Tuesday, March 26 – Our days are winding down….

Standard

The residents have now been here at FAME for three weeks and their time is winding down. I know that it’s a very different experience for me as I never have to say goodbye to everyone here, knowing that I will be back in six months and stay in touch with them in the interim. For my residents, though, they will have to say goodbye, at least for the moment, and whether they will make it back will be up to factors often out of their control. As they say, “life happens.” Spouses, children, careers can often get in the way and it’s not always as simple as it may seem. Global health came to my life very late and, looking back, I can honestly say that it would have been tremendously more difficult for me to have done it earlier in my family life and career. That’s unfortunate, but it’s also reality. Who knows, though, if had had a similar experience earlier in my training similar to what we are able to offer today.

Our morning started as all our Tuesday mornings do here at FAME, with a teaching session and it was Sheena’s turn to take the helm. She did an excellent job putting together interactive case presentations that required some involvement of the staff and she made it clear to everyone that she would call on people if no one volunteered. Thankfully, we had a decent amount of discussion over the cases so it worked reasonably well.

A full room with Sheena giving her lecture

Our patient volume was a bit more moderate today and there were fewer children, thankfully, considering that Dan and Marin were now in the air on their way back to Philadelphia and quite incommunicado as far as we were concerned. There was one return patient I hadn’t seen yet during this visit and that was my Maasai friend whose wife I have treated now for probably five years and I was concerned about how she was doing. We had been to their boma two years ago for a goat roast which he had given us in our honor and despite having found his wife’s chart from prior visits, we were unable to reach him by telephone. Every Tanzanian, including the Maasai carry cellphones with them and considering the Maasai where mostly only their shukas (plaid blankets), the cellphones are often carried in small pouches that they wear around their necks. As their bomas have no power to recharge their phones, you can often spot small solar panels on the roofs of their huts, large enough to recharge their phones.

A family coming to be seen by us

During the morning, I was given two letters addressed to me that had come from Rift Valley Children’s Village and were sent with one of our two translators who had been with us for the month and had grown up at RVCV. The letters had been sent in appreciation for the time we had spent with two very amazing young individuals who are both contemplating careers in the health field and had spent time helping us with translation during our clinic there. In reality, though, we are the ones who should be expressing our gratitude, for it is not only in directly helping patients here that we can make our greatest impact on the health of this community, but rather it is by sparking that interest in the next generation of caregivers that we can truly capacity build. I have no doubt that these two individuals, and the many others who we have worked with during our time here, will go on to become the future of healthcare in Tanzania and that the success of this country will be in their hands. This is what moves us and the reason we come.

One of our two thank you letters

Thankfully, my friend showed up to clinic today, but was without his wife which was initially a bit disconcerting until he told me that she was doing quite well. Thankfully, she has remained seizure-free for the last five years under our care and has had two successful pregnancies and his children are doing fine. When I had first seen her, we switched her to lamotrigine, a medication that has the best safety data for pregnancy and she has done fantastic ever since. Her previous medication, carbamazepine, had not been controlling her seizures nor was it the best medication for a women planning pregnancies. He had wanted to come earlier with her, but they were unable to mostly because of the expense, but he had come today because he wanted to make sure I knew how appreciative he was for our continued care of his wife. We stood out in front the emergency room, polar opposites as he was tall and proud and dressed in shukas, I in my western garb looking as I normally do. We chatted and hugged, and then hugged and chatted more for what must have been for such a long time, but didn’t seem so to either of us. Both from such different backgrounds, yet brought together here at this moment out of a common interest. Though Kitashu was there translating, there was little need for we were speaking a common language of mutual love and admiration that was unmistakable and did not require years of formal education or instruction for it was universal and innate. We go through life, not necessarily seeking those moments that will stay with us forever, but this was one as it spoke to me as a reminder of the commonality of man and the fact that we are no more than the acts we choose and the paths we follow.

One of our two thank you letters

It was lunchtime and it reminded me that we only had a few remaining. The lunches here are my favorite meals, not counting the lunches and dinners at the lodges, of course, and I look forward to each and every one. Five days a week we receive a meal of beans and rice and a helping of a very green vegetable that is very similar to spinach. I’ve always called it “mchicha,” but I’m not certain that’s correct, so don’t quote me on it. Everyone at FAME eats lunch together in the cantina that has been since the beginning and has not changed one iota. It’s served around 1 pm and continues until everyone has eaten or the food has run out. When Kelley and Laura were here, they said that the beans and rice reminded them of a standard dish in Puerto Rico and, if that’s the case, I could easily live there for the sole reason. For many of the workers, lunch at FAME may be their biggest meal of the day and their portions are heaped high on their plates, something I could never imagine consuming without taking a long siesta later in the day. What really makes the meal, though, is the pili pili sauce that is made from freshly chopped local peppers that are incredibly spicy and are blended fresh most every day. We heaping spoonfuls of the sauce on top of our beans and rice and it takes an amazing meal to a totally new level. On days when there is no pili pili, the meal is just that little bit less and it’s noticeable.

Our waiting area

Tuesday’s lunch, though, consists of ugali, the local stiff porridge that is made from maize and is ubiquitous throughout Sub Saharan Africa, though often by other names. It can also be made of cassava, but here is made from Maize. It is served for lunch with a meat stew in broth that is put over the ugali and then served again with our green spinach-like vegetable and, of course, lots of pili pili. Tanzanians eat their ugali with their right hand, but, I must admit, we use a spoon and it is often difficult to cut the chunks of meat in half with the spoon as they are not the most tender in the world as one might imagine. The other lunch, other than beans and rice and ugali, is served on Thursday, and that is the pilau. It is a brown rice that is mixed with chunks of meat and seasoned to perfection. And, yes, it is also served with our dark green vegetable to top off the plate. And, yes, we heap lots and lots of pili pili on it as we do with most of our meals here. Residents who have come have a varied response to the lunches, but I’d have to say that, by far and away, the majority of them have very much appreciated the meals.

Tonight, we had decided to relax at the Raynes house and to catch up on work that we’d love over the last days. Tomorrow night was Wednesday, a night that we would typically go out to visit with other expats volunteering here, so no one felt a strong need to venture into town to socialize.

 

Monday, March 25 – And back to our neurology clinic, though without our pediatricians….

Standard

(Author’s note: though these blogs were written following my return from Karatu, they were written with notes and a fond memory of our visit)

It had been a glorious trip to the Serengeti and perhaps an even more memorable trip to Kitashu’s boma over the weekend, all without incident, and we were now back at FAME to finish out our week. Dan and Marin would be leaving us today, though, to head back to CHOP and to resume their normal schedule there working in the neuro ICU taking care of very sick children with a tremendously greater repertoire of incredibly costly procedures than anyone here could ever imagine. They were scheduled to fly to Dar es Salaam first (a long story that if you’re interested you can ask either Dan or Marin about) around noon and then from there, would be on their way to Doha and then Philadelphia. They had to leave around 6:30 am to make the three hour plus drive to the airport, but both Phoebe and I were both up to see them off. Charles, our “fast Noah” driver was there on time to pick them up and whisk them off, though I know that each of them was already regretting having only come here for 2 weeks, something that they were both planning to rectify in the future, meaning that they would be back again. Of that, I was certain. A “fast Noah,” by the way, merely means one that is direct and doesn’t stop at every little town to pick people up. It is faster by nature of the fact that it doesn’t have to stop rather than how fast it drives.

