Our safari to Tarangire, having been a total success and having survived the wrath of the tsetse flies, was now a memory as we began our last days at FAME. I had planned to have the last three days of our clinic be more follow up than anything else, but apparently that hadn’t been communicated entirely to the rest of my FAME neurology team as I discovered that all of the days had been included on the flier posted around town. So whether it was the fact that it had been raining some earlier in our stay or just that everyone here seems to procrastinate as much as we do at home, we found ourselves completely inundated with neurology patients first thing Monday morning upon our arrival following morning report.

Angel began registering our patients as fast as she possibly could, but they just kept accumulating and we finally had to set a cut off otherwise we wouldn’t possibly finish before dark. Thankfully, we were all very rested from the night before, having gone to bed early after our safari and visit to the Maasai Market. There were also several patients who I knew would be coming today that included patients from Arusha that Pastor Chuma had called me about and who I had really wanted to be present for during their evaluations, but given the circumstances, there was no way I could possibly have done that while also managing to keep the patient flow moving.

One positive side to the morning, and something that surely made Susan’s day given her interest and future plans, was the fact that Ståle had come today with all of his children. Ståle is a Norwegian who has a non-profit organization in Mto wa Mbu that cares for many children and helps families of others in need of medical assistance. I had first met him back in 2013 or 2014 when I had diagnosed a young Maasai boy with muscular dystrophy and had written about having to tell his mother that he wouldn’t grow up to be a Maasai warrior. He had returned for care for several years, but was lost to follow up and Ståle wasn’t quite sure where the family had gone.

Since then, he has continued to bring us patients and these are either children living in his orphanage or those whose families he is assisting with obtaining medical care. Most of them have neurological disorders with the bulk of them being neuromuscular, it seems. We’ve continued to follow these boys who we’ve mostly diagnosed with Duchenne’s muscular dystrophy, a fatal diagnosis with most patients succumbing in their late teens of cardiac or respiratory complications. For Susan, though, the day conveyed a very wide range of emotions. True, it is always fascinating to see patients with disorders that interest you and which you will continue to see for the rest of your career, but there is also the sad reality that these young boys will die well before adulthood and, quite often, with significant struggles.

Two of the boys are brothers whom we have now seen for some time and have watched as they have deteriorated. The older brother was admitted to the hospital when we were last here in October due to respiratory issues, but on today’s visit, he actually looked wonderful, having completely recovered from that episode and appearing no worse from the standpoint of his muscular dystrophy, though knowing fully well that it will continue to progress. Worse yet, his younger brother, with the same disorder, but who is still somehow ambulating despite the laws of physics, has to watch his older brother continue to progress from the very same disease that will eventually rob him of his youth and, finally, of his life. Despite this, they both seem have remarkably positive outlooks making our job a bit easier.

We had seen a number of boys for Ståle during the middle of the day, so when another set of parents with a young boy having difficulty walking came in to see us, it didn’t seem to be overly presumptuous that they had also come with his assistance. The young boy had the typical story of having difficulty with walking over the last several years and he had been seen at several other facilities before coming finally to see us. He was clearly another child with Duchenne’s so when Susan had finished evaluating him officially (his diagnosis was one that we were fairly certain about shortly after his parents had begun his history and our examination was merely confirmatory) and began to discuss the diagnosis and implications with his parents, I mentioned that Ståle could perhaps help with some of the necessary support.

At first they didn’t say anything, but eventually spoke up to say they weren’t with Ståle and had just come to see us from Arusha as they had heard about us being here. What were the odds that another de novo Duchenne’s diagnosis would come in to see us on the same day that we just happened to be seeing all of the other MD kids? I guess when you advertise the only neurology clinic in Northern Tanzania (admittedly, Kilimanjaro Christian Medical Center does have a neurologist on staff, but I’m not certain how often she is seeing outpatients there), it is not too out of the question that these patients will quite likely gravitate to us, or at least that is what we are hoping for. In terms of treatment options, we have little to offer these young boys (granted, steroids are a short term option for those who are still ambulating), but in terms of what we can offer the families as far as a diagnosis and information so they don’t continue bouncing from facility to facility without answers, often spending money they don’t have on needless tests, our work here is often so important and impactful. It is not uncommon that patients have been seen half a dozen times without definite answers which is just so unfortunate.

The young boy who had been hit by a cow, suffering a head injury with loss of consciousness and was found to have a small subdural hematoma on a CT scan returned to see us as we had been on mobile clinic when he was originally seen at FAME. Indeed, his neurological examination was normal and there was no need to consider surgical intervention. He looked great and we gave him a clean bill of health advising them to return if he had any change neurologically, though that was extremely unlikely. Of course, in the US he would have been scheduled for a follow up scan to reassure everyone that it was getting smaller and may have even had two follow up scans, but that would be totally unnecessary for unless he had a chance neurologically, there would be absolutely no change in his treatment. We reassured his family and they were quite grateful for the care he had received at FAME and we were quite happy with how he was doing.

Dr. Jackie had also sent us a young Maasai boy who she had seen in the general outpatient clinic with a head injury he had suffered some ten days ago. He was still having significant post concussive symptoms and the history of his having been unresponsive for several hours was, indeed, worrisome. Jackie had done an extremely thorough evaluation, though, that included documenting a complete neurologic examination that would have made any neurology instructor quite proud and had found the child to be completely normal other than a significant cephalohematoma (blood under the scalp) that was resolving by history and was still tender. The question, of course, was whether he needed to have a CT scan and based on his clinical history and the fact that we were now 10 days out made us quite comfortable with the fact that he had not suffered a skull fracture or other injury of significance to have warranted a scan.

The father had come to FAME expecting to have his son get a scan that would have cost him a significant portion of his family’s income and that is always a problem in a system where there is no third party payer to have to deal with. When a technology becomes available such as the CT scan, and now the MRI (granted, in Arusha there is only one currently), the uninformed community is completely unable to assess the need for it. They see it as something that it is not, almost magical that can provide answers when there are unknowns or, worse yet, when there are no unknowns and it is simply the fact that they haven’t received a good explanation of their condition.

This is often the case with chronic headaches and the expectation that there must be something that is causing the headache, when, in reality, there is nothing we can put our finger on other than that they may have been carrying heavy loads on their head for the last who knows how many years. Our job is often difficult; to explain to a patient why they have chronic headaches and to help them understand that we’re not going to find anything on a CT or MRI scan and that it would be wasting their money to obtain one as it would not provide any answers or change their therapy. Technology is clearly a double-edged sword and introducing it into a health system without some form of checks and balances can be equally as harmful as it is helpful at times.

And finally, there is Mindy and a continuation of the tsetse saga. She had awakened with a painful ankle that was not particularly swollen, but was difficult for her to bend and she was fairly certain that it was related to her run in with the tsetse flies over the weekend. After a tremendous amount of reassurance and convincing her that a short course of steroids would not cause her serious harm and may even make her better, she relented and began taking them. Of course, we continually chided her following that with the fact that she was more manic than normal, but it was all in fun and her ankle slowly improved over the next several days. Oh, and she suffered no ill effects from the steroids as we had all expected despite her concerns. It was a quiet night at the Raynes House and Johannes prepared for his lecture on the finer points of the neurologic examination that he would give the following morning.

After much discussion the night before, we had all agreed to have our breakfast a bit early this morning despite Johannes’ initial objections. Once we had convinced him that we might actually have a better chance of seeing some more big game as in lions, leopards or cheetahs, he seemed to be more agreeable and eventually consented to disturb his beauty sleep with this prospect of a successful game drive. We all showed up for breakfast at 6am and were ready to depart by 6:30am, though the only problem was that we hadn’t yet seen our guide, Yusef, and it would not only be difficult to leave with him, but perhaps even more difficult was the fact that he still had the Land Cruiser with him at the staff area. I checked with the waiter and the word was that he was now apparently on his way to get us, and, sure enough, moments later he showed up and was ready to leave on time. Since we were not coming back to the lodge, as we’d be exiting through the main gate at the end of the day, we would not have the scrumptious picnic lunch we had been given yesterday, but rather the standard safari box lunch that is the usual fare when eating away from camp.

Since we had endured the tsetse flies the day before, we departed with the windows rolled up and the top down so as not to allow access to those little devils who had wreaked havoc on us yesterday. We stopped first at the gate and, despite the fact that it was a few minutes after seven which was their opening time, the gate agent was not yet there to take our park fees so we had to wait several minutes for him to arrive. This gate is significantly less utilized than the main gate and given this was low season here at Tarangire and that only three vehicles has passed through the day before, I couldn’t really blame him for getting a few extra minutes of sleep.

It was a cool and somewhat breezy morning and the sun was already well off the horizon with its bright rays of light beaming down on us. The sun, though, was not yet high enough to produce the intense radiant heat of the midday equatorial Africa, so we were able to drive with the windows closed for sometime without the risk of suffocating inside or having it turn into a sauna in the Land Cruiser. I had suggested to Yusef that we try a different route to get to the river this morning that would leave us in the far southern end of the park by the Silela Swamp we visited yesterday so we could then travel along the river towards the main gate at the other end of the park. We had wanted to leave the park a bit earlier than closing (6:30pm) today as we had to travel all the way back to Karatu this evening and would be dropping Yusef off in Makuyuni so he could catch a bus back to Arusha and I would drive us back to Karatu in time to perhaps catch the Maasai Market that happens there every 7th and 25th of the month. More on the market later.

