Wednesday, September 10 – Our team’s complete….

We received word last night of the Israeli air strike in Doha, Qatar, which was a little close to home for me considering that Patrick Liu, a fourth-year medical student and the final member of our team for the first rotation, was still on his way to FAME but was traveling through Doha. Thankfully, he had departed the airport there only hours before the air strike occurred and had arrived in Tanzania shortly after the actual time of the attack. Eighteen months ago, we were traveling home through Doha at the same time that Israel had launched a drone attack against Iran, obviously cancelling all east bound flights (flying through a drone attack is definitely not recommended), and putting west bound flights (such as our flight home to Philadelphia) in question.

American Airlines, which now flies the Philadelphia to Doha route, decided to outright cancel our flight rather than wait to see where things were the following morning, while Qatar Airlines cancelled none of their flights to the US. Being stranded in Doha was not something that we had planned on, so we were booked on the only available flight with Qatar which happened to be to Houston. The three of us (Jill, myself, and Christina Boada, one of my residents) flew to Houston, without our luggage I might add, had to overnight there as we arrived in the evening and there were no flights back to Philadelphia, and ended up home (again, without our luggage) the following day. It took a full week for American/Qatar to recover and return our luggage to Philadelphia, and other than a good story to tell, we had little else to show for our experience or the miles we had flown.

Patrick spent the night at the airport in the KIA Lodge, as did Jack the night before but with fewer hours to enjoy it, and we had transport arranged for first thing in the morning to bring him to FAME. He eventually arrived as we were beginning clinic, refreshed after his stay overnight in the lodge, though still a bit jet lagged with the time change of seven hours. Our team was now complete – Cat Kulick-Soper, our epilepsy specialist par excellence who had also been to FAME four years ago as a resident; Julian Gal – our epilepsy fellow from Penn; Residents Joe Geraghty and Jack Cook; along with the forementioned Patrick. This team would comprise our “first wave” of neurologists for the fall trip, though Cat and Julian will be departing after two weeks, Joe and Jack will be here for three weeks, and Patrick will be here for four weeks. Others will be arriving in the coming weeks, and I’ll introduce them at that time.

Our patient’s scan from March with fulminate neurocysticercosis – top row non contrast, bottom row with contrast

One of our first patients of the day was a fascinating 78-year-old gentleman who we had originally seen in the spring after presenting with a significant encephalopathy and seizures. His CT scan was very impressive and demonstrated numerous calcified and non-calcified lesions throughout both hemispheres with a significant number of the lesions enhancing including some that appeared to be ring enhancing. Neurocysticercosis is a condition in which the larvae of the pork tapeworm infect the brain and typically produce a small number of cystic lesions that eventually calcify as the organisms die and scar over. It is the number one cause of epilepsy worldwide and is highly prevalent in South America as well as other regions where pigs are raised. There is a significant amount of pig farming in the Iraqw areas surrounding Karatu, and neurocysticercosis is prevent here. This patient, though, had a more serious form of neurocysticercosis, called fulminant neurocysticercosis, or cysticercotic encephalitis, in which there is an overwhelming number of organisms causing extensive inflammation and often cerebral edema.

In patients with such an extensive infection, you cannot give them albendazole (a common antiparasitic agent used also for deworming children on an annual basis) as suddenly killing the organisms will result in a massive inflammatory response worsening the edema and very likely killing the patient. The natural history of the infection is for the larvae to die on their own and calcify, leaving a lesion that is certainly epileptogenic (i.e. could cause seizures), but does not result typically result in any neurologic deficits. The treatment of cysticercotic encephalitis, though, is to give steroids to suppress the inflammatory response and, thus, the edema, thereby reducing the risk of complications and allowing the organisms to quietly calcify on their own.

We treated this patient with high dose dexamethasone taper for nearly a month and hoped for the best, not really knowing how he would do and having very little else to offer. We also kept him on levetiracetam (for seizures) as having a convulsion with the amount of edema he had at baseline could be incredibly problematic for him. Seeing him walk into clinic today, albeit with a cane, was near miraculous in my mind as it was really a 50-50 proposition whether he would survive the infection given the burden of disease he had and in the setting in which he was seen. He had spent only a week in the hospital, dramatically short in comparison to what it would have been in the US with the same situation. He will remain on his levetiracetam and come back to see us in six months.

Cat and Joe “relaxing” in back of Myrtle on the way to town

Another very interesting patient that was seen today was a 29-year-old woman with the story that she had undergone an appendectomy a year ago and a month later had developed right-sided weakness that progressed over three months when an MRI and MRA (which we were able to see as they had brought the disc) were done demonstrating very significant encephalomalacia (mostly cortical) in the left greater than right hemisphere that was maximal in the left temporal lobe with loss of the left middle cerebral artery and diffuse vascular irregularities on vascular imaging that was concerning for an inflammatory vasculopathy. It was very difficult to restrain ourselves from getting a CT scan to see exactly where things were at the present, but she had had only some improvement over the last 9 months, not worsening. She was also having episodes of unresponsiveness that were concerning for seizures and had been placed on carbamazepine recently, but at a low, subtherapeutic dose (which is very common here).

With the limited studies that we have here, it was very difficult to conceive of an adequate evaluation, though our main concern was that she had suffered a stroke, possibly in the setting of an underlying vasculitis, but that the latter did not appear to be active at the present time nor did we feel that a CTA would necessarily sort anything out for us. We only had basic infectious and inflammatory labs here – HIV, RPR, ESR, CBC – all of which were normal, so we placed her on stroke prophylaxis therapy and hoped for the best. Oh yes, we also switched her from carbamazepine to levetiracetam as we felt this would be a bit more effective in this situation.

Julian, Cat, and Annie shopping for fabric

On the more mundane side of things, though equally significant in terms of our comfort here, the refrigerator in the Raynes house went on the fritz. Not only did we not have proper storage for our leftovers and milk, but more importantly, I had no ice to make my gin and tonics when we came home from the clinic. We had decided to visit Teddy today, the seamstress who has been making clothing and other items from the colorful local fabrics for our groups for nearly the last ten years. I loaded everyone into Myrtle, our short Land Rover, since Turtle was still in Arusha undergoing repairs, and off we went to town to first buy fabrics before heading to Teddy’s house on the other side of town. Anytime we are heading to town for shopping, we bring Dr. Annie with us to avoid paying “mzungu” prices, or those that are charged to tourists. In addition, it’s always best to have Annie with us to help with the clothing decisions as Teddy’s English isn’t fluent nor is my Swahili.

Cat, Patrick, Joe, Julian, Jack, and Annie at the fabric shop

On returning home, the sun was low on the horizon, and it would soon be dipping closer with every imaginable hue of orange appearing before us. Our next-door neighbors, Anil, his wife, Izabela, and their two children, had started a campfire, and we all sat around for dinner. The sky was clear, and the stars began to pop, with the milky way soon becoming the most prominent feature in the sky. The night was slightly cool, though incredibly comfortable and we all ate dinner together sitting around the campfire. Life is good!

Tuesday, September 9 – Interesting cases and a gorgeous walk….

FAME’s success over the last 15 years has been predicated on a number of key elements, though there are two that I have always found to be the most important from my perspective. There are also those that are clearly mandatory when undertaking a project such as this – the trust that’s built with the community and the sense of family that I have spoken of previously which has been created by FAME and its employees who come to work each and every day to make this a better world. Of the two key elements that are not so obvious, though, first is our volunteer program and emphasis on education, and the second is the fact that FAME is run by an all-Tanzanian clinical staff and can operate completely independent of the volunteer program as we demonstrated so clearly during the pandemic when there were essentially no volunteers save for our neurology program for a span of two years.

45-year-old woman with massive intraventricular hemorrhage who unfortunately didn’t survive

The volunteer program has been an essential component of FAME’s character from its very inception and has continued to attract doctors, nurses, and others from the US and many European countries who come for both long and short-term visits to work with FAME’s clinical staff and provide addition training in their various areas of expertise. It is certainly a bidirectional transfer of information, though, as the volunteers also learn a great deal of information, such as how to practice in a low resource setting, by working with FAME’s dedicated doctors and nurses. At last count, FAME is averaging in excess of 60 volunteers a year in all specialties that continue to provide current practices, though with the continued sensitivity that is always necessary when you are a guest in someone else’s culture and a long, long way from home. That requires an open mind and a willingness to see things through other lenses than our own, as well as the realization that you are not the center of the universe (being humble).