Meanwhile, still weary from our safari (except for Daniel who had remained at home spending relaxing periods in my hammock), the rest of us prepared ourselves for clinic without the luxury of having our two amazing pediatric neurologists with us who we had become quite accustomed to over the last several weeks. Though I have seen children throughout my career, I will be the first to admit that I am not a pediatric neurologist and the benefit of working with someone like Dan or Marin had not been lost on me for nary a second. Seeing neonates or young infants with congenital, genetic or mitochondrial disorders is not something I, or any adult neurologist for that matter, feel comfortable with and I am not ashamed to admit that. Our adult neurology residents do rotate through the very best children’s hospital probably in the world, but the training is cursory at best, and is certainly not expected to turn them into a card carrying pediatric neurologist when they’re finished. As I’ve mentioned before, probably a third of our patients at FAME are pediatric, and many of them are infants.

We had morning report at 8 am, as usual, and then it was on to our clinic beginning at 8:30 am. I usually try to reserve this last week for us to see the follow up cases who we had asked to return to either monitor a medication’s effect or to just see the patient again and re-examine them if that’s what was needed. Overall, though, it is often a mix of patients that waited until the last minute to come see us, some who have been cared by us before, but hadn’t made it back yet, and still others who just happened to see our announcements very late and decided to come in the last days. I had hoped that at least the majority of the children had been seen previously by Dan with either Marin or one of the other residents, but this wasn’t to be the case today as it seemed that we had a deluge of children brought to us throughout the morning. The residents resorted to texting Dan and Marin throughout the morning and for the rest of the day and, thankfully they were only in the air for a short time on their way to Dar, and so were readily available to provide consultative services for us, at least for today.

Though, luckily, there were very many adolescent children with disorders we all felt comfortable with, there were also those younger children with such things as developmental delay that can be a bit trickier to sort out. Despite all of this, we made it through the day and the residents continued to provide the exemplary care that both I and the patients here have always been so accustomed to over the years.

The Maasai Market occurs in Karatu twice a month, on the 7th and 25th days of the month and so, at the end of the day, there was still enough time for those who wished to check out the market and enjoy the sights. Just to clarify, though, there are several types of Maasai Markets that you can find here in Tanzania. One type of market is comprised of vendors that are in kiosks selling Maasai or Tanzanian handicrafts such as jewelry, wood carvings, baskets and just about anything you can imagine that you would want to bring home to someone as a gift. These markets are for the “mzungu,” which actually means “stranger,” but is actually more widely used these days to mean a white person. It can be used in both a derogatory and a non-derogatory manner and though I’d like to think that it is more commonly used the former, it is sometimes difficult to tell. So, the Maasai Markets with the handicrafts that I’ve described above are designed for the tourist trade and many towns have one or two of these in them where you can find things to bring home as gifts.

The other type of Maasai Market, and the one that everyone was going to visit today, is a market where the locals come together to buy and sell just about anything that you can imagine. The Maasai men will travel from the surrounding areas to sell their goats and cattle and local farmers will bring their vegetables to market. There are braided ropes and chicken cages, plastic containers of oil and bottles of honey, bags of rice and other grains. And then there are clothes. Sure, you can find clothes made out of Kitenge cloth here, but what you really find are the clothes that have been discarded and collected in our country, and then shipped to Africa in huge bales that are compressed and tied into 4’x4’x6’ blocks of solid cloth, until they are cut free and released, exploding into a literal rainbow of colors and textures that are then madly sorted through until one finds the right size and style and color they’re looking for. Some are new clothes, but most are used and you can find virtually every school in our country represented here in some way, shape or form. You can also find the Championship Superbowl T-shirts for the losing team if you are so inclined as they are printed in advance and then shipped over here immediately after the game so as not to cause any confusion at home. Sifting through the clothes can also be an adventure, as Jess and Jackie learned here several years ago in the company of Paula, our volunteer coordinator back then.

The practice of our hand-me-downs being donated (really discarded), bundled and shipped to Africa has always been a controversial area for a number of reasons (stunting development of local economies for one) and there has always been a little sense of incredulousness over the fact that you can spy every institution from home represented here on the streets of Arusha, and even more impressively, Karatu, can be a bit unsettling even to the most seasoned of travelers. The argument that these clothes would have ended up in the landfills if they weren’t here just doesn’t hold water in the long run, though, as that’s good for us perhaps, but not for the receiving countries. It is perhaps more of a commentary on our practice of massively over producing so that we can make sure to overstock the shelves of dozens of shops and department stores that all carry the same thing with merchandise that is duplicated over and over again just to prevent the possibility that one may not find what he wants at that very moment and may have to look elsewhere. Though the clothes are donated and probably shipped here by some nonprofit for little or no cost, there is no question that they are then sold on the docks in Dar to the vendors who load them into their trucks and cart them off to the market where they are then sold for what may be pennies to us, but not to those buying them. Seeing your alma mater worn in a remote village in bush, though, can be just a little bit disorienting at times.

This was of course the premise of a wonderful book called “The Blue Sweater,” the true story of a woman whose unsettling career amid the financial giants of Wall Street eventually leads her to Rwanda where she actually sees a young boy unmistakably wearing the same homely (read ugly) sweater that had been given to her as a gift when a child and which she had, with tremendous gilt, given to Good Will, or someone similar years before. This was, of course, only a very peripheral commentary in the story, which really revolves around the concept that throwing money into third world countries, like those in East Africa, is pointless, without first providing the means of a sustainable economy. In a true “teach a man to fish” manner, she teaches a group of women in Rwanda how to create a bakery that becomes incredibly successfully to the level that they are now supporting their families and all is well. But then comes the horrifically ugly genocide when she is back home for a few years and everything she has built for these women, who are both of Hutu and Tutsi descent, has crumbled as the result of a senseless conflict. She returns and interviews the women, many of who are now in prison, accused of otiosities and awaiting trial. Regardless of knowing the full story of the genocide or having watched or read “Hotel Rwanda,” “The Blue Sweater” in an engrossing story of one women’s discoveries in her quest to change the lives of those she is able to touch. I highly recommend it.

The Foundation for African Medicine Education, is the same sense, a “teach a man to fish” story as the mission here is not really to swoop in and provide care to patients without leaving behind the knowledge and expertise we bring to continue providing this care to patients in our absence and into the future. Though we are not training neurologists, per se, what we are doing is providing a basic understanding to those clinicians at FAME who will go on continue providing this care and, hopefully, teaching others as well. In this manner, we can continue to improve the lives of those individuals with neurological disease in the Karatu District along with their families and fellow villagers.

Sunday, March 24 – Leaving the Serengeti and an incredible visit to a friend’s boma….

Standard

Sunrise at camp in the Serengeti

It was our last day in the Serengeti as we’d be heading back to Karatu today, but we still had at least half a day of exploring before we left. We were up early for breakfast which was a delightful affair and made even all the more so by the presence of everyone’s favorite, pumba bacon (no longer an oxymoron, by the way, given all of the healthier versions of bacon we have in the markets) much to our appreciation. Though we had wanted to be on the road early, I think we all enjoyed sitting just a little longer for the meal today as it would be our last in camp. The camp, Tanzania Bush Camp, has exceeded everyone’s expectations, I believe, and have been here several times before, they have never let me down. The staff are incredibly friendly and have a willingness to help to goes well beyond. I’d highly recommend them to anyone setting up their own itinerary here or making suggestions to someone else. There’s little question that you feel fully pampered here at camp, but this is one of those times where it truly makes a difference and is more a part of the culture than anything else.

