It was Friday and our final mobile clinic of the Spring 2017 trip to FAME. I’ve written so many times about Rift Valley Children’s Village, but it’s very difficult to say too much about this amazing place. RVCV is not an orphanage, but rather a home to approximately 100 children of all ages were have been orphaned or unable to be cared for by their family and have been adopted by Mama India and her business parter, Peter. They grow up at RVCV which is their home and they go to school at the primary school that is next door. Eventually, they have the opportunity to go to collage and most do.

The reason that FAME is in Karatu is that Frank and Susan met India when they first came here with the idea of opening up a facility and India convinced them that Karatu would be the perfect place and that would also allow them to provide care for her children and the surrounding community which she would subsidize as she realized that her children would be healthier if the local community were healthy. FAME continued to provide these regular medical clinics at RVCV until very recently and now patients are sent to FAME as it is about a 45 minute drive to the Children’s Village from FAME. We have been tagging along with the FAME clinic over the past, but today we would be going by ourselves, though we would have a clinical officer with us to help with medical decisions other than neurology.

The drive to RVCV is absolutely spectacular (as are all of our drives anywhere around here) as you leave the tarmac just below the Ngorongoro Gate and travel along a slight ridge in between fields of green that go on forever. There is no sign indicating that the road leads to our destination, though there is one for the Crater Forest Camp nearby along with a sign stating “rough road,” typically ominous here considering that other than the tarmac, all the roads are rough. There are several lodges visible along the way just before we begin descending into several valleys and eventually climb up into a coffee plantation that we travel through a short distance until we reach the primary school and, behind it, Rift Valley Children’s Village where we’ll spend our day. There are always patients waiting for us sitting in front of the offices, though today, since we are here by ourselves rather than with the FAME general medicine clinic, they are all for us. There have been times when it’s been a bit overwhelming, though today are list is manageable. We unpack the medications and supplies from the vehicle and immediately get to work creating a list and getting rooms set up.

Considering one room has a bunch of stuffed animals, that will be Nan’s as she has been seeing children whenever possible. I should have mentioned previously, that for all of our mobile clinics, we keep separate records from FAME as it’s impossible for us to know who will be coming so we don’t have access to the FAME charts. Even when we have some form of an EMR at FAME, there is no cell service at Upper Kitete and the bandwidth on the cells is not great. We keep notebooks of all of our mobile clinics with past records so when patients return we can find their previous clinic notes. Not ideal, but it works 90% percent of the time or more. RVCV, on the other hand, keeps meticulous charts for all their children in addition to the patients who come from the town, so it is very easy for us to find our notes, though we still make copies of all our handwritten notes that we bring back with us and keep them in a binding the same as the other clinics.

RVCV also has a wonderful nurse, Gretchen, who has been there now for 18 months and is quite familiar with all of the patients including those from the local village next door, especially the children. She is able to fill us in on lots of back information that is not always readily available in the chart nor do the patients always offer it to us considering it is often very sensitive, dealing with all types of abuse. As such, we are often doing a fair amount of counseling here and, unfortunately, much with children who are quite commonly the victims of this abuse. Some of the stories are quite gut wrenching and, though there are authorities to deal with these instances, it is not always the most simple or effective. There is a social worker at RVCV who we are able to discuss these cases with and pass on the information we gather to her, but it still leaves us with a feeling of sadness often in not being able to rescue everyone, similar to how we feel with many medical cases that are not able to be treated here for lack of resources or otherwise.

Nan is in heaven considering the number of children we see at the this clinic and she wastes no time in getting started. We saw a number of epilepsy patients during the day and it so difficult at time as patients rarely know what they are taking, or how much or how often, when we ask them and we have to bring out tablets to confirm with them what they are taking. We were last here in October and many patients, as is commonly the case, have stopped they medication in the interim because they were “finished,” meaning that despite our constant education, most often in triplicate, they didn’t understand that they had to continue the medication for it to continue working as we are not “curing” their problem, but rather treating it.

One of the benefits we look most forward to at RVCV more than the other mobile clinics is lunch. This is extra important for Nan, who is always thinking about food and where will the next meal be served. When traveling to Empakai last Sunday, we all secretly place odds on when she would first mention lunch in the morning, but she fooled us all by lasting until 11am before asking about food. She was more than happy to discover that today we would be eating a delicious home made lunch in the volunteer dining room where the “mamas” always make an incredible meal for us. Today it was broccoli soup, salad, and cheesy pasta along with fresh fruit, including everyone’s favorite, mango. Lunch is always served at 12:30 so we didn’t have to worry about when to take a break.

After lunch, we visited the gift shop while waiting for our Tanzanian counterparts, who eat a more traditional lunch along with the staff here, to come back ready for our afternoon session. Having three rooms seeing patients allowed us to plow through the patients rather quickly and we were done shortly after 3pm, which was good because some of the younger boys were kicking a soccer ball around nearby and I know Jamie had been mentioning wanting to play soccer here for sometime, but it was readily apparent that Chris was also more than ready to play. Even Nan pitched in guarding the goal for a bit and it was great to watch the three of them running around with the children who were all so happy here at the village. It is a place of miracles and you can’t but help know that everyone of these kids was rescued from a harsher life had it not been for the India and Peter, The Tanzanian Children’s Fund and Rift Valley Children’s Village. Saying goodbye and leaving this magical place to head home is always tough. I know that I’ll be back as I have so many times, but for residents, this is likely their only chance to experience this place.

The weather today has been lovely and the drive home was so peaceful after having seen our patients, played soccer (the residents, not me, of course) and had a great lunch (Nan is very happy!). We arrived back to Karatu, our home for the last three weeks, early enough for Jamie to pick up the skirt she had made and then do some shopping as we’ll be heading into the bush tomorrow on safari. Yusef, our guide for this safari to Lake Ndutu in the Southern Serengeti, had called and was waiting up at FAME for me to give him the Land Cruiser so he could check it out before heading off to such a remote location. Nan and Abbey immediately went to the maternity and pediatric ward where they promptly assisted in finding a delivery going on so when we walked in a few minutes later, we found Nan holding a newborn and beaming from ear to ear.

Meanwhile, I received a text from Frank shortly before getting back to FAME informing me that somehow, Dr. Lisso had told them about a patient still “waiting” for us despite the fact that we didn’t have clinic. It was a huge imposition after having nine days of clinic here, finishing five mobile clinics and preparing for four more clinics at FAME that we had to see a non-urgent patient after hours. After briefly venting (a single text) to Frank (who was also pretty frustrated by the event) Jamie and I saw the patient, who actually turned out to have psychosis and had just been treated at the local hospital days earlier, receiving some injectable medication that they didn’t know the name of and didn’t have their discharge papers from the hospital with them. Argh!!! We just kept repeating “TIA” (This is Africa) and explained to the patient, who, by the way, was doing better after the injection that we really couldn’t treat him as he had very likely been given a long acting medication that we didn’t know the name of, and, besides, it was helping him. They were happy with the visit, though we were a bit perplexed as to why they had come, not to mention being still bend out of shape as to why we had to see this patient at 6pm on a Friday evening.

We eventually got home to eat our dinners, albeit a bit late, and got down to the work of preparing our lunches for the safari tomorrow as we wouldn’t be getting to our camp until dinner time. It was also Jamie’s birthday (sworn to secrecy on how many) and we had ordered a birthday cake from the Lilac Cafe which was running late, so Denis from the Lilac brought it to us during dinner. I had the desired effect either way as Jamie was quite surprised and we all sang happy birthday to her on Joyce’s veranda where we were eating. Later, I worked on my blogs while the Chris, Jamie and Nan made sandwiches, arguing about important things like the “appropriate” amount of peanut butter in a PB&J or PB and Nutella, the latter everyone’s favorite but mine preferring to stick instead with the more basic version of this American classic. Nan cut up a pineapple to eat with lunch and we each went off to pack for overnight in the Serengeti. We each slept with dreams of the wildlife we’d see the following day and the adventures we’d experience, having to awaken quite early for a 6am departure to head through the Ngorongoro Gate when it opened.

