported that he had improved when he was given IV fluids with the earlier episode, though there was absolutely no indication for that with this presenting episode. There were no tests to be ordered nor treatment to be given other than to reassure the patient and the family that he was well and that he would improve and be back to normal. There are very counselors here in Tanzania, so trying to find someone for him to see going forward was going to be very difficult. Sure enough, shortly thereafter, he woke up and his examination was perfectly fine.

We were home early enough for Jenna and Whitney to take a run down the road. Whitney decided to play football with some of the children along the road – who would have imagined.

We had decided to have a quite evening at home and LJ must have had a ton of energy as she decided to cook up some eggs and hash browns for dinner that were delicious. The dinners that had been sent to the house that night, for those of us who eat meat, consisted of fried chicken and boiled potatoes, which we would typically devour had it not been for LJ’s burst of energy, which was a very nice diversion from our usual menu. I’ll have the admit that the hash browns were especially good having cooked them in some sesame oil and margarine with onions and peppers. Throughout the evening, I was waiting to see what was going to happen with my Land Rover. The mechanics had told me to give them the car for a few hours, but it wasn’t until 10 pm that they finally drove back to the house to deliver it. I let Kitashu know that we wouldn’t have to rent another vehicle after all, though the mechanics would have to come back next week to finish fixing some additional things that needed to be done. Thankfully, though Land Rovers are incredibly finicky, they are also relatively inexpensive to fix. We would take Turtle out on tomorrow’s mobile clinic for a test run and hopefully she would hold together.

While sitting in my room working and waiting for Turtle to return, I could hear lots of music and laughter coming from the main room and it made me very happy to know that the residents were having such a good time, including Fien, who has fit in so well with the others. At one point, I wandered out of my room to find the entire group dancing together to songs I didn’t recognize, totally comfortable with the generational gap (several?) that existed between us. Sharing this experience with others, though, is all that matters, and there is absolutely nothing generational about that.

The residents had now completed a full week of work in clinic (save for the half-day orientation on Monday, and the half-day yesterday) and it was now time for us to have some real fun, as if what we had been doing all week wasn’t. Since my very first visits here to FAME, we have always made sure that we took time to see the country and visit friends and, given that we’re smack in the middle of the Northern Tanzania Safari Circuit, that means visiting the parks. Tanzania is repeatedly voted the number one site for wildlife game viewing, and it would be a crime to have visited here and not to have seen at least one park as part of your stay. The town of Karatu is the last outpost on the road to the Serengeti and borders the Ngorongoro Conservation Area, or the NCA, boundary.

The NCA was developed as a dual use region as the Maasai had to be relocated with the formation of the Serengeti National Park back in 1951 and having that land set aside solely for the conservation of wildlife. The NCA, on the other hand, serves not only as a place for conservation of wildlife, but also as the home for a very large population of Maasai who live and graze their cattle there. Remember, Maasai are pastoralists, meaning that they only graze their animals, which they rely on for meat and milk as food, and any grains or other necessities must be purchased or supplied by the government. Without going into detail, as there are many stories about what is happening at present and it’s unclear what is actually true, the government is relocating the Maasai to the Tanga region of Tanzania in the northeast of the country. To say that things are not going smoothly would be a gross understatement.

The Ngorongoro Crater, which is a caldera, or a collapsed volcano, sits completely within the NCA and is the largest of several craters in the region. Empakai Crater, which is an hour or so north of Ngorongoro, is smaller and open for hiking to the bottom where there is a lake that nearly fills the floor and is home to large flocks of flamingoes. It is well worth the trip there and I have done it on several occasions, though with the new three-week rotation, we have run out of the extra weekend to do this.

Ngorongoro Crater is immense. It is the largest complete dry caldera in the world and is ten miles across and 2000 feet deep. More importantly, it contains vast herds of wildebeest and zebra that do not migrate as there is no need, along with large numbers of Cape buffalo, hippos, elephants, Thompson and Grant gazelle, eland, ostrich, and countless bird species. There are no giraffe on the crater floor as it is too steep for them to descend, and there are no crocodiles as there are no large rivers with moving water. Cheetahs have become hard to spot there, but there are leopards (also hard to spot) in the forest, and caracals, a medium cat, of which I have seen several. There is perhaps the largest concentration of lions in Africa here given the amount of prey and the fact that they do not migrate and are always around. The crater is perhaps best known throughout Africa as the home of the endangered black rhino that, through the incredible efforts of conservationists here in Tanzania, have made a tremendous come back and whose numbers continue to grow. The black rhino is also found in the Serengeti in several locations, but is concentrated in the crater, so odds are better to see one there. The white rhino, which is found in the south of Africa, is far more common and about twice the size of its northern cousin. Its name, White Rhino, is also a bit of a misnomer as it was actually named for the shape of its muzzle, which is wide as compared to that of the black, which is sharp. The Afrikaans word for “wide” was mistaken as white.

The immensity of the crater is difficult to describe and is its own ecosystem, often with different weather caused by clouds that are trapped within and then blow over the rim throughout the day. There is a road that goes around about 75% of the rim and the road we’ll take today is the same that is used to travel to the Serengeti, though we will turn off to descent into the crater. There are three entrance roads – the one-way descent road, the one-way ascent road, and then a two-way road on the opposite side of the crater which are all self-explanatory. Ascending over 2000 feet up the outside of the crater wall, the altitude of the rim ranges somewhere between 7000 and 8000 feet and can be very windy and cold. You enter the NCA through the Loduare Gate, which is where the tarmac ends as well. As a World Heritage Site, the crater is one of the crown jewels of Tanzania and, thus, is heavily protected by the government to the degree that the NCA is its own agency, separate from the other national parks and similar to the Serengeti, another of Tanzania’s jewels.

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Loduare Gate opens at 6:30 am and, as it’s always advantageous to be there as early as possible, not only to beat the crowds, but also to get to the crater floor as early as possible to see the animals before the heat of the afternoon sun. With that in mind, I had set a tentative departure time of 6 am this morning as it typically takes about 30 minutes to get to the entry office to pay as well as the gate. Today, we were traveling in tandem with Pete, Amanda, and their two small children, Oliver, and Astrid. It was a cold and cloudy morning and, as we ascended just to the gate at the base of the crater wall, it became very misty and windy. As I walked into the office to take care of registration and payment, I could not help but to have an overwhelming sense of trepidation given my history of difficulties with their process of entry in the past. Last spring, I had no problems with entry, and I guess I should have known that was too good to be true. When I showed the clerk our vehicle registration for Turtle, which has private plates on it now and which took some time to make that happen, he immediately pointed to the fact that the vehicle was still registered to a safari company and that it didn’t matter whether the plates were private or commercial.

We were at a complete impasse, but the clerk was understanding and called Leonard, who then, at 7 am Sunday, worked his butt off to get us a booking number in the system which would then allow me to pay for the entrance. What should have been a simple process, though, turned out to take more than thirty minutes, all the while, dozens of safari vehicles were passing through the gate on their way to the crater. We eventually found the reservation number in the system but were then unable to pay as that part of the software was apparently down or slow at the moment. Thankfully, the clerk gave us an entry pass that would allow us to go down to the crater and then pay on our way out later this evening, though having to show the permit to enter to numerous rangers both at the gate and then at the descent road, no one seemed to understand just what to make of the permit so I had to explain it over and over to them. Regardless, we were now on our way and heading up to the crater rim.