A group shot with our camp crew

Lilac-breasted roller

We headed off once again in the direction of the Maasai Kopjes, but looped around towards the village of Seronera before reaching them. Some of the sights included a hippo pool with virtually, and literally, tons of hippos basking in the morning sun, constantly flicking mud and water onto their backs and occasionally rolling completely over (a real feat for an animal this size) to prevent from becoming sun burned which they can easily do if they’re not too careful. The most striking thing, as you might imagine, is having all of those hippos in a pool and the accumulation of their feces and urine, which makes for a pretty ripe concoction and something that you will smell long before you hear or see them. Not that you would ever consider having lunch next to such a pool for the sole reason that the hippo is the deadliest animal in Africa and can run far faster than you would every imagine, but the stench would cause you to so quickly lose your appetite that it could be marketed as an incredibly successful, though not popular, weight loss program.

“You looking at me?”

Marabou storks

We came upon a huge heard of wildebeest and zebra at one point that were making their way to a small river crossing to drink, but looked very, very nervous and it became readily apparent why when we spotted four lionesses moving in their direction and clearly on the hunt. They were positioning themselves for a kill and very quickly things became very tense and exciting, but somehow, they let the bulk of the herd through, leaving some stranded zebra by the water. We were super excited as it really looked as though they were serious and we were going to see a kill, but they became disinterested, letting the stragglers through and then making their way across their way across the river towards some other animals. It was decided that they were not serious enough at the moment and, so, we moved on in the direction of Moru Kopjes.

Lionesses hunting

Lionesses hunting

Vitalis had taken Kathy and me to the Moru Kopjes last year and they were some of the most beautiful landscape I had seen here so it was decided that we would go there again. There are black rhinos in this area as well, though we didn’t see them last year and struck out again this year, unfortunately. There was less wildlife there at the moment as the grasses were not optimal for the migration despite being very green and lush. The topography, though, made up for the lack of animals that were present here. We did see some elephants very up close that were crossing the plain, much to Dan and Marin’s approval as they had missed our elephant escapades at Manyara several weeks ago and we could only see them from the distance in the Crater. The elephants that we did see were three huge ones crossing the road around us so both of them had a great experience of seeing these amazing and huge animals up close and in person.

Why did the lion cross the road?

A Montagu’s or pallid harrier in flight

In the far reaches of Moru Kopjes, we visited the Maasai drawings and Ngong rock, two vastly different sites. The Maasai drawings are not ancient, but are drawings made by the Maasai who come to this spiritual site as part of their rituals of manhood that include the circumcision ritual (held every seven years for late adolescents and young men who come of age) and also when the men go into the wilderness alone for months to prove their manhood that previously included killing a lion, but no longer does. Ngong rock is a large boulder that sits atop the kopjes and when stuck with another rock makes a “singing” sound of hollowness that is different than any of the other boulders around. It is also in a lovely spot and we took every advantage of our time here to relax and explore the rock outcroppings. Jon clearly made the most of it, though, scrambling to the top of a large boulder and then finding it a bit more difficult to get down. Perhaps he had been inspired by the movie on free soloing we had watch last week or maybe he just had the urge “because it was there,” but either way, it was an impressive feat that no one else chose to undertake for good reason.

A blacked headed heron

A secretary bird

From Moru Kopjes, we made our way slowly back to Naabi Hill to leave the park. We would have lunch there which is a popular place for trips heading into the park from Ngorongoro as the distance is just right. There’s a small store there that sells cold soft drinks and, in the past, Pringles had been a big hit, but not so with this group. I took care of the payment to transit the Ngorongoro Conservation Area heading back to Karatu and after we had all rested up we were back on our way passing Oldupai Gorge and heading to the rim of the crater. Kitashu, one of the two social workers at FAME, along with Angel, and someone who is exceedingly responsible for our neuro clinic to run smooth, is Maasai and his boma is just off the rim road at the turn off to Endulen, where there is a small hospital and dispensary. Kitashu had asked us to visit his boma if we had time and with this invitation, we had all agreed that it would be great to see him there.

At Moru Kopjes on visiting Ngong rock

Marin, Adys and Jon at Ngong rock

We called as we were close and he met us on the main road outside of his boma, which is actually a grouping of a number of bomas for his father and his brothers. Kitashu has one wife and now has a baby that is about a month old. We drove along a winding trail between structures until we pulled into a small area outside his hut. He was dressed in his traditional Maasai clothing that he wears at home on the weekends and greeted us all very warmly as it was clear he was very happy to see us. What we had thought was going to be a short visit to say, though, was actually a formal visit with his entire family as I’ve been greeted in the past when visiting friend’s bomas. We were so honored to be there with his family, yet they were equally honored by our visit and, as I later discovered, we were the first of anyone from FAME who had visited him since he had been working there. In all fairness, it’s a trek to get there from Karatu unless you’re also visiting the Serengeti or the Crater, but over this month, our group had developed a special closeness with Kitashu and, in the end, we were all so happy to have come.

Jon beginning his epic climb

Success

Kitashu invited us into his wife’s hut (huts are only built by the woman and belong to them) where we met her and their new baby. What I hadn’t known before, though, is that it’s tradition for the new mother to remain indoors after childbirth for a full six months and she is brought meals by other family members. A Maasai hut is comprised of a center room of approximately eight to ten feet in diameter around which are found two other rooms, one for the husband and male children and one for the wife and female children. The beds are raised a few feet off the ground and are made of cowhide stretched over wood slats. There is also a room for kitchen goods and a small cooking fire nearby. The last parts of the hut are made up of the entrance way that leads to the outside and a large room for the goats to be kept inside at night (cows remain outside in a small corral that is surrounded by brush and wood.

Lesser flamingo with a smoky backround

After visiting with Kitashu and his wife, his sisters-in-law lead Sheena, Adys and Marin off to one of their huts while Kitashu helped Jon, Dan and me dress in their shukas (the plaid cloth the men wear) in a proper Maasai manner. The woman later came out dressed in a bright blue cloth wearing lots of Maasai jewelry including the beaded collars that the Maasai women wear when dancing. The entire village was out to share in our visit and it became very clear to us that this was a big event for them. Kitashu’s brothers wanted to show us how they make fire using rod of hard wood that they place in a depression of a softer wood and then spin between their palms, handing the chore off to each other when they tire. They use their knives to make slits in the softer wood next to the little depression that collects the embers and then they are cut away and placed into some dry grasses that they’ve collected. They weren’t successful today in creating a big blaze, but I’m confident that if it had been a necessity, they would have continued until we had a nice little fire going.

Kitashu greeting all of us

Adys, Sheena and Marin greeting Kitashu’s wife

Kitashu’s wife and new baby

After the fire making demonstration, we all gathered in front of one of the cattle kraals where both the men and women lined up to demonstrate their dancing and singing. Sheena, Adys and Marin participated since they were in the appropriate dress, but of the men, only Jon was brave enough to participate in the traditional men’s dance that consists of repetitive jumping and stomping. I remember when I was here ten years ago with my children and visited one of the cultural bomas where they had also danced for us and my son, Daniel, had participated and had done quite well. Jon did great and though he didn’t reach the same altitude as Kitashu’s family members, he performance was quite respectable. I’m sure had I attempted in any way to join in the fun, I probably would have left the boma with some type of injury.