 

I completely forgot to mention that the night before, we had a ward consultation regarding a gentleman who had presented after the sudden onset of right-sided weakness and inability to speak or comprehend. Chris had gone to see him after we had returned from clinic and was happy to report that they had assessed him correctly after his lecture Tuesday morning which was very reassuring. He appeared to have a complete left MCA territory infarction on examination with a global aphasia, right visual field cut and right arm and face weakness with some sparing of his leg. He was also in atrial fibrillation which we had discussed at length at the lecture in regard to the fact that you should wait about two weeks before anticoagulating a patient due to the risk of hemorrhage. It was great for Chris to use as a teaching case, though not so great for the patient. He was a bit agitated when he was admitted, likely due to his global aphasia. So on morning report, we discussed his case and what his continued management would be going forward.

Nan, of course, was busy with her pediatric cases before and during rounds which she has been doing a great job with. This morning, the very tiny Maasai baby, whose name is Frank, had decent labs so he will go home today with his family. They live quite far and it will still be touch and go with him. The family agreed to come back next week to see us before we leave and we hope to reinforce the education that was given before he left when they return. He’s so small and without his mother, it will be touch and go. His family, though, was very motivated and seemed to want to provide excellent care for him.

We picked up Sokoine in town as he was buying our food for lunch so we could get an earlier start. Stopping at the grocery store with everyone getting out of the vehicle and choosing what they would like to eat can be a bit cumbersome and time consuming to say the least. We’re often delayed in town for 45 minutes picking everyone up and shopping for each days lunch. I had tried lunch boxes (which are what is used when you’re traveling on game drives so are quite commonly sold here) before, but it didn’t go over well with the Tanzanians as it wasn’t what they were used to eating. Since then, we’ve typically bought the various pastries that are all full of carbohydrates and typically fried so they are the furthest from a healthy diet that you can imagine. Everyone seems happy with these, though, so that has been our practice for the last several years. At least having Sokoine buy everything in advance will save us time, if not calories, carbs and saturated fats.

Clinic today was a bit interesting, considering Jamie’s first patient, which I had decided to sit in on today, wanted to demonstrate for us what his seizures looked like. This was a 21 year-old gentleman who was accompanied by his mother and spoke mainly Iraqw which is quite unusually for a young man. His mother described episodes that were fairly classic for seizures and, specifically, frontal lobe seizures that were reasonably frequent. As Jamie was examining him, he suddenly leaned forward and spit on the ground, then stood up with a very blank stare and was clearly having a seizure. We eased him onto the bed where she was examining him and his eyes were fixed to the right and he was not responding. This lasted only briefly and then he began trying to get up and was still quite confused. We put his coat under his head and he curled up for several minutes before he was finally able to speak and comprehend. He didn’t generalize, though his mother clearly described generalized convulsions in the past and this seizure was clearly a partial complex seizure without generalization and was quite consistent with a left frontal focus for his seizure. He had been put on phenobarbital sometime in the past, but the dose wasn’t clear and it hadn’t helped him at all. His mother had eventually stopped the medication due to it’s ineffectiveness and he just continued having seizures on a regular basis. How amazing it will be to possibly finally control his seizures after all these years. His mother was so appreciative and grateful that we were at least giving her son some hope that she was close to tears and couldn’t thank us enough even though we hadn’t even done anything yet.

Nan’s final patients of the day were also quite interesting. It was a mother and daughter who both suffered with epilepsy, though it wasn’t quite clear that it was genetic. Mom’s seizures hadn’t begun until her 30’s and her daughter’s seizure began at age 4 and she was now 7. The description of mom’s seizures by her husband, which very much embarrassed her, looked primarily generalized, but the description of the daughter’s seizures were less clear. While Nan was taking their histories, I gave the daughter my cellphone to play with for a bit and when I left with it after a while, she apparently burst out in tears so I had to give it her again. She was quite cute and thankfully seemed to be cognitively normal despite having had untreated seizures for several years which is so often not the case here. It was a struggle for us to decide what medication to use for each of them as we don’t have the full complement of medications to use that we have at home and some of the medications we have here are often in short supply and sometimes too expensive for the patients. We eventually came up with a plan that seemed reasonable, but it will require that they be followed up at FAME to make certain that they’re each doing well.

We were finished with patients and decided to have our lunch under the same tree, but try as I may, I couldn’t track down another chameleon and was very disappointed over that. After lunch, we discovered that we had more patients who had showed up in our brief absence, and since it was our last day at Qaru, it was only appropriate that we see them despite the fact that it was getting late.

We traveled back to Karatu, arriving back to FAME sometime after 5pm and decided to relax for the evening. We were planning to go on Safari for the weekend and needed to do some shopping, but that would wait until tomorrow after work. So, for tonight, it was dinner and work and then to bed. Tomorrow we would be heading off to Rift Valley Children’s Village for our last day of mobile clinic and then next week we will be back at FAME for neuro clinic again.

Today we were continuing our week of mobile clinics and after servicing the Mbulumbulu area to our northwest, we were now going to travel to the Endabash area and village of Qaru which is to the northeast. We had been looking for another site to have a mobile clinic and the district medical officer here had been supportive of it after having seen what we had been doing at Kambi ya Simba and Upper Kitete. We eventually settled on the village of Qaru, who were delighted to have us come to their dispensary and care for their residents. So it was set that we would spend two days in Qaru for our visit visit and see what came of it without knowing the volume of patients we were going to see, only that they were happy to have us there.

Glen Gaulton, who had been visiting with us since last Thursday evening, was planning to leave this morning as he was departing from Kilimanjaro International Airport this afternoon. Glen and I met with Susan and Frank yesterday morning to discuss future plans for our involvement with Penn as far as neurology was concerned as well as other services that might work for both FAME and Penn. The big topic of conversation for us, though, was the laptop ban for carry on luggage from primarily Muslim countries that had been recently announced. Thankfully for Glen, it would not affect him as it wasn’t going to be enforced until several days from now, but for the rest of us flying through Doha, Qatar, it would mean that we won’t be able to bring our laptops, tablets, cameras or any other piece of electronic equipment larger than our cell phone with us on the flight. Yikes! Each of us had been planning to do work on our devices on the long flights home and will no longer be able to do that. It will mean that we have to read a book or watch non-stop movies on the 7-8 hour flight from Kili to Doha and the 13 hour flight from Doha to Philadelphia. Jamie will be heading to Namibia after we finish at FAME and she will have an even longer flight to Doha. I did read somewhere that Emirates (who is also affected by the ban) is planning to allow people to bring devices on the inbound flights to Dubai connecting to the US and then would pack anything there in locked cases for no charge. It is said that the ban was based on specific intel, but there is also a suggestion that this is an economic retaliation against middle east airlines that receive government subsidies and can therefore offer lower fares which the US airlines can’t compete with. Regardless of the reasons for the bans, it is going to pose a significant hardship for all of us, not to mention the fact that I am going to have to check all of my camera equipment and hope that it will arrive at home with me and not disappear. The fact that all of these electronic devices will now be stored in checked luggage surely won’t go unnoticed by unscrupulous baggage handlers along the way. The consequences of this ban in the long run remain to be seen, but for our flights home it will be a real hassle.

The drive to Qaru leaves from the tarmac immediately opposite of the FAME road and travels northeast through a somewhat different landscape than that of Mbulumbulu, but it is equally breathtaking with long vistas of green fields among low rolling hills and occasional kopjies (Dutch for “little heads” and referring to the large boulders poking above the ground, often the home of many animals in more remote places like the Serengeti) scattered across the countryside. This is an equally poor area of Tanzania where small villages along the road are made up of a few shacks that account for not only the homes of the inhabitants, but also the small places of business. We finally reached Qaru after perhaps 45 minutes to an hour and drove through town to reach the dispensary. They had a wonderful dispensary with two wings, a male and a female, along with a central office that were all for us to use during our visit there. The nurses were so happy to have us there that they directed moving desks to each of the wards along with extra chairs and, in very short order, we were set up for three lovely offices in which each resident could see patients along with their interpreters.

