Wednesday, March 18, 2020 – It’s back to Mang’ola….

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The main office of the clinic at Mang’ola

Lake Eyasi is probably one of the more remote locations that I have ever visited, and it is probably one of the most unique places as well. I had already discussed the trips that FAME used to make to this region as part of its malaria education project that ended several years ago, and where we are heading today is a region that is not quite as far as we had traveled for those clinics, but close. Lake Eyasi is home to the Hadza, the last hunter gatherers in Tanzania, that are small tribe and who are slowly becoming smaller over time due to encroaching grazing by neighboring tribes, including the Datoga, whose cattle have reduced the Hadza’s normal prey. Lake Eyasi, which used to be home of large game such as hippos, kudu and other antelopes, has slowly seen a reduction in these animals so that the Hadza have resorted to hunting small birds, dik dik, and baboons for food. They are, unfortunately, a dying tribe of only 1,500 individuals and, once they are gone, not only will we lose their culture, but also their unique click language that is so rare in the world today. Mike Baer wrote a wonderful piece regarding his care of one of these remarkable individuals that is published on the FAME website and can be found here:

https://fameafrica.org/journal/2019/10/3/one-of-only-1500

Carrie (enjoying her apple) with Molly and Frances readying to see patients

Alice, Africanus and Robert

Marin and Amisha

Lake Eyasi has a number of villages that surround it and the region has been increasing in population due to the very successful onion farms that have continued to grow in the area. Picking onions is the main occupation here and during the harvest season, large trucks full of onions are continuously traversing the often treacherous roads bringing produce to market. Today we will be returning to Mang’ola where we had first visited last September for one of our mobile clinics that was so busy, we needed to come back a second day and ended up seeing over 70 patients over the two days. For today’s clinic, we had tried to anticipate this and scheduled a second day of clinic in a nearby village, hoping those who could not be seen on the first day here could simply travel on the second day to the other nearby village.

Joel and Lobiko waiting to take vitals

The clinic health officer going over coronavirus precautions with the townspeople

The washing station outside our clinic – social distancing was not yet a thing.

Anne, Kitashu and Joel getting our clinic organized

The drive to Mang’ola is through landscape far different than any we’ve seen so far on this trip. I’ve been through the region on many occasions over my ten years in Tanzania, but for the others, the topography appears incredibly alien, as if it’s from another planet. The road initially travels atop a very large expanse of relatively flat terrain, while dipping down into deep gorges every several miles to travel across dry streambeds, that though dry now, were very clearly recently with water from one of the many storms that have come through in the recent days. At the bottom of each gorge, one most often encounters a slab of cement that is meant to offer safe travel across, though their appearance can be all but reassuring at times. The flash floods that travel through these canyons leave a pleasant looking meandering stream bed on the uphill side, but the downhill side typically appears as a steep drop off, having been completely eroded away by the quickly flowing water. Traveling in this region in the wet season is often impossible as these gorges can quickly become fast moving rivers that are impossible to cross.

Joel getting vitals on a patient

Frances working with one of her patients along with Lobiko translating

Africanus and Alice taking a history

Carrie (as a scribe), Abdulhamid and Molly evaluating a patient

The road is quite easy to follow for most of our drive, but as we get closer to Lake Eyasi, there are multiple forks with no signage to direct you that often require some help from the local residents. As we crest a small hill, the Lake comes into full view and is many times its normal size with the recent days of rain that have fallen in the region. Despite this, it is still incredibly dusty as we travel along in tandem along the main road that is often blocked by herds of cattle, sheep and goats or erosions in the drainage areas. There are many, many small traditional homes as we enter the village perimeter and finally see some semblance of the town before we turn left and find the health center we’ll be working in today after a very short distance.

Kitashu chatting with a patient

Joel and Lobiko dispensing meds

Dr. Anne, Amisha and Marin evaluating a patient

A friendly spider

Having been here last September, the setup is still quite familiar to me and everyone gets out of the vehicles to check out where we will be working for the day. The district health officer is the same one who had been there in September, greeting us with enthusiasm and quickly checking as we survey the rooms we’ll make into our examination rooms for the day. He had been incredibly gracious during our last visit here, especially after we had returned the following day to the remainder of the patients, and he’s happy to see us back again as we’re here to help his community and he’s grateful for that. As we arrived, there was a very large group of patients outside of the health officer’s building where it turned out he was addressing them on the coronavirus situation and subsequently demonstrating the handwashing stations that had been set around the health center with one just outside the entrance to our building. Even in this incredibly remote region of Tanzania, there was already growing concern by the general population of the impending pandemic and this was becoming ever more clear with each coming day.

Amisha evaluating a patient

Joel getting vitals

Dr. Anne evaluating extraocular movements

Amisha working on the neuro exam with Dr. Anne

The health center here in Mang’ola is really very comfortable for us as there are many rooms in the buildings were given for the day and we quickly made arrangements for who would be working together and in which rooms. There were benches for some of the patients to sit on while other sat on the floor of the large outer room, and still others waited outside to be called. Everyone was triaged in advance by either Kitashu or Dr. Anne and I think we did very well with only a few non-neurology patients being seen that day. Dan and I sat outside on the large covered porch that bordered the entire front of the building and was a great perch from which to watch the comings and goings of all the townspeople. Both Dan and I were particularly drawn to the many children who gathered outside, some of who were patients of ours, but others were here with their mothers. Many of the children were particularly well-dressed and it was all I could do not to continually be taking their portraits, though I could resist just a few of them. Dan seemed to have made friends with one young boy who sat on his lap forever playing with his phone taking some pretty nice selfies of the two of them.

Dan and his friend

A fine selfie

Curious children

There were many great neurologic cases that we saw in Mang’ola, but the best of them had to be the young woman who came in with a neuropathy that was clearly hereditary given her age and, with further questioning, was quite clear that it was Charcot-Marie-Tooth disease, or hereditary motor and sensory neuropathy (HMSN), a rather common group of genetic disorders affecting the peripheral nerves. With further questioning, it was very likely that other family members also had the disorder, so, like any good clinician with a research background, Dan, who happened to be staffing the patient, inquired about having the other family members come to see us. After the initial thought of sending one of our vehicles to pick up the other family members, it became readily apparent that it was far easier to have Dan go to their home, though that is not something normally done here and required some long discussions with the health officer and a village elder to get permission to do so. Eventually, Dan left with one of the drivers to visit the family, not far from the clinic, though, given the topography, a bit further than I think Dan had expected. I was truly jealous of the fact that he got to do the exploring this time, but he had clearly earned it given his commitment to the program with his second trip to FAME.

Dan’s visit to a patient’s home

Amisha and a young patient (obviously her favorite)

Marin pitching in with Lobiko in an improvised exam room to finish up with patients

Dr. Anne with a patient

Not to be outdone by the bats at Upper Kitete (you’ll have to read my older posts for stories of the “bat cave” there), there were several of these nocturnal creatures under the rafters of the building and quite aware of our presence. They would shuffle along just underneath the roof and between the rafters as you would stop to look at them as it seemed to make them nervous. I’m sure they were not happy with our presence and the crowd of people that had come to see us. Along with the bats, there were also relatively large lizards (not Komodo dragon large, of course) that were creeping along in nearly the same space as the bats, but neither could care less about the other and were far more concerned that I was stalking them for photographs. For those of you who don’t know, my love of reptiles goes all the way back to my childhood and time spent in our family pet shop.

A friendly visitor

A friendly spider

Marin undoubtedly writing directions for a patient

Marin hard at work

A typical mode of transportation for our patients

As we said goodbye to Mang’ola for this trip and began our trek home in the waning hours of daylight, I think we were all contemplating not only another successful day of neurology clinic and mobile clinic too boot, but there is little question that each of us had in the back of our minds growing concern for the impending coronavirus and what our days ahead here would hold for us. It was clear that the pandemic was growing in intensity and even though there were no reports of its presence yet in Tanzania, we would have to pay particular attention to our travel plans in the future. We did have plans to go out to Happy Day this evening as it was the night that all the ex-pats in town met to share stories, but given the long day we had (we left at 7 am) and the time we arrived home, no one had the energy for a night out and we all decided that we would earmark next Wednesday for our last visit with everyone.

