Sunday, March 8, 2020 – It’s off to the Ngorongoro Crater…

Standard

The descent road

Part of the “cultural immersion” here is also to experience the unique things that this wonderful country has to offer, and that includes perhaps the most amazing wildlife parks in the entire world. Tanzania has long been considered to be the top safari game park country in the world, and though I cannot attest to that from personal experience as I have not been on game drives in any other African countries, I can say that I have researched this question over the years and have consistently come to the same conclusion based on surveys of well-established travel companies who book these trips. Regardless of whether one can say this definitively or not, since having come to FAME first in 2009 on my initial visit to the country, I have continued to enjoy my trips to the parks to see the landscape and the animals. Even more so, I have enjoyed sharing these experiences with those who accompany me here as it is truly the experience of a lifetime and compliments the work we do at FAME. Each Sunday that we’re here, we travel to one of the nearby game parks and, on the last weekend of our visit, we travel for two nights to the Serengeti, probably the most famous of all game parks in the world.

A starling (not sure which)

For at least six years, if not more, I have driven my own game drives in the parks and have continued to do so each time we visit. For today, though, given the heavy rains that have been falling and the fact that a significant amount of the Crater floor is closed due to the shear amount of water, I’ve decided that it would be best to hire a guide to take us there just to be on the safe side as spending the night in there after getting stuck is not a good option given that the lion density is the highest in the world in the Crater. Vitalis, who has driven us on many an occasion in the past, was free and would be spending the night in Karatu so we could leave as early as possible and get to the gate when it opened. The Crater is my absolute favorite place to drive, so it would really be a loss for me in that regard, but it is always important to be safe here and that was my main consideration in the decision. The afternoon before, Carrie had decided that she would singlehandedly make everyone’s sandwiches for lunch – peanut butter with banana or pb&j – which was a real help so that we didn’t have to worry about it after coming home from Gibb’s the night before. We were to meet Vitalis down at the junction of the FAME road with the tarmac in town at 6 am, meaning that we would have to loaded and ready to depart at 5:45 am. We had bought water and snacks the evening before and were well-stocked between those groceries and the number of snacks that had been transported here in our duffel bags. Regardless of the situation, there was little chance of us starving.

Black-headed apalis

An unidentified raptor

Augur buzzard

It had rained a bit overnight, but the morning air felt still and cool as we drove off the FAME campus heading for town to pick up Vitalis. We had a packed car with the eight of us as Turtle can seat nine total using the middle seat in the rear row once we had picked him up. We arrived at 6 am sharp and Vitalis hopped in the driver’s seat as I climbed into the back and we were off. The gate was virtually empty as we drove up and that included the baboons that usually stalk the vehicles here, looking for windows open only a crack and in which they can climb in to steal whatever food may be unattended or, even if attended, that they can steal. They know exactly what lunch boxes look like inside a vehicle and they are like a heat seeking missile when one is in sight. I have seen them go through the narrowest of cracks in the window and they are relentless in their search and destroy mission that they have undertaken. Not having baboons at the entrance was one less thing to worry about this morning and Vitalis was in and out of the gate office in no time at all such that we were on our way up heading for the crater rim.

Auger buzzard in flight

Common eland, the largest of the antelopes

The drive up is through what I refer to as a primordial forest of tall trees rising out of the canyons far below, trying their best to reach for the sunlight amongst the thick canopy and tangled vines. We immediately encountered a lone Cape buffalo as we left the gate and spotted more as we drove along the crater rim. As we reached the rim road, the cloud cover became quite thick and it was impossible to see much down below in the crater itself, but the sky above was opening up to so that the sun begin to shine by the time we reached the descent road on the far side. There are three roads down to the crater floor; the descent road and the ascent road, each of which are one-way, and the two-way road on the opposite side of where we would be heading.

The business end of a male Cape buffalo

Cape buffalo

Before you arrive to the descent road, where you must again check in before entering the crater itself, you are driving along the backside of the crater with distant views onto the Serengeti Plain and Olduvai Gorge (or Oldupai, which is Maasai for the local sisal plants) far below. This road is also the one that continues and crosses the Serengeti, so all traffic must pass along it on their way to Mwanza and Lake Victoria. The descent road itself is quite steep, but Turtle handled it without breaking a sweat and, in no time at all, we were on the floor of the crater, but not before stopping several times to view the animals close by which included a number of birds that made Dan quite happy. The weather was absolutely gorgeous at this point and it was clear that we were going to have perfect weather for at the least the early part of the day which is always the most important as the animals are most active in the cooler early hours. As I had mentioned earlier, the floor of the crater was quite wet with significant amounts of water everywhere, but the roads were quite decent and we were never at risk for getting stuck in any of the locations where we drove.