3-year-old child with bilateral subdural hygromas prior to drainage

When speaking with anyone about global health, the conversation will always lead to single concept that is often the most important thing to consider and cannot be overlooked – Sustainability. For without sustainability, all is for naught. The fact that FAME has an all-Tanzanian clinical staff was by no means an afterthought, nor has it ever been something that has been reconsidered as FAME developed through the years. If anything, the philosophy has been increasingly reinforced along the way, and its importance has been continuously demonstrated. When the pandemic hit in March 2020 (while I was here at FAME with my team, by the way) and it became readily apparent that the volunteer program would at least be temporarily shutting down as were the borders and flight patterns throughout the world, having a self-contained medical and nursing staff without the need for outside help became a necessity and a God-send.

3-year-old child following drainage of subdural hygromas with little improvement

Even more apparent, though, was the fact that the training and education that had been provided to our clinical staff over the preceding years had now proven to be key to the success of FAME in the coming years, allowing for the long-term sustainability of a rural based healthcare center (hospital) dedicated to providing patient-centered care for a population where access to healthcare had previously been very limited. Over the ensuing months, as it became increasingly clear that the pandemic was here to stay and would change our lives forever, FAME by was called upon by the government (don’t forget that we are an NGO) to provide the necessary training and education to the other healthcare facilities and workers in the region concerning proper practices, providing further proof that the careful planning and sustainability were essential to our success.

4-month-old child status post VP shunt with massive porencephaly

This morning’s lecture was provided by Dr. Anil, an emergency medicine physician now volunteering at FAME. Anil is from New Zealand and had learned about FAME as these things always go from a friend of a friend of a friend. Ultimately, it involved Dr. Pete and Dr. Amanda, who had just finished a two-year volunteer stint here at FAME earlier this year. Pete and Amanda were from Tasmania and were being funded by an Australian non-profit, NGO that provides support for volunteer physicians. Amanda, an emergency medicine physician, was here following the completion of our new emergency department, so spent her time developing protocols and teaching just about every aspect of emergency care to the clinicians and nurses at FAME. Pete, a pediatrician, spent his time working with our neonatal intensive care unit and inpatient pediatric population. It was sad to see them go, though they had been here for a full two years. Our lecture today had to do with traumatic head injury, a topic near and dear to our hearts.

Following the lecture, we received report on several interesting patients, though unfortunately, we had very little to offer them. One was a young 45-year-old woman who had presented with a severe headache and was found to have fairly massive intraventricular blood on her CT scan. She subsequently decompensated and passed away, though I am doubtful that anything would have changed the eventual outcome – had someone placed an extra ventricular drain (EVD), she may have survived a bit longer, but her quality of life would have been non-existent, and she would not have survived long, regardless.

The other patient presented at morning report was a bit more troubling as it was a child who had bilateral subdural hygromas and severe atrophy (collections of fluid, not blood) on CT scan. Problematically, though, the imaging also demonstrated severe global atrophy and as expected, the child had severe developmental delay and hadn’t met any of their normal milestones since birth. What had been described to me as chronic bilateral subdural hygromas (which, after reviewing their scan I would have agreed with) are essentially spaces between the brain and inner surface of the skull that become filled with cerebrospinal fluid as something must occupy the space in the absence of brain due to atrophy. The key is that it’s not acute and not under pressure in most circumstances. The child underwent bilateral burr holes, which had been recommended, but what normally happens in these situations, and happened here, is that the fluid just reaccumulates as there is nothing else to fill the space (the brain doesn’t bounce back since it’s a chronic compression).

Inpatient consults for the day included someone who had been advertised as a patient with a basal ganglia hemorrhage, though after looking at the image, both Joe and I were equally concerned that this could represent a lobar hemorrhage, something that would have a broader differential and a different workup. Clinically, the patient was hemiplegic, but this did not add anything to our differential, unfortunately. Jack also evaluated one of the patients (an 8-year-old child) in the ward with suspected TB meningitis who had been receiving his anti-TB meds for several weeks, but still looked very, very sick. It would be fair to say that this child’s prognosis was guarded at best.

Perhaps the most interesting patient in clinic today was a young 4-month-old child who had a very significant perinatal history, had seized shortly after birth and was noted to have a large head circumference concerning for congenital hydrocephalus. They had received a VP (ventriculoperitoneal) shunt for the hydrocephalus at 2-months of age, and it was unclear whether they had improved at all following the procedure. They had brought the child in for us to evaluate because the child was not improving after the shunt and continued to have seizures despite a very high dose of phenobarb. We did not have the previous imaging as it had been done elsewhere along with the shunt, and we were concerned as to whether the shunt was fully functional.

On examination, the child could do very little – they were moving their extremities, but they did not otherwise respond. Our recommendation, in addition to decreasing the phenobarb and adding levetiracetam, was to bring the child back to the other institution to make sure their shunt was functioning, but they told us they had done that already and were told it was. The family requested that we obtain another CT scan here at FAME, and we were all quite happy that we did, for it revealed the fact that the child was missing the vast majority of both of their hemispheres, which was the reason for their failure to reach their milestones and had little to do with hydrocephalus. Ultimately, we had a long discussion with the family regarding the child’s very poor prognosis, and that other than trying to help with the seizures, there was nothing that could be done to improve the child’s devastating neurologic functional status or their prognosis. Though we had little to offer the child, we could certainly explain this to the family and try to prevent them from going to another healthcare facility looking for answers.

We finished clinic early enough to head out on a hike through the fields behind FAME before sunset. The region here is gorgeous with rolling foothills bumping up to the edge of the Ngorongoro Conservation Area that rises more abruptly and eventually meets the crater rim. There are lots of animals in the conservation area, and they will on occasion come down from the slopes, so it is important to be alert. Cape buffalo are very aggressive, but would rarely chase a human here, though not the same for the occasional leopard that comes down from the hills. There have been sporadic leopard attacks in the area over the years, but walking in numbers would drastically reduce the likelihood of any unwanted encounters. Our walk was lovely as is always the case here. The weather over the last few days has been beautiful – cloudy and cool in the mornings, strong equatorial sunshine by midmorning, and a high in the afternoon in the upper 70’s with low humidity. You really can’t beat it.

Friday, April 4 – We’re off to the Serengeti, but first Oldupai Gorge….

Oldupai Gorge and the “castle” in all its glory from the overlook

With Vitalis’s shida (trouble) traveling from Arusha to Karatu yesterday on a Noah (a step up from a dala dala that stops at each village and packs about 20 riders in a small van the size of a large telephone booth) where he was stuck in Mto wa Mbu for several hours, we were just a bit delayed in our departure. He came at 6:00 am to get the vehicle, but had to wash it, check it out mechanically, and pick up some water prior to our departure. We didn’t leave Karatu until about 8:00 am, slightly later than I like, but at least we were on the road. Ashley, Laura, and Theandra were all packed and ready to go when he arrived at the house, and he had already picked up Saidi, who would be joining us for the weekend, in town.

Professor Masaki giving his history of Oldupai Gorge lecture to the residents

Looking at the skeleton of the oldest rhino to have lived in the crater – 57 years!

The drive to Oldupai Gorge was uneventful and we met Professor Masaki, my friend whom we have visited for the last 8 years and is one of the directors at the gorge, in the parking lot for him to give the residents a talk about the history of the gorge. It is so amazing to me that Oldupai is visited by such a small percentage of those who pass by here on their way to the Serengeti. Having visited this site so many times and seeing so few vehicles here (even in the high season, there are typically only a handful here) while hundreds pass by on the main road several kilometers away. Oldupai (the correct spelling as many of you have heard me speak of in the past despite the fact that most Western references use the misspelling of “Olduvai” after the German neurologist who first visited here in 1911) is unquestionably the single most important archaeological site in the world and for the history of humankind.

Standing in front of a cast of the Laetoli footprints

It was here that Louis and Mary Leakey spent their entire careers searching for our closest ancestors, and only after nearly 30 years did, they find their first fossils confirming the significance of this region in the history of man’s evolution and finding that multiple lineages coexisted here for a significant period of time. Mary Leakey outlived Louis, but continued to work at Oldupai and nearby sites, and helped unearth the famous footprints left by a family of Australopithecines at Laetoli in 1976, and which were at the time the oldest proof of bipedalism by a hominid at 3.7 million years. To this day, Mary Leakey’s camp (and Land Rover) still exist at Oldupai and are now the site of a living museum in her honor. I had the privilege of visiting the Leakey camp long before it was open to the public, when Professor Masaki took me there in 2017, and brought me into one of the buildings that stored non-hominid remains, though I was still very impressed by the ancient mammoth tusk he had me hold that day which was probably a million years old.

After visiting the wonderful anthropological museum at Oldupai, in which numerous fossil replicas are stored of the early hominids and many other fauna, we decided to eat lunch there as the time was getting late and everyone was hungry. Though there are no black kites (such as those in Ngorongoro Crater that dive bomb you while eating lunch), the smaller birds were very aggressive in trying to steal any morsel of food they could find. At least they weren’t likely to steal an entire sandwich in a flurry of flapping wings as do the kites.