The patients were already there waiting for us as we arrived and the residents each jumped right in to see them so we were off and running quite early. One of the most important parts of these clinics is the pre-screening of patients before they are seen since we are there to see patients with neurological disease and not those with arthritic or orthopedic issues. Our role is not to do general medicine when we are there as they have clinical officers at the dispensaries for that and since we are charging only a small fee that doesn’t come close to covering the cost of the visit and medications, we cannot subsidize anything but neurology. Early during the clinic, Nan came out of her office at one point with a bit of a frustrated look saying that she couldn’t evaluate her 37 year-old patient who was complaining of chest pain. Clearly, that would not be considered a neurological problem on the face of it, but after reassuring her that it was unlikely that the patient had an acute cardiac condition, I sent her back into the room to ask a few more questions and after a some further assessment she not only found that that woman didn’t have a cardiac condition, but very likely had a neurological complaint that she could actually treat. Alls well that ends well.

Jamie saw a woman with a clear psychosis who has been under the care of the government psychiatric nurse and receiving long acting antipsychotic medications, but we were unaware of the actual medication she was on and both she and her husband were asking if we had anything other medications to suggest as she had been having side effects. A call to the government dispensary to gather information didn’t go as planned as they were apparently unaware that we were in the area and wouldn’t provide us with any information. In the end, the patient was directed back to the dispensary since we were unable to treat her without knowing what she had been treated with previously and what she was currently receiving.

Lunchtime came and we put shukas down on the grass in the shade of a tree next to some boulders where our care was parked. This was a small kopjies and the trees were growing out of the rocks with their roots exposed. It was a lovely spot and while looking for lizards, I found a beautiful chameleon that was colored an amazing green and black at the moment. He threatened me with open jaws that were merely for show and puffed out his throat to make him look bigger. In the end, though, he settled down and we were able to handle him gently so that everyone got a chance to have him walk on their arm and marvel at his independently moving eyes, each moving in a 360° circle separately. Everyone other than Angel thought he was so cute as she went screaming around the car and wouldn’t return until he had been released back to the bushes near where we found him. As soon as we let him go, he immediately turn to color green that exactly matched the bushes as camouflage in the manner we’d expect of any respectable chameleon.

We had a few more patients after lunch and were able to get back to town in time to stop by the fabric store we had visited before and Jamie picked out some fabric for a skirt they were going to make for her. At the same time, I saw a Thomson Safari vehicle parked just up the road from where we were and decided to see who was driving it. When I asked whose vehicle it was, a familiar looking gentleman stepped forward and I realized it was Mohamed, who had picked me and my kids up at the Manyara Airport in 2009 after we had returned from the Norther Serengeti while on our original safari. I’m not sure if I’d seen him since then, but we clearly remembered each other so we sat and shared a drink to catch up on things. What a very small world this can be. I showed him pictures of my kids from our safari as well as where they are now and he was so happy to see them as well as knowing that I’ve been coming back every since to help out at FAME. It reminded me of my first visit to FAME that was the result of volunteering for a few days in Karatu, and what FAME was at the time. From a simple outpatient ward then to the complex of patient care facilities that it is today, we have grown together over the last seven years.

It rained pretty heavily overnight and once again we were heading out to Mbulumbulu for our mobile clinic, today visiting Upper Kitete, which is our furthest clinic and about an hour and a half drive along the rift. From Upper Kitete there is an overlook that we often visit that sits 2000 feet above the Great Rift Valley with a view down to Lake Manyara that is just spectacular when the weather is clear as it goes on forever. Today, though, I am more worried about the roads since we’re heading back towards Kambi ya Simba and beyond where it doesn’t take much rain to make it treacherous.

Thankfully, we’ve been able to recruit George Mila, a long time employee of FAME and someone who has helped me out in the past when I’ve needed it. George will drive us to Upper Kitete so if the roads are bad or if rains while we’re out there, we’ll be sure to make it home or at least we’ll have someone with more know how who can help us out of a bind. With Glen traveling with us today that will make ten for a Land Cruiser that only seats eight. We normally use the refrigerator in the back for an extra seat, which we did today as well, but to seat ten, I am sitting on a soft drink crate with a cushion, wedged between the third row that will serve as my seat for the drive today. It was remarkably comfortable, despite the bumpy road and long drive, though I’m not sure I’d recommend it to anyone if they had a choice.

Tuesday mornings are for education, so before our drive to Upper Kitete, Chris delivered a lecture on stroke for the doctors that he had been requested to give. Chris is a master educator and provided an interactive chalk talk on a propped up white board using markers to run through the vascular anatomy of the brain, the NIH Strok Scale, and finally treatment rationale. Chris did an excellent job and though the participation of the Tanzanian doctors wasn’t brisk at first, they eventually chimed in with some of the answers. Jamie served as Chris’ “patient” to demonstrate the NIHSS and how to rapidly assess a patient to determine the size of their stroke. There were many excellent questions after he was finished with his talk that clearly demonstrated not only how important this subject is, but also how much they had gained from the presentation that Chris had given. We have always given these talks since I’ve been coming here and now the residents give them as they are all incredibly educators which is one of their key roles back home for the medical students and they provide the same here for all the medical officers and nurses.

The drive to Upper Kitete was quite uneventful as to any incidents, though the beauty of this region would compare to any in the world. The fields are lush and green as far as the eye can see and we pass tractors and workers along the way going to and coming from their daily labors. It’s quiet and serene here that belies the difficulties of life here, given the remoteness and occasional struggles to make do. It is a much simpler life for certain. Upper Kitete is the second to the last village on the road we’re traveling that ends as the mountains meet the escarpment and it is no longer possible to travel further by vehicle.

The dispensary at Upper Kitete is a bit more primitive than that of Kambi ya Simba. The two rooms we usually use are cramped and not ideal, but we’ve always made do. The one office has a square hole in the ceiling where there is a large colony of bats that can often be heard and there is always the aroma of bat urine, but I have never seen one fly out during the day so I am comfortable that everyone is safe. The other room we use is the labor and delivery room where there are two beds and a very small amount of space between them. As long as there are no patients in labor, we’re safe to use the room. Today, we were also given the dispensary’s clinical officer’s office to use which actually had a nice desk and bed in it on which to examine patients. Everyone got to work and Jamie drew the short straw meaning she would see patients in the “bat room,” though it took just a tad of convincing that she needn’t worry about the little creatures. Nan worked in the L&D room and Chris ended up in the office as this came available later and he was in the right place at the right time.

We had a smattering of the usual patients with headaches, neuropathy and seizures with none that stood out remarkably, though Chris’ last patient was one that took a bit more in the way of thought. He was a young boy of 5 whose grandmother was raising him and gave us a history of “drop attacks” that began at one year of age and had continued. When we hear the term “drop attacks” we usually think immediately of Lennox-Gastaut syndrome which is a devastating epileptic encephalopathy where children loose milestones and suffer injuries due to the multiple seizure types. We were also given a history that the child may have had spasms when younger, another worrisome feature suggesting infantile spasms. But he looked way too good to have either of these conditions and, in fact, his examination demonstrated normal cognition which went along with what his grandmother was telling us.

He appeared initially to be a bit sedated which wasn’t surprising as he was on 90 mg of phenobarbital, but he later awakened to fully participate in his evaluation which was also very encouraging. We wanted to convert him to valproic acid, but before doing so, he needed to get labs to make sure there were no metabolic issues that can be seen in certain children and which would be a problem if we put him on this medication. In the end, we convinced them to come to FAME next week to have the lab work done at which point we’d decide whether to switch him to valproic acid or not.

At the end of the clinic day, the clouds were rolling in from the valley below and we could hear thunder in the distance. We packed up and hit the road, skipping the overlook as the weather was closing in fast on us. It began to rain and did so most of the way back to the tarmac. We had wanted to stop at a friend’s shop in the village of Manyara so took a different road back and made it there just in time before they closed. I had wanted to get some wall hangings and items for the new house and was successful in doing so, while the others were looking for gifts to bring home with them. We eventually got back on the road and made it to Karatu in time to watch the sunset with dinner. Glen made us a great tomato, cucumber, onion salad to go with our cheesy pasta that Samweli made us for dinner. We relaxed for the rest of the evening with Jamie, Nan and Glen watching Lost in Translation on Nan’s laptop. It was a good day at Upper Kitete and we made it back safely. Tomorrow would be a new clinic location at the village of Qaru in the Endabash area of the Karatu district. Glen would also be leaving tomorrow morning and it has been great having him here to see what we have been doing at FAME.

