Wednesday, March 21, 2018 – A day in Upper Kitete….

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The Upper Kitete dispensary

A view of town from the dispensary

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 notice of our clinic posted at the dispensary

The Upper Kitete dispensary and our vehicle

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.

The outer clinic building where Susanna and Johannes were working

Susanna and Johannes seeing a patient with Emmanuel

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.

Mindy, Jackie and Susan seeing a patient in the treatment room

Susanna and Johannes seeing a patient with Emmanuel’s help

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.

Susan, Jackie and Mindy in the bat cave

Susanna and Johannes seeing a patient with Emmanuel

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.

Mindy, Susan and Jackie holding clinic outside

Jackie, Susan and Mindy seeing a patient in their outdoor clinic

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.

Patricia dispensing meds to a patient

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.

 

The neuro mobile team (sans me) – Johannes, Emmanuel, Patricia in front, Susanna, Jackie, Mindy, Angel, Susan and Omari in back

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.

The residents at the Overlook

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.

Climbing down to a better vantage point

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.

Susanna enjoying the view

Susanna checking out the best location to build a house here

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.

 

 

 

Tuesday, March 20, 2018 – If it’s Tuesday, this must be Qaru…

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Mindy delivering her headache lecture

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.

Mindy delivering her lecture on headaches

Parked at our mobile clinic

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.

Susan and Susanna setting up shop in Qaru

Susan and Susanna working with Dr. Jackie

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.

School children on break

School children with the neuro team

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.

School children playing at the water tower

New heights for the residents. The water tower at Qaru

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.

The choir singing

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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.

Susan, Susanna and Dr. Jackie evaluating a young patient

Our patient before being seen

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.

Susan, Susanna and Dr. Jackie evaluating a patient

Susan helping Dr. Jackie with her examination techniques.

Susan examining a cute patient

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.

Angel helping us with an elderly patient

Johannes and Mindy evaluating a patient with Baraka

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.

Mindy examining a patient

Mindy demonstrating during her examination

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.

Susan, Susanna and Dr. Jackie discussing a patient

 

Susanna working with Dr. Jackie on her exam

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.

 

 

Monday, March 19, 2018 – Day one of mobile clinic at Kambi ya Simba….

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Our Land Rover with Angel speaking to some of the local residents

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.

Susanna and Mindy evaluating a patient with Emanuel

Patricia manning our pharmacy

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.

Susan and Johannes evaluating a patient with Dr. Jackie

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.

Mindy and Susanna evaluating a patient with Dr. Jackie

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.

Johannes and Susan seeing a patient with Emanuel

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.

Susan and Mindy evaluating a patient with Emanuel

Sunday, March 18, 2018 – A trip to the boma, and, thankfully, back again…

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Johannes and Mindy very sad to have had to experience the Sopa Lodge. Susanna is obviously enjoying it.

Ngorongoro Crater from the lookout

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.

On our way to the boma

Being greeted to the boma

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.

Sokoine’s father

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.

Sharing compliments with Sokoine’s father

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.

Handing out candies…

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.

Mindy learning how to build a hut

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.

Sokoine and his father’s first wife

 

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.

Saturday, March 17, 2018 – St. Patrick’s Day in East Africa

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A Maasai family member washing clothes in the morning

Susan catching up on charts

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.

Mindy and Dr. Julius examining a patient

Mindy and Dr. Julius examining a patient

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.

Susan and Baraka evaluating a patient

Susanna teaching Dr. Julius how to test for reflexes

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.

Mindy and Julius evaluating a patient

Mindy and Baraka evaluating a patient

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.

Susanna checking someone’s gait

Dr. Frank and Johannes discussing a case

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.

Our neurology waiting room

Mindy and Julius with a patient

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.

The heavy rains just outside our exam rooms

The heavy rains just outside our exam rooms

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.

Susan and Baraka evaluating a young child

Susan’s pediatric patient

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.

Johannes and Emanuel evaluating a patient

Johannes and Emanuel evaluating a patient