Our journey back to FAME

 

 

 

Tuesday, March 17, 2020 – We’re off to the Rift Valley Children’s Village for the day…

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Since we would be leaving very early for mobile clinic on Thursday and there was a good chance that a number of us would be on our way home by next week, today was our last day to provide neurology education to the doctors. I had mentioned that it was requested that we provide more case based instruction and after discussing the options with Dr. Ken, he had requested that Marin discuss a rather complicated pediatric case that had come in with hyponatremic dehydration. Now this probably doesn’t sound like a neurology topic to most of you and, in fact, you’d be correct in that assumption. But the complications of the condition can be very neurologic and Marin did an excellent job running through how to calculate the exact sodium deficits that exist and how quickly they should be replaced. The talk was very well received by all of the doctors and given the fact that even I could understand it, she had clearly done an excellent job explaining the subject.

Driving to RVCV

Today, we would be heading to Rift Valley Children’s Village, a magical place that I’ve described numerous times here and would encourage everyone to look at the website www.tanzanianchildrensfund.org. In a story quite similar to Frank and Susan’s, India Howell came to Tanzania in 1998 after climbing Mt. Kilimanjaro to manage a safari lodge, but quickly recognized the many children at risk who had either been orphaned and were on the street or whose families were unable to care for them. She created RVCV in 2004 along with her Tanzanian partner, Peter Mmassy, as a permanent home (not orphanage) for their children for who they are their legal guardians and the children remain at the village until they are ready to go off for college. The village is now home to over 100 children with many having gone off to college and returning for the holidays to help with their brothers and sisters.

The condition of our roads

Following the other vehicle

The location of FAME in Karatu has everything to do with RVCV as from the beginning, it was India’s plan to provide her children with the very best medical care which was initially supplied by FAME as twice monthly medical clinics to not only RVCV, but also to the surrounding community of Oldeani. The latter was essential as the children from RVCV and Oldeani all went to school together and she recognized that without the health of the surrounding community being improved, it would difficult for her to maintain the health of her children. RVCV also partnered with the Tanzanian government to improve school conditions and has assisted in managing both the primary and secondary schools. The graduation rates of the schools has far exceeded the national averages for both RVCV and local children alike.

Joel, our nurse and pharmacist, dispensing medications

Gusa pua yako (touch your nose) as demonstrated by Marin, Dr. Anne and Mom

In 2010, I first began to accompany the regular bimonthly medical clinics from FAME and quickly realized the need for neurology given the number of children with epilepsy and learning disabilities that needed further attention. Beginning in 2013, we have now been providing completely separate neurology clinics for RVCV as part of our mobile clinic week during which we provide neurological care to more remote communities. Many of the patients who continue to see us here have been with us since the very beginning. As part of their administrative building, there is a wonderful medical wing comprised of small offices where we can see our patients and their full-time nurse practitioner, Katie Anderson, has made it incredibly efficient for us over the last year or so. As we arrive, patients have been registered, divided into adult and pediatric, and we have four examination rooms, each labeled and ready for our use.

Marin and Anne with a patient

The facilities and grounds are, as you would imagine, impeccable and gorgeous. RVCV lies high on a ridge surrounded by coffee plantations which is the main labor for the surrounding community during the picking season. Children live in houses that are organized by gender and age and each has its own house mother who is in charge of their children, getting them ready for school and ready for bed at night as well as during meal times. The primary school is adjacent to the village so they just walk through a gate to get there. Children eat in their own houses where their house mothers cook for them. There is plenty of open area for sports between the houses and there is a large indoor gymnasium as well. Driving through the gates of RVCV is truly an awakening of what can be done with an idea and a will, much as it is driving into FAME for the first time.

Molly and Kitashu evaluating a patient

Presenting a patient to Dan with Frances listening on

The drive to RVCV is another matter altogether. Once leaving the tarmac just below the Ngorongoro Gate, the road travels along a ridgetop for some ways before descending into the first of several valleys with very steep descents and ascents that, in the best of conditions, can be a bit much for the faint of heart. Thankfully, the views from the road are just so spectacular that they do in many ways make up for the extra bumpy and, often, slippery ride. I have loved driving this “road” since my first visit here when I was in the little Toyota six-pack pick-up and turned out to be the only one with experience on mountainous roads with a stick shift. I was asked if I wouldn’t driving and don’t think that I could have answered the question any quicker than I did. That was first introduction to driving in Tanzania – being handed the wheel of that old Toyota at the bottom of one of the gullies. It’s been in my blood ever since, but of course today we had asked one of the drivers and, so, I was missing out on my fun, though sheltered from the stress of trying to drive in a downpour if one had occurred.

Marin, Dr. Anne and patient

One of my absolute favorite patients

The drive is initially along the ridge top with large planted fields on one side and steep hillsides on the other, comprised of smaller planted fields and the occasional homes of the farmers often place precariously, all descending far to the distant bottom of the valley. We eventually make a sharp left turn to begin the first of our steep descents as the road is constantly crosscut by deep gutters and humps that have been dug in an attempt to keep the rain water from running directly down the path, but rather diverting it to the side. Needless to say, it is very slow going. The road is also two way, but, of course, only wide enough for a single vehicle, so when any oncoming traffic appears, you much immediately have a plan of how it will be negotiated. Thankfully, speeds are so slow here, there is plenty of time for this. At times, though, the road is a single lane wide with a wall of dirt on one side and a steep drop off on the other, requiring just a bit more thought into the situation when this occurs.

Dr. Anne, Marin and Francis with one of their little patients

After the final ascent, we end up in the coffee plantation with its many, many coffee bushes producing some of the best coffee in the world. We travel through the plantation and up a small hill to arrive at RVCV and the small local village that surrounds it. Inside the gates, there are many patients waiting to be see already and, of course, Katie has everything incredibly well organized for us. We have two pediatric examination rooms, two adult examination rooms, a room for our pharmacy and Dan and I have the loveliest spot in the back to sit waiting to discuss cases. One of best things about our day at RVCV, though, is the lunch. The Village has many long term volunteers who all eat their meals together in the dining building that are all cooked fresh by the mamas. It is easily one of our best meals of the trip save for perhaps Gibb’s Farm. Our lunch today happened to be BLTs with homemade rolls, bacon (of course), cheese, tomato, salad, fruit and scrumptious cookies for dessert. I think everyone was incredibly satisfied after that meal – I know that I was.

Swedi translating for Amisha

One of the other programs run by the Tanzanian Children’s Fund is their microfinance and business development that is provided for the surrounding community. One of these groups, the Rift Valley Women’s Group, have been very successful in producing many handmade items from clothing to bags to jewelry that are now being sold in many of the lodges around Northern Tanzania. There is also a small duka, or store, on campus that we always visit now after lunch and there are amazing items that can be purchased, all made by women of the local community. Not only are supporting this incredibly worthy cause, but you are also bringing home a unique and beautiful creation by this remarkable group.

Carrie and Swedi with a patient

Before coming to RVCV today, there had been some concern about us being permitted to visit as it was anticipated that they would be securing the village in light of the Covid-19 situation. We were thankful to have been able to see our patients there, though upon our departure, Swedi, one of our translators who grew up there and was residing there as the colleges were closed, informed us that he would not be able to join us for the remaining two days of mobile clinic due to their concern and the fact that they would likely be shutting down travel into and out of the village the following day. Though we would miss his help dearly, we certainly understood the reason.

A shot from inside on the way home

DJ Amisha (note Frances’s green balloon for St. Pattie’s Day)

Despite a heavy rainstorm during the day, the roads were no worse for our drive home which was a welcome surprise to everyone. One of the new features we’ve had during our drives in Turtle over the last year, is the addition of a new radio and speakers. Since there are no radio stations to speak of here, we are able to use a USB cable and typically designate someone as the guest DJ for the drive. On our way home, Amisha was the DJ and we were fortunate enough to catch her during a rare rapping session that is now available on YouTube and is previewing on this blog. Just see below.

Dinner at home tonight were vegetable wraps made with chapati (pretty much a staple here), hummus and raw vegetables. Amisha offered to make stir-fry with the vegetables and chicken quesadillas with the chapati, cheese and left over chicken from the night before. They were absolutely delicious and a total hit.