During our time at the gate, though, the clouds had descended significantly, and it was now drizzling, so given that we would be climbing over 2000 feet to the crater rim, it was sure to be a wet and visually challenging ride up to the top. As we were preparing to get through the gate (of course, everybody and their mother wanted to look at our entry permit before they’d let us through), I nonchalantly flipped on the windshield wipers only to discover that they were not working at all. It wasn’t that they were working poorly and needed to be replaced, but rather they were completely dead and not moving at all. Not wishing to spend any more time at the gate than I already had, I just chose to soldier on and begin the long and winding ascent to the top. As we were essentially traveling through the clouds, the mist continued to build so that by the time we were nearing the top, the windshield was pretty well covered with moisture and significantly impairing my view of the road.

The drive up to the crater rim is probably my favorite drive anywhere I’ve ever been. You are ascending through a primordial forest of gigantic prehistoric trees reaching their best to find the sun and climbing up from the depths of the canyons we’re driving beside as we slowly make our way to the top. At nearly every turn, elephants have carved into the rock ledges with their tusks in search of the minerals they require for their nutrition. As we reached the rim, there were two things that were quickly apparent. First, stopping at the overlook for a view into the crater was totally useless considering that the visibility was now a matter of meters. Second, not having functional wipers was going to really suck. We had stopped once (the road is very narrow and treacherous) on our way up to clean the windshield, but it was now clear this was going to be a real issue as the clouds were becoming more and more dense as we drove. It was also incredibly cold.

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The rim road is considered treacherous in the best of circumstances and considering it is a narrow, two-way highway that is the only way into and out of the Serengeti and across the northern part of the country, this was not a great situation. Trucks and large buses traverse this region along with all the safari vehicles such as ours, and it is not infrequent that a collision occurs with multiple injuries and even deaths. Most of these come to FAME and it is a frequent reminder that rushing to get anywhere on these roads is never a good idea. With all that in mind, I did my best to maintain a slow, steady, and safe pace, stopping frequently to wipe the windshield with Whitney’s donated sweatshirt. Thankfully, Saidi was with us to do most of the wiping, though LJ did climb out of her front door window in front of a handful of Maasai who were probably wondering what these crazy mzungu were doing. We had absolutely no relief from the clouds and decreased visibility until just before we reached the descent road on the backside of the crater.

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It was incredibly windy and cold as we looked down into the crater and could see the bottom for the first time today, so much so that we left the roof down for the steep descent to the floor. Finally reaching the floor, the top was popped, and we were now in full safari mode and ready to explore. There were a number of vehicles at the first junction which typically means they have spotted something and, sure enough, there was a lone female lion initially lying, and then slinking through the brush with a group of zebras in the near distance. She eventually made her way into the taller grass where we lost her, though, and we were then on our way. I had decided to follow Pete in their Toyota Prado and we drove in the opposite direction I normally go, but to honest, there really hadn’t been any firm reason for that. We looped around through the Lengai Forest, which is the best place to find close elephants, the rare leopard (I’ve never seen one in the crater), and lots of monkeys – mostly baboons and vert monkeys.

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Having made it through the forest, the next stop was going to be the hippo pool. Hippos are pretty opportunistic regarding their homes but given that the crater floor is typically very dry at this time of year and even more so now, I figured that the hippos would most likely be found at the most permanent site for water in the crater which would typically be their normal pool. Last spring, this region was complete flooded and difficult to get through, but not so this visit and, as expected, there were several dozens of them in the main pool and a number of others lying out of the water and in excellent view. The number of birds near the hippo pool was also incredible and there were dozens and dozens of different species all in the same vicinity. It was a birders paradise and something I know Dan Licht would have loved.

Following the hippo pool, we made a long loop on our way to the lunch spot, eventually arriving alongside a beautiful lake and very large marshy area. There are many hippos here, but the real sight is the Marabou storks that hang out looking for scraps and the black shouldered kites that soar above constantly looking for an unsuspecting tourist eating their lunch so they can snatch a sandwich or piece of chicken right out of their hand. Though I usually recommend eating in the vehicle, Amanda and Pete seemed to be a bit more adventurous, so we joined them out on the grassy area by the lake along with the storks and the kites flying overhead. It’s a bit eerie as you sit or stand eating your sandwich and watching out of the corner of your eye as to whether you’re about to be dive bombed by a pretty large bird that is agile enough to steal your food in a split second without even touching you. It is also a very fun pastime to watch as those unsuspecting individuals whose safari guides have chosen not to warn them be suddenly surprised by a diving bird with a three-foot wingspan deftly pluck their lunch from right in front of their face.

We had packed out lunch which consisted of peanut butter and jam sandwiches along with our hot pack dinner containers that we had filled with cut up pineapple and watermelon. Unfortunately, the hot packs, which are about the size of a bowling ball, acting as just that in the duffel we had placed them in along with the sandwiches. Many of the sandwiches, which had been wrapped in flimsy plastic wrap, were totally destroyed and what was left were pieces of sandwiches for some and others smeared to inside of the duffel. Meanwhile, the fruit remained perfectly intact, which was good as that in addition to the fractured sandwiches is all that we had for lunch.

After lunch, we took a long drive up to the river area near the two-way road and then around towards Engitati Hill, and back to the shores of Lake Magadi. As we were departing back through Lengai Forest, we could see streaks of rain in the far distance inside the crater, but thankfully, we made it through the day without a shower as we still had the issue of the broken wipers. We headed up the steep ascent road back to the rim road and then to the Ngorongoro Crater Lodge to visit with my friend Ladislaus and for the others to see this amazing resort. Ladislaus has hosted us for coffee for the last 4 or 5 years and it’s great for the others to see this amazing lodge that I was lucky enough to spend two nights in last April as Ladislaus’s guest. To say that it was a remarkable visit then would not do it justice. It was simply spectacular. While having our coffee today, I was so happy to see Marcel, who had been our butler for the two days of our visit.

We left the lodge with plenty of time to spare as the Loduare Gate closes at 6 pm and, if you’re not through the gate when it closes, you get to spend the night in the NCA along with the privilege of paying for another day there. In the past, I have raced down the road from the rim to make it to the gate with a minute to spare, but today we had time enough to stop at the overlook for the residents to see the view as it was covered in clouds in the morning. At the gate, I paid for our day with no complications this time and we were on our way home. Fien, the resident joining us who is from Belgium arrived to FAME today shortly before our return. We’re looking forward to getting to know her and having her work with us for the next three weeks. Meanwhile, dinner on Sunday is on our own, so we ordered food to be delivered from the Lilac café here on campus. It only took an hour and a half to arrive but was delicious when it did. Remember, this is Africa time here.

One the weekend days, there is no formal morning report meaning that everyone gets to sleep in for at least an extra half hour if they so choose. It was pretty clear that our volume would be a bit lower today as things had dropped off a bit yesterday, though once we got started, we heard about a few consults that needed to be taken care of in the wards, one in the medical ward and the other in maternity. In addition to these two new consults, LJ still had her very sick, young Maasai woman in the ward and continued to pursue her very complicated differential.

