March 11, 2016 – Our Friday Clinic at FAME….

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With our initial mobile clinics now over (we still have Rift Valley Children’s Village next week) we are finally able to focus on our work at FAME’s main campus with our advertised days for neurology clinic would begin today. Last week, we were able to spend two days seeing neuro patients in advance and I was very impressed with the number of follow up patients we were seeing which is always a good sign that patients are coming back to see us and are compliant with our therapies.

The morning didn’t exactly start off as planned, though, as FAME had planned for some time to have a workshop today and tomorrow that would include much of the medical staff and included our main interpreters, Sokoine and Angel. We had Dr. Anne to work with as she was assigned to the neuro team, but we were without an additional interpreter for us to run a second room. We already had patients piling up before we were even able to get started and after a bit of hectic negotiating, Susan found a wonderful translator for us from the Rift Valley Children’s Village. Daniel is an 18-year-old young man who has passed all of his national exams and is continuing on in secondary school with the hope of becoming a doctor one day. He arrived by mid morning and though initially quiet, quickly became an essential member of our team.

This always been an issue for us as we continue to rely on FAME’s manpower to staff our clinics and even though our working with a clinical officer or doctor benefits FAME, it is still removing someone from their rotation of work and given the already huge volume of patients they are seeing even without our clinics added on, it is difficult for them. My ultimate wish for our program is to obtain adequate funding to enable us to essentially pay a part of the salary for the clinicians who will work with us during our time here as well as follow patients in between our visits. That will be essential.

Daniel translating with our young girl with cerebellar problems

Daniel translating with our young girl with cerebellar problems

Following Daniel’s arrival, he began to see patients with Jackie and I sat in on the evaluations as Dr. Anne was working with Jess for the day. Being the pediatric neurologist here (and the only one in Tanzania at the time), Jackie’s was trying to see all the children that came. Our first patients was a delightful 11-year-old girl from the Karatu area who was accompanied by her mother who complained that her daughter was having difficulty walking and trouble with her eyes for the last five years or so and that these symptoms were getting worse. Sure enough, she had very definite nystagmus predominately to the right with some torsional component, dysmetria on finger to nose testing and ataxia on gait testing. She was also complaining of some headaches. It was quite clear that she would require a CT scan to rule out an intracranial (and likely posterior fossa) mass before we did anything else. When we discussed this with the mom (they are Iraqw from the Karatu area) she was quite clear that they could not afford a CT scan which would have to be done in Arusha at a cost of at least $200 and it would be for some time before our scanner will be up and running. Since Sokoine, Angel and William, the three individuals who would be the most knowledgeable as to whether we had any extra funds sitting somewhere, were all away at the training session, we would have to wait until next week to discuss her case further with them. We know, though, that it is highly unlikely that they will have it. Having our own CT scanner available in the future will obviously make these types of situations much more manageable. We’re just hopeful we can do something to help out this family before we leave.

Evaluating eye movement abnormalities

Evaluating eye movement abnormalities

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If anyone is interested in helping to fund the CT for this child, please let me know by email. You can go to the FAME website (www.fameafrica.org) and donate online. Just include the message “CT scan for young Neuro patient” and it will be directed appropriately. Thanks.

We continued to have great pediatric cases throughout the day for Jackie and she was the happiest pediatric neurologist in all of East Africa (as well as the only pediatric neurologist in all of East Africa). We had a cute young autistic child whose mother worked at Gibb’s Farm and had been doing all the right things for her up to date. There were some odd sensory integration therapies that mom was paying for, though, that we did not believe were helpful and thought they should discontinue as the cost was high for them. The mother had almost gone home as her daughter was so difficult to manage waiting for us, but luckily she stuck out the wait. I had to actually run after the young girl and practically tackle her outside our offices when we ready to see her. I carried her in as she was wiggling and writhing in my arms which was no small feat. Once in the office we were able to entertain her long enough for Jackie to do her evaluation. The mom needed to be seen as well, though, so their examinations were cut a bit short when the girl decided that enough was enough and it was time for her to leave. She had stuck it out long enough as had we, so we had no issue with her decision.

Our sweet little autistic child

Our sweet little autistic child

She saw a “floppy baby” (which is what I say I don’t evaluate as they can be very complicated) that she felt was very likely a genetic syndrome. The child has been receiving physical therapy as well as some questionable therapies that, again, we weren’t sure we’re benefiting the child and recommended stopping them. A young Massai boy came in with his older brother complaining of abnormal growths around his knees and elbows. What sounded like it might be our second case of neurofibromatosis turned out on examination to be symmetric bony overgrowth of those joints and what looked like a case of rickets. Unfortunately, we had already obtained a family history when we thought it was NF-1 and it turned out that his mother and another brother have the same problem. This threw a wrench into the diagnosis until Jackie, when doing some research while the patient was still around, found out that there is an autosomal dominant form of rickets that involves low phosphate. Unfortunately, that is one of the chemistries we can’t test at the present time. We did find vitamin D in the pharmacy and placed the child on that as it was the only thing we had here to offer.

Evaluating a floppy baby

Evaluating a floppy baby

Jackie and Daniel evaluating our your Maasai with rickets

Jackie and Daniel evaluating our your Maasai with rickets

One of last children of the day was a 15-month-old boy whose aunt had brought him in and had been seen by Verena, the long term pediatrician volunteer here at FAME, earlier in the day. He had been having fevers and was very lethargic, but all of his studies had been negative here as well as when he had been seen at several other locations. We just didn’t like the look of the patient and decided that he needed a lumbar puncture to make sure that he didn’t have a chronic meningitis. His fontanelle was still open which wasn’t normal, but it wasn’t bulging. Though would have loved to have had a CT scan first, it was impossible to send him to Arusha for one and we knew that we couldn’t really send him there for care either. We felt the likelihood of a contraindication was very low and didn’t fit with the fevers so we decided to proceed. The child was incredible strong and wasn’t happy once we positioned him and it was a struggle that went on for perhaps 20 minutes, but Jackie was persistent thankfully and we were able to get clear spinal fluid and an opening pressure that was high normal and likely somewhat elevated by his screaming. I had my arms wrapped around the baby holding him and towards the end of the procedure I had sweat dripping in my eyes which were burning horribly such that I had to squeeze them shut just to continue. It was one of those comical situations that we laughed about after all was well and all of us couldn’t wait to get home and shower. We sent the baby home as the aunt was actually breastfeeding her own baby and the other family member with them was pregnant and looked ready to deliver. We asked them to come back on Monday so we could check him out again.