This will be our week of mobile clinics for the neurology team and there is always a bit of stress associated with making certain that everything we need has been loaded in the vehicle as we can’t come back for anything once we’re out. When I first arrived in 2010, FAME had been running a big mobile clinic to the Lake Eyasi region one week every month since they hadn’t opened their hospital and the clinic visits were at a low enough volume that it was still doable to split the clinical team and make things work. In 2011, Paula Gremley, who had been working with FAME at the time on the mobile clinics to Lake Eyasi, suggested that she and I travel to several villages in the Mbulumbulu region of the Karatu District where we would see only neurology cases specifically as each of the villages have their own small government dispensaries so we weren’t looking to do general medical care there. Paula, who ran her own non-profit at the time, was interested in providing neurological care to patients in the region and so it worked out perfectly with my trips to FAME and an interest in developing a neurological presence here.

Paula, unfortunately, left to return to the US shortly after our “mini mobile clinics” (in deference to the large mobile clinic to Eyasi) began, but it was a concept that I had felt strongly about as did Susan and Frank here at FAME. When the funding for the Eyasi trips had ended (They were funded by Malaria No More, a Dutch based non-profit), the Neurology Mobile Clinics became the main functioning remote clinic for FAME other than the Rift Valley Children’s Village (RVCV) biweekly clinic that was run at RVCV to care for the patients there as well as the adjoining local village. Since 2012, we have been running a series of mobile clinics in two villages in the Mbulumbulu region as well as at the RVCV accompanying the FAME general clinic there.

The Mbulumbulu region is a remarkably gorgeous area that follows along on the high side of the rift and forms a triangle bordering the Rift Valley and escarpment to the southeast and the Ngorongoro Conservation Area to the northwest until it reaches it’s apex about half way to Empakai Crater. This region is populated mainly by the Iraqw and is blessed with extremely fertile soil so that it is heavily farmed with many varieties of crops. Driving through this area one is continually reminded of the main occupation here which is farming as there are always people in the fields working, and certainly now as we are nearing harvest time before the big rains of April and May. The road is generally good, though once it is raining it can become quite treacherous and I have learned that the hard way in the past having gotten my Land Rover, a virtual tank of a vehicle, stuck axle deep in the mud after running off the road during the heavy rains of April.

For this year’s mobile clinics, we have chosen to visit two of the original villages in the Mbulumbulu region, Kambi ya Simba and Upper Kitete, though we’ll do only one day in each where we have done two days in each in the past. Kambi ya Simba is the closest of the two villages, about 45 minutes away, while Upper Kitete is almost exactly twice the distance, or about 90 minutes away. For this year, we will be going to another village in a different region, Qaru, in the Endabash region, and spending two days there. Sokoine and Alex had been meeting with villages in this region and chose Qaru over the others for several reasons. We will then finish off the week at Rift Valley Children’s Village on Friday.

We had told our patient with HIV and the abnormal CT scan with presumed toxoplasmosis to come at around 8 am on Monday, and sure enough, there he was, having traveled several hours by bus to see us so we could explain his medications to him. Jamie met with him and went over the protocol which wasn’t simple and then explained it to the nurses as well so they could reinforce it with him. He will be coming back to see us next week as well so that we can assess whether he’s had any clinical improvement and after further discussion with everyone, we’ll very likely do a repeat CT scan to gauge if there’s been any improvement in the edema we saw on the first scan, indicating that the medication is working for him. We will have further decisions to make regarding whether we continue him on this course of therapy or not and we’ll cross that bridge later when we’re there and have some more data.

I typically have someone drive us out to the mobile clinics, especially this time of year when a heavy rain can come down without notice and turn the roads into a slip and slide in no time at all. This morning, there was no one available to drive, which meant that I would do all the driving and would also keep my fingers crossed that it didn’t start raining while we were out there. Again, the preparation for these clinics is crucial due to the number of meds we bring, medical tools, and, of course, our lunch which has to be enough for all of us and something that everyone can eat. After filling our fuel tank on the Land Cruiser, we drove a bit further through town to pick up lunch. I sent Nan and Jamie along to make sure what was being acquired would be to their approval as some of the lunch items can be a bit bizarre at times. We ended up with samosas, vitumbua (sp? Fried rice cakes that are delicious, but dripping with grease), donut-like pastries that aren’t very sweet, bananas, and avocados. We also had a huge selection of drinks and addition to the water we bring and which you don’t travel anywhere here without considering any safari (journey) can be an adventure you may get stuck in the bush for hours in the hot sun or torrential downpours as they change that quickly.

We arrived at Kambi ya Simba without incident and found no patients waiting there for us, but it was around 11 am and Sokoine informed us that many people here were still finishing their morning chores so would likely begin showing after noontime. Sure enough, a few patients began to show, but not the volume that we had hoped for. There were a few children for Nan, one of whom was a very cute little two year-old child whose mom brought her in because she wasn’t able to run and play like the other children. It was clear that she had a mild right hemiparesis on her exam that had been present since birth so in the end she was another child with mild CP, though she was functioning very well cognitively with only mild delays. Nan felt she would do very well long term and she instructed mom on some simple exercises she could do that would help with her physical issues. Mom had also described two episodes of seizure in her life so Nan decided to treat her for these as it would be difficult to tell if she were having additional seizures and, if she were having more, they would also negatively impact her development that was already delayed. We stressed the need for her to follow up at FAME for refills of her medication and to see us back in October to re-evaluate her when we’re back.

The other patients were a smattering of typical complaints here – headache, neuropathy, back pain – but at the end of the day before our departure we were asked to see a 17 year-old schoolgirl who had been brought in with a severe headache and was in their small ward there. It turned out that her headache was only a minor problem and the more significant issue was the recurrent episodes of prolonged unresponsiveness she was having which would last up to 11 (!) hours and without any clinic story suggestive of seizure. What she had was a conversion disorder (psychogenic) and further investigation by Nan and Jamie it was discovered that she had significant traumatic issues in the past that were contributing to this and was also clinically depressed. After we discussed the case further, it was decided to place her on fluoxetine (Prozac) as she would clearly benefit from a course of antidepressants. Unfortunately, what she really needs is counseling and psychotherapy, but these really don’t exist here in any reliable fashion so we would have to rely on the medications and letting the clinical officer there know what our thoughts and recommendations were so they wouldn’t treat her with anything else for these episodes.

Psychiatric disease is very prevalent here as it is elsewhere, but often presents very differently than it does back home due to cultural variations. Prolonged episodes of unresponsiveness lasting hours and hours is quite common which we don’t see quite as much at home. I have my suspicions as to why that is, but I’ll not bore anyone here with my hypothesis at this time. “Swooning” is quite common as I have seen many a patient brought in by their co-workers from the fields or from their schoolmates from school where they were basically not responding, are carried in, and miraculously wake up within a short time of being here and are back to their normal selves immediately. An unresponsive patient obviously creates lots of excitement and angst among the family and medical staff, which is perhaps the point, but is something that we have dealt with fairly frequently and is most often readily clear to us.

We departed Kambi ya Simba seeing perhaps fewer patients than we had hoped, but it still serves a purpose to visit these villages so they are aware of the neurologic disorders we can treat here. For the little girl with CP and developmental delay it will make a huge difference in her life having seen us at age 2 as opposed to at age 10 after she’s developed contractures or has been seizing intermittently for 10 years. Hopefully, we were able to also help the school girl with her depression, but that’s a tougher problem. We arrived home after dropping all of the FAME employees off in town and Nan went to the peds ward to check on her patients here. After relaxing for a short bit, we met up with Alex as we had plans for dinner at the Manor Lodge which is a lovely resort that sits high up on one of the hills overlooking FAME and town. The drive there is through the Shangi-La plantation (coffee) which is massive and then through a short easement that cuts through the Conservation Area where you can occasionally spot some wildlife.