As we drove, we continually gained altitude so that we would eventually reach the top of a small ridgeline that separates the portion of the park where we were staying from the Tarangire River that dominates the park. We dropped down the other side in the area where the airstrip is just in time to have the plane that had just landed and apparently dropped off passengers, take off just as we passed the end of the runway where we, thankfully, hadn’t made a wrong turn that would have left us a bit worse for the wear as we would have driven right onto the runway in the path of the departing plane. We drove around to the other side of the airstrip and promptly discovered a small pride of lions that consisted of two females and five cubs of various sizes. It was a pretty amazing find and we had he entire group to ourselves for the longest time and, even though they were mostly sleeping, every once in a while one to the cubs would get up and move around. Eventually, one by one, the baby cubs got up and strode off towards the higher grass and embankment and, one by one, disappeared, but not until we had a very nice time watching them lounging in the morning sun. Their two mothers soon followed to keep a close eye on them, undoubtedly, but before they did, Susan noticed that there was a male on the other side of the road making his way to a bush where we quickly recognized another there to be another sleeping male, clearly his brother.

Shortly thereafter, another vehicle pulled along side of us carrying a single passenger who we shortly learned had just flown in on the plane we saw at the airstrip. She had been there for a mere five minutes and had come upon the lions we were watching, but more importantly, it was quite auspicious that they had happened upon us, as the driver noticed that our rear tire was completely flat meaning that we really had no option other than to change it before driving anywhere. The females and the cubs had disappeared over the embankment, though the two males were sleeping in the tall grass less than 50 feet away making a tire change just a wee bit precarious. Yusef eventually got out of the Land Cruiser to begin the process while we all initially watched, and with Johannes capturing the action on an iPhone video, one of the males got up and began walking towards us with Yusef standing by the rear tire in between the two vehicles. Everyone began to quietly, but insistently, yell, so as not to startle the lion, “Yusef, get in the car quickly….” He very willingly complied to our urging, stepping around behind our vehicle and smartly slipped into the driver’s seat so as not to become the lion’s breakfast. Once the one brother had made his way across the road and to the spot where the females had previously been, spraying the area with his scent for a final farewell to us, he sauntered off to the embankment making it safe for us to go out and change the tire while his brother continued to sleep by the bush in the distance.

 

http://

(video courtesy of Johannes Pulst-Korenberg)

Once the tire was changed, we were once again on our way exploring the southern part of the river terrain. We drove up into the woodlands, but the tsetse flies were once again quite thick, causing us to retreat once again to the safety of the river where the flies were present, but nothing in comparison to what they were at their worst. We had seen our share of lions for the morning, including the somewhat close encounter while changing the tire, so we were now looking for the other cats in the park that included cheetah and leopards. Leopards in Tarangire have always been quite elusive for me as well as any guides we’ve had there, so I wasn’t holding out much hope for a spotting, but cheetah are much more often spotted in the park so there was still this opportunity. Unfortunately, there were absolutely no wildebeest and only a very rare zebra in the park as they were mostly outside the park where the grasses were plentiful and had no need for the park scene such that there was far less prey for the lions and leopards, while there were plenty of impala for the cheetah to go after.

Cruising along, Susan suddenly spotted a cheetah not far from the road in the tall grass as it leapt up in hot pursuit of an impala not far in front. She shouted, “cheetah!” to all our surprise including Yusef’s as no one had expected to see it at that moment and, in fact, we were all wondering if we hadn’t tipped off the impala as the cheetah, hot on it’s tail and seemingly closing in, actually failed to make the kill. Considering that cheetah have a 60% or so success rate in making a kill (far greater than lions) our presence may have had some impact in alarming the impala and ruining the cheetah’s chances. We continued to watch the cheetah for bit longer after the failed hunt, following it around until, I think, it was tired of us and wondered off into the woodlands far from our reach with the vehicle as the rules in the park insist that we use the already established trails.

We stopped at the main picnic site today for our lunch and broke out the lunchboxes, along with dozens of other parties of safari-goers, much different than the experience we had had yesterday where we were the only ones at the picnic site and had it all to ourselves. The picnic site is home to some very aggressive Vervet monkeys, who, despite the warnings posted everywhere and the general knowledge that it’s terribly inappropriate to feed any wild animals, have become more and more feisty over the years due to this totally inappropriate behavior by a small percentage of the guests there. There were children chasing the monkeys around and lunches being left unattended on picnic tables serving as easy pickings for the swift little primates who were doing what any self-respecting monkey would do given a similar opportunity. Both Johannes and I, standing together watching this mayhem, were particular offended by these individuals and Johannes joked to me that he would love to have tripped one of the children as they ran past us, completely oblivious to the fact that they were doing anything inappropriate.

Following lunch, we drove off into the area of the park known as the Little Serengeti for it’s resemblance to the vast, endless plain that serves as one of the main attraction for safari goers here in Tanzania. To me, this area of Tarangire brings back memories of having been hopelessly stuck axle deep in the muck in an incredibly remote location while trying to follow a route I had done a number of times previously, but this time had underestimated the amount of rain that had fallen in the previous days. We were on our way to Arusha to catch our flights home the following day and despite the fact that Jess Weinstein seemed to think that it was really exciting, the truth was that had we not been rescued by Leonard, who just happened to have arrived at the park shortly before our incident and was actually able to locate us in the middle of nowhere with my directions, we would have likely spent the night in our vehicle and missed our flights as this is not a place you can simply hike out of unless, of course, you’re interested in knowing the lions up close and personal. Leonard somehow found us and then pulled our vehicle out with his, much to the delight of his tour group, who found it to be an exciting adventure in Africa. I was more than happy to have been rescued at the time.

We left Tarangire National Park after a successful visit and we dropped of Yusef, having survived his run in with the flat tire and the male lion, in Makuyuni, a town at the crossroads to the Serengeti and Karatu, to take a bus home that evening so he would see his family. I drove us back to Karatu and, even though we were all quite exhausted, went to the Maasai Market that happens only twice a month and this would be everyone’s last time to see it. Johannes, Mindy and Susan decided to brave the crowds just to see what was being offered for sale, even though I had told them it was primarily livestock, recycled clothes from the US that come over in bales and other household items. Meanwhile, Susanna and I, having stayed back in the vehicle were suddenly inundated with people wanting to see us the more touristy items like ebony carvings. I hadn’t intended to buy anything from them, but each time I said, “hapana asante,” or “no thank you,” the price would drop until it became pretty impossible to say no any longer. The others came back to join us empty handed, but were quickly swarmed and hard to also partake in the buying. It was a very comical situation in some ways, but very much a part of being in Africa.

Waking up in a safari lodge or safari camp is an exciting proposition, no matter how you look at it. There is an air of anticipation and expectation that is hard to describe as there is really only a single purpose sitting in front of you and that is to see as many animals as you can during your game drive. There is always the hope to see the big cats – the lion, the cheetah and the leopard – and perhaps even a black rhino. There are no rhinos left in Tarangire, of course, long since having vanished due to overhunting and now only seen in the Ngorongoro Crater and the Serengeti. The black rhinos have been endangered now for many years, almost hunted to extinction (read Hemmingway’s The Green Hills of Africa for a sense of what it was like early last century), while the white rhinos of Southern and Southern Central Africa are quite numerous. The white rhinos, a misnomer that it refers to their color as it is actually is a misinterpretation of the Dutch word for “wide” referring to their broad lower snout, are quite easily spotted given their numbers in the wild, while it is something very special to see the black rhinos of Tanzania given their endangered status. So today, we were hoping to see the cats, but also knew that we’d see lots and lots of elephants.

We had a lovely breakfast in the mess tent that included eggs to order, bacon, cereal, fresh fruit and fresh fruit juices. Of course, there was also the wonderful coffee that you find here, freshly brewed and delicious. Once we were done with breakfast, everyone loaded up in the Land Cruiser, packed with everything we’d need for the day along with a huge picnic lunch in a basket that the lodge had prepared for us. Susanna sat up front with Yusef while the rest of us remained in the back and we all stood to get the best view possible. Once through the park gate, we very quickly saw several interesting sites. First, there was a recently killed and only half eaten male impala just off the road with two jackals scavenging it. They were a bit skittish of us and very slowly left the scene of the crime as we remained watching them. We would pass by the completely striped carcass picked to the bone by vultures later that evening. The second thing we saw almost immediately upon driving were two beautiful lesser kudu that were like a blur as we startled them and they ran across the road in front of us. I have never seen a lesser kudu in all of my dozens of trips here and it was a special sight for certain.

We had traveled for some time and I had thought that perhaps we had actually avoided the onslaught of the tsetse flies, but alas we suddenly realized that we had a number of them in the vehicle with us, as well as a cloud of them following behind. They are an incredibly efficient predator, as they seem to operate like guided missiles that don’t give up until you have either swatted them dead or they have scored a bite. They are actually silent as they do not buzz and, though, they are actually quite slow in flight, they seem to maintain the same speed as our vehicle so there is no possibility of out running them. The tsetse is a blood sucking fly that if given the opportunity will fill it’s belly with a meal, but often is disturbed partway through so will move on to another victim to finish filling up. On numerous occasions, I have killed these little devils after they have flown up my pants undetected and when I finally feel them crawling around and crush them, I have a large bloodstain on my pants. The problem is that it is usually not my blood and more than likely that of some animal prey so there is that bit of gross out factor of having some Cape buffalo’s (or any other animal on the plain) blood all over my leg.