Our lethargic baby falling asleep standing up prior to his lumbar puncture

Our lethargic baby falling asleep standing up prior to his lumbar puncture

We had planned to go out and eat at Carnivore that night, so it was a much needed excursion, both mentally and physically, to relax with good company along with the very best grilled chicken I have ever tasted, fries, and, of course, a cold beer. It had been a trying day for all. We have clinic again tomorrow and we all were looking forward to it.

March 10, 2016 – The Clinic That Wasn’t….

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We had decided in advance that if it had rained all night we would cancel our final mobile clinic at Upper Kitete as the drive had been so treacherous the day prior. We all had lots of busy work to complete and a free day at FAME to catch up would have been well used by each of us. It had rained some last evening during my birthday party, but overnight it cleared and the roads would be no problem so it was decided that the mobile clinic was on for the day.

Thursday mornings there are nursing educational lectures and Jackie had decided to speak about the bedside assessment and treatment of seizures. This would be an excellent talk for the nurses who are most often the first line for assessing events such as seizures and are also the ones to initiate treatment so it is very necessary that they have these skills. Everyone was very engrossed in the topic which was readily apparent in the questions that were asked during and following the session.

Jackie teaching the nurses about bedside recognition of seizrures.

Jackie teaching the nurses about bedside recognition of seizrures.

We arrived to Upper Kitete by late morning and were immediately confronted by the obvious lack of patients waiting for us. In the past we would arrive to large groups of patients milling around the building and we would be ready for a busy day at the clinic. It’s difficult to tell what the reason is for this change in volume and whether it has to do with missing the clinic last October due to the election or whether it could be related to the rains that have been falling. Sokoine has visited this area on numerous occasions to announce our clinic and that has been sufficient in the past. We had talked about doing only one day each at Kambi ya Simba and Upper Kitete while also scouting out sites for additional neurology clinics and I think it is probably the right time for that. I will likely try to get away for an afternoon next week so we can visit additional sites.

We waited for an over an hour to see if patients would show, but to no avail so decided to head to the overlook for a picnic lunch. As the villages we go to have very limited services such as a market or restaurant to get lunch, we have been stopping on our way out of town to buy an assortment of Tanzanian “take-out.” This includes delicious beef samosas, mandazi (something like a donut or muffin) and vitumbua (I’m not sure if that’s the correct spelling, but they are a deep fried, sweet rice cake). And, of course, the always necessary Fanta drinks. Fanta passion is my favorite here, but there is also Stoney Tangawiezi, which is a very strong ginger ale. We sat at the overlook having lunch for a bit, but then realized there were very dark and ominous clouds looming in the distance and in the direction of our travel. We quickly packed everything up, jumped in the Land Cruiser and began to head back to the main road, glancing back briefly as we passed the clinic to assure ourselves there weren’t any patients waiting for us and were on our way. Shortly after leaving Upper Kitete, though, we ran into a massive rain storm with tons of runoff already flooding the countryside. The runoff was flooding large sections of road and the drainage ditches were all full. As we came to Kambi ya Simba, which is about halfway back to Karatu, though, the rain suddenly stopped as we passed through the storm and the roads were clear. It was as if someone had just turned off the faucet. The rest of the drive back to Karatu was uneventful and we arrived at FAME unscathed from our brush with the flooding.

Unloading the radiology equipment

Unloading the radiology equipment

FAME was having some exciting times after we arrived in that the X-ray equipment that had been donated by GE had arrived after a day delay. This was a huge event as it has been in the planning stage now for probably over a year and the radiology building has been finished for some time. The technical aspects of this project have been overwhelming, but Nancy Allard, FAME’s ICU nurse/architect, has been overseeing things and has been doing an amazing job. The big news for the neuro team, of course, is that the radiology suite is going to include a new 16-slice CT scanner! Up until now, we have had to send all of our CT scans to Arusha, which is 2-1/2 hours away and that’s if the patient can afford the $200+ for the study. Having the ability to do our own CT scans will be revolutionary for us, but with that comes the issue of doing a CT scan just because it’s there and over utilizing the scanner. That all still needs to get worked out and I am planning to make up some algorithms that will help when deciding who needs a CT scan when there are neurological indications.

Pulling the one ton + CT scan out of the truck

Pulling the one ton + CT scan out of the truck

The CT scanner on the flatbed

The CT scanner on the flatbed

Lowering the CT scan

Lowering the CT scan

The CT scanner after still wrapped

The CT scanner after still wrapped

Our first look at the CT scanner

Our first look at the CT scanner

Moving the CT into the radiology suite

Moving the CT into the radiology suite

Positioning the CT scanner

Positioning the CT scanner

In any event, all of the radiology equipment showed up in a large box truck that included the CT scan weighing in at over a ton and everything was boxed with “no tilt” and “no impact” warning labels that would register “red” if any of the pieces were mishandled. They were all meant to be unloaded with a forklift, but there wasn’t one in working order anywhere in Karatu, so they finally found a small crane to use. With some amazing maneuvering and a bit of “Tetris” work, they were able to unload everything, including the CT scanner, and just in time as it began to rain a bit and they needed to get everything inside or undercover so as not to damage the electronics. Finally, everything was moved to its respective resting place and the work of the GE engineers could begin in earnest. One big problem will be the energy requirement for the equipment to operate – though FAME is now attached to “the grid” and has moved on from relying solely on solar power to function, the current generator here is not capable of powering the radiology equipment here during the very frequent power outages that have been plaguing the country. And that’s just one of the many logistical problems that needs to be solved prior to the radiology suite being fully operational. I believe it will only be a matter of time for all of these issues to get worked out and hopefully for our next trip in October we will have access to our own CT scanner that will be just shy of a miracle considering all the hurdles that have been overcome to get to where things are today.