We left the museum area of Oldupai and descended into the gorge itself, traveling back in time as we moved to the oldest sediment layers, eventually reaching the black volcanic base that occupied bottom of this amazing geologic complex. We traveled across the now dry main riverbed, passing by the site where Mary had found Zinjanthropus in 1959, then representing the oldest human ancestor to date. We climbed the opposite side of the canyon on a road that has been essentially cut into the rock itself, driving by some remote staff housing, and finally finding the “road” to Shifting Sands. Calling it a road is a very generous term, for the entire distance is essentially two tire tracks in the sand and mud that constantly fork to avoid areas that are no longer drivable.

Once close to Shifting Sands, you can see the large pile of black volcanic sand that rises from the plateau and is constantly being blown in one direction about 5 meters a year. Originally ejected from Ol’ Doinyo Lengai, or the Mountain of God as known by the Maasai, the black volcanic sand is highly magnetized which accounts for the fact that it has remained together as it traverses the Serengeti plain, devouring brush standing in its way, though always moving in a westerly direction. The site is sacred to the Maasai, as is Ol’ Doinyo Lengai, and several other places in the area.

Departing Shifting Sands, the trail we take continues to the west and is a shortcut to avoid driving on the main road to the Serengeti, which is extremely bumpy, wash boarded, and rocky with safari vehicles traveling in both directions at very high speeds. Having had our windscreen shattered by a rock from an oncoming vehicle several years ago, doing almost anything to avoid taking this road is certainly an option you want to take. Having nowhere to fix the windscreen as we were traveling into the Serengeti National Park, we spent the weekend looking through a heavily duct-taped piece of glass that seemed like it could have collapsed at any moment, but it didn’t, and remarkably we were able to get home with it in that condition.

The trail from Shifting Sands intersects the main road shortly before it reaches the border of the Ngorongoro Conservation Area and the Serengeti National Park, though you still have about 30 minutes to reach the Naabi Hill gate where you check out of the conservation area and into the park. We were running a bit late, so didn’t hit the gate until about 3 pm, and still had quite a distance to get to the camp where we’d be staying for two nights, Dancing Duma. (“duma” is Swahili for cheetah). As we left Naabi Hill and descended onto the Serengeti plains that are within the park, it was truly remarkable just how green everything was as far as your eye could see and beyond. This had been evident as we came down from the crater rim earlier in the morning and as we crossed the Southern Serengeti on our way to Naabi Hill.

What was also very clear was that the bulk of the great migration was now in the Southern Serengeti and in the regions of Lake Ndutu and Gol Kopjes where you could see long lines of wildebeest and zebra that were easily several kilometers, and there were many, many of these, in addition to tens and hundreds of thousands of animals just scattered across the plains grazing. We knew that we would be coming back this way in the near future, and so we continued to move on towards the central Serengeti and the region of Seronera. As we crossed the vast expanse of the Serengeti on our way towards our camp, which was just west and south of Seronera, we spent time game viewing and spotting various animals. The ground was very wet from recent rains that had come through this region, and the road we were taking that traversed towards the Sopa valley had long stretches of very muddy road that required some extra attention for navigation to ensure we made it through in one piece.

Driving through this valley that I have become quite familiar with over the last several years since we’ve been staying at Dancing Duma, the roads seemed to be their typical muddy mess as there is less sun here to dry them out. We are constantly coming upon forks in the road as the main path becomes impassable and we veer off into the bush on two tire tracks that seem to have been driven only by the vehicle that came immediately before us or at times we’re making our own trails.

Arriving to Dancing Duma just before sunset, we were greeted by the staff with cold washcloths to wipe off the dust and glasses of cold and fresh fruit juice as our baggage was carried up to reception before sorting out which tents each of us would be staying in. Laura, Ashley, and Theandra were in the first tent which was a triple, and Saidi and I took the next two tents as singles as we had the entire camp to ourselves for the night. We decided on dinner at 7:30 pm after time for a quick shower and took photographs of the amazing sunset that unfolded before us as we relaxed before dinner. Despite having been to the Serengeti so many times before, each visit is like the first for they are all very different. I’m sure it’s overwhelming for those who have come for the first time.

Delicious beef samosas served with our before dinner drinks

We discussed our plans for the morning, though I knew we would be leaving early as Vitalis loves a predawn departure on the first day, as do I. We would depart camp at 5:45 am and have both breakfast and lunch on the trail, spending the entire day game viewing, getting back to camp near sunset again.

Tuesday, March 25 – A long stay at the salon for Theandra….

As I had mentioned earlier, I had decided not to commit the residents to a lecture the second day we were here, so we all had an extra half-hour of much needed sleep. Our normal schedule is having morning report at 8:00 am on weekdays with educational lectures at 7:30 am on Tuesday and Thursday. There is no morning report on Saturday, and we typically don’t work on Sundays. Clinic normally runs from 8:30 am to 4:30 pm mzungu (stranger) time, or 2:30 to 10:30 Swahili time. As we are on the equator here, which means that the sun typically rises and sets within a very narrow window of time, 6:00 am in mzungu time is the same at 0:00 in Swahili time, and 6:00 pm is the same as 12:00 in Swahili time. It’s really not very confusing and most Maasai as well as many other Tanzanians in the rural areas use these time designations such that the posted time for most businesses in Karatu will post both of these hours on their door. Swahili time really doesn’t use am and pm but rather refers to each time as being either in the morning, afternoon, or night for orientation.

Our support staff – Saidi (with camera), Joshua, Angel, and Veronica

It was turning out to be a rather slow day in clinic, partially because of the weather (cool rains) as well as the fact that it was our fourth week of clinic, so after some discussion, it was decided that later this afternoon, Annie would take Theandra into town to have her hair braided. Not being someone who has much hair sympathy (as Jill reminds me on a regular basis) nor pays any attention to my coif (hey, I’ve been cutting my own hair since the beginning of the pandemic), I was having a bit of a hard time fully comprehending the extent of the undertaking that was soon to take place. In any event, today seemed to be the perfect day to get this done given the volume of patients and the fact that we’d be able to finish at least on time, if not earlier.

Olais, Nai, and Laura evaluating a patient

Theandra, who had seen our neurocysticercosis patient in clinic the day before, rounded on him in the ward and found that he was better clinically – he was more alert and more oriented than he had been the day before which was certainly a good sign given the incredible burden of active lesions he had on presentation. Similar to the patient with the hydatid cyst that we had seen several weeks ago, treating these helminthic infections can be tricky as the organisms are massively immunogenic when they are killed, creating a very severe immune reaction that can in itself be the final straw in creating enough edema to herniate.

I decided to reach out regarding this patient to one of my colleagues at Penn, Steve Gluckman, who is a tremendously experienced infectious disease expert and had not only come to FAME with me several years ago, but had also practiced in Botswana for a number of years and had started the Botswana-Penn Partnership back in the early 2000s. I heard back from quickly with the confirmation that our treatment plan was at least correct as far as the consensus on treating cysticercal encephalitis, though he pointed out that there are no controlled trials regarding treatment to date. Given the fact that he was clearly improving, and not getting worse, we decided to stay the course and would watch him for several more days before discharging him.

Meanwhile, to follow up on our young girl with the massive hydatid cyst who we had seen several weeks ago and initially referred her to the neurosurgeon, but unfortunately, her family had taken her home instead to collect the necessary money to pay for surgery. She showed up to KCMC a week ago and was placed on anti-helminthic medication (we hadn’t started her unfortunately as we hadn’t planned the delay in her getting to KCMC) in preparation for surgical excision of the cyst. Hydatid cysts require very special handling as the cyst has to be removed intact without spilling the contents into the surgical site for if this occurs, it will induce a very significant inflammatory response that will create a number of other serious and concerning issues.

Walking down a street in Karatu at sunset

We received word that she underwent surgery successfully on Friday with complete removal of the cyst, though apparently, she did have some spillage of the cyst contents into the surgical site. I haven’t heard any updates, but hopefully she will do well. We heard from Dr. Dekker at KCMC who is the neurologist there that cautioned they had lost a patient with a hydatid cyst previously in the postoperative who had a similar issue, so we’ll keep our fingers crossed and pray that she does well and recovers the function of her left side over time. Seeing patients like these with hydatid cysts and neurocysticercosis, conditions that you see infrequently back at home except for in patients who have traveled from endemic regions of the world, really puts things into perspective. Much of the problem here, though, is that patients often come in at advanced stages of their disease due to the lack of access to health care that exists throughout much of the country.