In short order, the flies had everyone in the vehicle in rapid disarray trying to swat them away before they bit each of us, which leaves a nasty, itchy welt wherever that may be. I usually bring a number of animal books along with us to use as reference while game viewing, but these served more to use smashing the tsetse against the windows (most effective) or against someone’s leg, back or head (least effective). There was an agreement that any hitting or slapping that involved a tsetse fly was fair game as it was far less painful to be hit by each other than it was to be bitten by a fly. The flies were thick primarily in the woodlands and once we got through this region and finally approached the river, the flies began to thin out and everyone could once again focus on the game drive.

Shortly after reaching the river, Yusef learned from another driver that there were some lions sitting in a tree very far south of where we were, but since we had come to see them, we began driving a bit faster in that direction and after perhaps 45 minutes of hard driving we came upon two lionesses and a cub comfortably sleeping in an acacia tree. As we sat and watched them, they moved around and readjusted several times, but always went back to their basic stance of being laid out on the large branch, seemingly without a care in the world. From there we traveled down to the Silela Swamp, an area at one end of the park where there are often large herds of elephants and Cape buffalo. There is a picnic spot here along with much needed bathrooms and after a short stop, we drove along the edge of the swamp, but only found a few elephants here and there. We did spot a lone hippo with a baby and a number of birds. Two of the coolest sights, though, was a very large and gorgeous Nile monitor that was probably at least three feet in length and incredibly colorful, and some dung beetles working their hardest to roll a large ball of dung up a small embankment. They kept getting halfway up and then having the ball roll back on top of them. It was clearly a Sisyphus moment as we watched them do this time and time again and couldn’t help but feel sorry for them.

Not seeing much at the Silela Swamp, we drove back over the hill towards the river and traveled up about half way, until we reached one of the river crossings to get on the other side where there was a new picnic area. Lunch was scrumptious with cooked chicken in a broth, rice and pasta with sauce. There were also samosas. This was not the typical box lunch one gets on safari (which isn’t bad so don’t get me wrong), but rather a gourmet lunch on the road. I took a short nap on one of the cement seats for the tables, just out of the sun, but it was still quite warm during the middle of the day.

After lunch, we made our way along the river and were heading towards an area along a smaller creek where there are often leopards, but were unable to find any in the trees despite driving very slowly along the road. Mindy noticed lots of lion paw prints in the sand as we drove along, but we didn’t spot any additional big cats for the remainder of the day and spent most of the time watching the hundreds of elephants that we ran across with loads of babies, some only weeks old. Elephants are still the most majestic animals to watch in my mind, as for all the excitement of seeing a cheetah, leopard or lion, it is the elephant that really demonstrates the most social interaction and is the easiest to watch. They are graceful despite their size and just fascinating to watch.

We ended up at the main gate at around 5pm and still had at least an hour or so of driving to get to the southern gate and our lodge, much of which was going to be back through tsetse country, having once again to fight off our arch nemesis and to maintain our sanity. Our windows were already scattered with the dead remains of flies we had smushed with our books and the floor of the Land Cruiser had more intact bodies of those flies we had smacked against each other’s skin causing far less mutilation of these pests, though that was clearly not our intention. The Geneva Conventions did not apply in this form of guerrilla warfare and we were taking no prisoners.

Finally home, all I could think about was getting back in that pool and ordering a drink, so we practically ran to our tents, or at least I did, changed into my suit and headed off for the incredibly refreshing dunk that I had been thinking about for at least a few hours. It was clearly worth the wait as the water was just a bit cooler this evening and sun was lower than it had been yesterday when we got in. I immediately order my Amurula colada and just enjoyed the quiet of being in the middle of Africa in a pool watching the sunset. It would be difficult to imagine a more relaxing situation that I have experienced in the recent past, but this was certainly among the very best of them without question. We eventually made our way from the pool back to our rooms to prepare for another delightful dinner. The skies were not as clear as they had been the night before, so stargazing wasn’t quite as fruitful. We had decided to begin our day tomorrow a bit earlier than today, much to Johannes’ chagrin as we had to convince him that there was indeed the possibility of seeing more if we left earlier. Somehow, I’m still not sure he was convinced, but he went along with it like a good sport, so everyone went to bed a bit early with thoughts of more animals to see tomorrow.

We had scheduled today as another half day of patients as it was another of the residents “wellness days” and, in fact, we were leaving for an overnight safari to Tarangire National Park after lunchtime. I had arranged to have Yusef come from Arusha to drive us for the weekend and we were booked for two nights at the Simba Tarangire Lodge, a beautiful lodge of permanent tented rooms just outside the southern entrance to the park which meant that we wouldn’t have to pay for the park fee today, a savings of about $75, for each day you are in any of the parks you can expect to pay an entrance fee whether you are doing a game drive or not. The park fees have gone up over the last several years and probably rightly so as this is their main source of funding conservation and the objective is to keep the parks as they are for as long as possible and, hopefully, forever.

We had all packed for our trip before we left the house for morning report so there would be no last minute delays or forgotten necessary safari items later. Somehow, though, Johannes managed to forget his sunglasses, so spent the entire weekend with a bit of a squint that had nothing to do with his eyesight. Everyone was incredibly excited about the prospect of seeing animals this weekend and, having been to this lodge before, I knew that they were in for a surprise given how nice it is there. I had stayed there with Laura and Kelley in October 2016, so was looking forward to seeing the place in the wet season.

Our clinic was a bit light this morning, but there were still enough patients to keep everyone busy and I had planned to meet with a visiting doctor who was here to possibly set up a global fellowship program in cooperation with FAME. Despite the quiet clinic, there seemed to be lots of things going on this morning that kept us all quite occupied. During morning report, I told about a young boy who had been here the day before with a history of having been struck by a cow and fallen, striking his head and having about four hours of unconsciousness. This had all happened about a week ago, but they had done a CT scan on the child that had revealed a small subdural hematoma, not big enough to be causing a problem, and had sent him home. I went to review the CT scan after report and, indeed, the subdural was quite small, but just the same, was there, and I requested that the boy come back to see us on Monday so we could more thoroughly evaluate him. If, in fact, he was normal neurologically, then we wouldn’t recommend doing anything else and the subdural would eventually resorb over time. There was no mass effect or evidence of skull fracture on the CT scan so the boy had been very lucky. Even though the general surgeons in Arusha can drain subdural hematomas, it is not overly reassuring that the only neurosurgeon in Tanzania is in Dar es Salaam, some 10+ hours away by bus.

Dr. Caren was working with us for the morning which was nice as she had not had a chance to work with us before and, even though, it was only for the morning, she received some necessary instruction regarding the all so important neurological examination. I had to leave for a bit for a meeting which is always a problem considering the residents do need to staff all of the patients with me, so that did create a small backup in the patient flow, but all seemed to work well and it didn’t end up throwing too much of wrench into the system. I met at the Lilac Café, the very nice and comfortable little cantina here on campus that serves meals to visitors and anyone else who might wander by looking for a good cup of kahawa, or coffee, or even a cappuccino. When FAME built their hospital, they realized that they would have to feed the patients and patients’ families somehow, so the Lilac came into existence and has served everyone well. We sat outside for our meeting and the weather was absolutely gorgeous as the rains had seemed to let up and we were having a lovely streak of days with mixed sun and clouds which is exactly what you hope for here.

We actually finished with clinic a bit early and so were able to head back to the house before lunch. This was a good thing as I noticed in the morning that one of the Land Cruiser tires was flat and would have to be fixed prior to our departure. Yusef has been delayed in coming to Karatu so having him fix the flat was not an option, unfortunately. George, one of the driver mechanics here was nice enough to have changed the tire for me in the morning, a job that isn’t technically demanding, but in the hot sun and humidity, leaves me needing a shower every time I do it. You can’t travel on safari with only one spare as punctures were are so very common, so I would have to have the other tire repaired before we left. I drove down to the tire shop that we usually use to repair our tires where they found the leak and plugged it, then put it back on the vehicle swapping it out for the spare. He checked the pressures on all four tires after that and pronounced that we were now prepared for our safari. When I asked “how much,” I was told 5000 Tsh, or less than $2.50, an amount that would be unimaginable at home.

I returned home within 30 minutes, having repaired the tire, and we all went up to the cantina, essentially stalking it waiting for lunch to be ready. I’m not sure if it was the fact that we were hungry (the lunches here are amazingly delicious) or that we were all chomping at the bit to leave for Tarangire, but everyone devoured their lunch and we were soon on our way to town to meet Yusef. We were also picking up Sokoine, who was heading back to Arusha, so we would drop him off in Makuyuni which would be halfway there and then we would head on our way to the southern gate of Tarangire.

Tarangire is considered the home of the elephants here in Tanzania and a park that is much larger than people think. We passed the road to the main gate and continued along the tarmac until we reached the turnoff for the southern gate and the Tarangire Simba Lodge. The drive takes you through some very remote areas where there are small enclaves of population who are many kilometers from the tarmac and there are fields full of crops. This is a huge flood plane and the road is raised with frequent drops to allow the floodwaters to pass without fully washing out the road during a hard rain. Closer to the park entrance and our lodging, we enter the woodlands that make up this region and as we pass the gate, we have our first encounter with the dreaded tsetse flies that live here during various seasons. They had been plentiful when I was last here in October 2016, and I had hoped that perhaps they wouldn’t be now, but this wasn’t to be the case and our vehicle was quickly enveloped in a cloud of these little beasts.

