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.

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.

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.

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.

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.

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.

 

(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 7^th and 25^th 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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

 

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.

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.

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.

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.

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.

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).

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.

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.

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.

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.

 

 

 

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

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.

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.

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.

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.

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.

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 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.

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.

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.

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.

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.

 

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.

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.

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.

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.

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.

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.

Our mobile clinic week was now underway and we were returning to Upper Kitete today for our second clinic day there. We had had another site selected, but things had fallen through as far as scheduling was concerned and there really wasn’t enough time to find a new location given the amount of planning and announcements that have to take place for this. Up the road from Upper Kitete is the village of Lostete, which is the last village on the plateau and the end of the road literally, though we were hopeful that patients from that village would come visit us just down the road. Also, the road to Lostete is very often a horrific mess once the rains begin to fall and then it’s a very iffy proposition to make it up there. So, we’ve settled this year on making advance announcements there that we’ll be in Upper Kitete for a second day with the hope that patients will come there to be seen.

Tuesday mornings are education day and we’ve been asked to give lectures for all the days that we’re here save for the two previously given by Ann and Vic. With our pediatric neurologists here, it certainly made sense to have them give some of the talks and today’s was going to be on hypoxic-ischemic encephalopathy, or HIE, which is something seen at birth and not infrequently seen here. Marin filled the whiteboard with lots of information regarding the causes of HIE, both maternal and fetal, how to evaluate the children and, then, what to do for them. In the United States, it is now standard to immediately begin cooling the children which improves their prognosis as it reduces the amount of injury to the brain. What is really most important, though, as emphasized by both Dan and Marin, is that the child is not allowed to be too warm, such as a fever. It isn’t necessarily the most important to have expensive cooling beds or blankets, but rather to aggressively treat fevers and to not cover the baby or use the incubators warming system as readily. Allowing the baby to remain cool and treating any fever will probably capture a significant amount of the benefit seen with cooling such as they do at home. It was a great talk and very, very relevant considering the number of babies now being born at FAME along with those who are brought here immediately after birth. Even a small benefit and improvement in prognosis of these children will be immensely helpful to their quality of life and that of their family who must care for them for many years.

Yesterday, we had followed the other vehicle and had essentially eaten their dust for the entire drive to Upper Kitete, or an hour and a half. Since I’ve driven this route now for several years and know it well, there was really no reason in regard to directions, but there is some security in knowing that if we had any mechanical problems along the way, there would be a seasoned driver/mechanic there to help. Last October, we had just such a problem with Turtle and were without a driver when our alternator died leaving us about an hour out of Karatu essentially dead in the water. Thankfully, we had some semblance of a cell signal and were able to call Soja, who is FAME’s mechanic, to come rescue us with a new alternator and install it just as darkness was falling. There is no AAA here and for readers of my blog, you are well aware of some of the sticky situations that we’ve gotten into in the past, some due to mechanical failures and some due to pilot error (getting stuck in the mud in Tarangire several years ago).

So today, we took off well ahead of the FAME Land Rover as that way if we did have a breakdown, they’d find us easily and, perhaps more importantly, we wouldn’t have to suffer the clouds of dust that we did yesterday and which left the right hand side of my face with enough dirt on it to pot a plant. The drive went smoothly enough without incident and was tremendously more pleasant, though with each passing car, everyone still had to quickly slide their windows closed so as to avoid filling the car with pounds of dirt. Needless to say, the necessity of taking a shower as soon as we arrived back home was a given, even if it was typically cold as the kuni boilers (a wood fired hot water heater that is used here) are only fired in the morning and by the end of the day, the hot water and fire have been exhausted.

We arrived to Upper Kitete a bit earlier than yesterday as we were hoping to get to the African Galleria this afternoon to do some shopping. It also turned out that our patient volume today was fairly light making us even more hopeful of the possibility of our shopping spree. For lunch yesterday, Angel had purchased lunch boxes for everyone from one of the local restaurants. Lunch boxes are a staple here with everything revolving around the safari business as they are carried with you into the parks to sites that are good for lunch – i.e. no dangerous animals roaming around or those that are designated picnic sites. At certain places, you have to eat in your vehicle, such as Ngorongoro Crater, where the kites drop out of the sky to steal your food right out of your hand and in front of you face. Today, we decided to pick up a more traditional Tanzanian travel lunch that included a number of primarily deep fried items such as beef samosas, vitumbua ( a fried rice cake),  egg chops (a battered and deep-fried hard-boiled egg), sambusa (deep-fried, battered vegetable bites) and donati (yes, just as you might have imagined, donuts). All of this with a side of bananas and for drinks, various Coca-Cola products including Fanta passion and Stoney Tangawizi (both of my favorites). On our last visit, we discovered that they had actually released a sugar-free version of the latter called Stoney Zero, but I will have to admit (after many trials) that the sugar-free version is not nearly as tasty as the regular.