Buying limes for my gin and tonics in the vegetable market

Ashley saw a very fascinating young child today who had come to see us from the Loliondo district which is a region that is far north by the Kenya border and Lake Natron and is perhaps six to seven hours by bus. It is a remote area that has very little other than basic medical services and the region is primarily occupied by the Maasai. I have traveled up there once to spend time at a Thomson Safari camp and visited a hospital in the town of Wasso that had few doctors to care for way too many patients which is far too often the case in these remote regions. The topography, though, is gorgeous and rugged with the two main geologic features being Lake Natron, a saline lake that is a huge flamingo nesting site, and Ol’ Doinyo Lengai, or Mountain of God in Kimaa and is sacred to the Maasai. Ol’ Doinyo Lengai is an active volcano that last erupted in 2007-2008 and is unusual in that its magma is natrocarbonatite which is unusually low in temperature and is highly fluid. Flows of black lava can be seen over most of the volcano and on the lands surrounding it.

Walking around the indoor vegetable market

One of the many children we attract walking around the marketplace

The baby who had come from Loliondo was 9 months old and was essentially hypotonic, not having reached any of its gross milestones such as sitting up or rolling over, though it seemed to be very attentive during the examination. The baby was having trouble controlling its head movements and was also reported to have difficult swallowing. On examination, the most significant finding other than its hypotonicity was that it had intact reflexes.

The alleyways outside the vegetable market

Sunset over Karatu while walking back to the Salon

The differential was vast and all we could really check here was a TSH to rule out hypothyroidism, and a CPK to exclude some myopathies. Both of these tests were normal, and we were left with very little to do other than ponder, though we did decide to obtain an EEG the following day despite the fact that the baby seemed cognitively intact. As the family had traveled from Loliondo, they had planned to stay at least a night in town, so we did have the option of bringing her back. Ashley emailed a number of folks at CHOP to see if anyone had any other thoughts, though unfortunately, we had no means of checking for any of those that were suggested such as congenital myasthenia, mitochondrial disorders (her eye movements were normal though), and a vast array of genetic disorders. Without the means to test for any of these, we were at a loss of what we could do to diagnose here, let alone to come up with any treatments other than symptomatic. We did recommend that they see speech therapy at the Monduli rehab facility for their dysphagia and asked them to come back and see us in six months. It was tremendously unsatisfying to say the least.

We finished in clinic with plenty of time for Theandra to depart for the hair salon and Ashley and Laura wanted to accompany her. Annie would have to be there for the entire time to make sure things were being done correctly (this is a service that Annie happily provides us for without her oversight we would certainly run the risk of being taken advantage of) and that Theandra would not be charged a mzungu price which is what typically happens if any of us walks into a shop unaccompanied.

This is not derogatory in any way, just a fact of life here given the vast disparities that exist financially between a society in which the annual income in the Karatu district may be $250-$500 and what our incomes are in the United States. Though it is expected for anyone buying something here to bargain, including the Tanzanians, I have made it a practice never to haggle to the last shilling for whatever they are asking, a few shillings mean tremendously more to them than it does to me. That certainly doesn’t mean paying a totally unreasonable amount of money for something that isn’t worth anything close to what they are asking, but it just means being fair and not needing to feel that you got something for a steal.

I had a FAME board meeting to attend by Zoom from 5-6 pm, so Jill and I planned to drive down to the salon and see how things were going. We arrived at probably about 6:30 and it was clear that Theandra wasn’t even close to being halfway done with her hair, so Laura, Ashley, Jill and I walked the few blocks to the center of town to look around at the huge indoor vegetable market and some of the shops that lined the alleys close by. Karatu seems to come alive after sunset and there were lots of people shopping and walking the streets. The sunset was also particularly colorful and easily visible from the streets we were walking.

It was now dark, and we were walking through the small alleyways of Karatu where I have always felt safe, but it was time to get back to the salon and check on Theandra. When we arrived, she still seemed to have an army of workers surrounding her and I’m not certain that they had gotten tremendously further than they were when we had first left for the market. We sat for a while before Annie finally came to us suggesting that we all head home as it was still going to be some time before things wrapped up and we hadn’t yet eaten. Annie would stay there until the entire process was complete and would make sure to get Theandra safely home with Vincent, the taxi driver she uses and who has been driving Jill to the Black Rhino in the mornings. I sat up in the living room patiently (well, kind of) waiting for her to return which she finally did around 9:30 pm – having started by 5:00 pm, that was probably four hours of sitting in a chair for everything to be finished. Thank God that’s not an option for me!

Saturday, March 15 – A predawn departure and sunrise on the Serengeti

There is just nothing that comes close to sleeping in a tent (no matter how glamorous it might be) in the Serengeti – last night there were males lions roaring looking for mates, hyenas calling, rain, thunder, and lightning to remind us all just where we were, and not to wander outside for any reason. The sounds of the night were wonderful, but waking up very early, as we were doing for our pre-dawn game drive, gave us the chance to enjoy coffee in our tents looking out over the Serengeti savannah in what early morning light was present. We all gathered at the main tent, the sleep still in our eyes, and readied ourselves for another adventure. We would be bringing both our breakfast and lunch with us today and would find suitable places to enjoy them.

A dark chanting goshawk eating a grasshopper

Another mating couple segregated from their pride

The benefit of the pre-dawn game drive is, of course, experiencing sunrise on the trail in the middle of the Serengeti. The sunrise scene from the Lion King was pretty much spot on when it comes to what it feels like, though it really couldn’t convey the feeling of having the warm rays of the sun suddenly appear and warm everything with its radiant energy. This morning’s sunrise did not disappoint in any way, and there were plenty of “ohs” and “ahs” coming from vehicle as the sky slowly became orange, followed by the bright orb of the sun eventually peaking into a spectacular show of nature.

A black-faced vervet monkey with distinguishing anatomy

We drove around the Seronera area for most of the morning, looking for cheetah and leopards, and by breakfast time, we were close to the visitor’s center where there were tables for us. Breakfast was enjoyable with sausage, hard-boiled eggs, toast, doughnuts, pancakes, and fruit, as well as lots of coffee and tea. Yombe managed to find a nice refrigerator magnet for his collection at home at one of the little shops that surrounded the temporary picnic area as they are still doing lots of construction here.

As we left the visitor’s center area and began to make our way south for our continued game drive, we were nearing the airport when we came upon a head-on accident between safari vehicles which had just occurred and thankfully did not involve any tourists. One of the drivers was pretty shaken up and still in his vehicle as we arrived, so I got out as Vitalis was pulling our vehicle to the side of the road and helped to pry open his door and free him. He had injured his right wrist and suffered a large skin tear that required some antibiotic cream and bandaging. I have always carried a first aid kit with me in the car, though had not had to use it in the past, but it certainly came in handy this time as I was able to provide a very basic bandage and used Meredith’s triple antibiotic cream rather than what was in the kit. It reminded me, though, that I need to replace the kit since it’s probably 5+ years old and some of the contents may have expired.

We carried on with our game drive and were fortunate to see lots of animals along the way, though the leopard seemed to elude us. We found a lone male cheetah that seemed to be hunting, but there were no game in sight, and a mother with two young cubs sitting on an anthill as they typically do as they can survey the horizon from there. By one of the kopjes where there is a large spring, we ran across two male lions laying in the road, clearly sleeping with full bellies after having feasted on a kill. There was a female and several juveniles up on the rocks as well. As we looped around the spring, though, we happened on the bulk of the pride which was huge – around a tree were seventeen female lions and cubs all sleeping in the shade while another male, more senior to the other two we had spotted earlier, was also sleeping under a tree a short distance away. Far off in the distance, were some small herds of gazelle that seemed to have been spooked, and it didn’t take long to spot a group of hunting lions not far from them. Lions have to sneak up on their prey as they can only run at top speed for short distances, and it was unlikely that these lions were going to do so. After a bit, the five females that had been out hunting made their way back to the bulk of the pride with the alpha female, who had a tracking collar on, leading the way. All in all, this pride consisted of more than 25 individuals that we could see ourselves.

Through the Central Serengeti, there were massive herds of wildebeest and zebra that made up the body of the great migration and were quite happy with the condition of the grasses here. We eventually made our way a lunch spot that sits above one of the luxury camps and is a place I’ve come before with Vitalis to look over the savannah. The camp brings guests up here for sundowners (drinks) as it has a great vantage point for the sunset. After lunch, we made our way back towards the giant herds of the migration, and at one point, stopped at a watering hole that was filled with animals where were quite skitzy and would constantly come down to drink, then shoot back up the hill for some reason that wasn’t always entirely clear to us. I imagine being an animal of prey in the Serengeti wouldn’t be the most relaxing thing in the world, constantly worrying whether it might be your last moment on earth.