In front of Kitashu’s wife’s hut

Me, Jon and Dan with our Maasai paraphernalia

Once the dancing was finished, we all made our way back in the direction of Kitashu’s wife’s hut and were led to one of the smaller kraals next to the hut that was full of tall stinging nettle, but there was enough of a path for us to make it to the center without injury. There in the center of the kraal was a small clearing in which they had prepared a goat roast for us which was totally unexpected. A goat roast is event that is offered typically to an honored guest or guests and is not something that is done routinely. Goats are not eaten on a regular basis by the Maasai, nor are their cattle as they are a measure of their wealth so it wouldn’t make much sense to be eating your assets as that wouldn’t be very sustainable. It was a great honor for us to be presented this goat by Kitashu and his family and as we all stood in the clearing while he sliced off piece after piece for us to eat, there was a clear sense of mutual respect and community that was shared by all who were present. The goat was amazingly delicious and tender and though it is cooked by the Maasai without any spices, there is a smokiness to the meat that comes from the open fire. We all ate piece after piece of the juicy slices and Kitashu kept going around the circle handing us more of more until there was little left and we were now enjoying the ribs. Though his brothers did share in some of the meal with us, I’m sure we devoured the majority of the goat meat that had been cooked.

Jon joining the dance

Jon jumping high

It was now getting very late as we hadn’t anticipated the incredible reception that we received and we were once again under the gun to get to the gate before it closed at 6 pm which would have meant finding someplace to sleep in the conservation area or otherwise trying somehow to talk ourselves out in some manner. We packed up the Land Rover with Kitashu planning to come back to Karatu with us. It had been a wonderful visit to the Serengeti over the weekend and it had been the last game drive for everyone today. They had all seen four of the Big Five animals of Africa (elephant, rhino, Cape buffalo, lion and leopard), missing only the last. We left the boma and raced along the rim road heading toward the gate as fast as we dare, when suddenly, on the side of the road, there appeared a leopard walking. It was like magic, as if someone had decided that everyone couldn’t leave without seeing the Big Five. Regardless of how, the leopard remained on the road long enough for everyone to sure they had seen it and then it disappeared into the underbrush as mysteriously as it had appeared.

Kitashu serving us all goat

We made the gate with no time spare and waited while Kitashu took the paperwork to the office to check us out of the conservation area while baboons fought among themselves outside our vehicle, making a huge racket. The leopard, the baboons and the race to the gate was a parting ending to our game drives for this trip to Tanzania. We dropped Vitalis off in Karatu to spend the night before heading home to Arusha in the morning (he actually planned to hitch a ride with Dan and Marin tomorrow morning as would be traveling early to the airport to fly to Dar es Salaam) and then ordered dinner from the Lilac Café as everyone was far too tired to cook. Dan and Marin would be leaving in the morning, but the rest of us still had four days left of clinic at FAME and were looking forward to it.

A picture taken several days later by Kitashu of the same leopard we had spotted on the road

Saturday, March 23 – A very long day in the Serengeti…..

Standard

Predawn on the Serengeti

We had decided the night before that we would leave before sunrise on our game drive and have the camp pack us both breakfast and lunch so that we wouldn’t have to return until late in the day and quite possibly after sunset. Thankfully, though, and more so for the others than for me, we were able to make some coffee or tea and drink it down before we left. Having been a coffee addict my entire life, I certainly understood the need for this morning cup of Joe, but over the last couple of years, I have broken myself of that habit and no longer require that morning “fix.” I will have to admit, though, that Adys’ mixture of AfraCafe (Tanzania’s wonderful version of instant coffee that tastes amazing) and Cadbury powdered chocolate was particularly appealing and really hit the spot on our way out.

Dawn on the Serengeti

Dan looking for birds

We all readied our camera equipment, Dan and I each with our large “safari lenses” on our Nikon cameras that bring the action tremendously closer. On earlier safaris (game drives) during this trip, I was obviously not taking photos as I was driving so handed my camera off to others to use and have the same experience that I have had over the years. It really is amazing what a long lens does for wildlife photography and especially in a place such as the Serengeti or Africa in general. With the top up and standing in the cool air of pre-dawn it can become quite chilly at times and reminds you of just home much radiant energy the sun pours down on us here on the equator. I always advise bringing a light fleece to wear on these trips for the early morning and after sunset as it can become quite cool. The altitude of the Crater rim is 8000 feet, making for very chilly nights requiring lots of layers, while here on the Serengeti plains we’re probably at 4000 feet, which is still nothing to sneeze at.

Breakfast on the drive

A trio of rock hyrax

Part of the Great Migration

A friendly croc

Our drive took us in the direction of the Maasai Kopjes this morning and right by the launch site for one of the balloon companies who a good friend of mine pilots. We watched the balloon inflating and not yet airborne prompting a number of comments from the group regarding some type of dysfunction for which a certain medication could help, but alas it turned out that Jones (my friend and balloon pilot) had been delaying take off due to high winds at the launch site that were over the limit of safe flight. The balloon eventually launched with tremendous relief by all and we watched as it floated slowly away. Danielle Becker and I flew with Jones several years ago after he invited us to come and I will have to say that it was one of the more amazing experiences that I’ve ever had. Though I’ve never been in a balloon before , there was certainly something about floating effortlessly above the vast Serengeti plains in all of their splendor at sunrise, the animals moving about below you and universe above, the complete silence broken only by the occasional sound of a blast of hot air into the balloon to keep you aloft. We finished our flight with a champagne breakfast on tables set on the open grass and freshly made while we toasted the pilots of the two balloons that had flown in what we were told was a ballooning tradition. Whether that was true or not was of little consequence considering what we had just experienced. We had gone as guests on the flight, but if I were ever considering the experience again and asked by someone whether I would recommend it to them, I would answer with a strong affirmative.

Jon gazing over a large herd of wildebeest

Dan ready to photograph

Buddies….

The vastness of the Serengeti is something that you can only experience and is impossible to fully describe, though I am sure there are great writers who have done so successfully. I’ve mentioned before of Hemingway’s The Green Hills of Africa, which doesn’t take place in the Serengeti, but rather Lake Manyara, and is a non-fictional account of a hunting trip that he and his wife had taken back in the days of wild Africa, when rhinos filled the park in what seemed like an over-abundance, though, unfortunately, we have learned all too late that that wasn’t the case such that the black rhino were hunted to the brink of extinction of Tanzania and elsewhere. The Serengeti’s vastness isn’t really about standing on a tall mountain and seeing endless plains that reach to the horizon. It is about being there, with your heads often barely above the tall grasses, and looking out to see plains that stretch to what you see as the horizon is, only to reach that horizon and have the same scene repeat itself, over and over and over again, in a never-ending fashion that suddenly makes you aware of not necessarily your insignificance, but more so the importance of the universe of which you make up only a very small fraction of its entirety. It is humbling to say the least.

A mother cheetah and four nearly grown siblings

We explored the Kopjes during the morning, catching glimpse of occasional male lions doing what they do best, sleeping, as well as rock hyraxes, supposedly the closest living relative to the elephant, though recently debated. In between the Kopjes we saw every version of antelope, including the massive herds of wildebeest with their partners in the long migration, the zebra. The wildebeest and the zebra work well together in that they eat different lengths of grass and protect each other, the zebra acting as sentinels with their keen eye sight, watching for predators and warning the vastly larger number of “beesties.” The other antelope, which include the topi, eland, Grant’s gazelle, Thompson gazelle, and Cook’s hartebeest, occupy the grasslands along with the zebra and wildebeest while the woodlands are occupied by the impala and the dik dik. It is a cacophony of antelope here where they all live harmony together and in constant fear of the predators. Large lion prides roam throughout, often hunting in small groups while the leopard is a solitary killer. Cheetah are most often solo hunters, though you will often see two or three siblings or a mother and her older cubs hunting together.

A pair of lionesses on a termite mound

We stopped for a lovely breakfast under some trees where we were able to get out of the Land Rover and had chapati, hard boiled eggs, sausages, bacon, coffee, tea and juice, just to name a few of the things that were prepared for us. The bacon was the real hit of the day for everyone, I think, and it became known for the rest of the trip as “pumba bacon,” in honor of the warthog that is certainly related to the pig and is often hunted by the lion for this very reason I am sure. Later in the day, we also stopped for lunch that was a mixture of more delicious items that the kitchen had put together for us.