The patient flow was not overwhelming or the day, allowing us to finish up shortly after lunch and begin to pack up our things. As we were doing so, of course, a piki piki drove up with three men on it and as they dismounted it became readily apparent that the man sandwiched in between was actually unconscious and had to be carried to the grassy area in front of the dispensary. There are few things that get our attention more than an unconscious patient, so everyone quickly went over to assess the patient who was breathing just fine and had a good pulse, so that was quite reassuring. When it was eventually learned that he was merely inebriated, we were all a bit relieved as he was a very young patient and had that not been the case, the differential would have been quite large and nothing that we would have been able to handle here so he would have had to come back to FAME with us. We departed Upper Kitete that afternoon with the drunk patient having been carried into the nurse’s office with the plan to manage him there and quite confident that they could handle the situation on their own.

The plan was to take an alternate route to the tarmac as we were planning to go to the African Galleria just outside the village of Manyara. This road takes off about half-way home and used the be the road we used for every trip to Upper Kitete, but the other road we now use was found to be quicker and more reliable. Immediately after starting down this road, it became readily apparent that this had been a wise decision as the road was in horrible shape and this was without any rain. Had it been raining, this would have been an incredible mess for certain and would have brought back memories, actually nightmares, of the time my Land Rover slid off the horribly muddy and slick road into the muck, hopelessly miring us in a sea of slimy mud that even the local farmer refused to help us for fear of getting his tractor stuck. It took the help of another vehicle from FAME, lifting and digging out each wheel at a time and then supporting them with rocks. The other vehicle couldn’t even get close for fear of becoming stuck itself, so it eventually pulled from afar and we were freed after several hours. Not one of my finer moments driving in Africa as the clinic we were heading to had to be cancelled. It was very disappointing for everyone.

Meanwhile, we were finally able to navigate this bouncy road and make it to Manyara and the gallery, only to learn that it had closed for the afternoon as all the employees were attending the funeral of a prior employee. How disappointed everyone was after having left Upper Kitete early only to find the shop closed, but it was clearly for a good cause as funerals here are a very big affair as they a time for all those to show respect to the departed and to the family. As we drove home from the gallery, we came upon many, many cars parked on the roadside at one spot with markers in the road warning drivers to slow down. There were many hundreds of people there and this was clearly the funeral that had closed the gallery. The funeral typically goes on for three days and is a huge and important affair with the host family arranging to feed all of the guests during that time.

 

It was the beginning of our mobile clinic week and I think everyone was very much looking forward to heading out into the bush to explore more of the Tanzania they had now come to know. Adys, Jon, Sheena and Daniel had been here now for a full two weeks, while Marin and Dan had now been here for a week. Everyone was half way through their visit here and it’s always sad to reach that milestone. We had had a wonderful safari to Ngorongoro Crater yesterday with a wonderful sighting of two rhinos for a long stretch of time and very close, so everyone was still on a bit of a high from that standpoint.

Our neurology mobile clinics were an offshoot of the larger mobile clinic that FAME used to do when I first came in the Lake Eyasi region where we would take the bus, a few Land Rovers, about 25 doctors, nurses, and other workers, as well as a ton of medical supplies and would spend a full week in the bush running clinics for the Datogo and the Hadzabe. These clinics were funded by a grant that lasted three years, but early on, Paula Gremley and her business partner, Amiri Mwinjuma, who worked in the area mostly helping disabled patients, suggested that I accompany them to the Mbulumbulu region of Karatu to provide neurological care to two villages there. This was in 2011, and I have continued to visit both Upper Kitete and Kambi ya Simba twice annually since that time. The Mbulumbulu region sits on a plateau bordered by the mountains of the highlands on one side and the escarpment of the rift valley on the other until in the distance, these two borders meet as the mountains descend directly to the valley floor below.

This region was settled by the Iraqw and the fields here are incredibly lush and fertile with maize and other crops growing and being harvested. The soil is a gorgeous red-orange and motely tilled either planted or readied for crops. Most of the work here is done by hand or with teams of oxen and the fields are full of workers. It’s an incredibly different and tranquil world here and life is dictated not by the hands of a clock, but rather by the seasons and the angle of the sun. Life is changing here, though, even in the short time that I have been coming as at Kambi ya Simba there is now a beautiful dispensary and multiple buildings for all aspects of healthcare there. In 2011, I was in a field under the midday sun with a desk and chairs for my office and a waiting room that consisted of a log on which my patients sat. Upper Kitete, though, remains much the same as it was in 2011 when I started, save for a small building next door to the dispensary that we used on one occasion but haven’t since. Oh yes, there are new outhouses at Upper Kitete and a flushable, though squatty, toilet at Upper Kitete.