A gorgeous scene on our ride home

With the time difference being originally eight, and now seven, hours ahead of the us, we were able to come home from work and begin listening to the early news which was obviously all about coronavirus and Covid-19 and where things were heading in the world. The experience in Italy was devastating, though despite all of the news, there had been no widespread outbreaks yet in Africa. We knew that it was only a matter of time and that unfortunately, there was probably a discrepancy in the testing being done compared to the west, and, as a result, the reporting. Meanwhile, FAME had by now installed wash stations in the entrances to every building and had its isolation ward set up and functional. Throughout our trip, though, we have been consulting with authoritative sources at home to help make decisions based on the most recent facts regarding the outbreak and our need to return home early for our own safety. It continued to be the case to this point that there was a greater risk of exposure to coronavirus at home than there was in Tanzania, though it would require constant vigilance and monitoring of the situation going forward.

Monday, March 16, 2020 – Kambi ya Simba (Lion’s camp)….

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NOTICE – I want to first reassure all of my readers that every member of the team has arrived safely to the US as of Saturday, March 21, and Sunday, March 22. I would also like to apologize for the delay in posting these blogs, but given the circumstances, it became more difficult to get things written in real time.

Molly and Amisha taking advantage of a coronavirus washing station on our arrival

When I had first come to work at FAME in 2010, they had been providing a very large mobile clinic to the Lake Eyasi region of Northern Tanzania, a very remote area where the Hadzabe and the Datoga live very isolated lives with little in the way of medical care. It was a very large operation, utilizing Rosa, the all-wheel drive disaster ambulance from Japan, then outfitted to provide room for probably seven passengers and all the gear needed to provide medical care to around 100 patients a day who came from the surrounding areas. Rosa had solar panels on top to provide the necessary electricity for Dr. Joyce to set up a mobile lab, extra batteries to provide emergency power and everything necessary to provide medical and some surgical services in the field. It was essentially the FAME version of a MASH unit.

The waiting area outside our exam rooms

The mobile clinic was an entire week when we would be away from the main campus, eating and sleeping together in whatever accommodations we could find in the local cinder-block government buildings that were as hot as hell and had no power, but an outside choo (two bricks to stand on and a whole in the ground) and a shower stall in which you could take a bucket shower in privacy. Hot water was a hit or miss phenomenon depending on what time you awoke and, considering the sweltering heat all night long, that was typically well before sunrise and the local woman had not yet had a chance to boil water for us. It was a monthly clinic as long as the weather allowed as flash floods would frequently wash away those regions that had roads or make those that did not impassable. As an adventure, there have been few that exceeded it in my life. They were long, long days, everyone was beat and sleep was not something that required any extra initiative.

One of the corners right above our heads containing a few Nairobi flies. They were as thick as I’ve ever seen them.

Molly, Anne and Carrie presenting a patient

Alas, all good things must come to an end and the grant that funded the clinic, from a Dutch non-profit, Malaria No More, was only for three years. The other purpose of the clinic, in addition to providing health care, was to provide education and there were malaria videos shown to the people that came along with information on STDs. Paula Gremely, and her partner, Amir Bakari Mwinjuma, supplied much of the education and non-medical part of the logistics such as how to feed 20+ people that were part of our contingent (we had two or three Land Rovers that also came along). In 2011, Paula and Amir both discussed with me the thought of providing a neurology specific mobile clinic, on a smaller scale, to the surrounding villages around Karatu that could be done in a single day each and would make those patients who had treatable neurological diagnoses, such as epilepsy, aware that they could easily receive medications that would change their lives, and they could also come to FAME, if needed. In April 2011, only my second trip to FAME, Paula and Amir brought me, a clinical officer, a nurse (to act as our pharmacist), and a big box of medications to Kambi ya Simba as our very first neurology mobile clinic.

Molly, Anne and Carrie presenting a patient

Alice and Africanus evaluating a patient

At the time, there was a tiny dispensary at Kambi ya Simba, a ragtag little town in the Mbulumbulu region of Karatu district and was the closet village after leaving the tarmac at Rhotia to have enough organization to warrant our visit. We borrowed two desks, one for me and one for the pharmacy, set them up in a clearing out in front of a small church nearby, and went to work. We had plenty of patients to be seen and it was difficult to convince them that it wasn’t proper for all of them to stand around my desk while I was taking a history and examining the patient. There are no HIPAA rules here, but over the years, we have worked very hard at FAME to respect every patient’s privacy with the utmost care. I gave my camera to Amir and, even though it was a complicated digital SLR, I told him to just use the zoom to frame the shot and the camera would do the rest. He took hundreds of photos, many of them spectacular, but the one he should with examining a young Down syndrome patient placing his hand on my head while I listened to his heart absolutely won me over as one of my favorite photos from here that has characterized our work.

The visiting group at the entrance to the dispensary

Our waiting patients

Unfortunately, after 16 years in Tanzania, Paula had to go home for family reasons and her work ended. I haven’t seen Amir in many years, but I know that he stays in touch with FAME and I will always remember him as one of those people who have the biggest hearts and know how to utilize it constructive. So, after ten years of continuing to provide neurological care at Kambi ya Simba twice a year, we are going back today with a vastly different effort than that very first visit. We now have two vehicles going given the size of our team – three residents, medical student, pediatric neurology nurse practitioner and a fellow CHOP attending, most requiring an interpreter, two drivers given the horrendous road situation with the rain, a nurse to dispense medications and a social worker. While our team has grown over the years, though, Kambi ya Simba has also become a huge collection of medical wards, offices, radiology suite (not sure if their equipment is up and running), labor and delivery and whatever else is necessary to be a showcase government facility. In fact, we were told upon our arrival that members of parliament would be coming today to make some speeches, but that it would not interrupt our clinic for very long.

Turtle after our drive to Tarangire as we didn’t have time to wash her

Marin and a patient

The road to Kambi ya Simba, and to Mbulumbulu for that matter, range from horrible to impassable, and it all depends on the rains. There is plenty of travel on these roads, from overloaded Land Rovers with people hanging on the sides and sitting on top, to larger trucks and even a bus that plies this route. The land here is incredibly fertile and it is almost exclusively Iraqw who live here with many of the older woman speaking nothing but Iraqw necessitating an extra interpreter for them at times. The road departs from the center Rhotia, heading north along the Great Rift escarpment, which explains its fertile soil as it is mostly volcanic, and you reach Kambi ya Simba in about 45 minutes. The roads today were not the worst I’ve seen, but they were bumpy enough and slippery at times for me not to be wanting to drive on them. I’ve written in the past about slipping off the road on my way to Kambi ya Simba, and it was not a pleasant experience at all. The mud on any these roads (there is only one paved road from Arusha to Karatu so essentially everything is unpaved) will almost instantaneously become as slippery as ice with just a hint of moisture on them and It becomes a challenge just to keep these big vehicles on track and in the right direction. We made it safely with George from FAME driving my vehicle and Julius driving the vehicle I rented from Kudu lodge in Karatu as none of the vehicles from FAME were available for our use this trip, the first time ever, due to a shortage secondary to their vehicles aging out of their useful life and upkeep becoming unmanageable. I had decided to rent a vehicle for our neurology mobile clinic, one of the jewels in our work here.

Some down time

Robert and Afircanus during our downtime

We left for Kambi ya Simba a little after 8:30 am and probably arrived sometime before 10 am after any errands that needed taking care of. We set up shop in the allotted rooms and managed to get at least three rooms for our work, which was essential as it becomes impractical to see the volume we do without a minimum of three and often four rooms. Everyone got started on their patient with Amisha and Marin initially working together on the pediatric cases. Molly’s very first case of the day happened to be a very, very nice man with a couple year history of weakness of his muscles and the inability to swallow. The important piece of his history is that he was a very, very nice man, for, as neurologists, there is a superstition that only it is only very nice people who develop one of the worst terminal neurological illnesses we have, amyotrophic lateral sclerosis, otherwise known as ALS or Lou Gehrig’s disease, as it affected one of the most amazing baseball players of all time, who, after photographs very likely revealed his early muscle wasting, was still able to play professional baseball with the early stages of this disabling and lethal disease. Of course, there were some pieces of information in our patient’s history that may not have completely fit, but they were less significant parts of the history as it is common here to explain diseases based on events that would have nothing to do with the onset of the disease, such as seeing a snake and developing seizures. The rest of the history, and often that which is most important, is somehow pushed to the background and sometimes very difficult to retrieve when it’s needed.