You then cross the gate into the lodge grounds were you enter another world of closely kept lawns and landscaping with gorgeous white washed cottages interspersed looking out over the coffee plantations that adjoin the grounds. The Manor House is a large lodge building with fireplaces and sitting chairs and perhaps the finest dining room in all of Tanzania. I had thought there was lots of silverware at Gibb’s Farm, but there was at least an extra setting here for an additional course so they had them beat. We sat outside on the veranda looking out across the rows of coffee plants in the distance with the hills dropping off to Karatu even further in the distance. Nan was enjoying the grounds taking more photos of flowers and eventually joined us as we relaxed under the clear sky to watch the stars begin to surface as there was no moon. The soft hues of the sunset faded away slowly to an amazing gradient of blues that began at the horizon and darkened to the night sky above.

We eventually moved inside to our dinner table where we enjoyed luxurious service and food to match. Glen selected a few nice wines to go along with dinner and it was a marvelous time with good friends and colleagues as we all share now in our love of Africa and of serving the people here where it makes such a difference. I know that I will be back as will Glen, and I’m hopeful that Chris, Nan and Jamie will consider it in the future, whether it be here at FAME or elsewhere, whether it be Africa or at home, it it is all the same. The lessons learned here will last a lifetime as will the memories, and they will carry it all with them for as long as they live. That is the beauty of it all.

We left Sokoine’s boma late morning and continued our drive northeast through the highlands towards our final destination of Empakai Crater. Empakai is a smaller version of Ngorongoro, though its floor is occupied nearly entirely by a large, shallow alkaline lake where flocks of flamingo normally make their home, but fly north to Lake Natron during the breeding season. The journey travels across some wide open plains where the Maasai graze their herds of cattle, sheep and goats amongst smaller herds of zebra and Thompson gazelle and an occasional lone wildebeest. Hyena and jackal can often be spotted in this area, but today we see none along the way and are satisfied with the game that we see as we hadn’t come for the wildlife necessarily.

Empakai Crater is also an intact volcanic caldera and today we’ve come to hike to the bottom. Along the way, we’ve picked up our Maasai guide who also serves to protect us should we run into a leopard or lion which in a vehicle is not an issue, but on foot can be a bit problematic. Philipo, our guide, has but one spear and one long knife to protect all of us in the event of an incident with a big cat or Cape buffalo and each of is confident that we will be the one he protects. Either that or we can run at least faster than the slowest in our group.

As you drive along the rim of Empakai, you can often catch views of Kilimanjaro far in the distance, but today there are clouds between us and the roof of Africa so it is not visible. Ol Doinyo Lengai is also in the clouds on our approach, but was thankfully quite visible later as we were leaving. It is a classic active volcano with lava flows occupying much of its slopes. Driving in, the road becomes rougher due to the recent rains whose rivulets have caused such erosion as to bounce our vehicle to and fro. As we approach the trailhead down into the crater there are campsites for the more adventurous and those making the long trek from Ngorongoro to Ol Doinyo Lengai by foot that takes several days and ends with summiting the volcano.

Once parked, preferably in the shade, we get our things together for the hike down to the crater floor which typically takes about 30 minutes and is literally all downhill along a path that switchbacks down the very steep crater rim. The weather was perfect for a hike, but we still brought our rain shells, water bottles and our lunch which we planned to eat by the lake, hopefully not in the company of the lions whose tracks were everywhere lakeside along with the hyenas. With over three-quarters of the hike completed, Abbey unfortunately twisted her ankle on the trail and didn’t feel comfortable descending any further as it only meant that much further to the top, so Sokoine started back up the trail with her to wait for us at the top. The rest of us, including Philipo, continued down to the bottom where you suddenly leave the dense forest and are deposited at the lakeside with tufts of tall grasses mixed with shallow ravines for the water to flow into the lake.

We walked along the lake for a short distance spotting several flamingos who hadn’t flown to Lake Natron with the rest of the flock, and then turned back to sit atop a small hill for our lunch break. We had brought our safari staple of peanut butter and jelly sandwiches, though this time there was the addition of Nutella to the menu much to the delight of Jamie, Nan, Chris and Glen. I was a stick in the mud and remained conservative instead choosing to eat only the PB&J sandwiches. We relaxed for a time on the small hillock on which we sat, watching for animals and finally seeing to reedbuck meander out of the forest to graze and then make a mad dash to the water, drinking quickly and then turning right around to return to the safety of the trees. There was lots of sounds coming from the forest and it was hard to tell if they were birds or monkeys or some wounded animal, but either way we were not going to check out the situation more closely.

It was finally time to begin our trek up the trail and back to the rim which was made a bit more difficult by the fact that Angel’s shoes had literally disintegrated with the soles separating from the tops meaning that they were worthless and that she was going to have to continue the hike barefoot. Chris worked on trying to devise something to tie around her feet, but in the end, she carried on up the hill wearing nothing at all on her feet and did just fine in that regard, though did have some moments of exhaustion from the climb. We all made it to the top safely and without further incident to find Sokoine and Abbey there waiting for us. Abbey had clearly sprained her ankle and would likely need an X-ray of the joint tomorrow to see if it was anything more serious.

We left Empakai traveling on the same road and past Sokoine’s father’s boma, reaching the big crater rim in time for us to stop at the Sopa Lodge that sits high above the rim road with a simply amazing 180° view of the crater. The view was spectacular and it was so incredibly relaxing as we sat having drinks near the pool looking out at one of the most beautiful landscapes that one could ever imagine. Ngorongoro Crater is not to be missed when you visit here, and even if you don’t drive down into the crater, the views are breathtaking. It will always be one of my favorite places on earth. We left the lodge shortly after 5 pm with the sun low on the horizon and began the long drive along the rim back to the viewpoint that we had passed in the morning when we were locked in the clouds. Unfortunately, the main gate at the bottom closes at 6 pm and it’s necessary to be through the gate by then or you risk spending the night on the crater rim with very few exceptions. The NCA is just not very tolerant of wazungu arriving late at the gate and we certainly had no intention of returning the rim. So I allowed everyone a moment to jump out of the vehicle to take a look and a photo and then it was back in to wind down the switchbacks we had taken early in the morning so we could make it in time to the gate with ten minutes to spare.

Dinners are made for us during the week, but not on weekends so we had to stop at the Happy Days Pub to find some food as we hadn’t prepared anything at home nor did we have the groceries to do so. Happy Days is a nice place with one many major downfall, being the fact that it easily takes an hour from the time you order until your dinner is served. Ordering drinks usually means you’ll be on your second long before there is any sign that your dinner is even close to being served. Once served, though, the food is actually very good – pizza, cheesy macaroni, and chicken curry with rice. As we say here often, TIA (This is Africa), and it seems to be a theme here as the Lilac Cafe has about the same lackadaisical pace when it comes to serving food. As I’ve mentioned before, the pace is quite different here and, for the most part, we are quite accepting of that. When hunger has set in, though, for certain members of our party who will go unnamed (read Nan), it can become a more serious matter and, thankfully, we have never seen that side of her. All joking aside, this has been a wonderful trip with everyone getting along great as expected, though we certainly enjoy poking fun at one another here and there. We arrived home rather late from Happy Days this night and after such an incredibly long day in the NCA, I think everyone was more than happy to call it a night. Tomorrow begins our week of mobile clinics in which we get to visit some of the villages in the district.

We all awakened bright and early Sunday morning ready for another one of our adventures. We were to pick up Sokoine and Angel down at the bottom of the FAME road on the tarmac at 6:30 am with plans to make it to the Ngorongoro Gate shortly after it opened that morning. Chris, Jamie, Nan, Glen, Abbey (a pediatric NP from Philadelphia who arrived here last Friday), Angel, Sokoine and myself were all traveling to the Ngorongoro Conservation Area (NCA) to visit Sokoine’s boma and to hike into Empakai Crater. Visiting the NCA means passing through the Ngorongoro Gate, which in the past, has, on several occasions, posed a major obstacle for us due to the administrative red tape and bureaucracy that occurs there. Only for the NCA do you need to put money in the national bank in the exact amount necessary for which they will give you a receipt which is then brought to the gate. Last October we were off a few dollars and had to wait until the supervisor would let us pass and then we had to drive to the main NCA office on the rim to pay an additional amount and which probably cost us a total of two hours delay.