A giraffe having a drink

Grant’s gazelle

A typical Serengeti scene

Everyone had a wonderful day of game viewing, but probably most of all, Dan, who is a passionate birder which is a breed all its own. I will have to admit, that when I was living in the suburbs, one of my greatest passions was my bird feeders and bird houses that I had located through our back yard that was heavily wooded. Having probably spent years selecting just the perfect locations for the feeders to completely foil the significant squirrel population that made their homes in our trees. I had cables strung between the trees from which the feeders hung with discs over eat feeder that protected them from the squirrels who would artfully perform their high wire acts with the thought of stealing some of birds precious seeds. I had also built my own version of woodpecker feeders from PVC tubes and galvanized wire strong enough to deter the squirrels who can eat through just about anything including wire that isn’t up to snuff. After twenty-five years living in the house, I had finally perfected squirrel-proof placement for the feeders, only to have moved on to downtown Philly where I now have no feeders. I do miss the birds and my feeders and nesting boxes, but I will have to admit that I also enjoyed the sport of out foxing the squirrels which probably doesn’t speak very highly of my goal in life in that regard if being smarter than a rodent becomes a pleasure in life. What can I say.

Dan’s interest in birds was far more academic than mine and it didn’t involve outsmarting rodents. He had an incredible knowledge of the birds here even though this was his first time to East Africa, having previously visited southern African on safari. For one with this interest, there is so much more to our game drives as the number of birds species far outnumber the species of mammals that we will see in any given days. Birding here is actually quite spectacular and the bible, Birds of East Africa, has so much information on so many species that it dwarfs anything related to the mammals. Spending the time with Dan, I found myself becoming so much more acutely aware of the birds despite having seen them numerous times before on the dozens and dozens of game drives that I’ve not only been on, but have also guided myself. Because of his acute interest in the birds, I had actually requested a particular guide and friend of mine, Vitalis, who drove me to the Serengeti last year and had impressed me incredibly with his knowledge of the feathered component of our game drives. At the end of our safari last year, we had given Vitalis my Nikon binoculars as a present and in appreciation of his keen guiding skills. Any guide with his knowledge and skill deserves a pair of wonderful birding binoculars.

A lilac-breasted roller

A lilac-breasted roller in flight

Some of the sights that we saw on this day included a lone cheetah on top of a termite mound who was nonplused with our presence, but didn’t seem to be on the hunting mood at the moment. Later in the day we had seen the amazing sight of a mother cheetah and her four adolescent cubs who were almost the same size as she was, all resting under a tree, but clearly checking out the terrain. It would have been amazing to see this group hunt as they most likely would have been able to tackle even a wildebeest adult, but it was in the midday heat and they didn’t look necessarily enthusiastic about using the energy. One of the funnier moments was when we were looking at a few lions sleeping and were parked alongside another vehicle. It contained an American couple and when we said hello and asked what they had seen, the woman promptly told us that they had seen a group of leopards a bit further back. What she was referring to was undoubtedly the group of cheetah we had seen and her husband promptly corrected her. The mere thought of a group of leopards, which are solitary animals other than a mother and her little cubs was a bit ridiculous on its own. Shortly after, we pulled up to a massive line of vehicles jockeying for position to see what was reported to be a leopard in the grass under a tree that no one could see or even confirm. We waited a few minutes and then decided that it was quite unlikely that the leopard would surface, but before we left, the woman we bumped into earlier pulled up alongside us and after we pulled away we all had a good laugh regarding what she must have said about shy leopard in the grass.

A morning yawn…

On the way back to camp that evening, we needed to find fuel to get us back Karatu as we had driven two full days on the current tank. Turtle has a 70 liter tank and her powerplant is a four-cylinder turbodiesel that is very fuel efficient and great for these excursions to the Serengeti and beyond. The station in the village of Seronera where most of the visitor information is for the Central Serengeti was closed or didn’t have fuel when we arrived, so we drove up to another station (there are only two here) that was thankfully open and had fuel and we were now in good shape for the trek home tomorrow. We made our way back to camp before sunset and all took showers as were dusty and grimy from our day on the trail. Jones was going to stop by before dinner to say hello so it was good that we had time to freshen up. In the end, he brought a group of young people with him, all of him were friends working at the Seronera Wildlife Lodge and who he had arranged to have dinner at the camp. We sat inside the lounge tent and caught up on things. I have been inexorably linked to the entire Temba family since I first came to Tanzania with my children in 2009, and I will continue to be throughout my life as I plan to continue coming as long as I am physically capable of doing so.

A black-shouldered kite

Surveying the landscape

We enjoyed another relaxing dinner in the mess tent with all the wildlife abounding just outside our camp and ready for the sounds of the hyenas once again as we sleep. Walking back to the tents, as I shine my flashlight away from camp, you can see the many eyes of the animals that tend to surround camp as they feel safer around us for some reason. We were told that a small herd of Cape buffalo had been coming every night for the protection and I surely didn’t look forward to running into one of them walking back to my tent. We had planned to have breakfast at camp tomorrow, but would bring lunchboxes with us since we would be heading home and wouldn’t be coming back to camp.

Mom and three cubs

 

Friday, March 22 – A morning in clinic and then off to the Serengeti….

Standard

Over the last several years, it has been become somewhat of a given that we go on an overnight safari for our last full weekend before wrapping things up. At that point in our time here, we’ve had plenty of days of clinic and would have only taken off the Sundays to go on a day safari. We have various options for the overnight trips and I have taken the residents to the Serengeti as well as to Tarangire National Park. This month, we’ve received lots of reports of that the tsetse flies have been overly obnoxious at Tarangire which was enough to have everyone unanimously voting for the Serengeti. Not that the tsetse aren’t there as well, but they are much more limited in the areas they infest, which is usually the wet woodland areas. I’ve written numerous times about these nasty creatures and they have become no less nasty over time. There is very little in the way of trypanosomiasis, or sleeping sickness, here, but that does not lessen the sting of this blood sucking nemesis. If you ever have the gumption to watch a very short horror flick with a very small leading character, just go to YouTube and search for tsetse and you’ll quickly run across videos of tsetse flies engorging themselves with blood until it looks like they are going to burst. Their bite is very painful and typically leaves a significant welt that may take some time to recover. I have several scars on one hand from blisters that formed after a tsetse bite.

Dan and Marin discussing a case on Friday morning

So, when offered the choice, there was very little question that everyone was interested in seeing the Serengeti, which, to be honest, is a real shame to miss coming all this way. We had been to Ngorongoro Crater last weekend which is quite impressive, but it doesn’t compare in the shear magnitude to the Serengeti in all its diversity. Throw in the Great Migration, and the Serengeti becomes a spectacle that can rival just about anything else in nature. We had all packed the night before or in the morning, that is, everyone but Daniel. As he would be extending his visit by a week to go on safari with his fiancé and most of being in the Serengeti, he elected to stay back at FAME and spend a relaxing weekend. Our plan was to be in clinic until about noon at which point our guide, Vitalis, would pick us up and we’d be on our way. At least that was our intention. Vitalis had taken Turtle the night prior so that he could check her out and make any last minute repairs that might be necessary before heading off into the bush where the chance for rescue after a breakdown becomes exceedingly slim. The flow of patients in the morning was steady, but we were able to head out by around noontime, though it did take some persistence on my part to prevent the OPD from continuing to send patients our way even after I had told them we would be leaving.