Marin and Swedi talking to a patient

Frances enjoying some time with out of our patients

We had a fair smattering of both adults and children to see here, keeping Marin and Amisha quite happy, and there were both follow up and new patients as well. Though patients seen here are not given FAME charts or medical records number, we keep the list of patients going and organized, always bringing back paperwork from the clinic done six months ago. Many patients requiring refills must come to FAME for those medications as they are not always available at the Duka la Dawa (pharmacy) in Kambi ya Simba. For patients who we have significant concern for in their ability to get to FAME or to be afford the refills, we may be more liberal in writing their script for several months. As I may have mentioned before, Leah Zuroff, our medical student from September (and recently matched at Penn for neurology – congratulations!) extrapolated out the cost to provide an entire cohort of our patients from September (405 patients) with visits twice a year, medications for a year and any labs they might need and came up with a figure of approximately $35,000 for all of the patients, a far cry from what is spent in the US for similar circumstances and where that wouldn’t even cover one patient for a several day stay in the hospital. Things are just so crazy in this world.

Amisha and one of her favorite patients

Marin taking a history with Swedi’s assistance

About noon, we had several reasonably new vehicles drive up to the clinic with lots of people getting out wearing suits, far different than the normal attire we see on these visits. Then, we heard loud sirens in the distance and a police pick-up truck with yet several more vehicles following including one identical to our Kudu rental Land Cruiser drive up, the police vehicle with a number of uniformed and armed police riding in the back all standing. Out of the other vehicles came individuals who looked very official along with several uniformed and armed military officers getting out as well. Everyone, including the armed personal as well as many of the local residents, finally assembled at the covered entrance to the dispensary where there was a large poster hanging and gave speeches that were impossible for us to hear as we were all gathered with our patients by our examination rooms, having been asked to stop working during their visit.

A fine demonstration of the Jendrasik maneuver by Marin

Following a tour of the facilities, the entire entourage eventually packed back into their vehicles with all of the armed personal and drove off in the direction of the center of town. Once they had left we were again free to finish seeing our patients who had waited patiently for the official visit end just as we had. We did have to squeeze a quick lunch break in, though, as we weren’t able to do it during the visit. Outside of my first to Kambi ya Simba, where we were actually fed lunch by the village, we have always brought our own food, given the size of our team, and it has always been our policy to eat in our vehicles, or at least outside of the view of the patients and family as it would be otherwise impolite for us to eat and not share with them. Bringing enough food for the entire village would obviously be a huge undertaking and not something that we were equipped to do.

Presenting their patient to Dan

A shy patient

We had seen a steady flow of patients throughout the day, some of who were follow ups for us, but the majority were new as has always been the ratio on mobile clinics as well as back at FAME for our general population of patients. We finished with our last patient at a reasonable time and were able to begin our journey back to FAME in the daylight, which is always a significant as it is unsafe to drive at night on these roads due to animals, domestic and otherwise, that may suddenly show up in your path. Susan had asked everyone to come over to her house tonight for a get together prior to everyone’s departure. At the time, Dan and Marin still had intentions of going to Gombe next Sunday to see the chimps, though the impact of Covid-19 was beginning to become more apparent on a daily basis and at that point, we realized that we had to be flexible. We had managed to finish our first mobile clinic of the week, and our goal was to be able to at least finish out our week of clinics as the patients were depending on our visiting them. We also had one new sight that were going to for the very first time.

Amisha incredibly proud of her patient titration schedule

We all sat on Susan’s lovely deck that evening to watch the sunset and share the time together, but the uncertainty of immediate plans certainly loomed heavily on everyone’s mind. My original plans had been to stay for the FAME Board meeting that had now been cancelled and it was more of a matter of determining just how much of our mission we’d be able to complete without risking not being able to get home.

 

 

Sunday, March 15, 2020 – It’s off to Tarangire National Park…

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Elephants up ahead

Each of the National Parks in Northern Tanzania are based on different ecological and geological features that give each park its very own character as well as the types of scenery and animals that you will see. Ngorongoro Crater is based on the largest dry caldera in the world and serves as its own ecosystem where the animals live year round on the floor of the crater and don’t migrate as they do elsewhere. The Serengeti is most well-known for its endless plains, which is actually the meaning of the word in Ma, the language of the Maasai. Lake Manyara is a park whose ecosystem is based on this very large lake that was formed as part of the Rift Valley and is home to many, many flamingo. The park is also the setting for Hemingway’s non-fiction novel, The Green Hills of Africa, which is about a hunting trip he took there with his wife in 1933. Unfortunately, there are no longer black rhinos left in the park as they were overhunted. Tarangire National Park, which is centered around the Tarangire River that dominates the landscape of this magnificent park, is well-known as the home of the elephants here in Northern Tanzania as there are thousands of them that populate this very large park and every day travel from the surrounding hills down to the river for their water.

Giraffes in the distance

Giraffes under an acacia

Tarangire National Park has been one of my favorite parks to drive for as long as I have been coming to Tanzania and driving myself which actually began in 2012. By that time, I had been on a number of game drives to all of the parks and one of the best teachers that anyone could ever hope for in the person of Leonard Temba. Leonard had been my guide when I first came here in 2009, on vacation with my two children and my only intention at the time was to bring my daughter, Anna, here as she was interested in wildlife management and it was means of exploring some of the most famous parks with her as we shared a love for animals and the outdoors. The three of us spent two weeks with Leonard, and during that time my children bonded incredibly with him, as I did as well, and from that chance meeting has evolved my love of this country and my effort to help in the best way I know possible – medicine, and, specifically, neurology. Leonard introduced me to FAME, which was only a year old at the time, and I was apparently bitten by the bug that has brought some many to this continent in a similar fashion over the years. Now, on my twenty-first trip to Tanzania, I have realized that it is more than just a passion, and it has become a mission.

An impossible river crossing

Banded mongoose

I have seen so much at Tarangire over the years while taking the residents there during our visits, and have enjoyed sharing it with them every time so that it never gets old for me. With all the rain we’ve had in the last weeks, a trip to Lake Manyara was out of the question as the lake swells so much that most of the roads are undrivable and the animals scatter. Manyara is a smaller park and the water would seriously hinder our ability to explore there. Since Marin and Dan had been to Tarangire for the day when they arrived, they were able to fill us in on what to expect. There were essentially no zebra or wildebeest as the herds had migrated out of the park with all of the wetness, but there were still plenty of elephants and giraffe to be seen. One problem was that there were many tsetse flies there, though I had hoped it was mostly in the wooded areas on their way out of the park to their lodge as we would not be traveling to that same entrance. Regardless, we had decided to go Tarangire for the day and would be leaving bright and early so we could get to into the park soon after it opened at 6:30 am which is when most of the animals are more active. We compromised at leaving FAME at 5:30 am which meant that most of the drive would be well before sunrise and we would get to see the sky brighten as we drove along for the morning. At the higher elevations we were driving through a few low lying clouds which greatly reduced our visibility, but other than that, we had no issues during our way and finally pulled into the parking lot at Tarangire with a brand new gate that just opened up in the last weeks.

A vulture raiding a bird’s nest in the tree. Note the victims trying to fend it off

A vulture raiding a nest in the tree

The entrance fee for a non-East African is around $55 with a little added for the vehicle, but all in all, an excellent price to spend the day in a park such as this where there is plenty of territory to explore and many, many animals that are great to see. At the entrance gate, their system was apparently down or, at least didn’t want to accept my credit card at that moment, so I filled out a voucher that allowed us to enter the park and pay them later before we left. The park was incredibly empty as I think we were the only ones to have gone through the gate that morning, but we did encounter a few cars later during the day. Still, this was far less than expected for the season and was undoubtedly due to the coronavirus situation around the world and, more specifically, to lots of cancellations by guests who had been planning to come on safari. There has been so much in the press over the last week, and, rightly so, as the pandemic has been announced by the WHO putting the entire world on alert.