March 9, 2016 – A Birthday To Remember….

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Rather than the light rains of the night before, it rained heavily all night such that we knew the drive would be very treacherous. Given that the roads would be questionable, I had Ema drive again and was very quickly justified in doing so as we were slipping and sliding our way to Upper Kitete. Driving an extended Land Cruiser which is more a less a tank along a slippery, rain soaked mud road with drainage ditches usually run on one if not both sides can be a bit nerve wracking to say the least. The good news was that the road past Kambi ya Simba has been recently improved and has a layer of ground up brick or cinder to improve traction. The improvement worked as planned and allowed us to finish our trek to the tiny village of Upper Kitete sitting on the high escarpment above the Rift Valley, but further to the north.

Jackie, Pauline and Jess en route to Upper Kitete on slippery roads

Jackie, Pauline and Jess en route to Upper Kitete on slippery roads

Where Kambi ya Simba has a very nice clinic or dispensary now, Upper Kitete is somewhat the opposite. There is a small government building that serves as the dispensary and there is a clinical officer and a nurse working there to provide the routine baby care primarily. We work in one office, which is where the nurse does medical work, and a second room that serves as the labor and delivery room with two beds in it. The office is also shared with a colony of bats that live in the attic and can often be heard through a large opening in the ceiling during the day. Their smell is clearly present, though, as there is the strong odor of bat urine in this room and, to a lesser degree, the the labor and delivery room next to it. I had been concerned for some time that I was exposing everyone to rabies by working in these rooms, but have since found out that African bats do not carry it like their North American counterparts do. At least that’s what Frank has told us and I’m pretty certain he wouldn’t joke about such a serious subject.

Jess and Pauline meeting baby Jessica

Jess and Pauline meeting baby Jessica

Often at Upper Kitete, our visit coincides with the well baby visits and it is always so reassuring to see all the beautiful and healthy babies here with their mothers getting weighed and checking in. Today, there were only a few of them coming for visits and Jess ran into one baby named Jessica and was so thrilled to have found someone here with her name. Each baby being weighed usually has it’s own little harness to attach to the scale hanging from the ceiling. It is a very cute process to observe and some of the babies are so calm and could not care less while other babies exercise their lungs until well after being taken down from the scale.

Seeing patients together in the labor and delivery room

Seeing patients together in the labor and delivery room

Anne examining a patient with the help of Jess and Jackie

Anne examining a patient with the help of Jess and Jackie

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Anne performing the Jendrasik maneuver while examine her patient

Our patients today at Upper Kitete were mainly headache patients and we didn’t have the normal number of patients we have seen here. We also didn’t have many of the return patients we had seen a year ago with epilepsy which is a bit concerning and I was hopeful they might come the following day or possibly have been coming to FAME to get their refills of medications which we’ll find out next week during our big clinic there. This has been the difficulty with following patients here in that we can make the diagnoses and treat the patients initially, but if they don’t follow up to refill their medications, all goes for naught. Jess and Jackie worked together after lunch as we had so few patients, but at least there were a some.

Jess and Jackie conquering the mountain at the overlook

Jess and Jackie conquering the mountain at the overlook

The gang at the overlook with the Great Rift Valley in the background

The gang at the overlook with the Great Rift Valley in the background

We finished quite early and decided to make a run to the overlook which is our favorite spot at Upper Kitete. It overlooks the entire Rift Valley from Lake Manyara on one side and far up the Lake Natron road on the other. There is so much history in this valley from pre-historic times to the present and there are many ancient cultures that lived here and long ago vanished. It is such a relaxing place for me as we watch the large birds of prey soaring on endless up drafts in search of prey. There are small dots of white on the valley floor 2000 feet below that are herds of cattle and goats as the Maasai graze their livestock and I can only imagine the huge herds of wild animals that use the roam this land. Some of them are still present as I have seen zebra, giraffe and some wildebeest along this valley when I have driven up to Lake Natron in the past, but we can’t spot them today from these heights. There are homes along the rift with perhaps one of the best views on this planet, but it is unclear is that is really appreciated here as it would be in the west. Prime real estate here has to do much more with fertile land for planting and away from any flooding. As we sit here on the edge of the world I think we are the luckiest people on the earth at this moment.

We left for home after the overlook and the road had dried significantly, but not completely. It was early so we were all looking forward to spending some downtime in the afternoon at FAME. I have spent my last three birthdays here in Africa and I had been very successful at maintaining a low profile with very few people realizing it. This year was not to be the case. When we arrived back to FAME I was told that I should be ready to go somewhere at 6:30pm so I obviously presumed that our little group was going somewhere for dinner to celebrate my birthday. That was not to be the case. As we arrived at the Highview Lodge nearby there was already a large number of friends including Pam, our previous volunteer coordinator form several years ago who I had not seen for some time. Frank and Susan, of course, Joyce, Verena, along with many of the staff from FAME. In the end, I think there were perhaps 30 people assembled and we sat outside having drinks at a very long table watching an amazing light show in the Ngorongoro Highlands with a lightening storm approaching.

The entire gang at dinner

The entire gang at dinner

After some time we went inside for dinner and all sat at a very long table and more people continued to show up as the evening went on. Dinner was a delicious buffet and I should have taken the hint when Jess continued to pass on desert. Suddenly, all the lights went out and we heard the entire kitchen staff singing and as they came through the dining area they were all dancing behind a birthday cake one of them was carrying over their head. It at first seemed like they not have known which table was celebrating, but it became quite clear that they were first dancing to every table before they set the cake down. They finally made it to our table and stopped in front of me but continued to sing and dance for some time before they put the cake down. It went on forever it seemed. I finally blew out the candles while they continued to sing and went on for some time more before they finally retired to the kitchen. It was quiet for only a brief time, though, and we heard them singing again and out they came, dancing through the tables and back in front of me. By this time I had begun to cut the cake and pass out pieces when Pam told me that it is tradition for me to feed each one of the dancers a small piece of cake with a toothpick. I cut up a bunch of small, bite-sized pieces of cake and proceeded to feed each one of them a piece of cake as they continued to sing and dance.