The woman in maternity who we were asked to see had a history of epilepsy and had been converted some time ago to lamotrigine given her age and the likelihood that she would become pregnant as some point soon, which was obviously the case as we were now consulted to see her in maternity. She had done well on the medication and had been seizure free for some time, though unfortunately, had stopped her medication a week prior to coming to the hospital and delivering by C-section. The day following her delivery (today), she had a generalized tonic-clonic seizure and, hence, we were consulted. Lamotrigine has a unique side effect in that it causes a very severe rash with a potential for a full Stevens-Johnson reaction (essentially severe burns to the skin and potentially fatal) if it is titrated too quickly, making it a more difficult medication to start safely, especially here when there are more concerns for health literacy or in adherence to medication regimens. Patients starting and stopping medications on their own can always be a significant issue, but with lamotrigine, it can be life threatening.

Without being 100% certain when she had stopped her medication (i.e., whether it had been days, a week, or several weeks), and obviously not being able to load her on lamotrigine, we had to come up with another solution, and levetiracetam (Keppra) provided exactly what was needed for the situation. Levetiracetam is an antiseizure medication that can be loaded orally or intravenously without concern for a significant adverse effect and provided us with a simple solution. The only problem we have here with using it extensively in patients, is that it is more expensive than the other medications we’re using, and it is not as readily available in duka la dawas (pharmacies) as several other antiseizure medications here in the country. Thankfully, though, it is a medication registered by the Tanzanian drug authority which means that it is not a problem for me to bring in as a donated medication. That doesn’t necessarily help with the availability issue but using it sparingly shouldn’t be a problem. Wajiha came to me with her plan, which was perfect, and that was to place the woman on a levetiracetam bridge, which means loading her on the levetiracetam and continuing it long enough for us to restart the lamotrigine and get it to a therapeutic level. She did suffer a seizure, which no one is ever happy about, but she didn’t appear to have suffered any complications, and we were able to get her back on her antiseizure medication without too much trouble.

The other consult that Wajiha saw was a bit more complicated. It was a 54-year-old gentleman who had been well the day prior when he came home from work complaining of a headache in the afternoon. Later that night, he apparently had stopped talking and his family had brought him to FAME at around 9 am obtunded, not moving his right side as much, and not talking. Wajiha had also noted that his right pupil was non-reactive. This was very concerning for a hemorrhagic event, and he was rushed off to the CT scanner to see exactly what was going on. The other piece of history was that he had been involved in a motor vehicle accident two months prior, and may have been complaining of headaches since then, making the likelihood of a traumatic bleed, such as a subdural hematoma, much greater. Two years ago, Sean Grady and Kerry Vaughn, had come to FAME to teach the general surgeons how to perform burr holes just for such occasions, to relieve the pressure from the subdural hematoma, which is very often an emergent, life-threatening event where time is of the essence and sending someone 2 ½ hours to the closest tertiary center isn’t feasible as the patient will die or either suffer permanent neurologic injury as a result. We also brought two manual craniotomy drills at the time and Sean had set these up in the operating theater and trained the nurses on how to prepare for these procedures.

The patient did indeed have what appeared to be bilateral acute on chronic subdural hematomas which would make perfect sense given the history. Unfortunately, treating chronic subdurals are a bit more complicated as they usually have what is called “membrane formation,” which means that you often must perform a full craniotomy to remove them otherwise there can be persistent fluid accumulation and what are called recurrent subdural hygromas (fluid) rather than blood, or a recurrent hematoma can occur. You can still treat the acute process with a burr hole as a life-saving procedure, but the patient will ultimately have to undergo a craniotomy to completely fix the problem. We made our recommendations to the treating team, and they were in the process of contacting KCMC for transfer which made perfect sense since, serendipitously, Kerry Vaughn happens to be there for the year as a neurosurgery global fellow.

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We had several headache patients in clinic this morning, at least two of who needed occipital nerve blocks, one of which had pretty classic occipital neuralgia. These are often referred to as “rams horn headaches” as they start on either side in the occipital region and radiate up over your head, usually unilateral, ending at your eye. They are caused by irritation of the lesser and greater occipital nerves, which is often caused by compression (often during the night caused by your pillow on the back of the head, or by excessive muscle tension and spasm of the cervical paraspinal muscles), and by injecting a local anesthetic (lidocaine) and Depo-Medrol (a long acting injectable steroid) over these two nerves, either unilaterally or bilaterally, you can relieve the pain either permanently or at least for several months. We do plenty of these procedures at home and it is something that I teach the residents how to do with their patients so they can become proficient and have this in their toolbox when treating headache patients. We see plenty of headaches here, and with the often-heavy loads women carry on their heads while working or doing household chores, many will have significant cervicalgia, or neck muscle spasm, leading the occipital neuralgia. Whitney had not done a tremendous number of these at home, so I assisted with her patient, which the other was done by Wajiha who had already done a number at home and was comfortable doing them on her own.

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With the lighter volume of the day, we had decided to work until 1 pm today and head to Gibb’s Farm for the afternoon followed by dinner there. I have spoken about Gibb’s so often, I’m sure that I’m repeating myself, but it is an incredibly lovely lodge that used to be a working coffee plantation and farm with more of a guesthouse atmosphere. The coffee plantation has been long since sold off, and though they still have a wonderful garden where they grow most of their vegetables for the restaurant, it is no longer merely a guesthouse, but rather has become one of the top resorts here in the Ngorongoro Highlands. An infinity pool was completed several years ago and the restaurant, which has always been top notch, continues to impress anyone who is lucky enough to eat there. Gibb’s Farm has also always been very supportive of FAME as well as the volunteers who come here to give their time and energy. From my very first visit volunteering at FAME in 2010, I have enjoyed visiting Gibb’s for an occasional meal and have always felt so at home there. I am always greeted by the staff and have come to know many of them very well. Nick and Sally, who have managed Gibb’s Farm now for the last several years, have always been the most gracious hosts and have gone out of their way to make us feel welcome and, even though we are not spending the night there, we are always treated as if we were.

With the lighter volume of the day, we had decided to work until 1 pm today and head to Gibb’s Farm for the afternoon followed by dinner there. I have spoken about Gibb’s so often, I’m sure that I’m repeating myself, but it is an incredibly lovely lodge that used to be a working coffee plantation and farm with more of a guesthouse atmosphere. The coffee plantation has been long since sold off, and though they still have a wonderful garden where they grow most of their vegetables for the restaurant, it is no longer merely a guesthouse, but rather has become one of the top resorts here in the Ngorongoro Highlands. An infinity pool was completed several years ago and the restaurant, which has always been top notch, continues to impress anyone who is lucky enough to eat there. Gibb’s Farm has also always been very supportive of FAME as well as the volunteers who come here to give their time and energy. From my very first visit volunteering at FAME in 2010, I have enjoyed visiting Gibb’s for an occasional meal and have always felt so at home there. I am always greeted by the staff and have come to know many of them very well. Nick and Sally, who have managed Gibb’s Farm now for the last several years, have always been the most gracious hosts and have gone out of their way to make us feel welcome and, even though we are not spending the night there, we are always treated as if we were.