The tsetse can carry a very serious disorder, trypanisomiasis, or African sleeping sickness, but they do not here, as there have been very few cases reported over the many years in Tanzania. It is endemic in other regions such as areas of Central and West Africa, but here it has virtually been eradicated. Needless to say, though, the mere fact that we’d be seeing them triggered extensive Internet searches on our way down including a map of the incidence of the condition in order to prove to Mindy that it was highly unlikely that any of us would contract this African sleeping sickness. That’s what I get for traveling with a group of highly educated, academic neurologists with an occasional touch of neurosis.

All throughout Tanzania, and primarily in the areas with heavy tsetse infestation, there are “tsetse traps” that hang in the trees which are essentially a cloth of dark blue and black that attracts these flies. No one wears similarly colored clothing on safari for fear of sending the welcome message to the flies, but despite this, they still manage to find you. As we pull up to the gate, there was a Maasai askari there dressed in a dark blue and black shuka and we all had to wonder whether what we were being told about the colors wasn’t some practical joke they were playing on all the mzungu visiting here. Thankfully, though, it was confirmed by a quick Internet search and everyone was relieved with that news.

We pulled up the lodge after our long and dusty ride and were greeted by staff with cool washcloths to refresh us and a cool tropical juice. The tsetse flies were still buzzing around our heads, but thankfully were thinning out so we could at least enjoy our cool clothes and juice and then sat down in the open lobby where the staff gave us our rooms and reviewed other information regarding dinner, internet and power, all questions that were quite pertinent to us. The girls were staying on one tent and Johannes and I were staying in another. We walked to the tents with the staff carrying our bags, as they always insist to do, and proceeded to settle in, but we had definite plans to be at the swimming pool as quickly as possible to refresh ourselves and to watch the sun beginning to set.

The pool here is pretty amazing, mostly for the fact that it has an incredible view to the west of the setting sun over the treetops. In all my visits here, I had never been in a pool in Africa, so this was a first for me and I decided to make the best of the opportunity. The water was cool and refreshing, but even more refreshing were the cold drinks we were served at poolside and enjoyed while floating in the water. I had a beer, though others enjoyed an Amarula colada that uses a cream liquor from South Africa made from the marula fruit that is known to make elephants loopy and ataxic when they eat it. I don’t believe that any of us became ataxic after drinking this tasty concoction, but I do know that we all felt quite relaxed and this was a perfect activity for the resident wellness day. We stayed in the pool until just before sunset, sipping on our drinks and just enjoying the wonderful African atmosphere. It was eventually time to get out, though, so we could prepare for dinner that was going to be served at 7:30 pm that night. We had given our choices of fish or pepper steak earlier while in the pool and were all looking forward a relaxing time for dinner to continue our wellness theme for the day. As expected, dinner was excellent and after dinner we all stood outside near the pool checking out the unbelievable amount of stars in the sky, naming constellations with our iPhone apps and amazed at what we could actually see. Perhaps the most well recognized was Orion, but the most special was the Southern Cross, seen only in the southern hemisphere.

It was finally time to head back to our tents as we were leaving early for our game drive in the morning and everyone was a bit shocked when our escorts showed up to walk us to the tents, one hefting a long shotgun and the other a long spear. The fact is that there are wild animals everywhere in Tanzania and even more so in these areas of the national parks or adjacent to them. One must always be vigilant here and, in fact, the askari had indicated that they had recently had to shoot a lion in camp so we were happy that they were armed as they were. Given the beauty of this place, we sometimes neglect the fact that it can be a dangerous place in other ways than we would imagine living in an American city.

 

Today was to be our last mobile clinic of this visit and we would be spending it at the Rift Valley Children’s Village near the village of Oldeani. Our visit to RVCV is always one of the highlights of this trip for the residents, and specifically for the pediatric neurology fellow, as it is an amazing place that was created by Mama India (India Howell) several years ago after she had been here working and fell in love with the country deciding to spend the rest of her life here. More importantly, though, she decided to create a safe home, and the emphasis is on home, for children that have either been orphaned or unable to be cared for by their families such that they have now become her children and not up for adoption as that would mean this wasn’t truly their home. Children here are cared for by house “mamas” and the children are organized by age and sex once they reach childhood. Children live here until they are ready to go away to school and when it is time for them to go to college, they no longer live in the Children’s village, but often come back on holidays to help with the work.

Children here attend a primary school that is right next door to the village and it was quickly realized that for her children to have a decent education and to remain healthy, she would have to come up with a plan that eventually involved helping to support the school financially with more teachers and to improve the facility. This not only benefited the children at RVCV, but also all of the local children attending the school so that eventually, the academic performance of all the children improved dramatically which was borne out by their testing scores and their ability to move on to secondary school, as this is a huge hurdle here in Tanzania. Children are required to go to primary school which is up through standard seven, or seventh grade, and then they must pass a national exam to determine whether they are eligible to go on to secondary school, form one through four, or not.

Mama India and RVCV are also one of the primary reasons that FAME is where it is today. The town of Karatu and its close proximity to RVCV was a huge factor as they would be able to provide medical care to the children’s village and their neighbors, the village of Oldeani, while FAME could also begin to provide the basic medical needs to the large Karatu community that also included the Maasai in the Ngorongoro Conservation Area. FAME has continued to provide care to these communities for the last ten years and the numbers continue to increase on an annual basis.

The drive to Rift Valley Children’s Village is one of the most scenic routes as you drive along the tarmac towards the Ngorongoro gate and then turn off to the west just before entering the NCA. The dirt road can be very rough at times and, in the rain, can become extremely treacherous just like any of the dirt roads here. You drive along a ridge top and then down into several ravines, before ascending again to a large coffee plantation that surrounds the village and is a main source of employment for the community here, The small village immediately adjacent to the children’s village is extremely poor and there are no permanent buildings, though there is one satellite dish that sticks out like an oddity as we drive by towards the entrance gate to RVCV. Once inside the gate, there is an immediate sense of security in terms of this being a home and the children are central to everyone’s attention here. We’re immediately greeted by the nurse for the children’s village, a full-time occupation as she not only cares for the children here, but also for the children of the nearby community. We already have patients waiting for us, a mix of children and adults, some of whom we have seen before, and others who are new to us.

FAME used to provide a general medicine clinic here every other week, but for various reasons, patients are now transported to the main campus to receive care, though we have continued to have our neurology mobile clinic here as it has made sense for our mission and is typically a very productive visit that everyone looks forward to. There were plenty of children here to keep Susan happy, while we also had a number of adults whom the others could see. The facilities are wonderful for us and we were able to run three exam rooms so patient flow was extremely effective for us.

One child who returned was a young boy who Susan had seen last week at FAME and had been documented to have had an absence seizure during the visit that was provoked with hyperventilation. This is a brief staring spell during which you can see eye fluttering and the patient is unresponsive for several seconds and then just will snap out of it. This is typically a sign of a primary generalized seizure disorder, though could also be merely childhood absence that is a less severe form. His episodes, which had not previously been recognized as seizures, were now interfering with his schoolwork so that he was placed on valproic acid to hopefully prevent further episodes. It would have to be titrated up and the day we were here was the day he was supposed to have increased the medication. His family reported fewer episodes, though we were able to provoke one again with hyperventilation. We recommended increasing the valproic acid as we had planned and seeing how he was going to go on the higher dose of medicine. Treatment for this condition will make a huge impact on this boy’s education and life and, had this not been recognized and treated, he would have gone on continuing to have these brief lapses in consciousness and probably falling further and further behind in school.

Though there are always obstacles, seeing how the children at RVCV are cared for medically by their nurse and also seeing the benefit to the local community is always something that gives hope to the future of at least this small part of the larger community. With continued awareness and involvement by organizations such as RVCV and FAME, the lives of a growing portion of the population can be made better with the hope that those individuals who have benefited will go on to create new programs for social equity and justice. Ultimately, this must all be something that is self sustainable, at least in the sense that it will eventually be all Tanzanian and the requirement of our participation will become less and less over time. It is quite clear that we are in the early stages of this process in regard to the neurologic aspect, though we have continued to make steady progress and perhaps with plans to train some of the doctors here to provide the neurological care that is so necessary, they will eventually be able to do so with gradually less and less help from us. Over time, the need for our involvement will become less and less, and that is our ultimate goal.

The Iraqw settled the Mbulumbulu region of Karatu District and today have vast fertile fields that they cultivate here with lots of plants including beans and maize. Though there are some lucky enough to own a tractor, or perhaps rent one from a friend, there are many, if not most, who still plow their fields by hand behind teams of oxen and on our drive to Upper Kitete and back it is the most common sight that we see in the fields. The Iraqw settled this area many, many years ago after having emigrating from Ethiopia, as did the Maasai. They were at odds for many years until their truce in 1986 that settled the feud that had been going on for such a long time. They now live at peace with each other and considering that we are treating mostly Iraqw and Maasai in our FAME clinic, I have never felt or heard of any dispute between them. The Maasai are herders and the majority of them in this region live in the NCA, or Ngorongoro Conservation Area, where there are many, many villages and bomas. This is the area that we had visited on Sunday for a social visit to Sokoine’s father’s boma. In addition to the Mbulumbulu region, the Iraqw have settled much of Karatu and areas south, which is where Qaru is and where we visited yesterday.