It’s always a chore to get out of FAME on time for these clinics as somehow patients show up for us to see and that was the case this morning as they as Onealy, our radiology technician had contacted me on Saturday afternoon that the CT scanner was finally running and they had scanned a patient of ours who clinically had a thoracic myelopathy (spinal cord injury). Since we were at Gibb’s Farm in the afternoon on Saturday, I told him to have the patient return on Monday and we would also look at the scan, so I guess in some way, the patient there on Monday was partly my fault. In any event, her scan was normal meaning that we didn’t have a clear explanation as to what was causing her myelopathy. In going through the same exercise that we do here repeatedly, it was not merely a matter of sending her off for an MRI scan, as we would have to find something that we could treat here and that is a very “if” in East Africa. Rather than sending her for an MRI scan that would be very costly for her, we elected to do a lumbar puncture as this information would help us immensely. Sehewa, who is an amazing anesthetist here at FAME agreed to do the procedure for us and we gave him the labs we needed and asked him to contact me once they came back. What we hadn’t realized, though, was that we were heading to Upper Kitete for the day, where there is no cell service whatsoever. I finally received the information once we were heading home and conveyed our instructions to Sehewa later in the day and he contacted the patient.

Usually, we take one vehicle with us on mobile clinic, but since we had such a large contingent of neurologists (four adult neurology residents and two pediatric neurologists plus me) it meant that we would have to drive two vehicles. After finishing with our myelopathy patient and a pediatric patient that Marin saw as someone handed her the chart, we were finally on our way into the Mbulumbulu district. I drove our vehicle, which was perfectly fine since it wasn’t raining and the roads were clear, albeit a bit dusty. We didn’t arrive in Upper Kitete until almost 11 am which was certainly much later than we had intended, but we were perfectly fine working as late as necessary.

Our turnout was a bit lighter than normal due once again to the planting season and the fact that most people were out in their fields rather than coming to see us. We had two rooms to work in, which was fine, and there were babies coming for their well-baby visits needing to be weighed, which is always such an enjoyable event. Each baby has their very own personalized harness that their mother has sewn for them and they are then attached to a “meat scale” where they swing in the breeze while their mother checks their weight. Some of the babies are completely unfazed, while others will scream bloody murder, but the most part, it all goes well and no one is worse for the wear.

One patient today is a young adolescent girl whose mother reports that she had not been to school in a number of months and has lost a tremendous amount of weight due to nausea and vomiting. Not really a neurological problem, but worrisome just the same, so we decided to bring her back to FAME with us to check her blood work and have her seen by one of the general folks. It took some doing, but we finally convinced her mother that it would be the best for her. We loaded them in the other Land Rover as ours was full and started our trip home at the end of the day. Leaving town, though, I remembered that I had wanted to show everyone the “Overlook,” which is this amazing view from on top of the escarpment down to the valley below. Our patient and her mother decided to wait at their home briefly while we drove the short distance to the incredibly scenic sight and then returned to town to pick them up. Paula had first taken me to this place in 2011, and since then I have brought every group here so that they could also enjoy it.

The drive home was uneventful except for the fact that the young girl had become very nauseated and was vomiting in the other vehicle. Thankfully, Sheena had brought enough Zofran with her to supply an army and quickly came to the rescue, running the medicine over to her. All seemed well, until we had arrived in Karatu and while the other car stopped to let out some of the FAME people, the girl and her mom also got out and were apparently planning to hop on a piki piki (motorcycle) to head back home for some reason which was never entirely explained to us. They were convinced to get back in and we eventually made it back to FAME where Marin escorted the young girl to the ward to be admitted and evaluated.

We spent a relaxing evening at home taking care of busy work and devouring our dinner of roasted chicken, mashed potatoes and vegetables and prepared for the next day’s mobile clinic which was going to be back out to Upper Kitete. We had taken care of the Overlook today and tomorrow we were hoping to stop by the African Galleria on our way home so that everyone could look at gifts to bring home.