In the late afternoon, the sky clouded up a bit more than it had been, and as we drove in the direction of our camp, lightning flashed above the far distant hills warning of the rain that was liking coming in our direction. Close to our camp, we came across a huge tower of giraffes (yes, a group of giraffes is referred to as a “tower” or “journey”) with great many calves and juveniles among the group. The lighting was just amazing as it was the “golden hour,” that time just after sunrise and just before sunset when the ambient lighting is perfect for photography. It surely showed.

We made it back to camp a bit later than anticipated and after sunset, but there was still time for us to shower before dinner which was such a luxury. The dinner tonight was fully African and incredibly delicious as the chef at Dancing Duma is just amazing when you think of the kitchen being out in the middle of nowhere. It looked like it would likely rain overnight so the roads would be muddy in the morning, though simply saying muddy would not be a fair description of what we encountered the following morning.

Monday, March 10 – Our first neuro mobile clinic to Mang’ola….

Meredith greeting Meow in her rain gear – it was a heavy rain last night

Prosper and Saidi (inside) packing up the Land Rover with medications and supplies

After traveling to the Crater yesterday and spending the evening at Annie’s house, it was time to prepare for our first neuro mobile clinic. The mobile clinic concept has its origins in the very beginning of FAME when Frank and Susan would travel to local villages in the Karatu district with an entire crew – doctors, nurses, and lab techs, as well as a dancing troop that would help teach the local population about the issues with unsafe water and malaria. When I first came to FAME in 2010, I was able to participate in these clinics to the Lake Eyasi region (where we were heading today) that would last a week and would involve about half of the FAME staff. We traveled far down the shore of Lake Eyasi to villages were the Hadzabe and Datoga lived, holding clinic for the day and spending the evenings around a campfire sharing stories about the day and other aspects of the world in general. I specifically remember the nights and the early mornings before sunrise as there was absolutely no light pollution and the stars were incredible.

Saidi registering patients in the morning

As we were on hallowed ground in the world of anthropology, one of my first true loves, I remember calling my mom, the one who had instilled in me the love of nature and the inquisitiveness that has led me to where I am today, early one morning to excitedly tell her that I was standing on ground that Australopithecus had walked millions of years ago. It was not long after, or perhaps even when I had called her, that she developed dementia and passed away two years later. She was a truly remarkable person who I think of quite often and wish she were still here to share in the work we are doing as she is as responsible as anyone for it having happened.

Angel, Veronica and Saidi registering a patient

Our neuro mobile clinics began in 2011 at the urging of Paula Gremley, a tireless social worker in Northern Tanzania who had worked with FAME in the early years. One day, she asked me if I’d like to accompany she and her co-worker, Amiri, to travel to a few close by villages to see neurology patients. It took little convincing for me to jump in their Land Cruiser along with a nurse (to distribute medications) and a clinical officer (to translate for me), and off we went to the Mbulumbulu region of the Karatu District. That very first clinic at Kambi ya Simba (we are still going there fourteen years later) was held under a blue sky in an opening in front of their small church and was the beginning of what would become a sustainable effort to bring neurology to the villages where there were many patients who weren’t aware they had treatable disorders such as epilepsy.

Sabine, Alois, and Noor evaluating a patient

Our clinics, which have covered a number of the regions around Karatu, are now comprised of bringing the team of neurology residents along with our translators, a social worker, a nurse to dispense medications, a FAME driver for the second vehicle, and an outreach coordinator. We travel in my two Land Rovers and bring all the necessary medications to provide prescriptions for the patients we see, and to refer patients back to FAME for any additional testing such as labs, echocardiograms, or radiology studies. There is readily available transportation to Karatu and FAME by bus for the patients we are seeing in all the villages, though the patients often are unaware that they have treatable conditions making our traveling to the villages so necessary. Once we’ve identified patients who we can provide some relief, it’s our hope that they can travel to FAME for refills of their medication, though often, the issue not a matter of whether they can travel or not, but whether they can afford the refills of the medications we’ve provided. At the present time, we do the best we can, but without specific funding for this purpose, we’re unable to provide more than a month or two of medications when we see them in clinic.

Yombe and Steve presenting a case to Meredith behind and elephant ear fern

Traveling to villages to provide these neurologic services also requires the cooperation of the clinical officers and staff at the dispensaries we visit. Those dispensaries that have welcomed our efforts had continued to receive our support, and each visit here, we will travel to six or more of these clinics to maintain the sustainability that is so important to providing health care and is so important in obtaining the trust of the communities we have served. As mentioned, we have continued to provide services to the Mbulumbulu region and Kambi ya Simba since 2011 every six months. What began as an open-air clinic in the middle of the village now utilizes a much more modern facility that was built several years before the pandemic, and we are provided multiple examination rooms to see patients there. Rift Valley Children’s Village has also been a site that have supported with neurology clinics from the very beginning of my work here, but that’s been a given considering the connection between FAME and the Children’s Village. The region of Mang’ola and Lake Eyasi, where we will be heading today to the town of Barazani has been a site that we have gone to now for probably six years and we have seen a great many patients there with neurologic illnesses. The village of Mbuga Nyekundu, where we will be heading tomorrow, is also in the Mang’ola region and has a gorgeous new dispensary for us to work in. On Wednesday of this week, we will be traveling to Mang’ola Juu, a very small village on the slopes of Oldeani Mountain that has perhaps the most primitive dispensary, though many patients in their area. Lastly, the village of Basodawish is the most recent addition to our mobile clinics and has been very receptive to making announcements in their region so that we have had many patients to see there.

Sabine presenting to Meredith and her two helpers

I had hoped to have our second vehicle here in time for the today’s clinic, but unfortunately that was not the case as there was more shida with heavy rains knocking out a few bridges making travel difficult. Additionally, only one of the wipers was apparently operational, making travel in the rain that much more difficulty, as well as the fact that the police at the traffic stops weren’t very understanding and kept interrupting their travel requiring them to repeatedly explain the situation every time. Thankfully, Saidi had a friend with an identical Land Rover to Myrtle that we could rent for the day, and he would allow me to drive which was obviously an issue as I didn’t want to take another FAME driver away from FAME. We had to strap our medications and supplies to the top since we have fewer seats than anticipated, though it all worked out in the end, and I drove the vehicle we were renting for the day. Once everything was sorted out, which put us behind by approximately one hour, which actually wasn’t too bad all things considered. We were finally one our way out of town and heading in the direction of Lake Eyasi, which in the past was a very questionable road frequently washing out at the mere sign of a drizzle, though has been completely reconstructed in the recent years and is much more pleasant to drive.

Alois and Sabine presenting a patient to Meredith

The trip was essentially uneventful as we drove through incredibly rich farmlands growing predominantly corn (maize) and onions with workers in many of the fields either planting or harvesting as we couldn’t tell which they were doing. This region is a very significant exporter of produce to other areas of Northern Tanzania, and particularly of onions as I recall that on numerous occasions, we’ve stopped so our Tanzanian colleagues could purchase bags of onions for next to nothing. Our journey skirts around the foothills of Oldeani Mountain until we finally approach Lake Eyasi, viewing it in the distance. The lake is one of the Rift Valley lakes (Eyasi, Manyara, and Natron) that have formed with this geographic feature that runs through East Africa.

Recent supplies put aside after a cholera outbreak at the dispensary

The town of Barazani is a rather desolate place that lies on the shore of Lake Eyasi and is primarily agricultural in existence. There are some fishermen who live right on the beach, harvesting small fish that live in the lake with long nets that they drag out with boats and then haul onto the beaches pulling out large quantifies that are then dried in huge piles. The dried fish are supplied to be ground up as chicken food and are shipped throughout the country. We’ve visited the beach before on numerous occasions and have even jointed the fisherman in the boats and have even helped them haul in their nets ashore using burlap sacks wrapped around our bottoms. The smell of the fish at the height of the harvest is incredibly strong and a bit nauseating for the uninitiated.

Sabine teaching Alois, Nai, and Noor some neurology after clinic

We pulled up to the Barazani dispensary, where we have been coming for several years, and the clinical officer, who has also been there for the entire time we’ve been coming, came out to greet us immediately. We have had a great working relationship here and have seen a great many patients here in the past, at times even a bit overwhelming having to ask patients to come back the following day to see us. It was also well baby day today at the dispensary, so all the infants and their mothers were waiting to be seen by the nurse there, though I know that Riley had hoped they were all there to see her. The number of patients here were less than we had hoped for to start, but it was early and once word got out that we were there, perhaps more patients would show up for us.

Meredith helping Yombe and Steve with a movement patient

Our outreach coordinators spend time visiting these villages where we have our mobile clinics in advance of our arrival, though it is often a matter of what the weather is like or whether it is planting or harvesting season with the need for everyone to be in the fields. Today, though, we ended up only seeing fifteen patients or so which is really about half as many as we would like to see in the day. The resources to get here are obviously the same no matter how many patients we end up seeing, but the expense per patient is clearly the greatest with the fewer patients we are seeing. Besides, the more patients we see here, the better for everyone as it provides a greater experience for my residents and teaching opportunities for the Tanzanian clinical officers. Spending the day at a mobile clinic with few patients to see can be quite a disappointing experience.