As it was a gorgeous day outside, there were certainly plans to swim by the residents and so everyone brought their suits with them to Gibb’s, though we had a few stops to make prior to heading in that direction. We actually hadn’t exchanged any money since we’d been here as I had received shillings from Pendo for some things I had brought to her from Doha, but we were almost out of those and the residents were in need of exchanging their own dollars in case they ran across the need to purchase anything such as the visit to the wood carver or the painter on the way to Gibb’s Farm. In the early years, there were numerous “Exchange Bureaus” to be found on almost any street corner so that you could get Tanzanian shillings without an issue, but this changed about five years ago when it was discovered that some of the money exchanges were actually laundering money, not necessarily for illegal activities, but rather with the goal of tax evasion. Overnight, the exchange bureaus were closed down and, after that, one could only exchange money at the bank which was problematic given their hours of operation and lack of weekend availability.

More recently, there are now official exchange bureaus opening that have better hours and ease of use and require you to present your passport to avoid any similar scandals as have happened in the past. It should be noted here that exchanging any more than several hundred dollars requires one to bring a wheelbarrow or moving van with them as the largest bill here is 10,000 Tanzanian shillings, or $4 USD, at the current conversion rate of approximately 2500 Tsh to the dollar. Exchanging $1000 would require you to receive 250 10,000 shilling notes, certainly not something that will fit in your wallet, or even in your pocket. After exchanging our money at the new exchange bureau in town, it was time to stop by the Deus Market, which I have been going to since 2010 for the sole reason that I was told to go there and have some belief that there has always been some connection between them and FAME, though they have also been helpful and friendly when we’ve shopped there. We needed to pick up some water for our trip to the crater tomorrow as I would be taking the group and needed to make certain that we had essential supplies.

We picked up Saidi on our way as he would be joining us for dinner, and Amos was tagging along as we were planning to visit Athumani, an artist friend that I have known for years and have several pieces of his at home and in my office. I had only discovered at our last visit, that Athumani is also very active within the youth of Karatu and teaching them art as a means of being able to support themselves even if they were not planning to pursue art as a full-time career in the future.  Athumani’s art is very colorful and I’ve loved it ever since I first met him as an artist in residence at Gibb’s Farm, though he has since moved on and has a small stand where he displays his art on the side of the Gibb’s Farm road just shy of the lodge where is his next door to the wood carvers and Phillipo, who has a small family coffee farm and roasts our coffee for us personally. A few things were purchased from Mbuga, the wood carver, and we finally on our way to Gibb’s as we would be visiting Phillipo on another day.

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Arriving to Gibb’s Farm is difficult to describe for those who have not previously been initiated to the sheer beauty of Tanzania and the Ngorongoro Highlands. Dramatic is an understatement. Perhaps breathtaking may be closer to the truth. Gibb’s Farm is an island of calm nestled at the foot of the Ngorongoro Crater Rim and adjacent to the Ngorongoro Conservation Area. Driving up the incredibly bumpy and, on occasion, near impassable road to anything but Land Rovers and Land Cruisers, one could not possibly imagine that such a place exists at the other end of the journey, yet, upon passing through the gate, it becomes readily apparent in very short order that you have stumbled upon something very, very special. The views are immense and ever changing throughout the day and the season, and the landscape is just impeccable. The view from their veranda and the pool area goes on forever in the distance. The plants and flowers are amazing.

Everyone in the group went for a swim except for me as I had to deal with some shida (trouble) with Turtle as one of the rear doors had decided to unlatch and swing open without warning on the rough road which is not an acceptable thing, especially when you’re on a game drive and there are animals about. Nor if the person in that seat happens to be sleeping. I took the vehicle to the fundi (specialist) at Gibb’s to see what they could do for it, but he only changed one bolt to a longer one which I didn’t think would fix the problem (spoiler alert – it didn’t work during our Crater drive the following day). After their swim, everyone sat around the pool relaxing and that included Saidi, FAME’s volunteer coordinator who was also joining us for dinner, and Amos, one of our translators and a friend of Athumani, who had come along with us for the afternoon.

At 5:30 pm, the local Iraqw choir from Tloma Village came up to sing for all the guests. I have seen them many times and they never disappoint, though singing at Gibb’s with the backdrop of the view over the acres of coffee plants and all the other greenery and the valley beyond, it is difficult for anything to go wrong in that situation. In addition, to the choir singing, they had set up a very nice outdoor bar for all the guests to which we were invited as well. Some of our group did not drink, but for those that did, which included me, the gin and tonic with a sprig of rosemary was delightful and a perfect finale to an absolutely lovely afternoon.

We were set up for dinner at the outside table on the veranda and it could not have been more perfect. Though the weather was a bit cool, light throws had been placed on each of our chairs and everyone but me seemed to take advantage of them. Dinner was delicious as usual and the dessert of “deconstructed tiramisu was a perfect complement to the evening. We departed Gibb’s Farm, all commenting on what a great night it had been as well as how very full we were. We would be leaving early for the Crater tomorrow morning, so I stopped to top off the tank on the Land Rover at the Bamprass station that is open all night. We still had lunch to make for our safari when we got home.

Morning report, now overcrowded as I have discussed earlier such that only one or two of us attend, is where we hear about any new patients that came in overnight requiring our services and we also hear updates on the patients currently admitted who we are involved with. LJ has been following a very unfortunate, and very sick, young Maasai who is four months postpartum and came in with weakness among her myriad of other issues that included severe anemia, severe hyponatremia, and heart failure. Her weakness, the neurologic problem that had prompted our involvement in her medical care, was in a particular pattern in being that it was only proximal (shoulder/hip girdle), and she had good distal strength. She also had significant pain in movement. LJ has been working vigorously and relentlessly on her case pretty much since her arrival (both LJ’s and the patient’s) and it eventually involved calls to home (Penn) to discuss the case with both hematology and infectious diseases. She is determined to crack this case and I have little doubt that she will given the current level of her involvement and sleuthing. I’m sure that we’ll have more on this later.

The other inpatient we are involved with is the gentleman with the spinal cord injury that I spoke of yesterday. He is a young man with multiple traumatic injuries, but most significantly is his complete spinal cord level of L1 and possible transection given his imagine. He has received steroids, which is pretty much all we have to offer here, though will require stabilization of his spine to prevent further problems and we have referred him to KCMC for continued management of that issue, though were told this morning that his family was insisting to take him home to a local healer for their care.

This is not an unusual circumstance here as a large percentage of the population will receive at least some of their medical treatment from a local healer, or shaman, for an extensive list of ailments. When I first came to Tanzania in 2009, I had been introduced to a wonderful Maasai healer that was running a clinic at Gibb’s Farm, mostly for the local Iraqw who worked at Gibb’s, but also for the surrounding villagers. At his clinic, Menyengera Lazaro Labiki treated patients for varied conditions with a host of local plants and always had a large carafe of “healing tea” in the clinic waiting room for patients and passersby to drink. With an afternoon free from our volunteer work that I was doing with Daniel and Anna, we asked to go on a nature walk with Labiki and, over the next several hours walking around the grounds of Gibb’s Farm, he shared with us many of the local plants that were used by the Maasai and others for medicinal purposes, many of which we tried. Walking through the forest chewing on leaves used for indigestion and similar “more benign” ailments.