Me, Jess and Nick

Me, Jess and Nick

Enjoying the entertainment

Enjoying the entertainment

My birthday cake

My birthday cake

Unwrapping my birthday present

Unwrapping my birthday present

Denis and me with my portrait

Denis and me with my portrait

Feeding the staff their pieces of cake

Feeding the staff their pieces of cake

Besides the party, I also received a wonderful gift of a portrait painted by Denis who is one of the workers at the Lilac Cafe, the small cafe here at FAME. He does amazing work that is displayed and for sale in the cafe, but the portrait is really over the top. Most of his work is Tinga style, but this is real life and very accurate. It will have a place in my office or my apartment as soon as I’m home.

Dancing with the staff

Dancing with the staff

Dancing with the staff

Dancing with the staff

Dancing the Charanga

Dancing the Charanga

Apparently, the fun wasn’t over yet as they next urged me to come dance with them. Anyone who knows me well is quite aware of what it takes to get me to dance, but I wasn’t about to disappoint anyone, so I got out from behind the table and began to dance Charanga style with them. When I showed Leonard the photos later he began to laugh so hard he couldn’t stop and when he finally did, he said he was pretty impressed. As I said, I didn’t want to disappoint anyone and certainly didn’t want to give anyone the impression I was a lightweight. It was a totally amazing night and a birthday I will never forget. It was so great to have so many people come out for my party and a real statement as to the family that FAME is here. Everyone is here because the want to be and everyone is here because of the good that comes from FAME. I couldn’t imagine anywhere I would have rather been that night.

Day Two in Kambi ya Simba

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The lightening and thunder began well in advanceb and the rain started around bedtime, but it was a light rain that fell slowly throughout the night. It was enough of a rain, though, that I decided to have Ema drive for me as the roads can become very treacherous here this time of year and there is no automobile club to come to the rescue. Four years ago my Land Rover slid off the road on the way to clinic and that memory remains fresh in my brain. Much of life here revolves around the weather – travel is clearly dependent on whether the roads are passable and volume at our clinics will depend on whether patients can get there by walking or vehicle. Planting and harvesting are also times that will cause our clinic volume to be low.

On Tuesdays we have a doctors lecture and it was decided that Jess would do a lecture on dizziness, which is always a frustrating subject for neurologists. It is not that the dizzy patient is complicated, but rather that there is really no specific definition for “dizzy” so the group of patients is very heterogeneous. There are patients that are lightheaded, weak, vertiginous (spinning), or fuzzy headed. The first job is to determine what they are complaining about. Jess covered primarily the neurologic causes of vertigo and how to break them down into central (brain) or peripheral (inner ear and nerve) causes. She did an excellent job for the doctors and gave them a good algorithm to cover the dizzy patient.

Jess lecturing on the dizzy patient

Jess lecturing on the dizzy patient

After her lecture was morning report and then we left for mobile clinic. The drive to Kambi ya Simba for our second day of clinic there was uneventful, but the rains likely have kept some patients away. We ended up seeing only about seven or eight patients that day which is far lower than our average that we have seen there in the past. It’s always a bit of a dilemma as to whether it is worth our while to travel that distance for so few patients, but we never know how many will show and the patients that are seen are often returns. By traveling to the villages, though, people become aware of what FAME has to offer and it is certainly possible for them to get there if needed.

Our first patient of the day was a woman who first described two episodes of prolonged loss of consciousness, but it was readily apparent that she was depressed and the episodes weren’t seizures. She had actually had the episodes for some time and had been depressed. Her care was a bit tricky for a number reasons and in the end we placed her on fluoxetine, which is available here, but with the proviso that she come to FAME in two weeks to check in and make sure she was doing well.

A worried mother with granddaughter on her back and daughter sitting next to her

A worried mother with granddaughter on her back and daughter sitting next to her

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Our other patients were afflicted with the more common disorders including one gentleman who had had a stroke in the distant pass and had been placed on aspirin in the past, but was no longer taking it as he had run of the supply given to him. His blood pressure was also very high and he wasn’t on any antihypertensive medications. We placed him on the aspirin, but asked him to come to FAME for further testing of his cholesterol and kidney function before starting him on any medications. We don’t have access to these tests in the field here. Both Jess and Jackie stayed busy seeing the patients with Dr. Anne and Sokoine, but we finished early and left for home.

A patient waiting for clinic

A patient waiting for clinic

Arriving back to Karatu during the afternoon is always a treat as it gives us time to explore the town a bit. Both Jess and Jackie had been interested in having a dress made from their lovely conga cloth here so after dropping everyone else off in town, I took them to the tailors shop that I have gone for the last several years. Nick and I walked to the vegetable market while Anne helped the girls describe what dress and skirt styles they wanted. They found some wonderful cloth to use for the clothing and their dresses will be very inexpensive and custom made.

It was home early for dinner and we all spent time chatting before an early bedtime after a long day and tiring day.

Our first mobile clinic in a year….

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As you may recall, because of the elections last October we were unable to travel to the villages for our mobile neurology clinics. The reason was two-fold. Though there was no violence, there was some unrest and demonstrations that were concerning enough to avoid so as not to be caught up in them. The other was that we were concerned we might become part of the propaganda machine going on during the election if someone tried to claim that we were being sent by the government or even the opposition party. It was a lose to our program not to have made this available, but in the end a necessary decision for everyone’s safety and for FAME.

Our first stop for mobile clinic was Kambi ya Simba, a small village in the Mbulumbulu division of Karatu district where I began my clinics five years ago. We used to see patients in the middle of an open field sitting at a desk, but they now have a nice infirmary set up there with offices that can use for our evaluations. Sokoine was working as our coordinator so he worked to triage patients and to determine that they were clearly neurology patients as we try our best not to do general medical care while we are on mobile as the clinic is being supported by neurology funds. We ended up seeing 15 patients, the number being a bit low as it was also market day in Karatu which meant that many people were in town so we’re hoping there will be additional patients tomorrow.