Ngorongoro Crater is truly one of the wonders of the world. Its name is actually a misnomer as it is really not a crater, but a caldera formed by the collapse of a massive volcano some 2.5 million years ago. In fact, it is the largest dry caldera in the world, measuring  10-12 miles in diameter and two thousand feet deep, with a large lake in the middle and thousands upon thousands of animals that remain in the crater year-round and are not part of the Great Migration. Most every animal that is in the Serengeti can be found in the crater other than the Nile crocodile (there are no flowing rivers in the crater to sustain them) and the giraffe, as the crater walls are far too steep for its access. One animal that the crater has and is known for, though, is the endangered black rhino that was near extinction not long ago and thanks to the dedicated conservation efforts of many in Tanzania, it has been increasing in numbers. The rhinos in the crater are all monitored at every moment so that the rangers know were each one is at any given time which has led to an increase in their numbers. There are also black rhinos in the Serengeti, but the populations are quite separate. The rhinos have very poor eyesight and, therefore, depend primarily on their hearing for defense which means that they are rarely out when it is windy in the crater. When I first came to the crater, I did not see a rhino and it took me several other trips there until I had finally spotted one. I have seen many since, but never very close, at least not in the crater. Going into the crater today, in addition to seeing big cats, we were looking for rhinos.

The gate entering the Ngorongoro Conservation Area from Karata is about 16 km west of Karatu on the hardtop or tarmac. Here is where the last paved road heading west across the Serengeti ends until you reach Lake Victoria. The gate is an imposing structure and opens at 6:30 am, which is the earliest that you can check into the NCA. Trucks and buses traveling to Lake Victoria take the same road that we are taking, though today we will be heading into the crater and not the Serengeti. We had planned to leave at 6 am and made it pretty it on the road pretty close to that. I have had major delays in the past getting through the gate as it is heavily dependent on having all the correct paperwork and sometimes that can be a problem. I had come up to the gate several days ago just to get things taken care of and am glad that I did as everything went quite smoothly this morning. We were through the gate in probably 15 minutes or less and on our way into the NCA and eventually down into the crater. As we traveled through the gate, it reminded everyone of Jurassic Park which is actually not a bad comparison given the size of each which is quite large.

The road winds slowly up to the crater rim through what is literally a primordial forest with trees reaching to the sky from the bottom of the deep ravines or valleys that lay on one side of the road as we hug the mountainside on the other. It was an amazingly beautiful day with not a cloud in the sky and the normal clouds that sit on the crater rim early in the morning on most occasions are not present. As we reach the rim, the massive expanse of the caldera exposes itself for the first time and we stand on the overlook with the most incredible view one could ever imagine. Every detail of the crater lies in front of us. In the foreground of the crater, there are tiny bodies of water or small lakes from which extend small channels in various directions that immediately remind each of us of neurons with their numerous dendrites and axons. Leave it to nerdy neurologists to make that association. It was quite cold standing on the overlook and everyone was incredibly excited to get into the crater, so we began our drive to the opposite side of the rim where we would find the one-way descent road and make our way down to the floor.

As we travel around the crater, there are constantly views to the floor at various places, as well as tremendous views of the surrounding countryside which is all the conservation area and the home to very many Maasai living in their bomas. The purpose of the conservation area is that it is multiuse. The Maasai who live here graze their cattle throughout the area, often alongside herds of zebra and wildebeest. There are also Cape buffalo and elephant who trample their gardens or small plots of crops. Lions will also attack their cattle at night which is why the livestock are brought into the middle of the boma at night to protect them. As we reach the southern edge of the crater rim nearing the descent road, the view south looks towards the Southern Serengeti and Olduvai Gorge stretching far into the distance. There is a valley in front of us that contains numerous bomas and is lush and green at this time of year. A shallow lake occupies the center of the valley where the herds of livestock and wildlife mingle among themselves throughout the day.

We’ve finally reached the top of the descent road where we stop to check in with our paperwork. The views from this spot are equally impressive as those from the overlook so prior to loading back into the vehicle, everyone has a chance to take photos. Most importantly, we finally raise the top on Turtle so we’re in full safari mode now and it only increases the excitement that’s been building, more so given the fact that no one on board, save me, has been to the crater before so it will all be new to them. The descent road is wickedly steep, rocky, narrow, and, thankfully, one way. Leaving the Land Rover in first gear to stay off the brake is best and it is a long way down to the floor. The candelabra trees, a unique succulent here rise up alongside the roadway as we descent. We get our first good glimpse of the wildlife as we approach the bottom, but when Marin first spotted what she thought was a “dead lion,” (no worries, it was only sleeping as most lions do throughout the day) it became clear to everyone that we were going to see much more than just antelope here. There was a total of five male lions here, two adults and three youngsters, the latter with shorter manes. They were all sleeping, but one of the older males stood up at one point to move into the shade where he promptly plopped down alongside one of the other males. That was about as much activity as we witnessed from this group of lions today.