The drive to Upper Kitete is about twice as long as to Kambi ya Simba as you travel along the escarpment above The Great Rift Valley. The geography here is such that the area between the ridge demarcating the NCA to our north and the escarpment becomes narrower and narrower until it is no more and you can travel by car no further. Upper Kitete is near the end of the line, though there is one more town, Lostete, that is truly at the end of the road and where we plan to do a clinic in October. The road to Lostete can be very bad in the rainy season and rather than risking getting stuck or unable to make it to a scheduled clinic, we have decided to wait until the dry season for our inaugural neurology mobile clinic there.

Today, the roads were fine and we finally had the Land Cruiser fixed so we didn’t have a borrow a vehicle from FAME and I’m sure was much appreciated since the stretch Land Rover we had used on Monday and Tuesday is one of the primary transport vehicles that is used to shuttle staff from town to FAME in the morning and evening. The seating in the Land Rover is for nine, though someone has to sit on the front console sitting backwards since we had ten of us going the days before. The Land Cruiser seats only eight plus the cooler it the back makes nine, but we again needed it for ten, so had to use a soda crate for someone to sit on to take ten. It wasn’t the worst thing in the world, but it is a very, very bumpy drive so each of took turns on both days sitting on the cooler. I think each of us became fairly nauseated, or at the very least queasy on the drives when having to sit in that seat.

As much as Kambi ya Simba has drastically changed since I began coming to these sites in 2011, Upper Kitete has remained essentially the unchanged other than the addition of one building that has three unfurnished rooms and new outhouses. The main dispensary is entirely unchanged and looks exactly as it did     on my very first visit here seven years ago. There is a nurses office on one side that we have used on occasion and did so last visit I believe, but today we were asked to use one room in the new building and the treatment office, where much of the routine care is given in the dispensary, and a room that I have referred to as the “bat cave.” I have used the treatment office since originally coming here and it is particularly memorable in that it has a square of ceiling missing in one corner of the room that leads into the rafters. There has always been the faint odor of bat urine coming from the hole in the ceiling along with occasional squeaks from the bats as they socialize, but they are mainly silent and have never come out during one of our clinics. The odor has never bothered me, nor does it appear to bother the people of Upper Kitete as no one has ever chosen to change anything about the room, the ceiling or the bats.

Susanna and Johannes were working together in the other building where they had a desk and chairs to use to evaluate patients (always helpful), but no bed or examination table. They were working with Emmanuel, who is Iraqw and can always switch quickly between that language, English and Swahili. Susan and Mindy were working with Dr. Jackie in the bat cave, but after they had seen several patients, they moved to the outside and were seeing patients in the outer walkway of the dispensary to have more fresh air as Mindy complained that she was coughing from being in that room. I’m not sure that I really believed it, though, but had no problem with them working outside as the weather was beautiful and the clinic wasn’t crowded so there was more than enough space to accomplish their work.

There was the regular smattering of patients that we see at most locations here, those being headache, generalized body pain or numbness and epilepsy, but one young woman who had seen us was a particularly sad case who had been seen by us previously and was developmentally delayed in addition to having seizures. We had wanted to titrate up her carbamazepine in the interim since our last visit, but unfortunately the patient had not followed up with FAME. The family felt strongly that the medication had not helped her and had perhaps even made her worse. What was striking about the case is that she is moderately delayed and non-verbal, but yet had a three-year-old child that her mother was caring for.

This rather tragic situation is something that I have seen on several occasions in the past and it is even more unfortunate given the fact that birth control here is free, including the implantable long acting progesterone, the Implanon implant device. Thankfully, her family had already taken care of the family planning aspect and had had the implant placed which actually made our job just a bit easier since we wanted to switch her to a medication, valproic acid, that can cause very serious birth defects and so is not used in women of childbearing age unless we can be assured they won’t become pregnant. Her Implanon device was good for five years and had been placed within the last year, so we were safe from that standpoint. The other issue, the fact that she had become pregnant and now has a young child that her family is raising, is unfortunate and thankfully her family has taken the initial steps so that it will not happen again.

 

We had finished our list of patients and were ready to leave when another patient came late to be seen and it was a child with possible epilepsy, so there was no way that we were going to leave as far as Susan was concerned. Though we could have instructed the patient to come to FAME and see us, there was no way to know that that would actually happen so we added the patient to our list and Susan proceeded to see him. Within moments of hearing the story, and I was listening in with the hope of expediting the visit, it was clear that the child was not having seizures, but rather non-epileptic events as they were clearly situational. What was a bit concerning to Susan, Mindy and Jackie, though, was that the child had burns on the back of his hands and they were told that he had fallen into an open fire which didn’t make much sense as to where the burns were. They were worried the child was possibly being mistreated so they spent extra time explaining to the family that the episodes, though not epileptic and not requiring medications, were also not something that he was doing intentionally. There are no social safety nets here in this situation and all we could hope for was that we they were able to get the point across to the family. Hopefully we did.

We had finished up seeing patients in time for us to briefly drive to the Overlook, a spot on the top of the 2000-foot escarpment that overlooks the Rift Valley and allows a vantage point so you can see Lake Manyara far to the south and up the valley far to the north towards Lake Natron. As you approach the Overlook, it appears that you driving into oblivion as the road merely ends at the edge of a dramatic cliff, but is really the incredibly steep embankment that was formed millions of years ago. This region, and nearby Oldupai Gorge, were the birthplace of mankind over five million years ago and everyone on this planet has descended from those individuals who migrated from here to populate the rest of our planet over the centuries and centuries that have followed. We all stood at the edge of this amazing precipice, as I am sure our ancestors did millions of years ago, in wonderment at was laid out in front of us. Huge birds of prey could often be seen soaring high above the ground, but far below our feet, looking for prey as they have always done since the beginning of time. One can easily imagine prehistoric birds having flown these same updrafts, perhaps looking for different prey along the evolutionary line, but prey just the same.

It is impressive how remote this site is and how little know it is. Most in Karatu have never heard of the area as the drive here is one you wouldn’t take unless you needed to, as there is nothing beyond us other than the small village of Lostete. We are lucky to have been invited to continue here to Upper Kitete over the last seven years and I’m thankful to Paula and Amiri for having introduced me to these sites. And I am lucky enough to bring my residents back here twice a year and share it with them for each individual has a different reaction to the grandeur of this place. To me, it is always a highly spiritual moment when walking to the edge of this precipice as I know countless other generations of our ancestors have done in the millions of years that this has existed.

The drive back to Karatu is always breathtaking and today the weather was particularly cooperative so the views were again breathtaking. The escarpment remains immediately to our left as we travel with Lake Manyara and Mto wa Mbu, or Mosquito River, the village at the close end of the lake, laid out before us at the bottom of the valley. We returned home with plans for dinner and then heading out to Happy Day as it was once again Wednesday night, when all the expats meet at the pub to socialize and share stories. I hung out with the other directors of programs here while all of the younger volunteers shared stories or did what those half my age do these days. It is a wonderful community of volunteers here that come from different countries on different continents, yet all have so many things in common. There is such camaraderie of purpose here that can’t go unnoticed.

 

 

 

Hopefully, some of you may recall the 1969 mediocre comedy with Suzanne Pleshette, “If It’s Tuesday, This Must Be Belgium,” about a tour guide taking American tourists across Europe. Of course, I’m probably dating myself, but this movie did infuse itself into our vernacular for those of us from that era and became an appropriate phrase to suggest that one was in a different location each day of the week. Our mobile week is just such a situation, in which we travel to a different location on each day of the week, so it can be a bit disorienting trying to remember exactly where you are.

Since it was Tuesday, though, we had another educational lecture to give to the doctors and clinical officers here. Mindy delivered an exceptional lecture on headache emergencies that was case based and built on some previous lectures they had been given by other residents. As Mindy deftly referred to her lecture, it was about patients presenting with headache who shouldn’t be sent home on amitriptyline. Any resident who has worked here with me would easily understand the reference as this is probably the most common medication we prescribe here, most often for headache, and its sister medication, nortriptyline, is one of the most common medications we prescribe for headache in the US. Her lecture was very concise and held everyone’s attention throughout.

Today, we were traveling to the village of Qaru, which is south of Karatu in the direction of the Haydom Hospital, but only about an hour away instead of three. Following our adventure in the Ngorongoro Conservation Area on Sunday, our Land Cruiser had some necessary repairs, namely reinstalling the rear driveshaft, or propeller shaft as it is known here, and replacing the center bearing that had to be shipped from Arusha. It was unrealistic to think that this could have actually been done overnight, though Soja, who does all the maintenance on the FAME vehicles, had tried his best to accomplish this. He had almost come through, but, in the end, needed to test drive the car and wouldn’t have it ready until nearly noon which would put us too far behind on our itinerary. So, we borrowed the FAME stretch Land Rover once again, though that is a bit of a hassle here as that vehicle is used to shuttle staff at the beginning the end of the day. Omari was once again going to drive us, for as much as driving here is one of the great pleasures in life for me (those of you who know me are well aware of this), I have also come to realize that the FAME drivers are quite equipped to manage any mechanical breakdowns that may occur and would otherwise endanger the entire mobile clinic mission if we weren’t able to reach or destination. For this reason, I am willing to sacrifice my time behind the wheel and sit in the back of the vehicle to be driven. I have become more tolerant of not being in total control and it has been a good exercise for me.

Qaru is a very small village, one of many other nondescript villages along this main thoroughfare that travels from Karatu heading south through somewhat less fertile land than we saw yesterday in the Mbulumbulu region, but is still covered with crops everywhere. This region is also primarily Iraqw, who are farmers, as opposed to the Maasai, who are livestock herders. As we reach the center of Qaru, we turn left and follow the signs to the dispensary where we will be holding our neurology clinic for today only. Unfortunately, because of the vehicle problems (my Land Cruiser being in the shop and having to wait for the Land Rover stretch) we are well over an hour late and those patients who were waiting here have gone home for lunch and will be back shortly.