Jess and Angel getting a history having to use an Iraqw translator to Swahili

Jess and Angel getting a history having to use an Iraqw translator to Swahili

An Iraqw Elder

An Iraqw Elder

Jackie and Dr. Anne evaluating a pediatric patient

Jackie and Dr. Anne evaluating a pediatric patient

Our patients spanned the normal spectrum that we see in the villages. We had headaches (several of which were classic migraines), back and neck pain, generalized body pain (know here as GBM – kind of freaked me out when I first saw it written on a chart), and epilepsy. Non-epileptic events are very common here which always makes things interesting considering the difficulty that is often present in obtaining an accurate history. Overcoming this can be a real challenge and is obviously critical in caring for patients. We had a number of children for Jackie to see which was good, though several of them were new cerebral palsy children who we could only refer to Monduli which a government rehab facility near Arusha. She was able to spend extra time with the moms though, going through some of the necessary exercises to help with their trunk tone, etc.

Jackie, the pediatrician

Jackie, the pediatrician

Jess and Angel obtaining a history with Pauline observing

Jess and Angel obtaining a history with Pauline observing

A young cerebral Palsy patient with Jackie

A young cerebral Palsy patient with Jackie

Jess and Angel with a patient

Jess and Angel with a patient

Jackie and Dr. Anne

Jackie and Dr. Anne

Jackie doing an eye exam

Jackie doing an eye exam

Dr. Anne performing the neuro exam under Jackie's tutelage

Dr. Anne performing the neuro exam under Jackie’s tutelage

We returned to Karatu early enough to visit the Maasai market which happens there twice a month and which I’ve never visited before. It is a massive outdoor market where they sell lots of goods, but it is mostly clothing that is placed in large piles by each vendor. Then everyone sits around the piles and sifts through them with the intent to find something they like and which fits. The clothes arrive in bales that are shipped in and I have to imagine originated in the United States based on the appearance of most of the clothes. I hadn’t really researched their origin before, but one look on the Internet quickly answered my question along with the controversy that has been created by the practice. The clothes are all from charities in the west that have been donated, but were either unsold or unwanted and they are then shipped predominantly to Africa. Unfortunately, these clothes are not then donated to the impoverished, but are sold in large markets such as the Maasai markets here in Tanzania and others throughout Africa. Based on the amount of clothing present, this would produce a very significant profit to someone along the way. This practice apparently began in the 1980s when before the clothes were donated to the poor. The textiles industries in many countries have been significantly harmed by the practice.

Jess and Jackie checking out sizes

Jess and Jackie checking out sizes

Pauline, Jackie, Jess and Anne shopping for clothes

Pauline, Jackie, Jess and Anne shopping for clothes

The vendor for these clothes

The vendor for these clothes

A view of the Maasai market

A view of the Maasai market

After the Maasai market, we all ran home to shower and was off all of the dust and sweat from the day and make ourselves ready for a visit with Daniel Tewa and his family. I’ve mentioned Daniel in the past, but he is a friend who I met while on our original safari and we have remained close ever since. He has graciously entered us with authentic Tanzanian dinners and long discussions of Tanzanian history and politics. He has an amazing memory for details and it is always great to hear what he to say about a subject as it is always guaranteed to be enlightening. He and his family are incredibly gracious and we were again presented with a wonderful traditional Tanzanian meal including Chagga stew of bananas and meat. Jess had a 7:30am lecture to give so we had to excuse ourselves by 9:30pm otherwise I am certain we could have stayed until midnight with the same intensity of discussion and continued hospitality. These are just some of the reasons I continue to return to Tanzania year after year and why everyone who I introduce to this country and its people falls in love with this small part of Africa.

The Green Hills of Africa….

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The last day of our safari began with a gorgeous sunrise viewed from our breakfast table nestled above Lake Ndutu. Fresh coffee, juice, toast, pancakes and a Spanish omelette made up the menu as the clouds on the horizon brightened with the rising sun that eventually declared a new day. Another morning on the savanna of the Serengeti, each one bringing the promise of a totally new experience. We said goodbye to the camp staff after breakfast as we would not be returning and ventured out on the open plains.

Our view from camp. Lake Ndutu in the background

Our view from camp. Lake Ndutu in the background

It was getting warm already by 8am and the sky was completely clear without a cloud to be seen except far on the horizon. We visited our friendly leopard spot again only to find him not home and in the grass somewhere between his trees. There were vehicles waiting, but since we had seen him several times before we decided to move on. We wound through semi-dry river beds between the marshes for some time and then onto the hilltops looking for animals and eventually came upon a wonderful pride of lions consisting of a male in his prime, several females, an adolescent and younger juvenile. The male was originally across the creek bed from the females, but as we drove by him he seemed irritated as he got up and slowly meandered to the creek to take a long drink, then across it and over to join the females of his group. He had a magnificent mane and appeared very healthy and well fed. We sat and watched them for some time, but as is usually the case, this pride was having their midday nap. And since lions can sleep for up to 20 hours a day you can be pretty certain that unless they’re on the move when you spot them, they will likely remain sleeping for some time.

Simba!

Simba!

Enjoying the breeze

Enjoying the breeze

A Gorgeous Mane!

A Gorgeous Mane!

I was excited today that our drive home was going to be via a different route than is normally taken. Instead of taking the Oldupai road to the crater and out of the conservation area, we would traveling on the Endolen road which runs far to the east and through a completely different topography. I had never been on this route before and Yusef, our guide was going this way as he had heard that part of the migration was still in this area so there should be good animal viewing. There were very large herds of wildebeest and zebra occupying much of the view as we drove along the edge of the savanna with a smattering of Thompson and Grants gazelles. We eventually came upon a beautiful cheetah that Yusef had spotted sitting under a tree. They are such superb animals and so graceful in their appearance compared to the lion and even the leopard. The cheetah is built for speed and their power resides in their grace and endurance. The lion is powerful for the short pursuit, but beyond that is unable to sustain the attack. It will give up before 200m of pursuit. The leopard is powerful in its brute strength along with its stealth. It pounces for the kill and then relies on that brute strength to carry its prey high into the tree for storage.

