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.

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.

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.

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.

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.

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 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!

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

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.

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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.

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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.

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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.

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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.

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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.

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.

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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.

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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.

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.

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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.

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.

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.

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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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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

Yesterday’s clinic had run very late for everyone involved as we were seeing patients well up to sunset, something we try to avoid given how beautiful it is to watch this event each night from our veranda. The weather has been gorgeous here with only a light rain the first evening that we arrived, which we were told was a good sign and an indication that our visit was blessed. At home, we are also so focused on having “good” weather, but when your livelihood, as well as your life, depends on having adequate precipitation for your crops, the rains here have a completely different connotation and are greeted with a sense of joy rather than the dread we sometimes attach to it at home.

I will have to admit, though, that having been here during the rainy season with some of its more torrential downpours, hasn’t been a pleasant experience and at times has been downright scary. Last year, we had barely made it out of town as the heavy rains fell on our last day and the flooding just outside of Karatu, as bad as it was, was only a harbinger of what we were to see in the village of Mto wa Mbu where there was several feet of water that we had to drive through for several miles, constantly making sure that we were still on the tarmac considering the drainage ditches on either side were several feet deep and would have swallowed our vehicle. Having made it to the airport that day to fly home felt like a real accomplishment.

Within minutes of our arrival this morning, our clinic was already full for the day, and we would only have room to accommodate a few additional patients who would be referred over from the OPD during the course of the day. Patients present to registration in the morning and an attempt is made to triage them to the OPD or to neurology based on their complaints, but unfortunately, that system is less than perfect and isn’t that different than what we see at home. One issue that we have here, which doesn’t exist at home, is that our neurology clinic is subsidized, meaning that patients seen by us will have their visit, medications for a month or two, and any laboratory testing covered for a single payment of 5000 Tanzanian shillings (less than $2 at the current conversion rate). We try to do our best to triage out any patients with MSK (musculoskeletal) complaints as that isn’t our purpose here, but it’s sometimes tough as patients see the option of seeing us as a means having their medications paid for even it’s not a neurologic issue. In addition to the neurologic patients here, we also see the psychiatric patients as there is a significant crossover with the medications that are used, and neurologists receive some training in treating psychiatric disorders during their residency.

One of the teams went to the ward today to follow up on our patient with the ring enhancing lesion that had originally come to FAME last week and who we had initially seen on Monday. Amazingly, the patient looked significantly better neurologically – she was more awake and attentive and could follow some simple commands despite still having a significant aphasia. Though she was still receiving steroids, which can always cover up anything but only reduce edema and are not a long-term solution, they were actually being tapered so, if anything, their effect was being significantly reduced and, despite that, she was improving. That was encouraging as her evaluation for a primary cancer with a CT chest, abdomen, pelvis and good breast exam was negative, and abscess was still on the differential. The decision was made to switch her to a PO antibiotic and discharge her home after about 24 hours as long as she continued to do well. We will plan to have her come back to see us in a month at which time we will also plan to obtain a follow CT scan, hoping that it is improved.

We were all starving by the time lunch rolled around, which is typically between 1:30 and 2:00 pm – everyone working here at FAME (which, by the way, now has over 200 employees and is the largest single employer in the Karatu district) from the housekeeping staff, to the groundskeepers, the nurses, the physicians, and the administration, eat together at lunchtime. I have always been amazed at the amount of food that is served to most of the staff at lunch, typically a very huge heaping plate full, but quickly came to realize that this meal was very likely everyone’s main meal of the day as those at home would very likely be more sparse given the daily struggle with food security that so many of the population here have on a daily basis.

My favorite lunch by far is the rice, beans, mchicha (a dark green vegetable tasting much like a cross between spinach and kale), and pili pili (Tanzanian fresh salsa that is very hot) that is served three days a week, and on the weekends as well. Today’s lunch, Pilau, which is rice cooked in meat broth and chunks of beef, is the favorite of most others that come to FAME, and I’ll have to admit that it is very tasty, though the meat is very tough and chewy. The Pilau is served with shredded cabbage, which is very, very tasty along with the rice and pili pili, though I’m totally fine skipping the meat.

The other meal that is served for lunch is ugali, a stiff porridge made out of maize, that is served with a stew of tiny little fish (tiny sardines that are harvested from the nearby lakes), and mchicha. Thankfully, for those of us who aren’t partial to the fish stew, they will also serve beans with the ugali, and that is typically my choice on those days. I’m pretty adventurous when it comes to things that I’ll eat (Jill claims that I’ve never met a cuisine I didn’t like and is probably true), but I’ve tried the little “fishies” before and they just don’t do it for me.