It was break time for the school students, of which there were probably 100 or so, and they seemed to be having a blast at the water tank that sits up on a rock and had been opened to irrigate some banana trees nearby. A number of the children had climbed high onto the rock to play with the water coming out and every time I pointed my camera at them to take a photo, they tried to duck behind the tank as if I were somehow going to turn them in to the authorities. I think they eventually realized that that wasn’t the case and relaxed a bit, though by then, recess was almost over and they all began to gather up to head back to class. We got a few photos with the group of them and now they were all extremely excited to be in the front and have their photo taken. Since our patients hadn’t yet shown up, it was decided that we would have lunch, but there was some wonderful gospel music coming from the other side of the church where I found a small group of a cappella church singers rehearing a song. It was so nice to just sit and listen to their wonderful voices as they seemed to have absolutely no concern about me being there and even offered, “karibu,” or “welcome,” on several occasions to make certain that I knew I was welcome. It was truly a lovely moment to be a part of something so meaningful to them.

http://

We eventually had our patients show up for clinic and there were several very good neurology patients along with some children for Susan to see. One young girl named “Brightness” came with her mother and she absolutely lived up to her name as she was a very bright and interactive child, though who had been having many frequent seizures for at least several years, but was otherwise totally intact neurologically. It was rather exceptional that she was so intact having had seizures for so long, but the description of the episodes was quite convincing for seizure and she had responded briefly to phenobarbital that had controlled her seizures quite well, but her family had run out of the medication at some point. Her seizures were suggestive of localization related epilepsy and carbamazepine would have been a good medication for her, but she was under two years of age and we don’t usually use it that young. It was a decision we had to make, so decided to put her back on the phenobarb until we are back in October and encouraged them to come back to clinic so that we could re-evaluate her. It was just too risky to put her on the carbamazepine now as there would be little help is something wasn’t going as expected and we just needed to have a few more months of majority under her belt.

A very interesting patient who returned to see us this time was a young girl who is now seven-years-old and who we had first seen in October when Sara had evaluated her at that time. She was very clearly developmentally delayed, but had a significant loss of trucal tone such that she was unable to walk, or even stand. She scoots across the ground on her haunches with her legs bent underneath her and can attempt to pull herself up on furniture, but isn’t able to do very much once she does get up on her feet. She looks ataxic, but really has no other significant cerebellar findings and has been fairly static since an infant without any real progression. We feel fairly strongly that she primarily has some form of a birth injury given her delay along with the fact that she hasn’t progressed, and we’d love to see a CT scan of her brain, but it would really serve any purpose most likely doesn’t have anything we could really treat regardless.

Our last patients of day were two tough cases for very different reasons. One was an elderly gentleman who had been recently treated (though not for long enough) for brucellosis and now came in with numerous symptoms along with findings on exam that were very concerning for neurobrucellosis, especially given his prior inadequate treatment with antibiotics. He had significant finding on examination that included cranial nerve deficits papilledema that were very objective and given his history, we were quite concerned about him. He was told that he should come to FAME where we could do a thorough evaluation that should include a CT scan and a lumbar puncture, the former test to be done both for diagnostic reasons as well as to make sure it would be safe for us to tap him given the papilledema and focal findings on his examination. He said that he would need to go home to discuss it with his family first, which often means you won’t see them again, and then was promptly hoisted onto the back of a motorcycle with his family member behind him to be transported home. He disparately needed to come in the hospital, and though we all hoped that we would see him again, I knew from past experience that it would be a less than 50% chance that we would.

The other last patient wasn’t difficult for medical reasons, but more for social reasons. He had a history of a seizure disorder that hadn’t really be treated as his parents hadn’t allowed him to see a doctor, and, in fact, were unaware that he was even seeing us this day. He had been brought in to see us by an aunt or a next door neighbor, we weren’t quite certain which, and he needed medications. It was unclear to us whether he would be able to stay on medications as his parents weren’t in favor of them, but he was really old enough to make these decisions himself. It was another case of treating a patient in the short term and being hopeful that they would continue treatment in the long term as well.

We left Qaru that day at least with some satisfaction that we had seen excellent neurological cases that could benefit from our expertise, though in the end, it wasn’t entirely clear to each of us how much we had truly been able to impact the life of our patients. Dr. Jackie was working with us, though, so we knew that these were great teaching cases so that in the future she would be able to recognize and treat these disorders effectively. In the end, that’s often the very best that we can do.

 

We arrived home a bit late again, but early enough to run into town where everyone could shop for fabrics that they would have clothing made from as the fabrics here are so colorful and unique. Susanna didn’t partake, but even Johannes decided to make a foray into the experience by ordering some clothes for himself. We finally arrived home that night, quite tired and ready to crash. We had dinner and each worked on our various projects with the residents continuing to enter patient data into our databases that are for our own use to know what types of neurological disorders we are treating here along with an epilepsy database to determine whether we have ultimately made an impact here in the treatment of this disorder that is very manageable as long as it’s recognized for what it is.

 

 

Today is the first day of our week-long neurology mobile clinic, where we travel to four local villages in the Karatu District that are more remote and usually require anywhere from an hour to an hour and a half travel by safari vehicle from Karatu. I first began providing this service in 2011, with the help of Paula Gremley, an expat who had lived in Tanzania for a number of years providing help with social services for neurologically impaired children through her own NGO, and Amir Bakari Mwinjuma, her Tanzanian partner in the project. Paula and Amir were the first to take me to the villages of the Mbulumbulu region of the Upper Rift and I have been coming back ever since to provide neurological services to this rather remote corner of Karatu District that was settled exclusively by the Iraqw in the years past. Paula accompanied for a few years, but traveled back to the US for personal reasons several years ago. With FAME’s continued support, though, I have been able to continue these clinics each time I am here (barring political or weather events that prohibit our travel here) and bringing residents to these amazingly beautiful parts of Tanzania is always a highlight of their visit here.

The clinics vary in size, often depending on the weather or the time of year (i.e. harvest time), but there are always some patients who come to see us, many of them returning every six months. It is not our mission to provide general medical care in these locations, as they do have dispensaries where there are typically clinical officers to provide that care and our purpose is to exclusively see those patients with neurological illness only. This can be challenging and requires a bit of triage, though we have angel to do that for us this year. It is always tough to tell at times whether someone has a neurological problem until you have evaluated them so we often see patients with osteoarthrosis (run of the mill arthritis) or what they refer to here as “GBM,” which means, “generalized body malaise,” but has an entirely different meaning in our world as it refers to glioblastoma multiforme, or one of the most aggressive primary brain tumors that has a very poor prognosis even with treatment. When I kept seeing this written in the charts of patients here, I wondered to myself why there was such a high incidence of this malignant brain tumor here. Thankfully, I was in error.

The first clinic of the week was to be in Kambi ya Simba, or lion camp, that is a small village it the Mbulumbulu region and just shy of an hour away. The roads to the Mbulumbulu region can be very treacherous in the rains and I’ve managed in the past to get my vehicle hopelessly mired in the mud, having to be rescued by Ema, one of our FAME drivers and quite to often my hero here when I seem to find myself in trouble on the road. Roads here become skating rinks in the rain as the “Karatu clay,” the orange or ochre clay that coats everything on the roadside in the dry season when it is dust and everything underfoot and under tire when it is wet, becomes a slippery, sloppy mess. Add to that that deep drainage ditches on the side of the road that are formed by the quick downpours that occur here, and you have a sure bet to spends hours trying to extricate yourself should you happen to slide off the driving surface. These days, during the month of March, I have a driver from FAME take us to Mbulumbulu, and the other sites if possible, since they are much more experienced at driving here than I am.

As I mentioned, the road to Kambi ya Simba is close to an hour from Karatu, and by the time we get our lunches, waters and anything else for the day, it always seems like we arrive between 10:30 and 11am for our clinic. Just shy of the dispensary where we are seeing patients, a huge panel truck that we are following up the hill became stuck, delaying us for several minutes while it was being dug out, though we eventually were able to drive around it with only minor trepidation. As we pulled up to the dispensary here, I barely recognized it as there is so much construction going on. The first two years I came here, I saw patients in the field by the church using a desk and chairs to sit on under the open sky. Then we began using the labor ward and over the last two years have used a new building they had constructed. Now there are nearly a dozen buildings where there used to be none and we’re given our own building, though they did have to carry desks and chairs for us to use to see patients.

The truck we had driven around was actually heading here to deliver construction supplies to the jobsite and arrived shortly after we began to see patients. Previously, we had seen numerous epilepsy patients here, but none of them seemed to return which is always a bit worrisome considered the now more realized issue of SUDEP, or sudden unexplained death in epilepsy, in patients with epilepsy that is more prevalent in patients who are poorly controlled with their seizures. The patients today turned out to mostly be those with arthritic pains or “GBM” and neurological disorders were few and far between, unfortunately. We were not overwhelmed with patients, but since we started late, it took a while for us to finish causing us to arrive home a bit later than anticipated. I think we were all a bit overwhelmed from our experience yesterday, and so were all pretty much exhausted as we headed home so decided to have our dinner and then a relaxing evening at home.