Once down on the crater floor, your perspective of the topography completely changes as it is now a flat plain that you are sitting on surrounded completely by 2000 foot high cliffs in all directions. There are relatively easy landmarks by which to navigate and definite highlights such as the hippo pool, Ngoitokitok Picnic Area, the Lerai Forest, the Munge River and Lake Magadi. We initially drove around the periphery spotting many jackals and hyena along the way, but eventually made our way to the hippo pool where there were plenty of hippos cooling in the waters there. In the past, I’ve seen several serval cats here, but not today. As we made our way around in the direction of the picnic area where we planned to have lunch, we spotted two large black rhinos which everyone had hoped to see today. They were a fair distance away initially, but were moving laterally from us in the direction of one of the roads that they would eventually need to cross. We waited long enough to snaps hundreds more photos, but at the right moment, I began to move the vehicle in the direction of where they were heading.

Initially, there were probably half a dozen vehicles watching the two rhino, but as word got out on the two-way radios, over a dozen cars began to accumulate at the site so I hung towards the back of the pack so as not to interfere with the animals. The rhino are very skittish which became evident as they looked as though they wanted to cross the road, but their pathway was blocked by the many vehicles so they just continued to walk parallel with the road and eventually just changed direction. At one point, they were interacting with a small group of Cape buffalo, forcing the buffalo, a pretty feared animal in its own right, to the side with ease. The rhinos finally crossed the road in front of us, despite all the vehicles there, and made their way to a more secluded spot behind a bluff so that they couldn’t be seen as well by everyone. By this time, I think that everyone in our vehicle had had their fill of rhinos, at least for the moment, and were very interested in getting to the lunch site.

The Ngoitokitok Picnic Area in the crater has to be one of the most beautiful sites in the world to sit an eat one’s lunch. Beside the fact that you’re sitting inside a massive caldera that is millions of years old with 2000 foot cliffs reaching up all around you, there is a lake with hippos floating in it and more birds than you would ever hope to count. Everyone is free to walk about here, though I have seen lions visiting this spot in the past. The most impressive birds here are the black kites that patrol the region from high above and have the remarkable eyesight typical for a bird of prey. They can spot a sandwich in someone’s hand from far above and then drop in a remarkable feet of acrobatics, divebombing the unsuspecting person and stealing their food just as they are about to put it into their mouth. And all of this without ever touching their victim and without any warning whatsoever. Since my first visit here, I was taught about the kites and the need to stay in your vehicle to eat or else suffer the consequences. There is usually one group who have either decided to disobey their guide or their guide had decided in advance not to tell them. Who knows? But for those of us watching, it can be a pretty crazy show and well worth the cost of admission. We did keep an eye on the kites throughout lunch as they were checking out every vehicle that had stopped for a meal. There are lots of weaver birds circulating here as well, and they’re brave enough to come into our vehicle, but do far less damage than a giant kite would do with its enormous wingspan. While on the crater rim having lunch one time, I hadn’t thought that the kites were there, but one located my piece of chicken that was inches from my mouth and promptly swooped in to grab it without having even grazed me in the process. That was a bit startling, to say the least, and had quickly gotten the attention of not only me, but also everyone else sitting in our little circle.

As we left the picnic area we decided to head towards the Munge River area looking for any cats, but unfortunately, did not see any today. Driving along the river, we did run onto large groups of Cape buffalo, who always look a little bit disturbed by our intrusion, to the degree that at times they look as they would love to charge the vehicle, but thankfully haven’t. We drove along the opposite side of the river for a long way, ending up sitting on the top of a large hill that has a great vantage point to see the entire crater floor. There had been clouds gathering and small ran showers in local areas that forced us to close the tops on the Land Rover on one occasion, but only temporarily. It was getting late and we had planned to pick up Kitashu at the junction of the road to Endulen around 4:30 pm.

Driving up the one-way, paved ascent road, winding up and up on continuous switchbacks, there are constant vistas of the crater, each one more beautiful than the next. A short backtrack to the junction and we met Kistashu, who piled into the vehicle and we were off on our way back home to Karatu. You must check out of the NCA by 6:30 pm, which is when the gate is locked and, without an official document, you end up having to spend the night there which can be a bit of an issue without having first arranged some form of accommodations. Sleeping in your vehicle can be a bit of a struggle while sleeping on the ground outside can be just a bit too dangerous. We made it to the gate with plenty of time to spare, unlike a few times in the past, checked in with the rangers and we were shortly on our way having had a wonderful day we had in the crater, one that everyone would certainly remember for years to come, and headed off to Karatu and Happy Day pub for dinner.