Back in March 2015, we were on our way to a safari in the Crater on the most beautiful day you could imagine when, only a few kilometers into the park, my Land Rover suddenly lost it’s forward momentum going uphill and we were stuck only to find out later that our clutch plate had totally disintegrated requiring a tow back to town. When we stopped at the gate being towed out, they told us we couldn’t have our money back as we had already entered the NCA, but they would allow us to come back the following day and do the safari for no charge. Unfortunately, we were flying out the following day and were unable to do that so we all lost the money we had paid for our entrance into the NCA and to the Crater.

With the new administration of Magufuli, though, there seems to be a new process that entailed the same filling out of paperwork and depositing money to the bank, but when we arrived at the gate, it took us probably 5 minutes to finish the process there and be on our way. I have never been through the gate in such an incredibly fast time and was sure that they were going to find some reason to delay us there. Miraculously, they didn’t and we were on our way in short order, though I was constantly looking in my mirrors as I was sure that we had done something wrong and they were going to be chasing after us at any moment.

The weather wasn’t horrible, but it also wasn’t clear at all and it kept drizzling on the windshield on our way up to the crater rim where the weather can be downright nasty in the morning since you’re up in the clouds. The drive to the crater rim is through a forest that can best be described as primordial, with tall trees and hanging vines that look straight out of Jurassic Park. The road winds steeply up and up with steeper drop offs into the canyons that exist on this side of the rim. Around each turn you clearly expect to see a tyrannosaurus rex standing in the road. We finally reach the crater rim where there is a lookout to view this spectacular geologic feature, but we are totally socked in the clouds and that will have to wait for our drive home when hopefully the weather will have improved. The Ngorongoro Crater is the world’s largest completely intact volcanic caldera (it is 20 km across!) and is home to an incredible assortment of animals that don’t migrate out of the crater along with a large number of the rare black rhinos.

As we travel counterclockwise around the rim (the opposite direction than if you were heading to the Serengeti), the forest remains lush and green and then suddenly, the skies open up to reveal a wonderfully blue sky accented with the wispy clouds that are slowly dissipating along with the angle of the sun. This is common weather at the rim, where, at over 8000 feet, the clouds roll over the rim either into or out of the crater depending on whether it’s morning or evening. We eventually come to the two-way road down to the crater floor, but that is not our destination today and we turn away into the Ngorongoro Highlands that sit at the same altitude and is home to many, many Maasai boma, the traditional homes of the Maasai comprised of a grouping of round huts covered with grass roofs and cow dung walls and typically enclosed with a brush fence. Each boma is home to a single family that is made up of a husband, his multiple wives and all of their children. Animals are held in small circular corrals that sit at the center of the boma most typically. The lush green grasses that are present now will sustain a large number of families so that the area here is filled with bomas.

Our plan for the day is to visit Sokoine’s father’s boma, where he was born and raised and where he attended primary and secondary school prior to leaving for college. Sokoine’s father is a very successful Maasai with many, many cattle, five wives and lots of children and grandchildren. Their boma sits in the middle of the fertile valley that flows west from Ngorongoro Crater in the direction towards Empakai Crater (our final destination), Ol Doinyo Lengai (“Mountain of God” to the Maasai and a fantastic volcanic cone that is still active) and eventually leading up to Lake Natron on the Kenya border. We turn off of the main road onto a small trail of tire tracks and after a short distance arrive at their boma which is made of up of many huts and animal enclosures as several of Sokoine’s brothers also still live here with their families. In this area where there are numerous bomas, each is not surrounded by an enclosing barrier that you see in other less fertile areas which I suspect is due to the fact that these are actually small communities unlike the lone bomas you would see elsewhere.

As soon as we arrive to the boma, everyone is out to greet us and there are many, many young children all fascinated by the wazungu (white people) who have come to visit them as this would be a very exciting event. This area of the highlands is probably visited by far less than 1% of the visitors who come to Tanzania to see the wildlife. We had stopped at a boma a short distance from the top of the two-way road when we had visited here in 2009, a “cultural visit” to the Maasai which is what most safari companies offer and is the typical view that westerners see of the Maasai here. These are bomas that are paid to have people come visit and though it is certainly a reasonable peek at their life, it is nothing like visiting a friend’s boma which can only be done when you’ve been here for some time. We are not here as visitors, but rather as friends of Sokoine and are therefore greeted as such and are honored guests.

I had given Sokoine money to buy his father some gifts for our visit which is the tradition here as it is elsewhere, though the gifts may be a bit different than at home. We are bringing 10 kg of rice, sugar, black tea, and dip and medicine for the cattle. We immediately walk off to greet his father, who was sitting a short distance away surrounded by several of his grandchildren. One of them was holding a baby goat who was so cute that I couldn’t help but take him from the child, only to discover that he was bleeding profusely from his ear as they were in the process of marking him, or cutting a small hole to identify it as belonging to their boma. So after realizing that I had blood dripping on my arm and thankfully not all over my clothes, probably a bit longer than it would have taken most to realize this or more likely they wouldn’t have impulsively taken the goat in the first place, I handed it back to the boy so that Sokoine’s father could finish the job of marking him with a very sharp knife over the loud objections of the poor little goat.

We eventually walked over to our vehicle to take out the gifts and present them to his father. I have said before that the Maasai are very understated in their emotions so the thank you from his father was very brief but heartfelt as he instructed his youngest wife to heft the huge bag of gifts and carry it off to her hut or wherever they were planning to store it. Sokoine had also bought a bag of candy for us to distribute to the children and the minute he handed the bag to me I was immediately surrounded by dozens of children with their hands extended. It was impossible to tell who had already gotten some candy and I’m sure that many of them were getting seconds and thirds, but their cries were too much to resist so I just kept handing them out. After a while, though, I handed the bag to Angel to finish the job of distributing them so I could walk with Sokoine and his father. Knowing of Sokoine’s accomplishments and where he is today, I could not help but think of him twenty years earlier having been one of these young children dressed in shukas in bare feet, many of them carrying their younger siblings on their backs. What a stark contrast to come from the boma and achieve what he has, but then I must realize that I am using my western standards to make this comparison and it is not the goal of every Maasai to leave the boma life, but rather only a few, for his father is a very successful man and this is certainly what he has chosen for his life.

We spent a good amount of time with his family at the boma and mostly all the lovely children who were schooled in the tactics of tag and taught how to play patty-cake by Nan and Jamie quite expertly. We were able to watch all the cattle being herded through the boma on their way back to their enclosures or nearby so they could be milked by the women, squirting directly into their calabashes to be fed later directly to the babies. We had delicious “chai” which in the boma is black tea boiled directly with fresh milk and sugar. It is an amazing beverage and was appreciated by all.

Later, I walked with Sokoine to visit his older brother who is a veterinarian and was visiting the boma to tend to their cattle. I watched as they had a large bull on the ground with its legs lashed and who was being neutered in an extremely humane manor of just disrupting the vasculature and other structures traveling to the testes with a large clamp device. His brother had left the boma as well to become a veterinarian, but returns to care for the bomas cattle, many of which are his as his father has actually distributed them already to all of his sons. Sokoine’s mother wasn’t in the boma as she is currently living near Oldupai Gorge and tending to their sheep and goats who are grazing there.

I think we all left the boma with a new sense of the Maasai culture, certainly the residents who hadn’t visited a boma yet we’ve been treating these lovely people at FAME for the last weeks. Even I, who has visited Sokoine’s family before as well as several other bomas, find that each time there is a new sense of familiarity and greater awe for this proud and wonderful tribe who continue to persevere in their simple and ancient lifestyle, yet provide the opportunities for those individuals such as Sokoine and his brother, who despite their lives outside the boma, have remained connected.

Saturday’s are rather slow for us as they often are for the clinic in general. It is a normal schedule here, though, and we are open for business from 8:30 am to 4:30 pm, or 2:30 to 10:30 Swahili time. The Swahili clock begins at our 6 am and everything after that is referred to by the hour, such that our 7 am would be 1:00 and so on. It seems to be mostly the Maasai that use this clock, but I’m sure other tribes do as well. The Maasai normally have their cellphones (carried in a pouch around their neck or tucked into their shukas) set to Swahili time and I find Sokoine often telling me our schedule in this manner at well which can draw a quizzical look from me most often.