Mother and child

An agama lizard

We had time to eat some of the mac and cheese we had saved from yesterday’s dinner so we’d have so food in our stomachs as we departed. Again, Daniel was staying behind to man the fort, the rest of us got our bags together and waited for Vitalis to show up so we could get packed. Since we were going for only two nights, there wasn’t an excessive amount of baggage for us to load and once it was done, we were on our way down the FAME road in the direction of town. Despite our intention of getting an early start on the drive, we discovered that we had to go to the bank to pay for our entrance fees to the Serengeti. Last year, I had been able to pay with a credit card at the gate, but as is typical here, the gate and park protocols change on a regular basis and there is little in the way of any notice. The problem was that none of us had anticipated needing this type of cash and all of our money was back in the safe at FAME. Thankfully, Dan and Marin had taken their money and passports out of the safe since they would be leaving the morning after we return, but it was touch and go as to whether we would have enough. Also, we didn’t know the exact amount that was needed until we went into the bank and had them process the quotation that had been entered into the system. What should have been a relatively simple affair turned into well over an hour of frustration trying to get our papers processed and then, trying to get all of the money together that we needed. Everyone contributed, including Vitalis, leaving us with just enough between everyone to cover the necessary tip at the camp and nothing whatsoever to spare.

Vultures out on a limb at Naabi Hill

We stopped at the market on our way out of town to stock up on waters and we were finally on our way. To get to the Serengeti, you must pass through the Ngorongoro Conservation Area which requires you to pay for transit. This is the same drive we took last Sunday on our way to the Crater and luckily, the necessary transactions at the gate were a snap and I was able to put everything on my credit card. Plastic is wonderful. In no time at all, we were climbing up towards the crater rim and through the primordial forest that makes up what is left of this massive mountain that has left for eternity its enormous caldera. Given the time, we drove by the overlook and continued on our way, past the descent road we had taken down to the bottom of the crater and turned in the direction of the Southern Serengeti, past Olduvai Gorge, the site of Mary and Louis Leakey’s famous discoveries, and on to Naabi Hill, the official entrance to the Serengeti from the Conservation Area. The drive from the Crater Gate to Naabi Hill usually takes several hours and is a very long and very dusty ride. As vehicles pass by in the other direction, there is the immediate sound of everyone sliding their windows shut to avoid the pounds of dust that will be immediately sucked into our vehicle. The dust here is ubiquitous and permeates essentially everything.

Looking for prey…

Early in the drive we begin to see small groups of wildebeest, the tail end of the migration, with many babies and the always present Thompson and Grants gazelle that cover the open plains. Occasional groups of Eland, the largest of all the antelope in Africa, show up from time to time. The closer we get to Naabi Hill, the more animals we begin to see along with the many birds, particularly the Corey Bustard, the largest flying bird in Africa. Naabi Hill serves as the entrance to the Serengeti and, most importantly for the government, where one must pay their fees to enter the park. With our luck today, nothing was going perfectly smoothly and Vitalis found out that the bank had made a mistake when we paid our fees there and had forgotten to charge us an additional small amount for the vehicle and guide that had to be paid in TShillings. What would have taken us a minute at the bank ended up taking about 30 minutes for Vitalis to pay them the money using his phone (M-Pesa is similar to Apple pay except you have to put the money on your phone in advance – no credit and no debit cards). We all took the time to climb up on top of Naabi Hill which offers an amazing view of the surrounding plains that clearly have given Serengeti its name which means endless plains in Maa, the language of the Maasai.

Hitching a ride….

A White-backed vulture

We were finally on our way to camp once we were able to take care of everything at the gate and we were way behind schedule. We stayed on the main road for a bit, but then veered off somewhat to the east in the general direction of the Maasai Kopjes and to our camp. The Central Serengeti topography is dominated by a unique feature called Kopjes, which are essentially large boulder islands, some of which can be quite large, and are arranged all throughout the endless plains, some that are in a line like a mountain range, but separated by flat plains in between, and others that are quite random. Rough roads, or really trails, connect the Kopjes to each other so that you drive from island to island and it is here that all life is centered in the Serengeti. True, the wildebeest and zebra are out in the grasses, but it is the lions and leopards that live in the Kopjes who prey upon them. The other “big cat” is the cheetah that likes to lay on one of the many termite hills so that it can scan the distance for its prey. Cheetah have to sneak up on their prey and for this, they require grass that is high enough for them to hide as they move close enough to unleash an attack, which is sudden and powerful. Cheetah have the highest “kill rate” of all of the big cats here at nearly 60%, while lions have a meager 25%, and leopards are in between (African hunting dogs, very difficult to find in the Serengeti, have the highest success rate of all of the predators here).

Two adolescent male lions at a watering hole

…And a third joins in

Driving along, Vitalis spots a lion off in the very far distance and as we come closer, it turns out to be a group of five younger males traveling together on their way to a watering hole. It’s hard to tell if when they’ve eaten last, but they don’t look like they’re hunting at the moment and besides, there are no prey as far as the eye can see at the moment. We’ve had the opportunity to watch them for a bit, but really have to get on our way as the sun is beginning to set and we’re still a long way off from our camp. Sunset in the Serengeti has to be one of the most amazing sights and tonight’s event does not seem to be disappointing us in any way. Once you think it’s at its maximum, it continues to impress you even further and never seems to end. We had noticed some fires in the distance, and some of the color may be enhanced by the smoke, but regardless, it was spectacular. Red and orange and yellow hues of every imaginable combination seems to add to each other as if they are competing for dominance. It just seems to be never ending.

And a lovely reflection

I can recognize most of the roads we’re taking, having driven here on numerous occasions, but the light is now really disappearing and the world slowly shrinks to whatever we can see illuminated by our headlights. It is difficult to explain darkness here as there are few external lights and the moon has yet to rise. I know we’re heading in the direction of camp and can vaguely make out some landmarks in front of us as we are approaching the area where our camp should be. As we get closer, it becomes readily apparent to all of us that one of the fires we had seen from the distance is actually burning right in the vicinity of our camp and we can see the line of flames on the hillside. At that moment, there were plenty of nervous jokes about the good price we had gotten on our lodging being a part of a “fire sale,” but in the end, it turned out to be a further away than we had originally thought. We turned on the road to get to camp and in the incredible darkness of the night, everything was a bit disorienting so that we ended up initially pulling into the wrong camp, but ours was only a short distance away. They had cool washcloths and fresh juice for us to drink and though we all would have loved to have taken showers with all of the dust, it was getting late and we needed to get to dinner.

A tawny eagle with an adolescent

I had stayed at this camp previously and it is really luxurious. There are two main tents, one that serves as a dinning tent and the other that serves as a lounge while doubling as the charging station for the entire camp. The table is a jumbled pile of cables and chargers for every device known to man. On each side of the main tents are seven individual, though quite large, tents that each have two double beds and a separate bathroom area with a shower, toilet and dressing area with sink. The beds and linens are nicer than anything that I’ve ever had at home. Since we were running late, dinner was served to us rather than the normal buffet and the food was delicious. Soups here are especially tasty and fresh and have always been my absolute favorite part of the meal at any camp that I’ve stayed at as they are clearly made daily and every flavor imaginable.