For our trip to Empakai Crater and Ngorongoro Conservation Area, I had decided to see whether Sokoine could possibly accompany us and perhaps we could arrange a visit to his father’s boma where he had grown up. He has been living in Arusha for the last several months, but had agreed to travel here and meet us in Karatu where we would buy some gifts to bring for his father as that is the appropriate gesture when visiting a boma socially. Their boma sits in a gorgeous valley that is beyond the big crater (Ngorongoro) and is among a number of surrounding Maasai villages that are so numerous there. I have been to his father’s boma on two prior occasions and there is always something new that I see for the first time so I never refuse an offer to go back. The residents were also all very excited about the prospect of visiting a boma so we left town that morning with lots of excitement and enthusiasm as we’d not only get to visit the boma, but also hike into Empakai Crater, which is truly a unique experience as the scenery is so unique and it’s rare that you are able to hike through a forest teaming with animals. No worries, though, for we do have a Maasai guide with us who carries with him a spear that can be used if needed, How he would ever protect a group, though, with a single spear against a charging lion is a little beyond me, but hey, we’re in Africa and that is how things are done here.

Since we weren’t leaving at the crack of dawn, there was plenty of time to make sandwiches for lunch along with some other snacks that we’d bring such as cutup pineapple, sliced cheese and, of course, some Coke Zeros. We also packed extra sandwiches for Sokoine and Philipo, our guide, who would protect us while hiking into Empakai. After meeting up with Sokoine in town and picking up all the supplies we’d bring to his father as gifts, we departed for the Ngorongoro Conservation Area gate that was about 20 minutes out of town to the west. Getting through this gate has always been a huge source of stress for me, as the requirements seem to continuously change every time I get there. Over the last several years, they have required that you deposit money into one of the national banks here and that would remain I that account until it’s used. You would take the receipt of deposit up to the gate and, as long as you had the correct amount of money deposited, they would grant you access to the NCA. You couldn’t use cash at any of the gates, as much of it would disappear. Thankfully, over the last year, they have now allowed the use of credit cards at the gate, so it has become a much simpler process.

On arriving at the gate this time, though, we were immediately confronted by a government official wanting to see all of the paperwork for our vehicle to make sure the appropriate taxes had been paid (which they thankfully were). Once inside the gate office, we were again confronted by another official asking us the very same questions. Finally at the window to purchase our entrance fees, the agent wanted to know which safari company we were traveling with and where our booking confirmations were. I took forever to convince him that I was the driver as he was somehow under the impression that Sokoine was our driver/guide and that we were trying to avoid paying additional fees. Once that was all straightened out, they let us on our way and we were finally through the gate heading up to the crater rim. The long winding road up to the crater rim is like driving through a primordial forest as the drop-offs are severe and the trees, many of which are quite large, are incredibly tall as they reach for a share of sunlight from the bottom of the gorges that accompany us as we make our way. Every form of vine imaginable are hanging from the trees as we travel up and up towards the rim which has an elevation of over 7500 feet. As we approach the top, the assent road immediately takes you to the overlook, with an incredible panoramic view of this amazing geologic feature.

Ngorongoro Crater is actually a massive caldera formed by an ancient volcano and is ten miles in diameter and 2000 feet deep. The walls of the crater are quite steep and there are only three access roads into it – a descent road on the far opposite side, an assent road half way around to our left and a two-way road half way around to our right. At the bottom of the crater there is a very large lake near the center and a smaller lake where most groups have lunch. Roads crisscross the bottom of the crater and from above, everything looks so close, but having been inside many times, it is a vast openness filled with animals that have no need to migrate as everything is here for them. The crater is also home to the largest collection of black rhinos in the world as they are an endangered species. Every type of animal is here other than the giraffe, as the steep walls are too difficult for them to navigate, and the Nile crocodile, as there is no flowing river here. It is truly a magnificent wonder and as you descent into it you feel as though you are entering another world.

This crater wasn’t our destination today, though, as we were traveling to Empakai Crater, which is smaller, but equally gorgeous and is unique as you hike down into it rather than drive. It is north of Ngorongoro and is one of three large caldera that are the remnants of a vast volcanic range of mountains that also includes Kilimanjaro far to the east. The drive around the rim has to be one of the most scenic roads in the world as you have the crater constantly on one side and you are looking out towards Karatu on the side we are on or the Serengeti on the far side. You travel up and down the undulations of the rim, always with the chance of spotting animals along the way. Two years ago, we had a leopard jump out into the road in front of us and then slowly wander alongside our vehicle in full view. This drive is an amazing experience in itself.

Once we were driving along the rim road this morning, though, we ran into a bit of a problem with our vehicle. A constant squeaking that we had heard earlier, much like one of the many squeaks you hear on a twenty-year-old Land Cruiser, began to get louder and then we developed a loud clunking noise underneath the vehicle that was a bit more worrisome. The clunk eventually turned to a loud vibration that would develop when we hit potholes that are essentially constant on these had packed mud roads. I could get the vibration to stop briefly by slowing to a stop, but it would quickly occur again and we were eventually driving at a snails pace to keep it from being constant. I had gotten out twice to see what the problem was, but thought it was in the suspension and hadn’t seen anything. On the third look, though, I spotted the problem, and it wasn’t good. The cross bearing on the rear drive shaft just behind the transfer case had come apart and it didn’t look like it would make it much further if something wasn’t done.

Becoming stranded on the crater rim wasn’t something I looked forward to as it has happened once before to me. Our choice was for us to turn around and hope that we could make it to the gate without breaking down or possibly limp another five or so kilometers to the Sopa Lodge and hope that they had someone there on a Sunday morning who could even look at the vehicle, and then the question would be whether they could even fix it. Either possibility seemed quite unlikely, but Sokoine, who studied tourist management before and had worked at several of the Sopa Lodges made a few phone calls and the prospect of having something done seemed to become a bit more encouraging. So we limped ahead towards the Sopa Lodge, driving about 30 kph maximum and, amazingly, made it to the Lodge with the vehicle still making forward progress, albeit at a fraction of my normal speed.

The mechanics had gone home for the day, but the manager made a few calls on his radio and we were instructed to drive back towards the staff housing where the “garage,” which was essentially a very small workshop with a compressor and a pit in the ground for the mechanics to stand in while they worked on the car. As we had pulled into the lodge, we had also discovered that we had a flat rear tire that also had to be repaired, but I eventually drove into the workshop on top of the pit and the mechanic got under the car to announce that, indeed, it was our driveshaft, but that he could fix the problem. The solution turned out to be taking the entire rear driveshaft out and then engaging the four-wheel drive that would essentially give us only front wheel drive since there was now no drive shaft in the rear. The remedy would allow us to drive, but having only front wheel drive in a massive stretch Land Cruiser wasn’t something I looked forward to, especially on these roads, some of which were quick muddy and rain soaked. Getting into any situation that would require four-wheel drive to extricate ourselves just wasn’t an option any longer, but that isn’t always up to the driver, unfortunately.

While the vehicle was being fixed, the others enjoyed the amenities of the Sopa Lodge, which arguably has the absolute best view of Ngorongoro Crater, and when it began to rain a bit, they sat inside the “Crater View Bar” which they had all to their own and had a picnic lunch. We were on our way after about two hours and, though, we had to abandon our plans to go to Empakai Crater as it was too far and remote to risk another breakdown, and we didn’t have enough time left to do it as the park gate closes at 6pm. Instead, we decided to just to go Sokoine’s father’s boma and visit his family. The short distance of six or so kilometers was a bit muddy, but we were able to navigate it safely and arrived to the small trail of a road that would take us to the boma. I drove a short distance and didn’t like what I saw ahead of us as the last thing I wanted to do was to get stuck in the mud here after all we’d been through. We unloaded the gifts we had brought and made our way the remaining short distance to the huts that were a short ways down the road.

As we entered the boma, we were first greeted by children which is always the case and then by other members of Sokoine’s family. His father has five wives, four of whom live it he boma as Sokoine’s mother is living some distance away near Oldupai Gorge where he father used to travel occasionally, but no longer can given his age (he is 86 now) and arthritis. His father, four of his wives, most of his sons and some of their families (including grandchildren too numerous to count) all live in this enclave of mud and dung huts that is referred to as a boma. Small corrals for the animals at night are located in the center of the boma to protect them at night against the lions and hyenas, thought they still lose animals to these predators on a regular basis, there having been a hyena attack the night before with the lose of two donkeys and injury to a third.

We made our way through the boma to find Sokoine’s father and eventually did find him sitting beside his youngest wife’s hut with lots of grandchildren surrounding him. He is a small and aged man, but one can clearly see his profound character and prominence when you sit with him and talk. Wealth in the Maasai world is based on cattle and children and he has many of each. We gave him his gifts, which were promptly stored inside his hut, and then we roamed through the boma enjoying the many children who were thrilled to have the hard candies that Sokoine had brought with us for this exact reason. A few of the older boys were fascinated by my camera so I put the strap around one of their necks and showed them where the shutter was. He promptly took lots of photos as I had the shutter still on continuous mode, but that’s OK as we’re in the digital age and I knew that I could just delete the photos later. Several of the boys wanted to try the camera so I patiently showed each one how to use it and allowed them to play with it.