Meanwhile, the day was quite hot as the afternoon wore on, and though we had planned to visit Teddy’s, our seamstress who makes clothes for the residents each trip, after work, it turned out that she wasn’t available, and we had to reschedule for Friday as we had other plans after work tomorrow. We have been using Teddy now for several years and she has really been incredibly helpful, though it’s also required Annie’s assistance since Teddy speaks only a small amount of English. Ten years ago, we had just picked out a random fabric store to buy the cloth as all of the shops have seamstresses available to make clothes, but there was always something that was lost in translation and despite the clothes coming out pretty good, there was always a bit of concern that something just wouldn’t quite turn out the right way, and trying to return things was really not an option considering the distance.

Without plans to visit Teddy for the evening, we were all now free to relax at the house, though the residents did have the burden of having to enter patient data into our FAME database. We have now kept a database with all the neurology patients since 2015 – demographics that include their tribe and village as well as primary diagnosis, secondary diagnosis, medications prescribed, and even some outcome data regarding out epilepsy patients where we have also kept longitudinal data for specific patients. The database has now become quite large considering that we’re seeing 400 plus patients each visit twice a year, and it’s been work in progress. Without the medical students here (most of them have avoided traveling with us in the spring as they would miss Match Day, when all the medical students nationwide are notified of where they will be doing their residency, which usually involves some post notification festivities), the residents have to take up the slack of the data entry which can be a cumbersome job at times when one is looking forward to a cold beer and some downtime.

We did need to exchange some money in town, though, and I had also wanted to pick up some gin at the liquor store for our wholly medicinal gin and tonics (antimalaria, of course), so Jill, Yombe, and I made the short trip to the currency exchange, which was conveniently right next door to the liquor store. Evenings in Karatu are always entertaining as it seems the entire population of the district are in town shopping and doing business with heat of the day behind us. The sun sets around 6:30 pm now and the temperature begins to cool in the evenings given our mile-high altitude. We came home and settled in for the remainder of the evening to enjoy the quiet solitude of home away from home in the Raynes House.

This morning’s educational lecture was being given by the local health minister concerning vaccinations and really wasn’t for us as it was being given in Swahili and would therefore be of little use for what we are doing here. Meanwhile, our neuro clinic had now been officially announced throughout town meaning that we were quite likely to see many more patients today than we had seen yesterday. It took a few minutes for things to get organized as patients had to first go through registration and had to then be triaged to the general OPD, to other specialty clinics, or the neurology clinic. By the time all was said and done, though, the two benches where our patients sit waiting to be seen were steadily filling up as the morning wore on.

When I had first visited FAME in 2009 while on safari here and having asked to see a Tanzanian medical facility, little did I know the impact that it would have on my life or the complete change in trajectory of my career. Now, 15 years later and some thirty plus trips, I have come to realize all too well how such seemingly inconsequential events direct our lives in ways that we would never have imagined. That is the story, though for nearly every other ex-pat I meet working in Africa as it was typically not their intention to return or to remain here when they first visited. Rather, it was the people and the culture here that drew them by some unknown but irresistible force to change their lives forever. Frank and Susan had come to climb Kilimanjaro with no intention whatsoever to have completely uprooted their lives when Frank became ill with the altitude, landing him in a hospital to recover. The doctor in the hospital told him simply, “we need doctors here much more than in the US,” and took no time at all for them to make the decision that brought them here to Tanzania and to create FAME.

That very first visit of mine, I can clearly recall sitting in a small office with Frank and Dr. Mshana, while they ran neurology cases by me, having never imagined that I’d be sitting in East Africa hearing about patients. It was at the end of that session, when Frank quite innocently asked me if I could come back sometime, that the idea first percolated through my brain, but hadn’t yet taken hold. Returning home, it was the fresh memories of the people here and the true beauty of this country that continued to call to me, and despite several incredibly challenging personal events, I somehow knew that Tanzania and FAME were meant to be a part of life. I returned in the fall of the following year for what would be the first of many visits and for what continues to be a passion of mine. This is such a similar story to that of so many others who have come before and after me that it is not by chance that we have all ended up spending a good portion of our lives in Northern Tanzania.