Me, Riley, Sabine, Noor, Anne, Nai, Alois, Yombe, Steve, and Meredith in our group photo

We departed Barazani at around 4:30 PM and it took us about an hour to get home. The weather was still gorgeous for the trip home, and everyone was pretty beat when we finally arrived and unpacked our gear. The word was that my other Land Rover would finally be arriving sometime tonight, though I thought to myself that I would believe it when it finally happened. Amazingly, Turtle finally showed up around 9 pm, my to my surprise as I was about to go to bed, but here she was with the driver/mechanic. The plan was to have him drive us tomorrow to make sure everything was good, so I told him to head into town and meet us at 7:30 am in the FAME parking lot as we would be departing at 8:00 am for our next clinic. My fingers were still crossed that the whole thing hadn’t been a dream.

Sunday, March 9 – A birthday in Ngorongoro Crater….

(Photo credits – Yombe Fonkeu, Riley Kessler, and Jill Voshell)

Noor, Meredith, Sabine, Riley, and Jill at the entrance to Ngorongoro Conservation Area

Up early for our upcoming safari, I drove Myrtle up to the main FAME parking lot and let the keys with reception as the plan was for the fundi to work on the car while we were gone. At least that was the plan, but more on that later. I had asked our guide for the day to meet us there, but I couldn’t find him initially as he was waiting in the Lilac Café parking lot on time. You wouldn’t think that it would be difficult to track someone down at FAME, but it has grown so large over the years, it is now more common than you’d think. Roman was to be our guide and driver for our day in the crater, so I hopped in his vehicle and directed him to the Raynes House to pick up the rest of the group.

From my earliest times in Tanzania, it had been the realization of a dream for me to be driving in East Africa, exploring the backroads of the Great Rift Valley and its surrounding regions. Had someone ever told me that this would be case, I would not have believed them for a second. Yet, here I was, having spent well over two years of my life so far, driving through the places I had studying about as an adolescent and young man, experiencing the very thing that I never thought would have been possible. So, with this in mind, you can understand why it wasn’t what I had necessarily wished for on my birthday, to have someone else drive us to the crater, a “responsibility” I look forward to four times year when I act as the guide and take my team of residents into this incredible natural wonder which is often the very first game drive experience they have.

For this trip though, I would be given the day off as far as guiding was concerned, and with that, any need for me to make decisions for the day. I will admit, the day was much more relaxing for me than it typically would have been had I been guiding, and I accepted my role willingly and gracefully. It had been the first time in many, many years that I had visited the Crater as a guest, rather than a guide, and I did rather enjoy it.

The clouds were hugging the crater rim in the early morning hours, and my favorite drive in the world, rising slowly on switchbacks through a primordial forest, was shrouded in mist. The overlook at the top provided little in the way of a view, though we could certainly stop on our way back to look where we had been for the day. Ngorongoro Crater is the largest complete dry caldera in the world. It measures 10 miles across and is 2000 feet deep and contains populations of every animal we see in the Serengeti save for giraffes, as the walls are too steep for them to climb safely, and Nile crocodiles. The once populace cheetah is no longer seen here as they were unable to compete with the vast numbers of hyenas. The animals in the crater do not migrate but live out their lives here as they have everything they need. The crater is also home to one of the densest lion populations in Africa. All this adds up to an unforgettable experience in one of the true wonders of the world.

The day went well with lots of lions and one distant rhino, albeit laying down, and it was a good first safari for everyone along except for Meredith, who had been the crater with me three years ago. There were no sandwiches stolen by the kites at lunchtime even though we set up tables to sit and eat (something I never do at the lunch spot). Unfortunately, the Ngorongoro Crater Lodge is now closed for major renovations, meaning that we couldn’t stop for our coffee and cookies with my friend Ladislaus that is usually a special treat after a day in the crater. We traveled home as we had plans for dinner at Dr. Anne’s tonight where we would also celebrate my birthday. It’s been 15 years since I’ve had my birthday in the US and that has never been an issue for me as I’m never the best at celebrating myself. We had a big bash 9 years ago for my 60^th, with a party at the Highview, though I’ve kept it lower key since then. We had a lovely dinner, and everyone got to sing happy birthday to me. Life is good.

Saturday, March 8 – Morning clinic and an afternoon at Gibb’s….

Stopping at the market to buy bread for our safari lunch

After a week of neurology clinic at FAME, it was time for a bit of a break, and I had scheduled us to be in clinic for only the morning. Of course, as many of you may already know, trying to schedule for only a half day is rarely successful in accomplishing what you set out for as you usually end up working the entire day regardless of what you had planned. Thankfully, Saturdays are usually not as busy as weekdays and few patients show up in the morning to be seen. Had thirty patients been present at the start of clinic, I’m not really sure what we would have done, to be honest. That wasn’t the case, though, and we were able to get through everyone by around one in the afternoon. That is until we were told there was a baby to see who was on the ward. Riley and Annie went off to see the baby, who it turned out was very sick, and we made recommendation for beginning a neuro evaluation, but it would require the baby get a CT scan and lumbar puncture.

Lunch is served every day, so we took advantage of having my favorite meal at FAME, rice, beans, and mchicha before heading back to the house. We had wanted to head up to Gibb’s Farm to take advantage of their pool, and had planned to leave around 3 pm which would give us several hours of the warm afternoon to enjoy. It was very cloudy that morning and we all worried about whether we’d see the sun or not, but the blue sky opened up and it was a gorgeous afternoon after all. Myrtle’s rear door had been fixed, though I had still not received an ETA regarding Turtle, and time was running out for us as we would need to secure a vehicle for our trip to the crater tomorrow. The word was that they were fixing some last-minute things and every time they took it out for a test drive, they would find something else to fix. The last word I had was regarding an electrical short in the dash that would take more time to fix, but that hopefully we would get the car in the evening.

View of the vegetable garden from the loo

Gibb’s Farm was, as expected, spectacular. Since my last visit here, the entire resort had been sold to a very large corporate entity, and the managers, Nick and Sally, who had been in Karatu for some time, were no longer there. First, I had to make sure that we still had the same privileges for volunteering at FAME as I really didn’t want to show up at the pool and find out that we were somehow trespassing or were charged a fee, though thankfully this was not the case, and we were still welcome to enjoy their grounds before our dinner. The pool there has an incredible view and is essentially an infinity pool looking off into the distance towards FAME and the outskirts of Karatu. The pool isn’t heated at all, and though it was a bit a jolt jumping in, that was the only way to do it and after several minutes, the cold was incredibly refreshing and welcomed. Yombe and I spent a good deal of time in the pool with Jill joining us as well, though none of the others decided to partake. Everyone relaxed and enjoyed drinks, or not, and before we knew it, it was time for the Iraqw cultural presentation that had been scheduled for 5:30 pm. Jill and I had seen it several times before, but the others enjoyed some of the traditional singing and dancing.

Dr. Elissa, FAME’s pediatrician, had decided to join us, as did Nish Dodie, a good friend living here in Karatu who runs the African Galleria, and we all sat relaxing at poolside until 7:30 pm, well after the normal 7 pm dinnertime, but no one complained. The night was delightful. Dinner was, as expected, tremendous and they had excellent selections for everyone including those vegetarians among us. It was a truly wonderful meal, though I think I ate more than I had intended as I was quite full on the drive home. We still had to make our lunches for our safari tomorrow and it was nearly 10 pm when we arrived home.

As for our safari vehicle, it had been decided that Turtle would not make it, and we were going to rent a vehicle from a friend of Leonard’s. The vehicle would come with a driver which meant that I was essentially given the day off as I normally drive the Crater trip and would now be able to sit back and relax while someone else too, over my duties. I spoke with Leonard’s friend, the owner of the vehicle, who gave me the name and number of the driver, but that night I was unable to reach him which worried me a bit. I told them we wanted to leave at 6:30 am, but I hadn’t received confirmation from the driver that he knows when we wanted to be picked up or exactly where. I went to bed with my fingers crossed that the driver would be there, and we would get an early start, but wasn’t 100% sure. That is how it often is here – everything is on a need-to-know basis and the details are rarely shared.

I’ve struggled with this concept over the years for I am typically quite the opposite in wanting to know all the details to help with decision making, but that is something that just doesn’t happen here routinely. In regard to Turtle, though, the decision was made that the fundi (expert) would get the car here on Sunday and leave it for us along with fixing the white exhaust issue with Myrtle.