Though Labiki was a very traditional Maasai, he was also quite comfortable with the intersection between the type of medicine he practiced and the Western medicine we were delivering at FAME. He understood that there were many conditions that he could not treat and would refer these to Western clinics rather than trying to treat them himself, yet he would also fully assess the patient and would often treat them in combination with Western medicine. Labiki had also worked closely with an ethnobotanist at the university in Nairobi to chemically study the plants that were used for traditional healing by many of the tribes in East Africa, and what was found was rather impressive as a huge proportion of the plants had a chemical makeup eerily similar to the medications being used in the West for the very same purposes. One that I specifically recall was a plant compound they were using for memory loss that had significant cholinergic effects and was probably providing some benefit for patients like the cholinesterase inhibitors that we’ve been using for the last twenty years for Alzheimer’s disease.

I had stayed in touch with Labiki for several years and believe that he is now running a traditional medicine clinic in Arusha with his brother, who is also a healer, but it has been year since we’ve communicated. There is certainly a place for both traditional and Western medicine in the care of patients here in Tanzania and FAME has run programs with traditional birth attendants for this reason. Rather than alienating those who are trying to make a difference, whether it be traditional or Western, cooperation is a much better solution and has a much greater reach into the community.

One of the inpatients here who we were not involved with, was a tourist who had injured themself while on safari and now that they were stabilized, medical transport to Nairobi and then home had been arranged. Thankfully, FAME now has a wonderful new ambulance (new to us but purchased used) that had been funded by several FAME board members last spring and is now available to transport patients to other facilities or to the airstrip for flights out to Arusha or Nairobi. I believe that I’ve mentioned it before, but there are really no ambulances here that transport patient to a primary medical facility, just to be perfectly clear. All of us have evacuation insurance here that will cover medical transport out of the bush (yes, that includes FAME) by air to a tertiary center either in Dar es Salaam or Nairobi, the two closest centers that have the capability of providing true intensive care medicine. Having a dedicated ambulance that is fully capable of transporting the sickest of sick patients is a huge plus for FAME and will be necessary with our new 10-bed emergency room that will be completely shortly. I am certain that a second ambulance will soon be necessary (imagine having an emergency arrive to the ED when the single ambulance is on the road to KCMC, three hours away) considering the likely volume that we will see in the new ED – if there are any donors interested in such a project, please let us know!

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Meanwhile, we had a midday visit from Teddy, our fantastic tailor, who has made so many wonderful outfits for the visiting residents over the last four years since I was first introduced to her. She was here visiting the RCH (reproductive and child health) clinic with her baby and had brought some fabrics for the residents to choose from while also measuring some of them for their custom-tailored clothing. Our plan was also to head into town after work to look at some of the fabric stores and then bring things over to Teddy’s as she would be waiting for us.

We had planned to have a conversation with the family of the child we saw several days ago who had hydrocephalus and the horrible porencephaly/hydranencephaly (essentially complete loss of both hemispheres except for a small rim of cortex in several areas) on their CT scan. Providing a VP shunt would do nothing for the patient’s function or prognosis, but it would potentially make them more comfortable and extend their life. Dr. Anne handled the phone call to the parents as they weren’t planning to come back to clinic, which always makes these types of conversations much more difficult. Despite telling them that a shunt would in no way prolong their baby’s life or improve its function, they seemed to be interested in having the procedure done (which, of course, they would have to pay for here) as there was some sense that a shunt could potentially make the child more comfortable in the end. I had already spoken with Kerry Vaugh, the visiting pediatric neurosurgeon who trained at Penn and is now at KCMC for the year as a global health fellow. Having her here during our visit has already made a significant difference in the management of our patients requiring neurosurgical intervention as we can rely on her for curbside and formal consultations, both for patients remaining at FAME as well as those that may require transfer to a larger facility such as KCMC.

Having finished neuro clinic at a reasonable time, we had wanted to head into town for a fabric run and then our visit to Teddy’s. As a large group of mzungu (Swahili for stranger, but more often now used to mean a white person), we stuck out like a sore thumb, especially when it comes to shopping, and this was quite obvious by the crowd we quickly attracted. It was just before sunset which a time of the day that many are out and about doing their shopping for the day. I delivered the group to the fabric shop we usually buy material from, and it wasn’t long before many others decided to join us as they were sure they had things that the group would like in some nearby shop that they were connected to. Eventually, they decided to walk down the block to one of the other shops, of course being escorted by others who wanted to sell them additional material. I followed behind, making sure that everything was legit for the last thing I wanted was to lose one of them in some seedy shop where they shouldn’t be. In the end, that was not the case, and everyone found the fabrics they were looking for.

Once their purchases had been made at the various shops, we loaded back in the vehicle, now well past sunset and made out way to Teddy’s. As expected, she was there waiting for us with Allen, her toddler who is not a bit over a year old. It was a very nice evening and I sat on her porch in a plastic chair playing Wordle and the New York Times crossword puzzle while Teddy measured each of the residents and make sure of what clothing designs they wished her to make for them. Throughout the evening, local children would come to visit Teddy’s shop, which sells staples in addition to her tailoring business. I wasn’t sure if the children were coming to visit or whether they were coming to see the mzungu crowd, but either way, they were delightful and incredibly polite.

I was also so pleased to see Dorthea at Teddy’s as she is someone who I have known now for twelve years as she originally came to me as a patient in 2011 with uncontrolled seizures and had been unable to attend school. We were able to get her seizures under control without too much trouble and she returned to school, eventually completing secondary school. I had introduced Dorthea to Teddy at the end of our last visit here in April and she is now apprenticing with Teddy and learning a trade. I am so thankful to Teddy for having taken Dorthea under her wing like she has, and it has been wonderful seeing Dorthea having such success. It was a simple plan that has been very successful and, for that, I am incredibly happy.

The theme of the day seemed to be patients who not only stretched our clinical acumen, but also brought to light the many ethical considerations that encountered virtually every day we are here. Practicing medicine in a resource limited setting, such as FAME and Tanzania, causes one not only to make decisions that are based on the medical information, similar to what we do on a daily basis at home, but also from an ethical standpoint based on so many other factors such as financial and cultural issues that are not always so obvious. Our patients today presented challenges that were in this realm and the decision making that was involved were excellent lessons for everyone.

As it was Thursday morning, it was again time for an educational lecture at 7:30 am and today was our turn to give it. Wajiha and Jenna had decided that the talk would be on headache, and they would focus on the more common headaches that are seen in clinic – tension-type and migraine – though would also go over “red flags,” those parts of the history that would make one concerned the headache was secondary or being caused by another process and potentially life threatening. As you can imagine, we’ve given many headache lectures over the years, each one perhaps subtly different, but always carrying the same messages and reinforcing the essentials of caring for patients with this incredibly common condition. Given the growth of FAME over the years with new doctors coming often, and the expected turnover of clinicians here (though our retention rate has been amazing over the years), repeating lectures only serves to continually update the staff and further cement the appropriate clinical practices for the neurologic disorders that we see with them.