Made in the shade!

Made in the shade!

A cheetah along the Endolen road

A cheetah along the Endolen road

The Green Hills of Africa reference relates to our drive back through via the Endolen road. I hadn’t driven through that area on any my previous adventures, but I will be sure to visit the area again in the future. For anyone traveling to Africa, though, be sure to read this Hemingway short non-fiction novel that describes a hunting trip he took in the 1930s with his wife to Lake Manyara. It is a wonderfully descriptive story as only Hemingway can achieve and though I am certainly not a fan of hunting rhinos, he brings the true feel of the African safari to his pages.

The Endolen Road

The Endolen Road

The Endolen road from Lake Ndutu begins in the Serengeti savanna and slowly rises to climb the heights of the Ngorongoro Crater rim. As it does, the vegetation becomes more and more lush and the herds of Maasai cattle, goats and sheep more numerous. The road winds through mountain valleys and over hills covered by flat-topped acacia trees that are so synonymous with Africa. We climb and climb until we’re almost in the clouds with views in all directions including the dry lakebed of Lake Eyasi where the Hadza and the Datoga reside.

Up to the Ngorongoro Crater rim

Up to the Ngorongoro Crater rim

We pass Endolen Hospital that is supported by the Lutheran Church and dozens of Maasai bomas and small villages. The land here supports huge numbers of Maasai with their livestock and communities. Small children scream and whistle as they run towards the road waiving at us as we drive by waving back. It is a truly peaceful region that is mostly untouched by the outside world and the people here are quite happy. They are only poor in the eyes of those who cannot understand their existence. But it is quite clear driving through these magnificent valleys and hills that life here is as it should be for the Maasai and there is a message to take away for us. They have so little, yet they have so much and perhaps this is what we need to learn from them.

The Big Cats of Ndutu…

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Our first full day at Lake Ndutu started very early with a game drive beginning in the dark. The earliest you can begin a drive in the conservation area is 6am which is well before sunrise and really quite chilly. It’s coffee or tea and we’re on our way with plans to return to camp for breakfast around 8:30am. We drove out to see what we could find in the big marsh, but saw little in the way of animals. Certainly no prey for the lions or cheetah, but on the way ran across some bat-eared foxes resting just outside of their burrows. They are nocturnal animals and the time to see them is at sunrise after they’ve been active for the night. They are small little fluff balls that are certainly cute enough to want to exit the vehicle and pet them, but restrained ourselves and moved on.

A bat-eared fox checking out the world from the safety of its burrow

A bat-eared fox checking out the world from the safety of its burrow

A bat-eared fox on top of its burrow

A bat-eared fox on top of its burrow

Three lionesses out for a morning stroll were the next animals to catch our attention. They were on the move, but with little prey in the area it was very unlikely they would find anything to attack any time soon so we eventually moved on. They were very reminiscent of the group of four we encountered last March and watched for the entire morning until they finally attacked a small group of Zebra and found the baby could run as fast as the others sealing it’s fate as lunch for the foursome. These three looked less intent on hunting so we left them and made our way back to camp for a delicious camp breakfast of toast, pancakes (really crepes), eggs to order and fruit. All with a lovely view of Lake Ndutu as the sun continued to rise in the sky and the day grew warm.

Two of the three sisters we followed

Two of the three sisters we followed

A lion in the magic hour

A lion in the magic hour

After breakfast we immediately went back out on a drive and decided to visit the leopard tree. There were several vehicles already there and as we arrived it was immediately apparent that the leopard was feasting on its kill from the day before high up in the tree. Shortly after our arrival, though, the leopard decided to descend the tree and ended up in the tall grass between several trees. It’s amazing how such an animal can hide itself in the tall grass in immediate view of a number of safari vehicles without detection. We strained our eyes for some time before finally spotting the orange coloration of this magnificent cat as it moved towards another tree, climbed the trunk and found itself another perch on which to rest after having gorged itself on the baby wildebeest. After satisfying ourselves that the leopard would not be moving in the near future, we moved on in search of more animals.

The lounging leopard after feeding

The lounging leopard after feeding

We drove for what seemed forever to the west and towards the Serengeti proper with only a smattering of animals along the way until we ran across a small lion pride of females lying beside a watering hole in the heat of the day. They was clearly a benefit to lying on the downwind side of the water with its evaporative cooling during the midday heat and sun.

A pride of lions midday at the watering hole

A pride of lions midday at the watering hole

Big cat snuggling

Big cat snuggling

We traveled back to the marsh areas to stop and have lunch in the shade of an Acacia tree. Our lunch boxes were full of small things from camp including a piece of chicken, a piece of corn fritter, a pancake, a mayonnaise and onion sandwich, yoghurt, fruit drink, two small pieces of cake. You definitely work up an appetite on safari so I know that at least my lunch box was great appreciated and emptied. Immediately after lunch we ran across another small pride of lions without their male, but with several adolescents. Since it was midday, this pride was also sleeping in the shade of an acacia tree and was actually being observed by wildlife experts with a video camera to document their movements.

We drove around the rest of the afternoon in search of cats hunting but only managed to turn up the three females we had seen earlier in the day. They were returning from somewhere, but didn’t look to be in much of a hurry and it was doubtful they would be doing much more for the rest of the evening. Earlier we had driven over to Lake Masek, but hadn’t turned up much there to see other than a small wildebeest and zebra herd, so had returned to the marshes to see what else we could find.

Getting comfortable at the end of the day

Getting comfortable at the end of the day

A perfect spot on the limb to sleep

A perfect spot on the limb to sleep

One of the three sisters later in the evening

One of the three sisters later in the evening

We returned to camp early enough to relax a bit and shower before dinner. We sat around the campfire, or the “bush TV” as they refer to it here, with a view of Lake Ndutu and its wonderful flamingoes, and not a care in the world. “Life is good” is an understatement and we all realize how lucky we are to be here at this moment.

And in the beginning….