I spent several years coming on my own to provide neurologic services and education until 2013, when my first trainee accompanied me, and since that time, the program has continued to grow exponentially, thanks to the continued support of my department at Penn and the University’s Center for Global Health. What began as solo trips to FAME and the development of a plan that included neurology clinics at FAME and mobile neurology clinics every six months has now grown into twice annual visits of six weeks each and includes annually up to 16 adult and pediatric neurology residents, several medical students, and additional neurology faculty who decide to accompany our groups. Each year, we will now see upwards of 1000 neurology patients with a vast array of neurological diagnoses, the common of which is now epilepsy, and patients are returning to see us more and more as time goes on.

The education part of FAME’s name (The Foundation for African Medicine and Education) refers in part to the partnership we’ve developed with the Tanzanian caregivers who work at FAME, and like all volunteers who participate in FAME’s programs, we work hand in hand not only with those clinicians working here FAME, but also with other Tanzanian clinicians who come to FAME to volunteer their own time with the chance to learn and also to enhance the likelihood that they will be hired either here or at other sites around the country.

When I first visited FAME, there were perhaps 6 full-time neurologists in this country of over 50 million people and there was no training program for neurologists here in Tanzania. It was clear to me that patients with neurologic disorders would have no chance of seeing a neurologist, but perhaps even more importantly, the clinicians here, both clinical officers and physicians, would never have the opportunity to be taught taking a neurologic history or performing a neurologic examination by a neurologist. To me, that was devastating, and in a recent study published by the group in Zambia led by Deanna Saylor, they surveyed medical students and post graduate trainees throughout Africa regarding their fear of the neurosciences or anything neurological, known as “neurophobia,” finding that a third of the respondents endorsed having “neurophobia,” and that neurology was rated as the most difficult compared to six other medical subspecialties.

With this paucity of neurologists and neurological training in mind, I sought to create a rural training program in which we would bring neurological training to the frontline rather than creating an academic training program at a tertiary institution. By doing this every six months, and in a sustainable fashion, we could familiarize a large group of clinicians (currently around 20) at a very busy center (FAME is currently seeing around 30,000 patients per year) with the neurologic evaluation and management of patients with neurological disease, and combat neurophobia. Even further, we could identify several individuals with an interest in neurology to become our “boots on the ground,” evaluating and treating neurology patients here on their own, as well as having us available for consultation in the US by using WhatsApp whenever necessary. And, in addition to providing the clinical teaching we’re doing at FAME, during each of our sessions, the residents will present several lectures and case-based talks on various neurologic topics to further reinforce the neurologic care we have been providing.

All in all, the plan seems to have been hugely successful in so much as the care that we are providing the population in Northern Tanzania within our catchment area (roughly 2.9 million individuals) has benefited those with neurological illnesses such as epilepsy, headache, stroke, Parkinson’s disease, back pain, and many others. Patients who have had chronic seizures for their entire lives, unable to attend school or hold a job, have suddenly become seizure free and given a life with some promise. It is so unfortunate that these patients were without the care they deserved and was readily available for so long, but it is also incredibly rewarding to see these patients, who are forever grateful, for the care they receive. There is very little else in the world that can so completely restore one’s faith in mankind or to confirm those career choices we’ve made and at times may question.

As expected, the clinic was quite busy for our second day considering the announcements that had been made in town after our arrival. The number of patients we could see in one clinic day very quickly reached its maximum, and patients were told they would have to return the following day to be seen, which thankfully here is not a huge problem for people coming from the Karatu district. We had several inpatient consults in addition to the outpatient population, and in the end, the number patients seen totally nearly thirty.

Each of the residents worked with one of the clinical officers who were volunteering and Dr. Annie, my “boots on the ground” neurologist who has worked with me now for over ten years, worked with one of the groups. Noor, who is accompanying us from Pakistan and is working as an observer, also spent time with one of the groups, though has also had the freedom to roam to the OPD to see other patients at her will. I’m sure she’ll come away from this experience with lots of new neurological expertise but will also have plenty of opportunities to see other patients along the way. Meredith and I shared in the staffing duties, though I spared her from having to staff the many HIE (hypoxic-ischemic encephalopathy) babies that Riley was seeing. In the past, many of these children perished in early childhood, though now with more accessible health care in the region, we are reassuringly seeing them. Though it is certainly a mixed bag, experiencing the love they are given by their families can only help but make one feel warm and fuzzy inside and know that there is hope for the world after all.