We attended morning report at 8 am to hear about any new patients in the ward for us to see and for Nan to catch up on her pediatric patients, all of who were doing well at the time. Since the day was rather slow in the morning (it rained again over night) and we had no patients by 8:30, we decided for all of us to continue on rounds and see the inpatients with the rest of the team. Nan had been following a little child with severe asthma who was doing well and ready to be discharged. She was walking up and down the outside corridors later to prove how well she was doing.

Our little Maasai baby who weighs just over 1.5 kg has been doing great and feeding well. We spend some time in the room during rounds to let the family know that we had been contacted by a very generous reader of this blog who had wanted to donate enough money to buy formula for probably 3-4 months and would allow the baby an excellent chance to develop when they otherwise would have fed the baby cow’s milk which lacks all the necessary nutritional elements. Though the Maasai are normally very stoic, it was quite clear that the family was overwhelmed and very appreciative. The woman who has been with the baby the most at this point is a second cousin of the mother (who had passed away three days after delivery) and she would be the one mostly caring for baby “Frank.” The baby’s sodium has been low so they weren’t planning to go home until the first of the week, but we would be setting up a plan for them to bring him back on a regular basis to be checked. They live down in the Lake Manyara region and it is certainly possible for them to make the trip which will be very necessary as the baby is still not out of the woods by a long shot. The mortality rate for Maasai babies is high to begin with, and considering this baby’s size at full-term, it is a miracle that he’s doing as well as he is and probably a testament to the incredible care he’s gotten at FAME and with Nan.

Egbert, our pharmacist, finally confirmed with me that we had the medications necessary to treat our gentlemen with the abnormal CT scan and HIV for toxoplasmosis. As I had mentioned earlier I believe, the government clinics here will treat these patients with the third line recommended therapy for CNS toxoplasmosis and it was our decision to use the primary recommended regimen as we thought that would give him a better chance of success and us a better chance of telling whether it was working successfully. I counted up all the pills we had received, matching them to the regimen we had obtained and there were barely enough to hold him until he would be returning, so we will have to order more that will be sent to him on the bus. Unfortunately, he was unable to get into clinic today as he lives several hours away by bus ride so we arranged to have him come in early on Monday morning to see us before we were to leave on our mobile clinic.

We had out patients throughout the morning, but by lunchtime, things had slowed down and though there were a few patients after lunch, we were able to end clinic rather early which was good as I still had to make a run to town for supplies for our housewarming party that night and the formal introduction of the Raynes House to the community here at FAME. Alex had been slaving in the kitchen all day making a Mexican feast of homemade tortillas, marinated beef filet and chicken, corn salsa, and fried Spanish rice balls. In addition to this, Brad was bringing his special guacamole and Annie was bringing her special retried beans. All that was left for me to do was to run into town for an extra case of beer, a few bottles of wine, and mango juice.

Unfortunately, Joyce and her sister, Terry, were out of town in Usa River visiting friends for the weekend, but we had a great turnout of all the volunteers in addition to ourselves, Frank and Susan (Frank stayed until after his bedtime of 8pm, making quite sure he had had his fill of the beef and chicken tacos), Brad, Annie, Glen, and even Sokoine, though, he did put up some resistance. It was a great time and everyone loved the house as they couldn’t help to do otherwise. Brad even blessed the house with Sage incense making sure each and every room received its smudging in a totally appropriate and spiritual manner. The haven’t had a chance yet to place the Mezuzah on the front door that Stephen and Liz Raynes sent with me, but that will be done shortly as it requires me to enlist the help of Erasmus to drill so mounting holes into the brick or metal door frame.

I do apologize for not having taken any photos of the party, though given the circumstances, they may have been incriminating and I wouldn’t have wanted to be party to shortening anyone’s career in the process. In reality, it was an incredibly wonderful evening with lots of friendship and great conversations amongst such a diverse group of individuals all here for the sole purpose of making this a better world. We had good music (Buena Vista Social Club on our little bluetooth speakers) and amazing food (Thank you Alex!!!) and were all able to celebrate our new home in Tanzania, made possible out of the generosity of the Raynes Family who were willing to place their faith in the work that we are doing here, knowing the impact it will have on so many lives that would otherwise have gone unnoticed. I am forever grateful for the continued opportunity we have to work here at FAME and for those who have made that possible.

Having arrived in the middle of the night after their incredible adventure of the day before, it was somewhat amazing that Glen was up bright and early with us this morning to head for our educational conference that Chris had been asked to give. He had prepared a lecture on stroke, a topic we have done a number of times before, but between new staff and the fact that this is a topic that can not be reinforced too often, we were happy to include it in our schedule. Unfortunately, there had been a miscommunication and when we walked into the conference room and saw all of the nurses there along with the doctors, we quickly discovered that had been an important nurse/doctor conference to smooth over an issue that had come up. It was 7:30am, when we’re typically having breakfast and preparing for the day and we were now all dressed up with no where to go. We walked to Lilac Cafe to get coffee and found, much to our dismay, that they were closed. So we waited around for morning report while the other meeting when on and on until much past when morning report and rounds should have started.

We were eventually able to organize our team so we could get started seeing patients and we found Renata there with one of her teachers. I received a text from her grandfather at the same time informing me that one of Renata’s teachers wanted to be seen by us and had requested Renata to accompany her to FAME. Before that, though, we had a gentleman to see who I’ve followed now for several years and continues to do well on his medications, but did have a few complaints that he wanted to discuss with us. After that we got to work on Renata’s teacher, though I explained to her that it was not appropriate for her to help us or be in the room when her teacher was being seen. This was tough, I think, for Renata to really understand since she so wanted to have her teacher see her working with us, but it was just not something that was possible, or appropriate for that matter.

Chris saw a gentleman in the morning who was having significant difficulty with slurred speech and who had actually been seen at FAME the week prior when we had been there, though we hadn’t been asked to see him for some strange reason. His symptoms had begun the week prior rather acutely and after a brief discussion it was readily apparent that he had likely had a brainstem or posterior fossa stroke explaining his symptoms. There was very little we had to offer him at the present time, nor could we really have done anything a week prior had he come to see us immediately, after the incident. We could, on the other had, check his secondary stroke risk factors and treat those accordingly with agents designed to reduce blood pressure, reduce his LDL and, lastly to begin low dose aspirin (75 mg here rather than the 81 mg we’re all familiar with in the US). None of these had really been done before and he had been diagnosed with a TIA, or transient ischemic attack so it is obvious that we really need to reinforce these strategies and Chris will do so next Tuesday when he gives his talk.

Nan had asked the mother of the child we had seen on Wednesday and who we believe to have some genetic syndrome to come back with the father of the child so she could evaluate both parents. They came in Friday after lunch and she went over both of them thoroughly, with no findings to suggest that they were also affected and sometime later she heard from her resource at CHOP that the child’s morphology was non-specific, and that though he could be worked up with genetic studies were he in the US, it would be very unlikely that any of these would ever lead to any specific treatment for his condition. So once again, we run into a dead end making a specific diagnosis, yet our hope is that we can at least give patients and family some information that will prevent them from continually searching for a cure for conditions such as this where none exists, not here and not at home.

We needed some groceries for the house so Glen and I decided to run downtown during a lull to visit the “supermarket,” which are stores here that for the most part are perhaps ten feet wide and fifteen feet deep with shelves packed with everything you could possibly ever need (not really, but they have lots of “stuff”). We weren’t gone long, but on our return, Chris informed me that he had seen a patient who he felt could benefit from occipital nerve blocks and that she had received them previously from us with some benefit, but that the pain had returned. Luckily, I still have supplies here to provide these blocks which are so often effective for patients who complain of headaches that radiate from their occipital region forward over their head to their eyes. Chris hadn’t wanted to proceed without me being there, though to be honest, he is more than knowledgeable about when to do these and had he gone ahead it would have been perfectly fine. We went ahead and provided her with bilateral blocks and hopefully she will get some much needed relief from this.