A giraffe with an itch

A giraffe with an itch

We popped the tops on Turtle and everyone prepared themselves for a day of game viewing. The weather was just incredible for the day with high clouds and lots of sun, but not too hot so as to make it unbearable. With the front hatch open, the sun was beaming down on me for the entire day so that a hat must for me, and everyone else for that matter. I decided to head initially to a spot where I have seen a lion pride several times in the past and, on the way, we drove past herds of impala. There was actually another safari vehicle in the area and they were mainly watching a lone elephant who was just off the road. As we stopped, though, we began to accumulate first one, and then several more tsetse flies in the car which was somewhat disconcerting as it seemed very predictive of what we were to expect for the day. We moved on to join up again with the main road while trying to dodge the tsetse flies which was somewhat successful, but if you’ve ever encountered these little beasts, they are like guided missiles, flying alongside the care regardless of our speed. They are much slower than regular house flies which means you can certain swat them, but unlike house flies, they are very difficult to kill without completely squishing them against the glass or the inside of the car. What normally happens is that you think you killed the little bugger, only to have it fly off to seek another victim. The rule in the car is that if anyone spots a tsetse on someone else, they have full permission to whack it as hard as they can without any warning. This has led to some interesting scenarios in the past and I think the residents are always a bit wary around smacking me, though Alice did a good job this time in the front seat next to me as I was driving.

A dik dik

A herd of impala in the brush

Tsetse flies are blood suckers and if you’d like to watch a YouTube video that is like something out of a horror movie, but google it. They have a long proboscis that they sink into you several times before you feel anything and then they begin to feed. Their abdomen fills massively to many times its normal size which explains what has happened to me on several occasions and what happed to Molly during this trip. They love to bite at your ankles and sometimes travel up your pants so that you feel something crawling around, grab it, realize it’s a tsetse fly and then can do nothing else but squish the hell out of it at which point you have a significant amount of blood on your leg and the inside of your pants. Thankfully, or perhaps not, the blood isn’t usually your own and it’s typically from one of the wild animals at the park, most likely an impala, wildebeest, Cape buffalo or zebra.

A juvenile Marshall eagle

A southern ground hornbill

As we drove up the first river crossing closest to main gate, the effect of the recent heavy rains was readily apparent as the bridge, which is rather low and close to the river’s surface was completely underwater by at least several feet and with an incredibly heavy current that would have washed our vehicle downstream had we attempted it. The Land Rover can actually cross fairly deep rivers as it’s designed for that, but it’s the current that was the problem here, not the depth. I usually drive up the other side of the river and back on the side we were on, but I was just going to have to make some adjustments and that really wasn’t going to be a problem. It was a really fun day of driving through the mud as there were very many deep pools of mud along the way, some of which required a bit of navigation, but we always made it to the other side. One trick with these hazards is always to make sure you see tracks exiting the other side as then you know someone made it before you and that’s always reassuring. Also, the Land Rover is like a tank and has a reputation for almost never becoming stuck.

A waterbuck in the distance

A lone male impala

We saw herd after herd of impala, but no wildebeest or zebra to speak of in the park. Thankfully, we had seen lots of them in the Ngorongoro Crater last Sunday, and today we were really in search of elephants and giraffe. It took a bit of time, but we were finally able to spot family after family of elephants and a tremendous number of babies, some very young. For the most part, the elephants pay little attention to you, unless, of course, there is a baby nearby in which case the mothers become very protective of their offspring, typically shielding them on the opposite side of their body so photos are sometime difficult. Getting too close to one of the babies, though, or demonstrating any threating behavior, can easily create an issue for you in which you have a very angry mother to deal with. The elephants are matriarchal and a family is typically composed of many sisters or related females with a dominant female. Males are separate from the family and running into a lone bull elephant with an attitude can also be an issue for you as it has been on several occasion in the past where they just won’t let you continue and you have to wait for them get bored, deciding to move on.

A lilac-breasted roller

Alice on safari

We drove all the way to the Selela Swamp on the far side of the park and made it there by lunch time. This is typically a very popular lunch spot, but today there was only one car as we drove up and the swamp itself, often full of hundreds of elephants wading in the deep water and mud, was devoid of any pachyderms, or any other animals for that matter. When it is so wet, like it has been in the last weeks, there is no need for the animals to seek out water and they become more scattered around the countryside. There really weren’t any tsetse flies here so it was a bit more comfortable, and we brought our sandwiches, mostly peanut butter and banana (Carrie’s specialty), out to one of the concrete tables for our meal. I drove down to the swamp edge after lunch, hoping to find something interesting, but other than some ostriches, we were unable to turn up any of the other interesting animals I’ve found here in the past.

Molly’s bloody tsetse fly kill on her pants

I crossed the river at the high bridge near Selela, and under us was a raging torrent of muddy water that made up the Tarangire River and had to have been 50 times the normal volume that I’m used to. We drove for a bit on the other side, spotting more elephants and giraffe, but didn’t turn up any large cats, unfortunately. Driving back, I drove up the Sopa Lodge road where I have seen lions on several occasions, but there was none to be found, so we decided to stop at the lodge for cold drinks that was a welcome break from the driving for me as we had been on the move since 5:30 am and my rear was getting a bit tired. After stopping at the lodge, we made our way slowly back to the main gate after a short detour onto the Small Serengeti Plain where we did spot a Hoopoe bird prancing along the road and allowing us to take lots of photos.

Posing for us

Up close and personal

We ended up leaving the main gate around 5 pm or so and getting back on the road to Karatu and FAME. One interesting event on the drive home was encountering a huge tree that had fallen nearly completely across the road and clearly hadn’t been there in the morning. I was driving along at a pretty fast clip (80 kph) and was focused on something with the radio at the moment and, given that the road is straight as an arrow, hadn’t been looking in the distance. Alice, sitting beside me in the front seat suddenly said, “tree!,” and it took me just a moment to realize what she was talking about, but when I did, we negotiated around the massive tree with all of its limb and everyone breathed a big sigh of relief. I’m used to herds of cows, goats, and sheep as well as an occasional elephant, but hadn’t encountered a downed tree across a major highway here yet. There’s always a first.

A couple of vervet monkeys at the lunch spot looking for scraps

Alice on safari in Tarangire

We arrived home a little before 7 pm and decided to eat in for the night since dinner is not prepared for us on the weekends. It was a mixed concoction of Amisha’s Indian food in packets that she had brought and other leftovers. Everyone was pretty exhausted from the day and I was certainly looking forward to my comfortable bed that night. Tomorrow we would begin our mobile clinics and it would be in Kambi ya Simba, the sight of my very first mobile neurology clinic in 2011. We didn’t need to leave super early since it wasn’t too far and I think everyone was really looking forward to experiencing these clinics.

A Hoopoe hunting in the road

 

Saturday, March 14, 2020 – A wellness day at Gibb’s Farm….

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Our morning was bright with a reasonably clear sky as we walked to morning report for Angela to say goodbye to everyone. As I had mentioned, I’m pretty certain that her experience had been remarkable for her in having been able to work here at FAME for the two weeks with us. But even more so, I believe, she had also enriched everyone else’s experience by her being here, not only those of us on the neuro team, but also the entire medical staff of FAME, for she brought with her the perspective of having been educated and practiced in West Africa and in a medical system that is more robust than here, though still African and thereby giving hope to everyone that it is possible to develop this with the boundaries of this continent. After report, I brought Angela back to the house to meet her shuttle to the airport and to say goodbye to very remarkable individual who I know will continue on with her passion for pediatric neurology and continue to make the world a better place for her patients. I felt her anxiety about the uncertainty of her travels home with the pandemic now emerging, as we knew it would, in sub-Saharan Africa, and that fact that she had several flights and layovers with the situation changing now on almost an hourly basis.

A view from the veranda

For us, though, it was back to work, but for only the morning as I had scheduled a wellness day this afternoon as mandated by the Graduate Medical Education office for all residents, whether they are working in paradise or not. We had all decided to travel back to Gibb’s Farm for their wonderful buffet lunch which is almost a legend among the residents who have come on this rotation. The morning, though, was a steady pace of patients and we were a bit late getting out of clinic, mostly due to the fact that a number of patients needed physical therapy and especially our last patient who had a stroke about a month earlier and was significantly weak on the one side, but improving. Having Frances here to see our patients has really been a God-send and there is clearly a need in the future to have a physical therapist here with us during our month given the number of patients that we’ve referred to her and she has had the opportunity to work with. She took her time with the patient and his family, instructing them on exercises that would not only hasten his recovery, but would also prevent contractures that, if they occurred, would limit the movement of his limbs permanently.