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Despite having been on many, many safaris during my time in Tanzanina, there is no question that it is one of the highlights of every trip here. Most often I am the safari guide for our day safaris, but every so often we are able to get away for more than one day to a more distant area and for these I prefer to have a driver. This enables me to do some photography which is clearly what I love and also allows those with me to have the full experience of a guided safari because, face It, safari work is not my day job.

We awakened well before sunrise for our trip to Lake Ndutu in the Southern Serengeti. Nick, Jess, Jackie, Pauline and myself were traveling there in hope of seeing part of the great migration – the circular route of the wildebeest and zebra following the grasses through the Serengeti and the Masai Mara, calving in February, March in the north and then moving to the south. I have been to the Ndutu region on several of my trips before including last March when we were fortunate enough to witness a lion kill which may be a daily occurrence, but is still not seen by every visitor to this region. Four years ago I witnessed a cheetah kill, which is something rare to witness on the other hand.

For the start of our trip we would be passing by Oldupai Gorge, the Mecca for anyone with an interest in anthropology. It just so happened that Jackie (who has an anthropology degree from Brown), Pauline (who has a keen interest and is currently reading “Sapien”) and myself (with essentially a physical anthropology minor) were very much looking forward to visiting this incredibly important site. I had met the director of Oldupai Gorge, John Paresso, last year and he had invited me to visit some time so I contacted him about stopping by to say hello. We arrived slightly behind schedule, but after meeting with John he offered to take us down into the gorge for a private tour of some of the sites and at the end of the visit, to stop by the Leaky Camp which is currently being preserved with plans to make a living museum there. John gave us an introduction to the site and it’s history and after a short visit to the museum, we were descending into the gorge to do some exploring.

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We first visited the site where Mary Leaky had found Zinjanthropus, or australopithicus bosei, a hominid that was 1.6 million years old. This was a discovery of monumental importance at the time, and still is to this day. There is a memorial that stands on the site and there are lots of fossilized and non-fossilized bones there from ancient animals of all sorts. The hominid fossils are, of course, all in museums.

Are next visit was a site called “shifting sands.” I had no idea what we were in for when we drove off towards the east and well away from the gorge, but it was worth the drive of several kilometers past Maasai bomas and herds of goats and sheep. As we continued to drive along wondering exactly what we were all looking for, we began to notice a large dome of black sand appearing in front of us. It looked somewhat alien and the closer we came it was clear that it was moving. The shifting sands of Oldupai is a collection of fine volcanic dust or sand that was ejected from an eruption of Oldonoi Lengai very long ago and has continued to move 17 meters a year in one direction with the wind. The surface of the dune appears to be in constant motion as the wind blows over it’s surface depositing the grains of sand to the far side. It is really an amazing sight to see.

Driving up to the shifting sands

Driving up to the shifting sands

A walk around the sands with John

A walk around the sands with John

The black volcanic sand of shifting sands

The black volcanic sand of shifting sands

Our next stop was a special vantage point that John wanted to share with us that he says only 2% of the guests to the gorge get to see. It was well to the north and afforded a view both up and down the gorge. At the bottom, the river was full due to the season and the Maasai were watering their stock as they have done for many years. It was easy to imagine australopithicus or homo habilis roaming the countryside in search of ancient game. It seemed very much as it was in the beginning.

Jess and Nick at the overlook

Jess and Nick at the overlook

We moved on from our wonderful lookout for our final stop at Oldupai and reached the Leaky’s camp after a short drive. The camp looks as it was when Mary still lived here and the buildings are mostly unchanged from that time. Mary’s house is still present – a round sheet metal home that would never pass in today’s world, but yet served her well for many years that she spent here. There were similar buildings that served as scientist housing as well as stone buildings that were used as storerooms. They are in the process of constructing thatched roofs over the buildings to protect them. John took us in the storeroom that has been used for fossils and it was like walking back in time, literally. One interesting piece was a 2 million year old elephant tusk that was just sitting on the shelf next to a cast of an elephant or mammoth tooth. All very amazing and to imagine that we were there, having read and studied about Oldupai and the Leakys, gave all of us a sense of awe that is not often felt.

Mary Leaky's Hut with new construction for a roof to protect it

Mary Leaky’s Hut with new construction for a roof to protect it

Two-million year old tusk and cast of elephant or mammoth molar

Two-million year old tusk and cast of elephant or mammoth molar

We all left Oldupai Gorge with a sense of huge accomplishment having seen and felt what we had and were on our way now to Lake Ndutu. We arrived to our camp later than expected and a bit weary from the travel, but after a nice hot lunch we were all revived and ready for a game drive. The drives in Ndutu proper mostly revolve around several locations that not only include the lake, but also a system of marshes and streams . We drove towards the little marsh and immediately spotted a number of vehicles parked near some trees in the distance. That typically only means one thing – a big cat. On this occasion, everyone was looking up which meant that were about to see a leopard. Just before we reached the cars, though, we saw something climb out of the tree. The leopard was in the tall grass between the vehicles, but had left its prey – a baby wildebeest – hanging in the highest tree limbs, well away from any intruders or would-be thieves. We waited for a very long time and eventually the leopard climbed into another tree and was cooperative enough to climb into the limbs were we could see it. The leopard is the most elusive of the big cats and many go without seeing one after many safaris. We watched this gorgeous animal for some time until we had to head back to camp for dinner as it was dark outside and ready to return.

The elusive leopard climbing its tree

The elusive leopard climbing its tree

A Lounging Leopard

A Lounging Leopard

 

On our way, though, we ran into a cheetah that was laying quietly in the middle of a dry marshy area. It was almost as if it had been waiting for us. So we finished up our game drive having see two of the big cats and one being the rarest in a very short period of time. We arrived back at camp in the dark and after having a wonderful dinner, all went to sleep having had a very fulfilling day that encompassed the beginning of mankind along with the amazing Tanzanian wildlife that seemed to fit so well together.

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The Golden Eyes of Cheetah

The Golden Eyes of Cheetah

A place to return….