Also, lunch for us was very late today as we had plenty of patients in the morning, so we all ran down to the Lilac Cafe, which the residents had been wanting to do since we’ve been here. The Lilac is a small cafe on the grounds of FAME that serves meals throughout the day, but also provides all of the food for the hospital patients as it was realized that something like this would be necessary once the wards had opened. Their food is good and necessary diversion at times from the food at the cantina that we eat for lunch every day which is rice and beans, rice and beans, more rice and beans with some ugali and pilau interspersed. Frankly, the rice and beans with greens that we eat each day is perhaps my favorite all time lunch regardless of where I am. The main issue with the Lilac, though, is that it may take close to an hour for your food to be served which can be an issue if you’re on a tight schedule. Luckily, this is Africa, which is what we tell each other multiple times a day and on many levels. Time is superfluous here and you accomplish what you accomplish in whatever time is necessary to do so. Having eaten lunch so late, we postponed our dinner back at the house and, instead, relaxed outside on our veranda to watch the sunset and share stories among friends which is what we do here. Life here moves at a different pace and one that is much more conducive to wellbeing and happiness. We are all grateful for that.

The morning was announced with a torrential downpour that began well before sunrise with a deafening clatter on the tin roof as if thousands of marbles were striking it in succession. The rain continued as we all had our coffee and tea while trying to decide the exact mode of transportation to the clinic – would we drive the short distance to remain somewhat dry or tempt our fate during a short pause in the deluge. Rivulets were launching off the roof onto the rock barrier below designed to prevent erosion and flooding that was clearly doing its job despite the continued onslaught of precipitation. Amazingly, these are not the monsoons, but merely a taste of what’s to come over the following months. Thankfully, the rain let up just before our departure and allowed us to successfully reach the clinic before becoming waterlogged.

The weather will often dictate how the morning goes in regard to the flow of patients as the main road to FAME can easily turn into a river of mud with little difficulty, and although passable, it is not the most conducive for a morning jaunt without some level of trepidation. And considering that many patients either walk, ride a piky piky (motorcycle taxi) or a take a bijaji (a small contraption that is half car and half motorcycle), all modes of transportation that would cause anyone to think twice about trying to make it to the doctor here. Given all of this, we usually expect the clinic to be quite slow on these mornings.

The morning was quite soggy and it rained off and on. Luckily we had some patients showing up for us, though, and it was back to business one they were able to drain “Lake FAME” in front of our clinic which wasn’t necessarily prohibiting us from seeing patients, but would have become a quick breeding ground for mosquitos had it remained any longer than it did. We were able to sit through morning report and most of rounds which is something we don’t get to do on most mornings, except for Nan, who has been rounding with the ward team daily to follow up on her pediatric patients. She has been an incredible help to FAME in this regard as they have so many pediatric patients here on a regular basis that include not only their premies, but also more general pediatrics with asthma and similar problems.

Ståle Anda is a Norwegian gentleman who has been here for many years living in Mto wa Mbu and who has an orphanage where he often takes in neurologically impaired children or helps Maasai families whose children have these problems. I’ve written about him several times before when he has brought children with old poliomyelitis, muscular dystrophy or epilepsy. Today he brought two patients for us, the first who had epilepsy and was a situation of converting them from a medication we no longer have a supply of here to another medication that we do.

The second child was far more interesting and, in the end, problematic. Paskalina is a 22 year-old Down’s syndrome patient who we hadn’t seen before, but had been admitted to FAME in January with a sore throat and was found to have a white blood cell count of 112 thousand incidentally. They were told that she most likely had leukemia and should see a hematologist at KCMC where they subsequently went and were given a provisional diagnosis of AML, or acute myelogenous leukemia. This is a blood cancer that is seen in a higher frequency of Trisomy-21 patients and related to the extra chromosome they have similar to many other disorders that we commonly screen for in these patients. This certainly wasn’t a neurologic problem, but since we have seen many of Ståle’s patients in the past, we offered to see Paskalina and, besides, we had the only pediatrician for miles around whose knowledge on this subject far exceeded anyone else’s here.

Paskalina is a delightful person who is functioning at a four year-old level is just a sweetheart. She doesn’t like seeing doctors and was very resistant to being examined, but quickly warmed up to Nan whose style and empathy would put anyone at ease in short order. She found no associated physical findings on her examination related to the blood cancer and she continued to look incredibly well. Unfortunately, when we checked her blood counts, her WBCs were still elevated at 68K, meaning that this was definitely leukemia, though we couldn’t confirm whether we were dealing with AML or ALL (acute lymphocytic leukemia), which would make a difference in the prognosis and whether they could be successfully treated. Her blood smears were sent to the US by email and we heard back rather quickly that it could not be differentiated between the two on the smear and would require flow cytometry, a test that is only available currently in Dar es Salaam at Muhimbili Cancer Hospital where all of these patients are treated in Tanzania.

To make the trip to Dar would be very expensive (but certainly not out of the realm of possibility) and very difficult for Paskalina, who would not only have a hard time with the 10-12 hour bus ride to Dar, but would have a very tough time seeing the many doctors there, some of who might have an amazing demeanor close to Nan’s, but many of who would not. We spent the next day or so sending emails back and forth to the US in attempt to determine what the next step for her would be and to help make the decision as to whether it was feasible and reasonable to send her to Dar to be evaluated and possibly treated. We finally heard back from the person who really counted, though, the head of pediatric hem/onc at Muhimbili who is the one who would be making the ultimate recommendations. What we heard from her was certainly not what we had hoped for by any means and was rather devastating to us all. Essentially, AML was not treatable here in Tanzania (treatment elsewhere like the US could likely be offered, but the prognosis would be grim regardless) and ALL was treated primarily in children, where they would be admitted to the hospital for six months during this time, and that this was not something she would recommend or offer in this situation.

Once again, the reality of caring for patients here was brought the forefront and, though, very difficult for us to accept in this case, we all came to grasp with it in our own way. I know it was very tough for Nan given her short attachment to the patient and the work she put into getting the answers we needed. The reality, of course, is that her prognosis had she been in the US would have been horrible just the same and the decision not to treat could have been just as easily made at some point during her care. It was still a blow to all of us and one of the many experiences of practicing medicine here that will forever remain with each of us.

On another note, the gentleman with the abnormal CT scan and HIV who we are planning to treat for CNS toxoplasmosis did return today for a discussion about the cost of the treatment we are recommending. It will cost over $300 for the six-week course of treatment and he will then have to be on chronic therapy for a minimum of six months. And remember, we are treating presumptive toxoplasmosis, which means that he may not improve if this is something else like CNS lymphoma. We discussed it with the patient and offered to assist him by covering half of the cost of the medication (this was primarily Jamie’s gracious offer) for the initial treatment. We would have to order it and our hope was to start it shortly so we could see him again before we leave to determine if the treatment was helping as 90% of patients have some radiographic and clinical improvement within two weeks if it is indeed toxoplasmosis. Repeating CT scans will be difficult, unfortunately, due to the cost, but we may try to get one before we leave and will all have to pitch in to get it. We’re all in agreement that it would be a good use of funds to manage his case.

Meanwhile, we have been waiting all day for Glen and Sarah to arrive. Glen Gaulton, who is the director of the Center for Global Health at Penn, had planned to spend time with us here (a week to be exact) to get an idea of what FAME is all about, what we do here and what potential there is for additional cooperation between Penn and FAME. Prior to arriving to FAME, though, he was spending a few days with Sarah Tishkoff who has been doing incredible genetics work in Africa for years and has a site at Endulen Clinic, which is in the Ngorongoro Conservation Area not to far away. Their plan had been to come here in the afternoon so Sarah could also spend the night and see FAME. With the heavy rains of the morning, though, it took them many hours to drive through swamps and rivers, getting stuck multiple times, and eventually arriving at around 9pm after their harrowing ordeal. Glen described one event while crossing a swollen river and getting stuck after being caught in the current when he wasn’t sure whether it was safest to stay in the vehicle with the rising water or make a run for shore. Luckily, they had to do neither and made it out somehow. I was happy when they finally arrived as it would not have been very good for all involved to have somehow misplaced them somewhere in the Conservation Area.