A view from the veranda

I had an errand to run downtown on our way to Gibb’s and certainly was not planning to again take the shortcut I usually do as I had discovered that road to have transected by a new river with all of the recent rain. I had needed to stop at the bank here to put some money in a friend’s account so that she could help us with a booking, but the bank closed at 1pm and we arrived a few minutes after. I would not have another opportunity to make it to the bank given our mobile clinic schedule next week, so this was a pretty serious problem for us. I walked up to the bank door where someone was helping customers to leave, and he must have seen the desperation in my face as he invited me inside to make my deposit.

A view from Gibb’s Farm

Dan bird watching and on the phone

There were only two tellers still there and behind each of them was a single customer, each who appeared to be from a local business and each with a bag or backpack loaded with Tanzanian shillings. I don’t know whether I’d mentioned this before or not, but the Tanzania shilling comes in bills no larger than 10,000, or about $4.50, which can make for a very interesting cash financial transaction that would practically require the assistance of a wheelbarrow in very many cases. The two customers kept unloading bundle after bundle of their bills and handing them over to each teller who, in turn, loaded them on top of a bill counter that would quite rapidly sort through all the bills and come up with the total for each stack. This went on for what seemed like forever while they were creating what appeared to be replicas for the base of the great pyramids on top of the counters. I finally reached one of the windows and was able to deposit the necessary money into my friend’s account and we were back on our way to Gibb’s Farm, much to everyone’s joy.

The fanciest bathroom you’ll ever find. Gibb’s Farm

The fanciest bathroom you’ll ever find. Gibb’s Farm

At Gibb’s, the weather was a bit questionable, so they had a nice large table set for us inside the dining room and looking out at the incredibly remarkable view down into the valley below in the direction of FAME. Their food is almost all grown or made on the farm including and there are dozens of different things to choose from, all equally delicious. There were homemade cheeses, salads, sliced meats, quiche, soup, bread, chicken wings, every type of chutney that one could ever imagine, and then the main courses – rice, osso buco, chicken ala king, pork belly, lentil stew and others. The most difficult decision we had was just what to put on your plate as you couldn’t fit everything, but, thankfully, you could go back for seconds. Then there was the dessert table that had several local cakes, a passionfruit mousse and a chocolate mousse. Finally, there was the locally grown coffee that is the best in the world. All in all, it was probably as good of a wellness day as anyone could possibly have imagined.

A zoomed out view of bird’s “killing fields.” The African paradise flycatcher is a small orange spec in the middle of the photo

A male African paradise flycatcher in full dress

A male African paradise flycatcher in full dress

A male African paradise flycatcher in full dress

After lunch, while out on the veranda waiting for everyone to regroup and head to our vehicle, we were witness to a very remarkable sight that was occurring just beyond the lawn and both in and over the coffee plants nearby. Dozens of birds of multiple species were swooping through the air in incredible feats of acrobatics as if they were the most adept fighter pilots in search of their prey, the innumerous insects that were fluttering about the shrubs and were seemingly easy targets for these guided missiles that had one thing on their mind. They would suddenly fly up from below, high into the air and change direction in an instant to follow the defenseless insects which appeared to be mayflies. The one bird that caught our attention, though, was the African paradise flycatcher as it had a long streamer of a tail that was bright orange and flowed behind its body of blue-black with bright orange wings. We watched this flycatcher float through the air catching bugs at will along with the other birds that paled in comparison for showmanship. It was an incredible sight to see this continuous feeding going on right in front of us and essentially non-stop.

A male African paradise flycatcher in full dress

A male African paradise flycatcher in flight

A male African paradise flycatcher in full dress

I took shot after shot of the flycatcher in the hope of capturing that one in a million photo. None of them were too that level, but some of the shots capturing the birds in flight were quite revealing with a sense of fluidity and skill that were remarkable. It was really a sight to be seen and everyone was thrilled to have experienced it, though I will have to admit that Dan and I could have stayed there forever watching the birds, while the others became a bit impatient, wanting to leave so that we would have some time for shopping at the African Galleria before it closed that evening. We left Gibb’s Farm and tackled the road out, which was better than our trip up on in regard to the fact that it was downhill and we were following our momentum. The roads this month have simply been atrocious and by far the worse that I have seen during my many Marchs spent in Tanzania. Next week, we would be tackling the mobile clinics and that will be a very interesting time.

Fighting over mayflies

Fighting over mayflies

Fighting over mayflies

The African Galleria is a wonderful store that has become an institution and sits on the highway connecting Arusha with the Serengeti and Ngorongoro Crater. Every safari vehicle visiting these locations must pass by their gallery and they carry every type of souvenir and art that one could ever imagine bringing home from Tanzania. There is certainly no reason why one wouldn’t prefer to buy directly from the maker, but in the Maasai villages, it is often difficult to tell where things came from. Similar with the ebony Makonde carvings that you see at the roadside and in the shops. They are carved by the Makonde in southern Tanzania, but difficult to purchase specifically from the carver that made them and they are most often not made in the roadside kiosks where you typically see them, even though there are carvers working on them in clear sight. Either way, it is certainly convenient to be able to shop for everything under one roof. The African Galleria has been a supporter of FAME for many years, having donated items in the past for silent auctions, and they also support a nearby school. I have been visiting their shop since I’ve been coming to Karatu in 2010, and have enjoyed watching as it has continued to develop into its own destination.

A male African paradise flycatcher in full dress

In flight

A male African paradise flycatcher in flight

We had intended for a short stop to the African Galleria, but it ended up being much longer as everyone found the shopping to be more fun than I had thought they would. Even with my gentle “herding” towards the end, it was obvious they were on a mission and weren’t paying attention to me, so Dan and I stepped out front into the open evening air and waited for everyone to finish. There were a few things that were purchased that needed attending to by the shop, so they treated us to some drinks before we left which was just a little added extra. Our drive home was into the setting sun and a gorgeous sky. We stopped at a little market at the junction of the FAME road to pick up some groceries for tomorrow as some of us (me, Carrie, Amisha, Alice, Molly and Frances) were heading to Tarangire on safari and would need to make sandwiches. Dan and Marin, who had been to Tarangire earlier in the month would be on another adventure, to Empakai Crater, north of Ngorongoro Crater. It is drive through some of the most beautiful landscape I have ever seen anywhere as you travel through a high valley on your way to Empakai where there are Maasai boma in every direction you look.

Friday, March 13, 2020 – A knock at the door….

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Life here at FAME is indeed very comfortable for us in the Raynes House as it has been in other houses I’ve stayed. I will have to say that it hasn’t always been that way as it probably took several years before the hot water situation was ever sorted out which mean cold showers during that time. Now, hot water is supplied by Kuni boilers, which are essentially hot water heaters that must be fired once or twice a day to provide us with the hot water necessary for everyone, or almost everyone to shower. That means that the boilers must be filled with wood or some other combustible material in order to be lit and that can certainly be a choir. The boilers are each shared by two houses, and how much hot water you have in the morning depends on how many people are sharing the house and wanting to take a hot shower at any particular time. Everyone taking a shower at the same time here means the hot water will run out very quickly and chances are there will very likely be many unhappy people that morning.

Marin, Amisha, Frances and Angela

Breakfast for us is usually whatever we want it to be since it’s the only meal that we are responsible for ourselves. It will vary from something fancy, like scrambled eggs (ala Carrie), or less complicated like a bowl of corn flakes and banana (ala Dr. Mike). I can even be simpler, such as a granola bar which many of us will do if we’re running late in the morning. I can often be found sitting at my desk in the wee hours of the morning, typing on my blog, so my mornings are most often the cup of tea and a granola bar later at clinic. On rare occasions, someone will run to the Lilac to pick up coffee for several of us. Though I have offered to Carrie that she can work on entering the patient data in the morning at the Lilac and have breakfast, she has opted to do them in the afternoon/evening and spend the days with us observing in clinic.