Whitney had been following a newborn here who was having seizures since our arrival, and we had finally decided to obtain a CT scan of the brain as it would affect what our recommendations would be as far as how long to continue the anticonvulsant medications the baby was on. Essentially, if the child had a neonatal bleed and was seizing as a result, then it would mean a longer course of medications prior to discontinuation and possibly consideration of a shunt if they were to develop hydrocephalus. On the other hand, if we were dealing with HIE, or hypoxic-ischemic encephalopathy, then we could taper the medications earlier. We received the images this morning (the scan was actually done the night prior) and the abnormalities seemed to confirm the baby suffered from HIE, meaning that the seizures would likely burn themselves out and there was less of a requirement for long term antiseizure medications. Unfortunately, it also didn’t bode incredibly well for the baby’s prognosis in regarding her development.

The issue of hypoxic-ischemic encephalopathy and neonatal resuscitation has always been a difficult one and something that greatly differentiates pediatric practices between high and low resource regions of the world. The basic fact that there are no ventilators here (or in any other low resource countries) to use if needed is a very practical limitation and the realization that there are no real NICUs (neonatal intensive care unit) here, at least in the same regard as we have them in the US and elsewhere throughout Western World. The other problem here and in other low-resource settings has to do with the social and financial consequences. There are no safety-nets here such as exist elsewhere in the world to assist in the care and support for either families or children in need. A child who is born with severe hypoxic-ischemic encephalopathy will be fully dependent on others and on society for their care indefinitely and a family, perhaps already be unable to provide for their children and themselves, will not have the means to provide for a newborn with such devastating disabilities. That is not to say that they a family would not wish to care for their child, but more so that it is their decision and theirs alone. It is not for the doctors and nurses to make for them, for in doing so, one could commit a family, and the child, to a lifetime of suffering. As I said, these decisions are neither simple nor easy to make, and there are no right or wrong answers. One must just appreciate the gravity of the situation and do what is best in any given circumstance.

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In a similar vein, another child arrived at clinic for Whitney to see and was brought by their parents. It was a six-month old child whose development had been severely delayed such that it was unclear that they were doing anything at a conscious level, and it was unclear that they could see. In addition, the child’s head was far too large for their age and with a bulging fontanelle, immediately raising concern for the presence of some form of hydrocephalus, whether obstructive or congenital. For babies with hydrocephalus, the only treatment that helps is a shunt, and typically a ventricular-peritoneal shunt in which the fluid is drained into the abdomen and reabsorbed there.

This child was not a straightforward hydrocephalus case though, as his development was severely delayed at best, and we had a significant question as to just how much function they had and exactly what their brain looked like. As it would certainly affect what was boing offered to the family concerning treatment, we recommended that the child have a CT scan so we could feel comfortable in this process. Though what we saw was not completely unexpected given the child’s incredibly poor examination, it was still a shock to see the amount of devastation that was present and, to be totally honest, that the baby had survived as long as it had. Though there was most of the brainstem intact, or at least it seemed so, the remainder of the hemispheres (the cortex of the brain and what makes us think) were virtually non-existent and were replaced by massive porencephalic cysts filled with spinal fluid. With this information now at hand, performing a VP shunt (ventriculoperitoneal shunt) may make the child more comfortable, but it would not improve the child’s function nor change their overall prognosis. This would all, of course, be predicated on whether the family would be able to afford the surgery for the shunt. We will do our best to communicate these rather intricate options to the family and hopefully have a path to follow shortly.

Next up was a patient that we had heard about during morning report and had arrived at FAME the night prior after suffering severe trauma and had a pneumothorax, broken ribs, and abdominal injuries. We were told that they also had numbness in their legs, and the inpatient team wished for us to see the patient in neurologic consultation. When Wajiha went to see the patient, though, it was quickly evident that not only did they have numbness in their legs, but rather they were not moving either of their legs and had an L1 sensory level. A full body CT scan had been completed the night prior and, what it revealed, was that the patient had suffered a complete dislocation of their spine at the T12-L1 level and had likely transected most of their spinal cord. Without the ability to see the soft tissue (i.e., with an MRI scan), we were unable to tell whether there was still some continuity of the cord as he could benefit from high dose steroids if that were the case, but either way, we recommended that he receive them right away to preserve whatever function we could. I sent the images off to Sean Grady at Penn just to get his recommendations in the meantime and the spine surgeons at KCMC (Kilimanjaro Christian Medical Center) were contacted as he will eventually need to have his spine stabilized.

Meanwhile, lunch today was pilau, one of the more popular noontime meals, though I am admittedly partial to the rice, beans, mchicha, and pili pili that is served five days a week. The East African pilau is quite different from Indian pilau which is made with curry and can be quite spicy while the pilau here is merely rice cooked in a meat broth, mildly seasoned and then with chunks of beef. Adding pili pili (Tanzanian very spicy salsa) to the pilau does make it spicy, but that is done to individual taste.

We had our normal smattering of patients today that included a Parkinson’s disease patient and the requisite epilepsy cases. At the end of the day, though, Wajiha saw a very complex case of a young woman who had suffered left MCA territory infarction several years ago for which we had no records. She had also had heart failure at some point and, even though she didn’t seem to be in failure at the time of our visit, we wanted to look at her echocardiogram to see if there was any reason to have her on anticoagulation. We also sent a slew of laboratory studies looking for other possible causes of her stroke, though in the end, it’s unlikely we will find anything to treat differently and will just leave her on her antiplatelet therapy and a statin as we did find that her LDL was rather high. As we did not have any of her imaging studies and really needed to know whether she had multiple vascular territory infarcts (i.e., was it cardioembolic or not), we decided to obtain a CT scan here at FAME. We were able to determine that the prior stroke was confined solely to the middle cerebral artery territory and, therefore, she did not require any additional treatment.

Thankfully, Turtle (our stretch Land Rover) had arrived earlier in the day from Arusha with its fresh new coat of paint and a number of necessary maintenance repairs having taken place that included a “new” rebuilt engine. Importantly, the refractometer was also in the vehicle, allowing Sehewa to finally take care of his photo ops given that he would be leaving tomorrow and would not be back for several months. Land Rovers are in a constant state of disrepair, not because they are neglected, but rather because they just take constant upkeep to maintain them and to keep them running. One blessing is that they are dirt cheap to repair and maintain here given the number of that remain on the road and are far older than Turtle and Myrtle. For game drives, they are the absolute best and after several years of trying to decide whether to go with Land Cruiser (Toyota) or Land Rover, I chose the latter and have never looked back. They are quite simply beasts on the trail and amazing vehicles that can take whatever is thrown at them. I drove Turtle back to the house from the main parking lot and it was just like meeting up with an old friend.

It is hump day here at FAME, though I really don’t think it has the same connotation here in Tanzania given that our schedule is a bit hap hazard. In the past, with the four-week rotation, we had a bit more freedom to fit everything in, though it does seem to have worked out reasonably well given the one less week for each team and now having twice as many teams (rotations) throughout the year. We’ll be working six days in clinic this week and taking our first Sunday off to go on a game drive to Ngorongoro Crater, a World Heritage Site and something not to be missed here if at all possible. Next week will be our mobile clinic week in which we will be going on the road for three days to visit more remote villages within the district and see patients in each of those locations. Next weekend will be our two-night Serengeti trip in which we leave on Friday morning and return on Sunday evening. Visiting Oldupai (or Olduvai) Gorge and Shifting Sands along the way to the entrance gate, we’ll get a game drive in on Friday afternoon, all day Saturday, and then Sunday morning, making the trek back on Sunday afternoon and visiting Kitashu’s boma on our return trip. The final week will be clinic everyday here at FAME, allowing us to see a few patients back for quick follow up visits in case we needed to re-evaluate them. This group will depart on Saturday, October 7, and the next group will arrive the following morning, October 8. It gives me a bit of a “ground hog” sense in that I will essentially repeat the entire schedule again including the Crater and the Serengeti, though our mobile clinics will be to different sites.