A gorgeous sunset

The unique feature of staying in “tented camps” as opposed to lodges is the absolute closeness of nature. Though the tents are fabulously comfortable and certainly nothing like backpacking on the Pacific Crest Trail (I will have to admit, though, that the little pup tent I started out camping in years ago has vastly changed and has morphed into an ultra-comfortable, lightweight, aluminum tubed structure that bears no resemblance whatsoever) nor what people refer to as “glamping” on the East Coast, they do all have one thing in common. And that is a very thin layer of fabric between you and the external world. Admittedly, there are bears in the High Sierra and wild concertgoers at many of the glamping sites, but neither of those compare to the nearby sounds of hyenas or of lions that sound as though they are sitting right outside of your tent and wanting to join you inside for a little nighttime snack. At all times during the night and in the early morning darkness, you are never allowed to walk outside of your  tent as you must be escorted by a guide who is often armed with a spear, though sometimes not, in which case your only hope is that you can outrun him (and in my case, that would be wishful thinking). There is really never any fear of being attacked in your tent and I’ve been doing this long enough to be very familiar with the sounds of the bush, but for anyone doing it for their first time, it is definitely an experience. I think everyone tonight must have had these thoughts in their minds at some point or another (read Marin), though I was quite confident that all would be present in the morning for breakfast unscathed.

 

 

Thursday, March 21 – A visit to Rift Valley Children’s Village…. 

Standard

 

Note: Thanks to Katherine Kuhlmann, FAME’s Communications and Marketing Director, for sharing her photographs with me.

Dan and Adys presenting in the morning

Well, I must admit that everyone was just a bit slower getting started this morning after our night at The Golden Sparrow. Everyone had a great time, though, so it was well worth it and it was an excellent release for everyone. It was also Thursday, so it was another morning of teaching and Adys and Daniel had volunteered for this one to discuss altered mental status. As expected, even with the hurdle imposed the by Sparrow, they did an excellent job of discussing this topic which can often be very difficult for the non-neurologist. Correctly identifying a patient with an encephalopathy as opposed to an aphasia will completely change one’s differential and what evaluations and treatment are recommended for the patient. It is not always as straight forward as it may seem and the differences can sometimes be very subtle, even for a neurologist. Adys and Daniel covered the topic perfectly and alluded to a number of the specific features that we use to differentiate them.

Adys and Ann evaluating a patient

Compassionate care

After our talk, it was matter of getting everything together for our trip to RVCV. We were planning to take only one vehicle today as Chris and Michael, our interpreters are both from there and therefore would not require a ride in the morning. Still, this meant that we would have twelve people needing transportation there and back as both Katherine and Phoebe were also planning to come. My Land Rover has seating for nine passengers, but if we put four across the back instead of three and also used empty plastic soda crates between the second and third row of seats, we could reasonably and safely fit the additional passengers in for the 45 minute trip to the children’s village. We wouldn’t need lunch today as we are served a wonderful midday meal by the cooks here who also serve the other volunteers at the village.

Jon and Daniel acting out their exam

The drive to RVCV is as spectacular as just about anything we’ve seen here. Heading from Karatu in the direction of Ngorongoro gate, we leave the tarmac just before the final hill and begin to head in a westerly direction along a ridgetop that overlooks wonderfully fertile farmland in all directions. We drop down into several ravines, only to rise again on the other side of each when we finally come upon acres and acres of coffee bushes that surround the entire area including the village. For the full story of Rift Valley Children’s Village, you’ll have to go to their website, but it was founded by India Howell, who is originally from Boston, and fell in love with Tanzania while on safari here (sound familiar?) She worked for bit in the tourist industry, but quickly discovered all the needy children, some of who lived on the street and others whose families could no longer care for them. India partnered with a Tanzanian to develop the concept of a children’s village rather than an orphanage, where all the children are adopted and raised here as their home with no fear of having to leave until they are over 18, and even then, they have their own housing just outside the village. There are children from all ages here, all living in their own homes separated by age and gender, each house being run by separate house mothers who are from the outside village.

Marin and Dan conferring on a patient

Daniel and Jon present a patient to me

There is a primary school situated just beside the children’s village and this is where all of the children attend school every day. Early on, India realized that sending her children to a school where the other children were constantly sick due to the poor access to healthcare and the poor personal hygiene. She offered to partner with the local community to bring in more teachers that she would help pay for and also developed a regular clinic that would be staffed by FAME and would occur every other week and would see patients from a catchment area that included the surrounding villages along with the children’s village. When I started the neurology mobile clinics here, it was an obvious choice to also accompany the FAME doctors when they came, but about two years, it was decided that FAME would no longer have a regular clinic there in which case, we decided to continue with it as part of our mobile clinic week. It is now only a neurology clinic and any patients needing general medical care will be sent to FAME by vehicle.

Dan evaluating a young child with severe bilateral esophoria

Dan enjoying his exam

Who’s checking out who?

We see a wide array of patients here and much of them are obviously pediatric, but the bulk of the patients seen by us here are epilepsy patients for various reasons. Having Dan and Marin here was a huge plus for us this visit as was the fact that the clinic area had been extensively rearranged since last October. We now had four examination rooms that were all set up for us in advance along with a room that we could use as our pharmacy. All of the patients to be seen that day had already been organized into adult and pediatric cases and had also been fully triaged so that we were only seeing patients with neurological complaints.

Marin and Christopher evaluating one of our long term patients

Adys’s very first patient of the day was a young man with poorly controlled epilepsy accompanied by his mother. The episodes were primarily causing loss of consciousness and some abnormal behavior and we discussed the need to continue him on seizure medication because of the nature of his seizures, but after we were finished discussing his case, we heard a very loud commotion coming from the room only to find him on the floor trying to crawl into the corner of the room with a frightened expression on his face. The seizure lasted only a minute or so and I was able to get him situated on the floor so he wouldn’t injure himself nor would he injure me. As he settled down, I was finally able to help him up onto the bed in the room where he remained until he came around and his post-ictal lethargy had improved to some degree. This was a very classic focal seizure, probably of frontal or temporal origin and it was the same as those that he had been having at home which was very important regarding the diagnosis and the fact that seizures are, by definition, very stereotyped. His medication was adjusted to place him on a more therapeutic dose.

Marin and one of her young patients

Adys and Dr. Annie presenting a patient to me

Marin saw a fascinating patient that became a real dilemma and something that we’re still working on. The baby was reported to be about 15 months old and had failure to thrive due to inability to take food adequately, having already been to a feeding program in Arusha, but failed to gain any weight there. The problem was that the baby examined more like a normal three-month-old from a cognitive and stature standpoint and just seemed to have a bit of diminished tone. No matter how hard she tried to clarify the history with the mom, the story remained the same which was completely perplexing. In the end, we referred the baby to FAME to obtain x-rays of her hands and long bones as well as an abdominal ultrasound to rule out some organomegaly consistent with some metabolic storage disease. The ultrasound turned out to be normal and the films will have to be read by someone at CHOP, which I will take care after my return.

Sheena and William evaluating a patient

Sheena catching up on her documentation

We always look very much forward to the lunches here as the house mothers cook amazing food. Today, it was fresh baked bread rolls with hamburgers, French fries, fresh salad and for dessert, chocolate oatmeal balls that were delicious. It was a wonderful meal that was well appreciated. After lunch, it was back to work to see the remainder of the patients and, eventually, a trip to the duka (store) run by Arturo and has a great selection of objects created by the Rift Valley Women’s Group. Everyone came back with a back of items and seemed quite happy with the selections they’d made. Sheena missed out on the group shopping spree and went over later and when she’d been gone for some time, we decided to call over to make sure she was still alive. She was, of course, and was also extremely happy with her purchases.