Africanus, Carrie and Alice evaluating their patient

So, this morning, as I was sitting at my desk pecking away on my blog, I was a bit surprised when, at 7 am, my thoughts were disrupted by hearing that there was someone at our door insisting that two doctors were needed at the hospital to help manage a patient. There are certainly neurological emergencies here at FAME that require our immediate assistance, though it is very rare for us to be summoned in this manner, and, there are no stroke alerts here as there are at home where we have TPA and mechanical thrombectomy to offer, neither of which are available here. Meanwhile, Molly felt that it was a nice throwback to medicine as it once was, receiving a knock on the door to politely request our presence and not some beeper or alarm. There was something about it that made her think of house calls and the days of all small town doctor, I believe. Whether or not that was the case, though, both Molly and Carrie volunteered to come up to the hospital with me, where we found Dr. Julius, who had been on overnight, in our emergency room (which also doubles for the endoscopy suite) with an acutely psychotic and very combative patient who was wresting with one of his family members.

Amisha and Anne evaluating their patient

We were told that our patient, a 31-year-old gentleman, had a similar episode a year ago and had been seen at an outside hospital and given Valium for a week and, after that, he had apparently returned to normal (for him). Unfortunately, though, he had not been placed on any long term medications nor sought psychiatric evaluation anywhere. From our perspective, we were most concerned that he would hurt himself or someone else, and we needed to get some control of the situation, which meant giving him a strong intramuscular sedative, in which case he probably wouldn’t be awake for some time. We were unable to access the haloperidol that I had brought in the past as it was locked away, but we were able to located some chlorpromazine (Thorazine), a powerful antipsychotic, which we proceeded to give the patient along with some lorazepam (an anxiolytic) to get things working more quickly. He continued to fight with us for several minutes, but it was only a matter of time before he fell rather suddenly fast asleep with all of standing there and very happy that the wrestling match was over. During the height of his psychosis this morning, he was having very clear visual hallucinations, but it was impossible for us to gather any history from him so it was unclear if he was having any auditory hallucinations in addition. He was transferred to the medical ward and later in the morning, the team went to gather more history, but it was very difficult as his wife was a rather reluctant historian and, other than the episode from one year ago, was not willing to admit much more, meaning that we wouldn’t have much more to go on from a standpoint of making a diagnosis. Our suspicion was that we were dealing with schizophrenia and were just not getting the straight story from his wife, but either way, he would be put on a chronic antipsychotic for now (olanzapine), and would have to be re-evaluated in the future to determine how long he would remain on the medication.

Presenting to Dan

Having finished for the moment with our psychiatric patient, it was almost time for morning report so the three of decided to run down to the Lilac Café and order coffees to go. We received our French presses of wonderful Ngorongoro Highlands coffee just in time to head to report and hear about a patient in the maternity ward who was a few days over 36 weeks and had very significant pyelonephritis that had been causing her to be febrile. A very brisk debate ensued among all the FAME doctors, the nurse midwife in charge, and the volunteer ob/gyn regarding whether the child should be delivered early or not. I will not burden you with the details of the discussion since I had very little understanding of what was actually being said given that my last journey into this realm, other than my own children, was over 30 years ago and it was not something that I had planned to pursue at the time. I’m not certain as to what the final decision was on the matter, but either way, it didn’t involve us.

Carrie, Amisha, Marin, Dan and Angela discussing things

Our patient who had been admitted yesterday with the question of Paget’s vs. osteopetrosis was now on IV antibiotics and was going home as he had family in the area that could continue to provide him his IV medications at home over the next week before being placed on oral medications for a month or more. This seemed like a very good plan as he had plenty of support from family, a number of who were actually in the medical field so could manage his treatment in the future as well. We believe that we had mostly come up with a solution for his chronic osteomyelitis, but there had still been no resolution regarding his underlying condition that was causing the continued deformity of his skill along with his difficulty opening his mouth. Treatment for Paget’s would have been one of the bisphosphonates which they do not have here and treatment for osteopetrosis, a hereditary disorder would be stem cell transplant which is certainly something that is not available here.

We had decided to go out to Happy Days tonight since it was Angela’s last day with us and she would be leaving in the morning. We had forgotten to have everyone say goodbye to her at morning report meaning that we would have her show up tomorrow to do so before leaving FAME. I can’t recall whether I had explained Angela’s connection in the past or not, but she had first come as a global health scholar to Penn last summer where she spent a month taking some short epidemiology courses and also was able to spend time with me in clinic both at HUP and CHOP. She is a board certified pediatrician in Ghana who has a keen interest in the various development disorders in children and, as such, pediatric neurology. When I discovered this, I had her meet a number of the peds neuro residents as well as the adult neuro residents. In the end, she would very much like to do further training in pediatric neurology and is looking into the various options to pursue this in the future. She had heard lots about my work here in Tanzania during her time in Philadelphia and had asked at one point if it would be possible for her to come observe us here. She had some vacation time at the beginning of the month and the stars seemed to align, enabling her to travel her to spend the two weeks with us. I believe it was a fantastic experience for her to have spent the time with us and was equally valuable for us to have spent time with her.

The young Maasai boy with TB meningitis improving every day

Happy Days (or Happy Day which it was originally known as) is a pub that is frequented expats here in Karatu and which has been around since I first came in 2010. It also has cottages that pretty minimalist, but adequate, and over the years have housed a number of volunteers throughout Karatu as well as some FAME volunteers. Peter Schwab stayed at Happy Days in September 2018, and was very happy there. It came under new management about two years ago and received a significant makeover in regard to both its ambience and its food. Where there used to be large picnic benches on the covered porch, there are now low tables with sofas and chairs loaded with pillows that are incredibly comfortable for lounging and eating. On Wednesday nights, which is the traditional expat gathering night there, they now have wood fired pizzas while on other nights their menu has more traditional pub food that includes a wonderful mac and cheese along with lots of other dishes and even a few burgers. I’ve never sat inside, which has also now received a similar makeover, since it is so pleasant outside, even in a rainstorm as the roof is covered.

Carrie, Molly, Frances, Marin, Dan, Amisha, Angela, Alice and me

Since it was Angela’s last night in Karatu, we all decided to take her out to Happy Days for a celebration dinner. The one thing that hasn’t changed about Happy Days, is the time to receive you meal once it has been ordered. It will usually take over an hour to get your food once you have placed your order and that’s just the amount of time you have to wait. No questions, no apologies. Thankfully, the food is very good and, in most circumstances, well worth the wait. And besides, it is like paradise living here in East Africa, so having a few beers with your fellow expats on occasion is well worth the wait. And besides, living here in East Africa, which is essentially like living in paradise every day, isn’t a bad place to relax and have a few drinks together with your friends. The evening was rainy, but under the covered porch we were dry and the air was cool. It took nearly forever to get our food, but no one cared for we were all among friends and, as they say, life is good!

Relaxing with a wonderful kitty on my lap at Happy Days

Despite the fact that life has been normal here, though, much of our focus did remain on the ensuing Covid-19 pandemic throughout the world and the fact that life was not normal over much of the globe and would very likely soon be affecting us as well. Angela was flying through Nairobi tomorrow and Kenya had announced their first confirmed Covid-19 case today. She had a layover there of 16 hours before her flight to Ghana and had anticipated going to a hotel, but was not thinking otherwise about leaving the airport and somehow not being able to get back in. We also knew that it was only a matter of time before we would be affected also and this inevitability did loom very large over us.

Thursday, March 12, 2020 – A slow start to a busy day….

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It was another slow morning that was very likely the result of the rains overnight, but it once again made me worry about the volume that we were seeing. I did have some concern that the local population may be worried about seeing a bunch of mzungu doctors at FAME when they were certainly becoming more aware of what was going on in the rest of the world with the coronavirus. Africa has been relatively spared to date, but the tightening travel restrictions have been in the headlines of recent and it would not be unreasonable for them to worry about us having brought something other than enthusiasm along with us. The news of our country’s new travel restrictions, not accepting anyone from Europe other than the UK, was something of a shock to the rest of the world and certainly to the European countries it affected and probably on further heightened the extreme anxiety over the situation without actually having made anyone safer. The fact that the decision was also a surprise to many of those in the administration and had been made unilaterally by our president was anything but a shock to me. It is questionable to me just how US citizens will be able to get home from Europe once the airlines begin cancelling flights since the majority of the passengers booked will not be allowed to enter the final destination being the US. That remains a mystery to me.