The full morning report, meaning doctors, nurses, and pharmacists, now occurs on Monday, Wednesday, and Friday. This is new for FAME and has been a huge success as we have the nurses present the patients, which is no small task, and then everyone discusses the medical and/or surgical aspects of the case. This includes the medical ward, surgical ward, and the maternity ward which includes the neonatal patients. Getting all of this done in the allotted thirty minutes can be a bit of a challenge, but this system seems to be working the best and it has remained after its initial institution. One problem, though, is that the conference room isn’t large enough for everyone to fit meaning that not all of us are able to attend. This morning, Whitney offered to be at the meeting and get whatever information she could on the inpatients who we were following as well as whatever new patients had come in and needed to be seen by us. This is most often pretty obvious, but there are times where you just can’t quite hear what is being said, so it’s essential that you stay on your toes and pay attention. Thankfully, the doctors here are not shy about asking for our help, so we will usually hear about a consult shortly after we start in clinic.

With four total residents here for this rotation, it does give us some freedom to have three teams seeing outpatients at any one time (with me staffing them) and then one resident who can float and see consults if there are any, and, if not, they can double up with one of the other residents in the outpatient clinic. Thankfully, we have more than enough translators to work with the residents as well as Dr. Anne, who is just coming back from maternity leave so is only working the afternoons at the moment. Again, the translators, other than Nuru, who is a pharmacy tech, are clinical officers and so are clinicians that can participate in the patient’s care as opposed to just translate for us. In this manner, we can not only evaluate our patients, most of who do not speak a word of English and sometimes not even Swahili, but also train the clinicians that we are working with and leave something behind after we’re gone.

I spend much of the day communicating with my friend, Leonard, in Arusha, regarding the stretch Land Rover that had needed some repairs while I was gone, but as is often the case, things don’t start getting worked on until just prior to my return. Couple this with the state of the power grid in Tanzania, which calling it suboptimal would be generous, and the fact that frequent brown outs are the norm now and constantly interrupting the ability to make the necessary repairs, the vehicle was not ready for me to take to Arusha. For this reason, I had driven our standard (non-safari equipped) Land Rover here, which was a bit of a tight fit for the five of us with all our luggage and required that I leave the refractometer that I had carried all the way from home in Arusha to come with the stretch vehicle. The word on the stretch was that it would be here tomorrow, which was a good thing as we would need it for our Sunday drive into the crater.

Of course, little did I know, but Sehewa, our nurse anesthetist/optometrist, has planned on taking photos with the refractometer as it has been donated and he wanted to send these to the donors. He would be leaving for the US on Friday for an educational opportunity at Stanford University, which they were sponsoring, so we needed to get the refractometer here sooner than later to take the photos. Hopefully, it and the stretch would be arriving tomorrow, fingers crossed.

Meanwhile, our clinic was once again quite busy as soon as we opened at 8:30 am. My head cold was little improved, though I had decided (or perhaps others had decided for me) to take a COVID test to make sure that it wasn’t anything more worrisome. This has happened to me before where I was sure what I had was a run of the mill cold, but just to be safe, I’d take a test to appease everyone else which I guess is the more considerate thing to do. The test was, of course, negative such that I’ve continued my streak of dodging bullets as I’ve not had COVID before, or at least not that I’ve been aware of. Despite having flown to West Africa in February 2020, then to Tanzania at the beginning of March 2020 (without masks, of course), and then scrambled home with the threat of the border closings only to have them fly us into NYC, and finally traveling back to Tanzania in October 2020, by myself and before vaccinations, I have somehow avoided contracting this nasty bug. I’m sure that most of you now think that I’ve jinxed myself, and even though I am more on the superstitious spectrum than not, I’ve recognized that there are just some things one cannot control.

Our young girl with the acute cerebellar syndrome, or at least that was our leading diagnosis at the time, was still unsteady, but was no worse than she had been yesterday. As her family lives very close to FAME, it was decided that we would discharge her home without rescanning her and have her come back in two weeks to re-evaluate her. Though her story wasn’t bad for an acute cerebellar syndrome, her exam really wasn’t as she had unilateral nystagmus. Trust me, this is all from Whitney and Dan Licht (on WhatsApp) as I would really know much about it though I have seen a few cases in my career.

Our clinic once again seemed to drag on into the afternoon and we were there far later than normal. As we were about to walk home, I received a text from a friend that one of their friend’s one year old had fallen from a low height and struck their head on the tile floor. Unfortunately, I would have to ask Whitney to see the child with me given their age, but we’d walk home first and then return after they had registered the patient which would allow us enough time to relax for just a moment. We headed back a short while later to evaluate the child, who turned out to be just fine, and we were back to the house in no time. Had the child needed a CT scan, that would have been another story as they would have had to be sedated, similar to the infant that needed to be scanned on Monday night and couldn’t be sedated on a full stomach.

In the three days we’ve been here, it’s been fairly busy, and this is always better than being bored I say. I think between the waning pandemic (at least for here), the increasing volume in general with the loss of some nearby government services, we are beginning to see a pickup in volume beyond the pre-pandemic levels which is always a good thing as it allows us to do more teaching with the clinicians here and for us to gait yet more experience.

Our first day of clinic, which I had intended to have been a bit lighter to enable the residents to learn the EMR here, not to mention practicing neurology halfway around the world, had somehow been kidnapped by the gremlins and turned into a bit of a free for all. I guess the saving grace was that having survived it, there wouldn’t be much that the residents wouldn’t be able to do going forward. Having gone back into the hospital late last night to review the CT on the ataxic child, it had been a late night for everyone.

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Tuesday and Thursday mornings over the last several years have been reserved for educational lectures at 7:30 am that are given by the volunteers and are attended by all the clinicians here unless they are away for their annual holiday or in the operating theatre. In the early days, I used to give these lectures myself, but have found that the residents, being the great educators they are, are perfect for this job and typically enjoy doing so. Depending on the number of volunteers in other specialties that are here during our visit, we’ll usually get a slot a week for the residents to give a talk. Dr. Ken is in charge of the educational lectures and, having already checked in with him on my arrival, he’s told me that we have Thursday of this week to deliver a lecture and we’d go forward from there.

Our lectures are those that can help the generalists here at FAME better take care of their patients, not only on how to treat the more common neurological disorders they will see such as headache, stroke, epilepsy, neuropathy, and such, but also which patients they should plan to send to us while we are here, or at least which patients they should seek help with. The challenge for the residents, of course, is to make sure that their talks are tailored to practicing medicine in rural East Africa. The threshold for ordering tests here will be much higher both from the standpoint of availability of the technology (ordering MRI scans on patients doesn’t serve much purpose here when there is only a single MRI in all Northern Tanzania, and it is two hours away from Karatu) and the affordability of the test for the patient. MRI scans are incredibly inexpensive by Western standards (approximately $200), but when you are in one of the poorest countries in the world (Tanzania ranks around 17 out of 195 countries in the world for GDP and its average annual income is around $1200 though we are in one of the poorest regions of the country), the cost of a test may be more than what a family makes in an entire year!