Daniel closing his charts so they don’t autoclose 😉

Phoebe and Dan during a break in the action

We left Rift Valley Children’s Village after a very successful and efficient day of seeing patients and a real sense of accomplishment. The cases that we’d seen were solid neurology and all of which we had something to offer, whether it was immediate treatment or at least some direction to head in regard to further investigations if appropriate. I took the more scenic drive home that turned out to be tremendously smoother than the primary road much to everyone’s joy as we were still loaded with the twelve occupants in Turtle and the less jostling meant happier passengers. This route does have a very, very steep downhill section driving to the bottom of a ravine and then a very, very steep uphill section coming out, but everyone held on tightly and Turtle took the hills like the pro that she is and in full Land Rover tradition.

Our clinic hallway

The waiting room at Rift Valley

We were scheduled to go to Susan and Frank’s house for the evening as this was the last night at FAME for both Dan and Marin for we are all heading to the Serengeti tomorrow, except for Daniel who decided to forgo the trip (despite just bit of FOMO) as he would be going there the following week with his fiancé after our time at FAME. Before going over to their house, though, we had to make what I thought would be a quick stop at the tailor’s shop to pick up all of the clothes that everyone (except me) had made from the wonder kitenge cloth ubiquitous here in Tanzania. It ended up being just a bit longer of stop than I had anticipated as there was a bit more shopping going on than I had been led to believe would occur, though I was finally able to rest everyone out of the shop and we were on our way. We had one more stop scheduled for next week, though, to pick up the additional orders made.

Daniel and Jon evaluating a patient with the assistance of Katie, the nurse at RVCV

Susan and Frank’s get together was a very nice affair as it always is at their home and we dined on wonderful local Camembert cheese from the Shangri La farm and both beef and vegetable samosas from the Lilac Café. Mixed with Safari beers, wine and Stoney Tangawizi, we were all quite happy and there was little need for the dinners that had been prepared for us that night, so we all saved our mac and cheese to eat the following day for lunch before our departure on safari.

Visiting the tailor’s shop at the end of the day

 

Wednesday, March 20 – It’s off to Kambi ya Simba and a night at the Sparrow….

Standard

Evaluating a patient in 2011 with Dr. RIngo

Kambi ya Simba is another village in the Mbulumbulu region and about half the distance of Upper Kitete. When I had first come here in 2011, there was literally nothing to speak of in regard to their medical facilities with only a very small dispensary that wasn’t sufficient for us to work out of so we held our clinic in a small field in front of the church. Patients would sit on a bench made out of a log and wait their turn to be seen. Quite often, the patients waiting would slowly encroach upon my open air office out of their interest in what was going on and I’d have to repeatedly ask them to sit back on the bench so as to maintain some semblance of privacy. I would frequently remark to friends that I had the nicest office here that anyone could ever imagine.

Paula Gremley, Pastor Temba and Dr. Ringo discussing things with a patients mother in 2011

One of my favorite photos – evaluating a Trisomy 21 patient in 2011

Over time, though, Kambi ya Simba has acquired an ever increasing number of buildings here for medical care and my outside office has vanished and has now been replaced by a state of the art dispensary, wards, offices and other equipment that have now developed into a lovely facility. A few years ago, I had arrived for mobile clinic only days after the prime minister had been here with lots of fanfare including a small monument, plaque and flagpole in the center of the grounds. Pulling into Kambi ya Simba that time, I commented to everyone that I was just a bit surprised to what lengths they had gone to welcome us. As the commitment by the government has continued to improve the facilities here, our clinic has become that much closer to what we have at FAME, though we are still working as a mobile clinic meaning that we do not have access to labs or X-rays without sending patients back to FAME for those.

Kambi ya Simba dispensary. Note the not uncommon occurrence of pushing cars here

One of our clinic rooms at Kambi ya Simba

Adys, Jon and Dr. Caren evaluating a patient

With the shorter drive to Kambi ya Simba it means we get an earlier start with our patients. We weren’t sure how many patients would show up, but in the end, there were quite a few and there were some fascinating pediatric cases so that it was extra nice having Dan and Marin here to sort them out. One very interesting patient we saw was an infant that had reportedly been developing normally until about three months of age when, following their Tdap vaccinations, the child began to become very weak and floppy and their motor development screeched to a halt. The baby was now seven months old and have very reduced axial tone, but reasonable strength, normal reflexes, and seemed cognitively intact. It was a very puzzling story, but the mother was quite clear that the child had been fine before their vaccinations that also included a polio vaccination, raising the question of whether this could possibly have been an issue with the polio vaccine having reverted since it was a live attenuated oral vaccine and in very rare circumstances can cause cases of polio. After many emails, text messages and a phone call to one of the neuromuscular folks at CHOP, it was decided that this was very unlikely to be polio, but was rather more likely a progressive muscle disease and that without further testing it would be impossible to determine what it was. Furthermore, regardless of the diagnosis, it was exceedingly unlikely that it would be a treatable process. In the end, it was decided that we would try to get an echocardiogram on the baby to determine whether there was any involvement of the heart.

Sheena examining a patient with Daniel scribing

Dan and Marin discussing a baby

Dan and Marin continued to have very interesting patients throughout the day and any thought of leaving here early to try for the African Galleria was pointless. We continued to have two adult rooms and one pediatric room throughout the day which seemed to work very well with Marin seeing the children on her own and Dan staffing her along with some of the adult cases. Our lunch today turned out to be the boxed lunches again, even though I think all of us would have been much happier with the Tanzanian food we had eaten yesterday. We ate again in the vehicles which is usually the case so as to avoid eating our meals in front of the residents here. These are the smaller things you have to think about here that wouldn’t even enter your mind at home.

Marin consulting on a patient with Chris translating

Dan and Marin discussing a pediatric case

It was a steady day of patients that kept everyone quite busy and though we had hoped once again to make another attempt at getting to the African Galleria, it was not to be as our window of opportunity closed quickly. Having learned the hard way with all of the dust we ingested on the first day, the two vehicles were now driving separately and it was much better experience for everyone. We arrived back to FAME in time to relax for the evening and catch another of the beautiful sunsets here as we had plans to go to Happy Day after dinner and then to The Golden Sparrow for some dancing. The Golden Sparrow is a restaurant and dance club that opened about two years ago and is the reincarnation of Carnivore, which was the previous iteration of this establishment. Carnivore was a dirt floored restaurant that served only roasted chicken, chips (fries), and fried plantains as well as lots of beer and wine. They also had a very small bar with a smaller dance floor that could accommodate only a handful of people. A night at Carnivore for dinner and dancing had been a regular highlight of our trips in the past.

Sheena taking a quick break from seeing patients

Kambi ya Simba dispensary. Note the not uncommon occurrence of pushing cars here

Two years ago, the owner of Carnivore closed its doors or, more accurately, it’s gate, and opened The Golden Sparrow. The Sparrow is a much more upscale version of Carnivore, and, to be honest, has much less of the charm and character than the original. There is a huge outdoor area for eating that does serve the same delicious roast chicken that was served at Carnivore along with a much larger menu than the original. There’s also an outdoor bar that serves whatever drink one could imagine. What really differentiates the Sparrow from Carnivore, though, is the dance club. It’s a very large and very dark room with tables and chairs and, most impressively, a disc jockey playing songs and taking requests. There are many locals here and far few fewer ex-pats, but everyone is enjoying themselves just the same and this has now been one of the social highlights of our trips here. Tonight, it was our entire neuro crew plus Katherine, and absent Dan, who claimed to be tired and not up to it, though I have no independent confirmation of this claim. We all had a wonderful night of dancing and had set a midnight curfew (which I had later regretted as it should have been a more conservative 11 pm considering we had a 7:30 am talk in the morning to deliver). Tomorrow we would also be heading to Rift Valley Children’s Village.

Ady, Jon and Marin at Happy Day

Most of the gang at Happy Day