Young zebra

Zebra colt and mom

There were large numbers of wildebeest, zebra, Thomson gazelle, Grant gazelle, eland, and Cape buffalo as well as smaller numbers of waterbuck, hyena, and jackal as we first drove around the perimeter of the crater before moving to the interior. From high on Engitati Hill, we could see far below into the swamps where there were numerous elephants roaming and decided to head in the direction of the hippo pool. As we neared the pool, though, there was one vehicle stopped looking off into the distance and, sure enough, there was a lone black rhino nestled among the elephants. It was quite dark in color and likely because it was covered in mud which is something the elephants also do to beat the heat on these sunny days. The rhino was a fair ways off, and though I have seen them much closer in the past, it is not uncommon to miss them entirely during a trip to the Crater. They are often quite hidden as they rely totally on their hearing to locate predators given their terrible myopia, and, if it’s even a little bit windy outside, it limits their sense of security and they become very nervous. Having a nervous and paranoid rhino on your hands is not something that would be a good thing regardless of the situation. The black rhino population in the crater have made an incredible comeback after becoming nearly extinct due to poaching through the efforts of the government and their strong anti-poaching campaign. All of the rhinos here are monitored on a constant basis by the rangers utilizing both electronic monitors and visual confirmation. There are also black rhinos in several areas of the Serengeti (the western corridor and the northern region), but really nowhere else. Also, for those of you who are curious, black rhinos are ½ the size of white rhinos, which, by the way, are not white, but rather have a “wide” lip and it was merely translated incorrectly from Dutch as “white.”

A rhino trailing the elephant

Hippos

After viewing the rhino and the elephants for some time, we turned our attention to the nearby water where, what appeared to be many large boulders along the shoreline, were actually many hippos resting out of the water. There were also many of them in the water and the ones on the shore did do some shuffling so everyone got to see them standing out of the water which is a sight. Hippos have to be very careful to avoid becoming sunburned, so will often go into the water and roll around to cover themselves with mud which protects their skin. Hippos do feed at nighttime and will roam for several miles to find food, returning to their home pool in the morning. Quite different than one might imagine, they are extremely fast both in and out of the water and can run down a human with little effort if threatened. Hippos kill more people in Africa every year than any other wild animal. Watching two bull hippos fight for territory should be enough evidence for anyone to do whatever possible to steer clear of these beasts no matter what.

Waddled starling. Photo by Dan Licht

Auger buzzard

From the hippo pool, we took a long route to the lunch spot as everyone was getting a bit “hangry” (actually, I don’t believe that now has to be in quotes as I just discovered that the word is actually in the new edition of the OED, which quite caught me by surprise.=) and it was after noontime. The lunch area was completely packed with vehicles, but Vitalis found a spot for us to park near the bathrooms as several of our group were in need of a pit stop. One of the women’s rooms had a long line extending out, but when Marin and Molly came back, after having just used the bathroom without the line, they calmly explained why it was that there was no line. Apparently, there was a lion nearby the entrance to the bathroom they had entered and that the rangers were directing travelers to the other one for safety reasons, but that somehow they hadn’t been warned and, given that they had no problem, were quite happy to have been able to relieve themselves and were equally thrilled that they hadn’t been eaten by a lion, as was I, when they found out the real reason for their speedy access. To be totally honest, it’s quite unlikely that a lion would have been interested in either Molly or Marin for lunch as on past visits to this lunch spot, there have been lions sitting on the rocks not far from where we’ve parked and walked around outside of our car and have paid little attention to us.

Alice and Carrie

Carrie, Alice, Angela and Molly at the lunch spot

A weaver visiting us for lunch

It is really not the lions or the hippos in the small lake that are most threatening to us, but rather the black-shouldered kites, who soar high above the picnic area using their amazing eyesight in the hope of spotting some unsuspecting tourist with a sandwich or piece of chicken in their hand. I have seen this happen numerous times and sometimes wonder whether the guides draw straws to decide which one of them will withhold this vital information from their clients, allowing them to eat outside of the vehicle and in range of these dive bombers with a three foot wingspan and deadly accuracy for anything that looks even halfway edible. I was once the victim of a kite while sitting on the crater rim having lunch on way back from the Serengeti. Neena Cherayil was sitting next to me on a log as I was about to take a bite of my chicken and suddenly noticed a very large shape swoop in from the side and with nary a warning other than the sense of a breeze that was created by its wings, my chicken suddenly vanished. I don’t think anyone would have believed me had it not been for Neena witnessing the entire event that had occurred in the blink of an eye. I am sure that the Marabou storks, who had been hanging around the lunch spot in hope of some scraps, were not particularly pleased by the action of their avian friends, but there was little we could do to help in the situation.

Lioness with her two newborns

Lioness and two newborns

Our lunch was eaten sitting inside Turtle to avoid any conflict with the kites, though we did seem to attract a number of smaller weavers inside the vehicle looking for crumbs that were far less imposing than the diving kites. After lunch there were dense storm clouds in the distance that were inside the crater and loud booms of thunder were heard in the distance. We knew that it wouldn’t be long before the storm overtook us and prepared to close the top if it began to rain heavily on us. Prior to that, though, we spotted a lone male lion lying in the grass that was visible as only a tan patch of fur that was barely visible above the grass. Eventually, the patch of fur decided to sit up, revealing itself, and gave reason to why the zebras in the vicinity seemed to all be in a tizzy, running back and forth and sounding the alarm.