Molly’s tremor talk in the education room of the admin building

Since it was Thursday, it was a day for our educational lecture. Dan and Marin were going to present, though Marin had to take an examination online for her PhD program and given that she was a bit preoccupied with that, Molly traded the day with them and was going to present on tremor. Again, they had asked that our presentations be more case based now, which was perfectly fine with everyone here as that gives a much better platform along with greater relevance when you think about these things in relation to a specific patient and trying to come up with a differential diagnosis, etc. The nurses were having their education meeting in the large conference room, so we were relegated to the smaller room in the education building which always happens to be locked up at 7:30 am while no one has the key to the front door. Luckily, someone had the side door key and upon entering the building with Molly a few minutes early so she could set up, a bat came swooping down the hallway directly for her, then thankfully made a hard about face and decided to hang onto an unlit light bulb on the ceiling for security. Bats are incredibly numerous here, which is a good thing, as they gobble mosquitos and other insects by the thousands to make our life better. On the other hand, they are not something that is good to come in contact with as are also known to be a reservoir for rabies. Thankfully, we don’t have to choose between malaria or dengue and rabies, but if we did, it would definitely be the former.

Registering our patient and getting vital signs

Molly’s lecture was well received and an excellent review of tremor that that doctors here could use going forward as we see a number of patients with movement disorders including both Parkinson’s disease and essential tremor. They will now have an excellent strategy for when they encounter these patients enabling them to differentiate their underlying movements and treat them with the appropriate medications as the treatments are very different, but both very effective. FAME had actually participated as the only non-neurologic center in a global project of the Movement Disorder Society for providing online consultations, and had submitted several, but in the end, the cases that were sent were those that we could deal with on our own and it became easier for them to send me videos of the cases with their questions. The online consultation service was an excellent option for a neurological center with complicated cases in which a neurologist has already evaluated the case and was in need of further assistance.

As we all made our way over to clinic, it was again apparent that there was no mob scene outside and it would be another slow morning. By late morning, though, things started to pick up and we ended up with numerous interesting cases. One of the cases was a young women in her thirties who was brought in by her cousin with symptoms of psychosis and was incredibly catatonic throughout her interview and examination. There was little question that she was floridly psychotic and with her catatonia, Alice wanted to give her a benzodiazepine challenge which in a catatonic patient will cause them to paradoxically awaken. Sure enough, she received 2 mg of lorazepam and, in a very short time, was back to her normal self and asking what had happened. She was sent home on a short lorazepam course along with olanzapine in the hope that it would best control her symptoms going forward and to come back in two weeks when we’ll still be here to see how she’s doing before we leave.

Young Maasai with the skull deformities and recurrent infections

Probably one of the more interesting patients we have seen here was a young Maasai who was otherwise normal developmentally and began to have abnormal growth of his skull about twelve years ago that has continued and several years ago, he began to develop either abscesses or boils that would drain regularly and appeared to be infected. The abnormal bony growth was so significant that it has affected the alignment of his eyes and he is now seeing double. In addition, he was now having difficulty fully opening his mouth and this was also becoming a concern. He had apparently seen doctors in Dar es Salaam before who had told him that it was not cancer, but they had suggested no other treatment. He had undergone a CT scan of the head back in 2018 here at FAME, which we had reviewed earlier and which demonstrated very abnormal bone thickness of the skull among other things.

He came in to see us today, having come from the Loliondo district which is about a seven hour drive away and close to the Kenyan border to the north. I have there in the past and it is a very remote region that is populated by the Maasai and is just south of the Maasai Mara in Kenya, an extension of the Serengeti that is north of the border. We had sent his CT scan images to CHOP to get more information from them, but had initially felt that this may have represented very early Paget’s disease. The other possibility after speaking with the CHOP folks, though, was that this may represent late onset Osteopetrosis. Either way, it was not something that was malignant and both conditions can often be complicated by osteomyelitis which is what we thought the recurrent infections were likely related to. We checked an erythrocyte sedimentation rate that returned at >140, an extremely high number that is most often seen in cancers or inflammatory conditions and was quite consistent with osteomyelitis of the skull which we had already thought was present. In the end, we decided to admit him to the ward for IV antibiotics, but prior to that, someone would aspirate what felt like loculated lesions on the scalp to gram stain them to get some additional information. Unfortunately, we really didn’t get any additional information from the gram stain. So, he was admitted overnight  and placed on the appropriate IV antibiotics for a week or so and then will have to be on a long term antibiotic course for his chronic osteomyelitis. None of this will help his abnormal bone growth, but it will hopefully help the chronic infection that he has with the osteomyelitis.

Our little girl with swollen knees

Another patient that was seen today was a young girl with swollen knees bilaterally that had been going on for some time. She had been brought to us for knee pain, which certainly isn’t neurological, but between the number of pediatrics we had here, it was decided that we would evaluate her and try come up with a plan. We spend a great deal of time communicating to the staff here and to the population exactly what are the diagnoses and symptoms that we evaluate and treat, but we still have to triage many patients who come to see us for several reasons. First, patients who have not been helped elsewhere, or those who feel that we somehow be able to evaluate them “better”  because we are specialists, will come to see us in the hope that we can make them better. The second reason, which is more unfortunate, is that we have chosen to subsidize the neurology clinic, making a single cost for our care, medications for a month and lab tests. This is obviously a situation that is very attractive to anyone as it is often far less than would be paid for any regular visit, and so patients will often come in hopes of being seen in our clinic when, in fact, they have no neurological complaints. Our rationale for subsidizing those with neurological disease is often so important to get them here to diagnose them, especially for the epilepsy patients, that we’ve chosen to continue this practice in an attempt to capture as many of these patients as possible.

The surgical scar on her right knee

The young girl had developed a swollen knee on only one side and had a surgical procedure in the past in which they opened her knee to make a diagnosis, but we had none of this records and when she came to see us she was on no medications or therapy. What she did have was an incredibly large and disfiguring scar over her one knee. Subsequently, her other knee became as swollen as the first and, without treatment, she had developed contractures of the knees and was unable to walk due to the joint abnormalities. We did X-rays of her knees and sent them back to the fundis (experts) at CHOP and she was given a diagnosis of juvenile rheumatoid arthritis and treatment was initiated. Whether she will regain function of her knees at this point is not entirely clear, but perhaps with aggressive physical therapy, which Frances gave to her and her family, she will one day walk again, even if it is with a noticeable limp.

Her swollen left knee

The last patient to mention for this day was a young Maasai boy who had come in with fever and mental status changes. When Dan and Marin had gone to see him yesterday, he had clear meningismus (a stiffness of the neck primarily to flexion indicating inflammation of the meninges) and so they did a lumbar puncture to determine what was going on. The findings were very profound in that he had a very high protein of 300 and a very low glucose of 20. A more typical bacterial meningitis with that low of a glucose would not be seen in a patient that was still responsive, but is much more indicative of TB meningitis, a relatively common disorder here given the high incidence of TB and, even more so, as a complication seen in HIV positive patients . This young boy of 12 was not HIV positive after we tested him, so had TB meningitis as a complication of his TB infection elsewhere and needed to be treated quickly as there is an extremely high mortality for TB meningitis even in treated cases. Another complication that we would have to deal with is that his CT scan demonstrated not only jugular vein thrombosis, but all cavernous sinus thrombosis, a serious complication of a basilar meningitis such as TB, and he would have to be place on anticoagulation in addition to his TB medications. There is a significant interaction between two of them that would require a higher dose of warfarin and he would need to be monitored extremely closely, otherwise his blood could become too thin and he could have serious bleeding. This would be a very difficult situation to manage for someone going back to the boma once he was finished with the IV portion of his treatment and his blood was appropriately thinned here.

Our Thursday evening was spent at home with our macaroni and cheese with massive amounts of garlic, thankfully made that much more cheese by Chef Amisha. Tomorrow would be Angela’s last day in clinic and we would all be sad to see her leave as she has been a very integral part of our team and a great addition with her knowledge of pediatrics. Teamed with Amisha, Dan and Marin, we have had a pediatric neurology dream team here and probably the best anywhere in Africa.

Marin and one of her patients