In addition to being sensitive to the available technologies, the residents also must be aware of the available medications we have here in Tanzania. For example, there is a new class of medications, the CGRP-inhibitors, that have revolutionized the treatment of headache in the western world and which we are using on a daily basis back at home, but none of these are available here given their high costs. Putting these in one of your talks would be useless as they will very likely never come here, or at least not in the near future. Likewise, for stroke, what has become commonplace in the US and the rest of the west, thrombolytics, or clot busters, are not available for the treatment of stroke here. But in this case, it is not only the cost of the medication that limits its use, but also the fact that it can’t be administered with a CT scan as there can be no bleeding present when it is administered, otherwise it will likely kill the patient. There are so few scanners available here that it is unlikely that a patient has had a scan until they possibly reach a tertiary center.

And then there is the issue of time with thrombolytics as they must be administered within three hours (or 4.5 hours in certain cases) of the onset of symptoms or the risk benefit ratio changes and it’s no longer beneficial to give the patient due to the high risk of bleeding. The distances one must travel to reach medical care, often on foot or by private car, would make this impossible for the vast majority of the population within the country. Further complicating the picture is that there are virtually no emergency services available here in the country. There is no 911, EMS, or paramedics that will come in shiny ambulance with its light flashing when there is an accident, or someone needs emergency help. That is all done by private citizens here, so when there is some catastrophic event such as a bus accident, which has happened on several occasions here in the recent years, victims are loaded into private vehicles by those individuals who have showed up at the scene.

The main purpose of ambulances here is to transport patients from a health facility to a center with higher technology that can more appropriately care for the patient. And these are all private ambulances that provide this service as there are no government services in this arena. When we travel here under the auspices of Penn, we are provided evacuation insurance for illness, but that only gets us from a major health facility back to the US. It does not provide transport from the bush (and that would include Karatu and FAME) to a place where we could be evacuated from, and, because of this, I purchase evacuation insurance for every resident, faculty, or medical student joining me here through AMREF Flying Doctors that will provide this service and is an absolute necessity.

Today’s lecture was on emergency medicine and was being given by Dr. Amanda, who is an emergency medicine physician from Australia and will be spending the year here along with her husband, Pete, a pediatrician, and their two small children. Their services are being supported through an Australian non-profit and the timing could not have been more perfect as FAME is about to complete a ten-bed emergency room, long in the planning and quite necessary for the region we are serving. This will provide dedicated space with up-to-date technology and allow FAME to care for patients without having to take up room in the clinic or the wards for these patients. Up until now, we have been seeing these patients in a small, two-bed emergency room that has also doubled at various times as our neurology clinic when we’re here and our endoscopy suite when necessary. On those occasions when we were utilizing the space, it was always a bit awkward having to make room for an emergency (separated merely by a room divider) and continue our neurology visit. Though emergency rooms exist here in Tanzania, they are typically seen only in the larger medical centers in Arusha and Dar es Salaam, and emergency medicine is a new and upcoming specialty that will certainly grow in the coming years with the help of physicians like Amanda and facilities such as FAME, who are willing to be at the forefront of this technology.

Our patients for the day certainly ranged the gamut for diagnoses, both in the pediatric and adult arenas. As usual, epilepsy occupies perhaps the largest swath of those patients seen and is one of those areas in which we can be the most effective. We realized quite early here that epilepsy held a very special place among those diagnoses that we treat here given the number of patients who suffer from this very treatable condition and the complete lack of physicians (i.e., neurologists) in this county to treat them. Hence the importance of our program at FAME as we are here to teach the primary healthcare workers (doctors, clinical officers, and nurses) how to manage this illness given the fact that not only are there few neurologists to treat the patients, but there are also no neurologists to teach the doctors and nurses in their training programs. Ninety percent of epilepsy exists in low to middle income countries which is exactly where there are no neurologists. The number of neurologists in high income countries is far more than 100 times the number that exist in low-income countries and that lack of neurologists in the countries where they are most needed can be felt in Tanzania as many of these patients have never sought care for their epilepsy or the care they’ve received was ineffective for so many reasons.

The impact one can make in situations such as this, where there is a complete mismatch of patients and resources (i.e., doctors), is more than phenomenal and would be awe inspiring for even the most cynical of us. Simply taking an accurate history, examining a patient, and placing them on the correct medication can be so life-changing for them that one quickly realizes the impact of our being here. And these are the easy things that require no new technology or even new medications, but just the know-how and the willingness to be open to the possibility that we can make a difference in the world. Most importantly, though, we can teach a man to fish and capacity build in the process of doing so, multiplying the effect we can have many times over by teaching those who are willing to learn from us. This is ultimately the mission of FAME, The Foundation for African Medicine and Education, with the emphasis being the last word of its name. The purpose of our being here is to teach, though a by-product of our being here is also to be taught and lessons that we learn are immense. One cannot help but to take away from this experience a much better understanding of who we are, and that the world does not revolve around us, but rather that we are an integral part of something that is much bigger than any one of us.

We saw two very classic idiopathic Parkinson’s disease patient who were both doing well on carbidopa-levodopa, the very same medication we use in the US, and even though there are many other fancy medications we could try which are not available here, we can make do with what we have. We also saw a patient presenting with a progressive cerebellar ataxia and was undoubtedly suffering from one of the spinocerebellar ataxias, a group of conditions known as “the SCAs,” and are genetic disorders of which there are many. There are no treatments for them, either here or in the US, and each has its own constellation of features and clinical course. Determining which of the SCAs it might be is an exercise that certainly is important and rewarding, though only from an academic standpoint (an apology to Stephen Pulst who has devoted his life to researching these). Even though we had nothing to offer the patient from a treatment standpoint, it is important to recognize that what we can provide them is an explanation of why he is having problems and hopefully prevent them from continuing to visit doctors looking for a reason why and spending more money and time in doing so, which would only be an exercise in frustration.

The day was again incredibly rewarding to the residents for they accomplished a great. I believe that we had seen about 26 patients or so, certainly nothing to sneeze at. Everyone was becoming more comfortable with the process here, from the residents who are seeing patients to our translators working in a team with the residents. Our translators, by the way, are all clinicians. They are mostly clinical officers, or the equivalent of a nurse practitioner, though perhaps even more independent, and so they have a very decent knowledge of clinic medicine. In fact, I will typically defer any final decisions regarding a differential diagnosis or treatment plan until they have had a chance to weigh in on the matter. Dealing with things like cutaneous anthrax, or brucellosis, or Tb of the spine, are not things that we run into on a regular basis at home and they are something that a clinician here is much more likely to think about than us.

We had a lovely early evening back at the house with a cool breeze on the veranda and everyone sharing stories from their very full day. As the sun slowly set and the sky turned a light orange on the distant clouds, I believe each of us was quite pleased in our own way for FAME, Tanzania, and Africa in general is such a place of wonders that it is hard not to feel you have somehow arrived in paradise.