 

There is some grass between the huts where were wandered, but the majority of the ground is covered in reasonable fresh cow manure and most of the children run barefoot through it with little concern while we watch every step trying to collect as little of it on our shoes as possible. I’ve been here twice before and I always enjoy just watching the residents interact with the children and women here for most of the men are out with the cattle during the daytime. Eventually, we all went to have a seat with Sokoine’s father inside his youngest wife’s hut. There was an outer area inside the hut that we first sat in a all shared a drink of the Konyagi, a strong gin that is made in the country and is very cheap, that we had brought as a gift for him as Sokoine made sure we know that true friends do not visit a boma without this gift in addition to the other many supplies we had brought like cooking oil, beans, sugar and such. I sat next to his father who recognized me from my previous visits and we exchanged complements with each other. After this, Sokoine took the others further inside the hut to see the living area where there are beds, room for some animals and a fire to burn for warmth. It is a very simple existence with absolutely no amenities. They bath outside using well water, milk the cows in the morning for their drink and occasionally slaughter a goat for their meat. The normal sustenance is ugali, which is the still porridge that is made from maize and is eaten either with vegetables or meat.

After their tour of the hut, we all again sat with his father and everyone got to ask lots of question, though Mindy was by far the most curious, having many excellent questions about their culture and religion, and, thankfully, stayed away from any of the more difficult questions such as women’s education and female circumcision, that is still practiced in the bomas even though it has been outlawed by the government. These questions would not have been appropriate to ask in this setting for certain, though they are huge issues that must eventually be tackled by the Maasai.

As we had to get back to the gate by 6pm, we eventually had to say our goodbyes to everyone at the boma, though the children all followed us back to our vehicle, still waving as we backed out of the small trail we were on and onto the main road back to the crater rim. We still were not home free as the road was quite slippery in some places so there was still the challenge of making it back around the rim and down to the gate in time. We eventually came to one incredibly slippery uphill section that I tried twice to get up and finally had everyone get out of the car to make my third attempt a bit lighter. Just before I got underway, a safari vehicle came down and the driver offered to take it up the hill for us. He did so successfully, and even though my machismo may have suffered a tad, I was just happy that the vehicle was now on the other side so we could be on our way.

I drove like a banshee for the remainder of the distance and, even with that, we made it to the gate with just ten minutes to spare as they close the gate at 6pm sharp and you have to pay for an additional day to get out, something that none of us would have been very happy about. We all felt the sense of having survived something meaningful, though, as we were all nearly stranded in the crater on several occasions and, given the remoteness of this area, that is a feat certainly worthy of a great accomplishment. We all cheered as we passed through the gate with minutes to spare, still with forward progress in our hobbled Land Cruiser, the little engine that could. We went into town directly to a local restaurant for some nyamachoma, or, literally, burnt meat, which is their version of barbecued beef or goat. We had a mixture of both, along with some chips, or French fries, and some beers and were all totally satisfied with our wonderful day, despite the challenges that may have made it all that much more satisfying to each of us. It was really an incredible day all around.

Today is our last day of the big neuro clinic at FAME, which is the one that we announce to the town of Karatu and surrounding communities with the hope that we can have most of the neuro cases come in during these six days. Next week we’ll begin our neuro mobile clinic, traveling to the more outlying villages where FAME may still be accessible to patients by taking the local dala dala (mini bus taxis) or larger buses, but patients don’t often realize that they have a treatable neurological problem so that I look at these mobile clinics as something to educate these remote communities of what we do. As I have mentioned before, the clinic has been lighter than normal with the early rains, though we’ve still had some very interesting cases and it’s given the residents a chance to catch up on their Swahili and Iraqw.

Once again, I knew that a friend from Arusha was coming today and bringing several patients with him so that was a plus. We had lots of peds today for Susan and she was quite happy about that aspect of the clinic. Two young boys who were brothers were seeing her this morning and were quite interesting as the younger brother had very clear febrile seizures with a very normal developmental history and examination. The older brother, though, had epilepsy that from a seizure semiology standpoint was very much localization-related as the seizures had clear focality with head turning and he had been on carbamazepine that was working quite well for him. The significance of all of that is that we would have expected the two to have a more common primary generalized epilepsy if this were indeed a genetic epilepsy, but the fact that that the older brother had focality to seizures and that he had responded to carbamazepine, a drug that morning makes primary generalized epilepsy worse and which is avoided typically avoided in these patients.

This is the place where an EEG would be invaluable in both children, as it would have easily answered the question for us on the spot. Unfortunately, the EEG we have here is no longer operational, though hopefully this is something we will once again have available here in the future. Had the younger brother not had a sibling with epilepsy we would have merely diagnosed him with simple febrile convulsions and that would have been that. But with the older brother’s diagnosis, it would certainly increase his risk of developing epilepsy in the future, but not to the degree that would lead us to treat him at this point. We did suggest that he could get an EEG at Kilimanjaro Christian Medical Center in Moshi, which is the only center in Northern Tanzania with those services, or possibly Nairobi, though it wasn’t entirely necessary at this time. At the end of the visit, I had mentioned that they could contact me through my friend in Arusha who had brought them, but it turned out that they had actually come on their own as their father comes to FAME for his medical care and had been here on Wednesday and had seen our notices of the neuro clinic, so had decided to bring his two sons to see us today. We were so happy that they had come, though, as the younger brother may have been put on medication prematurely had he been seen elsewhere.

When we did finally get to see the patients my friend had brought from Arusha, one was a young four-year-old child who had spina bifida, a neural tube defect that can be of varying severity and most often is an incidental finding, but can also, in much less common cases, involve the lower portion of the spinal cord leaving a patient with severe neurological deficits. This young girl, unfortunately, had the less common, more severe form of spina bifida, causing her to have a flaccid paralysis of her legs as well as complete loss of bowel and bladder function and had had surgery on her back just after birth. In addition, she had had hydrocephalus at birth requiring a ventriculoperitoneal shunt so most likely had another condition called an Arnold-Chiari Type II that is very commonly found in association with the more severe forms of spina bifida. She was clearly delayed developmentally in addition to her other neurological deficits, but was very interactive with good speech.

In addition to the life altering neurological deficits that she had, the other very sad issue was that her parents came here with the hope that we would have some type of treatment for their daughter. When Susan asked what their expectations were and they replied that they hoped that something could be done to help their daughter eventually walk and be independent, Susan’s heart dropped as she had to tell them that she would never walk, but could someday hope to use a wheelchair and still have some independence, perhaps. Though you can never be entirely certain as to what patients and families have been told in the past as people often hear what they want to hear, her parents were quite clear with us that they had never been told this before so I am sure that it was quite devastating for them to have heard this in no uncertain terms. Susan waited some time for them to digest the news that she had given them and then allowed them to ask as many questions as they had. There is absolutely no difference culturally in this part of the job and we could have easily have been at home delivering the same devastating news to parents with the very same reaction. This is not an easy part of the job, but is a very satisfying one when you are able to spend time and deliver the news with empathy and grace.

Meanwhile, Johannes was in the ward for much of the morning with a difficult patient that we had been asked to see for symptoms that were more concerning for a psychogenic illness, though after seeing him it was not so black and white. The young man had been having episodes that had been very anxiety provoking for him, but were felt to very possibly be cardiogenic in nature and related to either drops in blood pressure or alterations in his heart rate with the episodes. There is a disorder known as postural orthostatic tachycardia syndrome, or POTS, that is often the bane of neurologists, as it is unclear from our standpoint that it even exists, yet is so very often diagnosed and patients are labeled with this. Johannes felt very strongly, though, that this young man had some condition that affecting his blood pressure and pulse that were causing his episodes and that they were not purely psychogenic in nature. It was very helpful as this had been a significant management problem previously for this patient and now at least they would have something to focus on as far as treatment options going forward. These are quite often very difficult situations to figure out and there is often much that is lost in translation with the language barrier when trying to make these distinctions that are so important as they greatly affect the management of these patients. We do see quite a bit of psychogenic illness here, easily as much if not more than at home, and it can very often be quite challenging.

Susan had plenty of children today to fill her schedule and at one point, realized that she was behind in her charts and needed to do some catching up so it is clear that some things don’t change whether you’re on electronic records or not. During the middle of the day we had a tremendous thunderstorm with lots of lightening and thunder that seemed to be right on top of us dumping buckets of rain with bright flashes of light followed by their thundering booms that shook everything and could be felt throughout your entire body. For at least half an hour, it seemed like the heavens had let loose with all they had to give at the moment. As quickly as it began, though, it ended and the mud and puddles quickly dried as if nothing had happened and the world was right again. Blue skies and sun eventually appeared and we were quickly back in paradise.

We are prepared dinner here at FAME during the weekdays, but on weekends, we are left to fend for ourselves. The weekday dinners are quite delicious and healthy, for the most part, except for perhaps the mac and cheese that is a bit more westernized and unhealthy, but is still quite tasty. We had discussed celebrating St. Patrick’s Day here (yes, I had worn green and changed my name to O’Rubenstein for the day), but both Mindy and Susanna were both feeling a bit under the weather and we had plans to go to Empakai Crater tomorrow, so instead, we all went out to Happy Day for dinner, where we did find others, but certainly not a celebration by any standards. Happy Day has quite reasonably priced, mostly western food that includes delicious Pizzas, Tanzanian style. Not much tomato sauce and toppings that are a bit different, but all in all quite tasty and something that certainly hits the spot when one is craving it. Mindy and Johannes had burgers that were apparently very good. Susanna had stayed home for the evening as she wanted to get some sleep before our trip tomorrow, but she didn’t miss any celebration as there was only one other group of volunteers there and certainly no festivities to speak of. I think we were all a bit tired after the week of seeing patients so we chose to head home instead and relax for the rest of the evening. We weren’t leaving at the crack of dawn so that meant that at least we’d have an extra hour or so of sleep.