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Returning to FAME each time is like a homecoming for me and traveling companions are greeted and accepted by the community here as if they were family from the moment they arrive. That is just one of the things that makes this place so special. We arrived on Tuesday late afternoon after our somewhat delayed journey from Arusha. I guess it shouldn’t be that hard to describe what it’s like for me to drive up the escarpment of the Great Rift Valley and closer to Karatu. It is more than my second home. When I have brand new volunteers, though, it is an extra special treat. March here is lush and green and the hills are vibrant with color. We drive along the Rhotia Valley towards FAME and the farms are alive with activity and planting. There is a peace in the air that is both calming and reassuring as if life has slowed to a different pace in the few kilometers we have traveled. This is the Africa that I know and love.

I drop off Jess, Jackie and Nick with Pauline for their introduction to FAME and a tour of the facility while I make my rounds to the various building to greet everyone on my return. It has taken me some time, but I now know most everyone by name which is quite impressive for me. I give each and everyone a big hug on greeting them and it is clear they are so happy to see me on my return. The neurology clinic will soon be in full swing as the FAME outreach team has been scouring the countryside making everyone aware of our arrival.

Our Wednesday began with bang as we had lots of patients lined up to see us and I quickly had Jess and Jackie working seeing patients with Sokoine (our interpreter) and Dr. Anne (our clinical officer). It was quickly apparent that we had a tremendous number of return patients and a far greater percentage than we have had in the past. This was a great sign as we have in the past seen 2/3 new patients and 1/3 returns, but it may be more even now or even more returns today. This is the transition that needs to occur and seems to have happened with our repeated visits.

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Having Jackie here has already made a difference as we have plenty of kids to see and some of the syndromes are beyond Jess and Me and in need of a real pediatric neurologist. She saw two kids with new diagnoses of infantile spasms and several others that wold have been tough for us to put together so it was great to have her. Meanwhile, we had the normal smattering of patients with epilepsy, headache, movement disorder and, yes, the occasional psychogenic symptoms. Jackie was able to see two muscular dystrophy brothers that we’ve seen in the past which was great for her.

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The day was busy as we saw 24 patients for the day which was quite good considering that Jess and Jackie were totally new to this. They were both very excited about how things went and the overall experience which is a totally amazing one for so many reasons. But it all comes down to one’s pure clinical skills as we most often have very little history to rely on (no EMR) other than what we glean from the patient through a translator (and sometimes two) and then our neurological examination. You must rely on your instincts and everything you’ve learned over the years.

We had dinner on Joyce’s veranda last night and the stars were absolutely amazing in the clear evening hours. Somewhere to the north a thunderhead amassed with an eventual show of lightening in the distance that only added to the magic. Some light rains began in the early morning hours that lightly brushed our metal roof and ended shortly after sunrise. A short walk to the clinic along a gentle path and our new day had begun. The earlier rains meant that clinic would start slow, but it picked up before lunch with many more patients to be seen again. Children and adults, some puzzles that will require more thought, but all that we hope to help in some way or another.

We leave early tomorrow morning on safari to the Southern Serengeti and Lake Ndutu to view the Great Migration. It should be very exciting and we’re all looking forward to the adventure.

Africa Time….

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Monday, February 29, our first full day in Tanzania began with a very late morning for most as everyone was exhausted from our day plus travel over the weekend and our late arrival to the Tembas. Having a day to relax and catch up is crucial as we have plenty of work ahead of us and have to rebuild our strength. Having gotten up early I went to the fruit market with Leonard and Pendo to buy supplies for our breakfast – the tastiest of mangoes, pineapple, watermelon and the small, sweet bananas that grow on the slopes of Kilimanjaro. Life is good. A breakfast of fruit, pancakes with Maasai honey from Oldupai Gorge that must have some magical powers, or at the very least it sure tasted like it did. And the African tea that I dream of before I return each visit and Danielle loves so much – ginger and cardamom and everything else good in this world. Simply said, it’s to die for in my humble opinion.

I had some errands to run with Pendo – the immigration office and the Airtel store – after lunch while Jackie and Nick took a walk in the neighborhood and Jess slept trying to fight off a cold she picked up flying here. I was happy later to see that our walkers had found their way home as I realized it could have been an issue considering they really had no idea of where anything was and didn’t have a phone to call if they had run into a problem. At least the Airtel store was a success for my SIM cards as the immigration office was a bust to have my resident permit endorsed into my passport as I did not have the original permit with me. Oh, another visit on another day…or not.

After a wonderful lunch with Pendo, we took our obligatory trip to the Maasai Market, an institution in Arusha and where there is shopping and deals galore. There are easily over 100 stalls, each carrying pretty much the same merchandise with only subtle variations. The prices, of course, are all variable and negotiable. It would be considered rude to pay the first price quoted and so it is very important to know what you want to pay before you begin to bargain. It is part of the culture here. We did well to find some things we were interested in, all very traditional and unique to Tanzania, and will return home with these treasures in our emptied duffels that currently contain all the medical supplies being brought to FAME.

Me, Naema, Jackie, Nick, Jess, Pendo, Gabriella and Leonard before our departure to Karatu

Me, Naema, Jackie, Nick, Jess, Pendo, Gabriella and Leonard before our departure to Karatu

Tuesday, March 1, was our day to depart Arusha and travel to Karatu and FAME. I had hoped to leave very early, mainly to get there by lunchtime so we could relax and move in the afternoon ready to work the following day. Leonard’s Land Cruiser, our means of transportation while here in-country, had been in the process of being repaired over the last year and was so close to being ready, but still needed a few last things to bring it up to snuff for our use. I drove off with Leonard at around 8:30am to work on the vehicle – it needed new shocks for the rear, an alignment, a few tires changed, and some electrical work. What was supposed to have taken and hour or so ended up being close to three hours and delayed our departure until well after noontime. When I returned home to the others to let them know I was back, I summed up the situation by merely saying “Africa Time.” This is a universally understood and recognized term that is used here to refer to the fact that things get done when they get done and the world still continues to revolve around the very same axis it did before. No catastrophe, no harm, no foul. It’s just the way it is here and has always been. Time moves at a different pace and we are not the center of the universe. It has been that way since the dawn of the world which is quite evident as we travel through the Great RIft Valley and the birthplace of humanity. Yet we are but a small and often insignificant part of this great creation.