Friday, March 7 – Daniel Tewa’s home last evening and a visit to Teddy’s…

Sabine, Meredith, and Noor listening to Daniel tell his stories of living in an underground house

I’ll start today’s blog with last evening’s activity, which was our obligatory visit with Daniel Tewa. Before we could leave for Daniel’s, though, there was the matter of our transportation. One of my favorite words in KiSwahili is “shida,” which means “trouble” or “problem.” I think the reason I like it so much is that it sounds very similar to one of our very frequently used curse words that carries much the same connotation to imply that things are going well. To put it succinctly, we have been having car shida since our arrival in Tanzania a week ago when neither of my cars was ready for prime time due to unforeseen, though quite predictable, issues that each was having and delayed their availability for our use. Myrtle, my short Land Rover, arrived on Monday morning and still had an issue with the fuel adjustment causing it to blow white exhaust smoke (bad for a diesel), though was thankfully running perfectly fine.

The stretch Land Rover, otherwise known as Turtle (hence, Turtle and Myrtle), had undergone a major overhaul in the last months and was going to take several more days to be in ready shape for us. This was going to be an immediate problem for us as we were seven, and with the seating in Myrtle, that would require that two individuals would have to sit in the inward facing bench seats in the back of the Land Rover which are not the most comfortable by any means. What made matters worse, though, was that I hadn’t tried to open Myrtle’s back door until Thursday when we were all getting ready to go to Daniel’s, only to discover that the door latch was stuck, meaning that those sitting in the back would have to climb over the middle bench seat to get in, not a simple task for even the most limber. Latches get stuck frequently here and it’s usually just a matter of pouring some water on it and it will loosen, but no such luck with a simple fix tonight.

Yombe, Sabine, Riley, Meredith, and Noor listening to Daniel describe his underground house

Meanwhile, the missing Turtle would continue to complicate matters over the coming days as she was quite necessary not only for our upcoming recreation plans but was also an integral part of our outreach program, as was Myrtle, and that would be starting the first of the week. So, once we were all loaded into Myrtle, including the two brave souls who volunteered to ride in these thoroughly uncomfortable and jostling seats in which your head sits only inches from the roof and one good bump could easily buy you a visit to our neurology clinic. Clinic ran very long, and we weren’t able to get out before 5 pm which is usually preferable as it’s best to arrive to Daniel’s in the daylight. Regardless, we still made it there with enough daylight to visit his underground Iraqw tembe, or house, that he had constructed in the early 1990s as an example of the type of home in which he had spent the first twenty years of his life.

The front of Daniel Tewa’s underground house

For many years before this country’s independence in 1961, the Iraqw and Maasai tribes had been at odds over the ownership of cattle. The Maasai believed that all cattle were God’s gift to them and, therefore, they were not stealing cattle when they took them from the Iraqw, but they were rather being returned to their rightful owners. As such, the Iraqw built their homes essentially underground, allowing them to take their livestock into their house each night to protect them from theft by the Maasai. The homes were built with a dome of dirt and sod supported by crossmembers and upright poles of hardwood. Their homes were roomy enough for a corral on the inside for their livestock and each morning they would then be taken out for the daytime to graze in nearby fields. The homes were large enough for whatever the size of their family and could be anywhere from 5×5 rows for a young family to a much larger 10×10 and more for a larger family with older children.

As the country grew and tried to establish itself, it had numerous hurdles to overcome, and one of those was to figure out a mechanism to establish an infrastructure that could serve the population, but having 128 separate tribes in the country, each with their own villages, it was clear to the government that having everyone live together in combined villages with combined services would make things tremendously more manageable. So, in 1974, the government declared that the Iraqw tembe, and other traditional tribal buildings, illegal and that everyone should live slowly move into villages together, where the government could build roads, and power lines, and similar necessary services with much less effort and expense. Interestingly, the Iraqw and Maasai remained at war until a treaty was finally signed in 1986, and they were officially at peace.

Climbing on top of Daniel’s underground house

The Iraqw tembe that Daniel built, and now widely attracts both scholars and tourists from near and, is magnificent and it has clearly withstood the test of time and is a testament to its design and construction – so much so that the only damage it has sustained since it’s construction more than thirty years ago occurred when a pair of elephants, a mother and child, decided to walk across its dome and, in the process of doing so, caused one of the horizontal supports to crack and ended up with a leak until it was prepared. The depressions from the elephants feet are still visible in dome.

Given our later than hoped for arrival, Daniel suggested that we tour his house first, so we still have some daylight, and then enjoy coffee and cake afterwards. I had first met Daniel in 2009 when I had first come to Tanzania with my children and had elected to spend three days in Karatu volunteering at the Ayalabe School. As one of the village elders, Daniel accompanied us each day and invited us back to his home where he and his wife, Elizabeth, entertained us with dancing and coffee, and Daniel shared his underground house with us for the first time. When I returned to Karatu the following year to volunteer at FAME, I contacted Daniel in the hope that I could reconnect. Amazingly, he remembered not only our visit with him one year prior, but he also remembered my children’s names, asking me immediately how both my Daniel and Anna were doing.

A street scene in Karata while we’re out buying fabric

Choosing fabric (I’m waiting in the car)

When I returned to see him during my first visit to volunteer at FAME in October 2010, I came to his home and quickly discovered that in Tanzania, it is considered rude not to provide a visitor with a meal before they leave, and so I stayed to have dinner with Daniel and his family. We had a simple meal in his living room, eating with our hands, and he later told me that I was the first white person to ever return to his home after cultural visit, let alone honor him with my presence for a meal. Since that time, I have visited Daniel with my groups each and every time we’ve been at FAME, including two visits now that I have two groups each trip. Up until the pandemic, we had also had dinner with Daniel and his family, though after the beginning of the pandemic, and with each of my groups now being much larger, we have only come for coffee and lesson in Iraqw culture. We had another wonderful visit with Daniel this evening, and everyone went home with a much better understanding of the Iraqw culture and the history of this very young country.

Teddy’s son, Allan, on the right, reading a new book

The following morning, Friday, there was a “near miss M&M” conference that had to do with diabetic ketoacidosis and a young patient who had come into the ED recently and was very sick with DKA, a condition that is very serious, and can be lethal if not treated properly. In the end, the patient had done well, though had it not been for a few “lucky” catches, it could have gone much differently, and the purpose of the exercise was really to take advantage of the situation by creating pathways and algorithms that going forward would prevent any possible near misses in the future. Everyone participated and though the importance in teamwork was something that everyone at FAME has known since the very beginning, it was further reinforced so patients such as these will continue to be provided the very best medical care possible.

Our plans at the end of the day were to visit Teddy, the tailor that has made lovely clothing and other things for my residents for several years now, but we would need to visit the fabric store in town prior to going to her shop. Thankfully, we were able to finish the day at a decent time, and even better, I had asked the drivers at FAME to work on Myrtle’s back door. They were successful with some good old WD-40 and, with that, we now had much easier entry to the back seats, though they were still incredibly bouncy. We visited the fabric shop and Teddy’s and were home in time for dinner.

Calling accepted Penn medical school applicants from Tanzania to congratulate them

I still did not have Turtle, my stretch Land Rover and safari vehicle, which was now becoming an issue as we needed the car for our Sunday visit to Ngorongoro Crater, and without it we would have to come up with some alternative plan. I kept my fingers crossed that Turtle would somehow appear in time, but if she didn’t, at least we would still be able to go. Once you’ve booked your service with the Ngorongoro Conservation Area Administration, it’s often not very easy to get your money back and that did happen once many years ago when our vehicle broke down shortly after going through the gate. It took us hours to get the car towed back to town, and the NCAA was not at all concerned about giving us our money back for the day.

Mixing Mango gin and tonics (wholly medicinal, of course)

Tomorrow was to be a half day of clinic, and we had scheduled dinner at Gibb’s Farm for the group with plans to spend the afternoon around the pool there which is always a very special event. Gibb’s Farm has always been constant theme for us here at FAME – it is an incredible five-star eco-resort with farm to table cuisine and can’t be underestimated as an experience that is just always good for one’s soul. Not quite chicken soup, but close.

Thursday, March 6 – A very interesting patient, and a more interesting CT scan….

From its very inception, the education component of FAME has been one of the main foundations of our volunteer program here and is what drew me in on that very first visit back in 2009 when FAME was but a year old and had only just begun on its journey to bring quality and accessible healthcare to a region of Tanzania where none had existed before. In addition to working side by side with the clinicians of FAME, providing bidirectional education while providing care, volunteers have always provided educational lectures for the doctors and nurses here to further enhance that transfer of knowledge – twice a week, there are educational lectures in the morning that we have always participated in and once I began to bring residents here, that responsibility fell mostly to them as it has always been clear to me that there are no better teachers than our residents.

Sabine, Yombe, and Riley readying for their epilepsy lecture

In addition to the education that we provide here in our patient care and lectures, though, the other huge component of FAME’s education mission comes in the form of the opportunities that FAME provides for not only its nurses and doctors, but also others, for continuing education to advance their certifications and degrees. FAME is currently sponsoring one of our doctors to return for a much-needed OB/Gyn residency that will benefit our maternity program here immensely. I will remind everyone that residency training in Africa comes at a significant cost and is far different than what exists in the United States where residents are paid substantial salaries, most of which is supported by Medicare and the federal government, something that doesn’t exist here. Without sponsorship, paying for one’s residency training is beyond the reach of most Tanzanians and something they would never be able to obtain. The majority of physicians here are not residency trained but have only done an internship (their first year out of medical school) before heading out to practice medicine, obtaining the rest of their experience while on the job.

Absence seizure with hyperventilation (occurs at approximately 10 seconds into video)

Tuesday and Thursdays are reserved for educational lectures at 7:30 am (ugh!) and today would be our first neurology lecture for the staff. All three residents decided that they would talk about epilepsy given its overwhelming incidence here – as I mentioned before, 90% of epilepsy exists in low to middle countries of the world where there are the fewest neurologists and the treatment gap, those patients who are never seen for their epilepsy, or they ever are, never treated adequately, is massive. Over the years of being here at FAME, the numbers of epilepsy patients we have seen has been incredible and has grown exponentially so that it is now the most common diagnosis that we see here in our neurology clinics.

Though there are some conditions where our diagnosis and treatment have an immediate and dramatic effect (such as placing a wheelchair bound Parkinson’s patient on carbidopa-levodopa and having them walking when they return) treating epilepsy patients may at times take a bit longer for complete control, but the effects of treatment are equally profound. It is commonplace for us to see children with epilepsy who are unable to attend school due to their seizures, and once their seizures are under control, are able to return to school and lead a normal life with their classmates. We have seen this countless times over the years. Patients with epilepsy are also at an incredibly higher risk of injury (10x or more the risk) and often suffer burns by falling into cooking fires at home or spilling a pot of hot porridge they are carrying on them. These injuries, in addition to their continued seizures, will continue to affect them for their entire lives such that they may never have the opportunity to lead a normal and productive life. Not having an education or suffering a life altering injury as a child is something that can never be corrected.

Sabine, Yombe, and Riley covered the topic of epilepsy, from its definition, diagnosis, and treatment, in a concise and understandable manner for the doctors here so they could more easily recognize these patients, know what questions to ask, and have a better understanding of the medications that we use. It’s not that we haven’t given this lecture many times before, but there are always clinicians coming and going, including Tanzanian volunteers such as our translators who will take away knowledge that will benefit them going forward and even information they can pass on to others once they leave FAME. Our goal here is not to train neurologists or epileptologists, but rather to give these clinicians the knowledge they need going forward to feel comfortable recognizing neurologic illnesses and treating them. Having this information will make a huge difference in the lives of their patients in the coming years.

Steve, Dr. Anne, Yombe, and Noor evaluating a patient

After their lecture, it was time for us to begin clinic, though, Susan and I had wanted to have every meet with her for a few minutes now that they had experienced FAME to see what questions they might have and to impart some of the FAME philosophy that is necessary for anyone practicing in a low resource setting where the decisions that you make on a regular basis can have tremendously different implications, not only for the patients you are seeing, but also for those others you are working with. Our mornings in clinic have become a recurring theme with our list of patients reaching its maximum shortly after registration opens. The EMR we’re using is incredibly clunky (we are in the process of changing over to a new one currently) and patients don’t show up in the neurology queue for some time, giving us a false sense of ease until suddenly the list balloons and our waiting room benches begin to fill.

Perhaps the most interesting patient of the day was a young 5-year-old child that Riley saw who came to see us with a rather concerning story of a five-month history of progressive left sided weakness. On examination, the child truly had a significant left hemiparesis as well as a rightward gaze preference, and a bit of an ominous bulge on the side of their head, though I’m not sure we had completely appreciated that for we sent them for a CT scan. We discussed the situation with the family in as much that the child would clearly need a CT scan and, had the family indicated that they couldn’t afford it, we would have had to figure something out as there was little question that something serious was going on.

We did the CT scan with contrast as we were mostly concerned about some type of mass lesion given the progressive course, and, in a very short course, it was quite obvious to even the most uninitiated that there was a significant issue brewing that would need prompt attention, and it would not be something that we could do here. There was a 9 cm simple cyst occupying the majority of the right hemisphere and causing both midline shift and not only compression of the right lateral ventricle, but also significant compression of the left lateral ventricle with obstructive hydrocephalus. In addition, there was widening of the right coronal suture as a result of the expansion of the cyst and accounted for the bulge that was seen on examination. Amazingly, the child was awake and cooperative which was clearly a result of the chronicity of the lesion, though her hydrocephalus was very concerning, for though it had somehow become compensated, it would take very little to tip it in the other direction.

My first thought was that this looked similar to the hydatid cysts that we’ve seen commonly in the liver and is the result of an infection of the tapeworm, echinococcus granulosus. Though these cysts can also be seen in the central nervous system, they are far rarer, and I’ve never seen one before here. The treatment of hydatid cysts of the brain is very difficult as they must be removed without rupturing for fear of spilling the contents of the cyst into the subarachnoid space and causing massive inflammation and anaphylaxis. How to do that in this child would seem incredibly challenging, if possible, at all, as she absolutely needed to have the cyst decompressed as soon as possible to prevent herniation from the significant mass effect and hydrocephalus. I sent the images immediately to the neurosurgeon at KCMC and our plan was to refer them there emergently.

Nai, Riley, and Meredith evaluating a patient

We sat with the family and showed them the CT scan, if anything to impress upon them the urgency of the situation with the hope that we could convince them to do something sooner than later. Initially, the family told us that they would take the child home and try to go to KCMC in two weeks after raising the necessary money to have her treated. After much discussion, we were finally able to convince them to go immediately, though later discovered, when they hadn’t shown up, that they had gone home as was there initial intention and still planned to raise some money before heading to KCMC. This is most often the situation here as everything is done on a “cash on the barrelhead” method, though when it involves children, there are usually ways around this that have to be done with incredible sensitivity so as not to upset the fine balance that currently exists. Reaching in your pockets and paying for the care of patients doesn’t benefit the system, reinforces the image of the great white savior, and alienates every other Tanzania health care worker who can’t afford to do the same. As of this writing, we are still actively working on trying to get to the child the care that she needs.

Contrast this with another patient that Yombe saw today whose history was tremendously more benign, and there was far less concern over what might be going on neurologically. He was a young man who had had two episodes of loss of consciousness that were less concerning for seizure and much more suspicious for cardiogenic syncope. During his evaluation, he had undergone not one, but two MRI scans that demonstrated a small occipital arachnoid cyst without any complex features or concerns that this could be something else harmful. The patient had also gone to Aga Khan Hospital in Pakistan for another opinion though we did not have his records from that institution unfortunately when he was seen by us.

Sabine teaching Alois the neurologic examination

We were able to review his MRIs that had been brought to us on film, most to confirm that we agreed with what had been reported, though the description of his events did not sound particularly epileptic. We decided to obtain an EEG for completeness sake (we currently have access to a portable EEG device through the generosity of Brain Capture, a Danish company – www.braincapture.dk). This EEG turned out to demonstrate only some focal slowing in the region of arachnoid cyst but was not epileptogenic. Our recommendation was going to be to pursue other possible etiologies to his episodes of LOC, such as monitoring for cardiac arrhythmia, though we continued to have little concern for an underlying neurologic issue.

Dr. Anne performing an occipital nerve block with Alois

The contrast between these two patients, the young child with the gigantic hydatid cyst and the gentleman with two episodes of LOC who had undergone two MRIs and traveled to Pakistan for another opinion, was exceptionally stark. The second patient was incredibly reminiscent of those we so often see at home who have traveled to Penn to receive their second or third opinion for a completely benign process, or one that is not neurologic, and insisting that something must be wrong while in the process requesting additional testing that we know is unreasonable. The patient with the giant hydatid cyst, on the other hand, who was critically ill and had taken five months to come see someone for her issues, required initial convincing to have them seek the care that was so crucial, only to find out that despite our best efforts, they had not heeded our advice due to concern for what the cost of that care would be. We are hopeful that she’ll be seen soon enough to make a difference, though even with the best of care, her treatment will be challenging.

Alois, Nai, and Riley evaluating a patient

We were heading off to Daniel Tewa’s home for the evening, though I will catch everyone up on that in tomorrow’s blog.

Michael In Tanzania

Travels and Global Health

Fall 2024