Grey heron

Black-headed heron

Shortly thereafter, this became even more apparent as a lioness sat up in the distance followed by another male lion. They then began to mate and it was clear that this was a “honeymoon” couple, as they are called here when a pair will typically be on their own for several days. A honeymoon couple will mate every 30 minutes or so for 48 hours or more to ensure they are successful and you can almost check your watch on the interval. This pair were obviously not hunting at the moment and the other male in the grass looked equally tranquil, so the zebra seemed to have little to worry about from these three potential hunters, but there were very likely other lions scattered throughout the area that hadn’t yet revealed themselves and were continuing to sleep the day away as they so often do.

Yellow bishop. Photo by Dan Licht

Pied avocet

The rain finally came, but it wasn’t torrential and we were still able to do some viewing as we drove around the lake and into the Lerai Forest where you can see an occasional leopard, along with elephants, but today we only saw lots of baboons with many babies, many of them nursing, on the side of the road. The rain had stopped well before we reached the one-way ascent road and we slowly made our way up the steep and winding road that was paved about a year or so ago given the number of vehicles that were unable to get out of the crater in the wet season or during a hard rain. We stopped at the overlook since we were unable to do so earlier in the day given the cloud cover that was now gone other than the distant rain clouds that had contributed to the rain earlier. The true extent of the flooding on the crater floor could now be fully appreciated as there were many small “lakes” that could be seen scattered about and the volume of Lake Magadi, normally almost a dry lake bed, was now occupying a significant portion of what could be seen in the distance. Though the volume of water here did limit much of the navigable land for us, all of the animals remain as this is its own ecosystem meaning that the animals do not migrate from the crater as it is their home. The antelope that are born here, remain here for their lives. There are at least three large lion prides that have established their territories and continue to be the alpha predators here, while the cheetah have mostly been displaced by the ever increasing hyena population. In the past, I have seen numerous cheetah, as well as serval cats, but not in the last four or more years due to this shift in predators.

African spoonbill. Photo by Dan Licht

We arrived back in town at a decent hour, dropping Vitalis off at the bus station so that he could travel back to Arusha tonight, while the rest of us stopped in town for a few things to make dinner rather than going to Happy Day or the Lilac Café, both good choices, but with lengthy wait times for your food. Everyone had a very satisfying day at the crater and we looked forward to our coming week of clinic and then another safari on the following Sunday.

Our group at the crater overlook

 

Saturday, March 7, 2020 – Thankfully, a somewhat quite day….

Standard

Our trips to Tanzania have been for the purpose of developing a neurology presence here in Northern Tanzania and at FAME while also providing education to the doctors here so that in between our visits there would be a better chance of these disorders being appreciated and treated more effectively. It has been clear with the data that we’ve collected that we are making a difference over time and there has been much better appreciation for neurological disorders here, such as epilepsy, so that patients can be assessed and treated. Though I must admit, that when I first came, neurology was not on FAME’s radar as a specialty that they were targeting, and it still is not part of their 5-year plan (reproductive and child health, and surgery have held those spots from early on), though it has become evident over time that there is an incredible need in a region and country where there are few neurologists and very many neurological patients with a significant amount of disability. When looking at the global burden of diseases, neurological illnesses, when you include stroke, meningitis and HIV-related neurological complications make up a huge percentage of this number and have an even greater impact on disability-adjusted life years, or DALYs, as a great many of these diseases do not kill, such as cancers, but leave their victims disabled for the remainder of their lives. So, it goes without saying that the need here for our work is great.

View of the Highview Hotel and FAME (below) from Gibb’s Farm

The first question you must ask yourself in any sort of global health program, or global program of any sort, though, is whether it what the recipient perceives as necessary for their well-being and progress. Trying to convince someone that what you’re trying to do will often end in failure, or worse, if it’s not what is needed, it will end in failure with certainty. Thankfully, the need for a better understanding of neurological illnesses was something they recognized here at FAME immediately during my first visit as, even before I developed the neurology clinics, I was being asked by every doctor here to come see a patient with them to help manage the neurological aspects of their problem. Once we passed that test, that is, making certain that what we were doing was something that they both wanted and was needed, and it was clear that having a recurring clinic was something that would build trust in both the doctors and patients, I was then free to think of ways that I could make it more efficient. After Daniel Becker, the first resident/fellow to join me, came in 2013 as she had heard so much about it during her time with me in residency, it became clear to me that residents and fellows could provide the same training to the doctors here that I was doing and it would only increase the number of doctors and patients that we could work with if I build a program.

Bird photographer extraordinaire

Even better, while providing something here that was so badly needed, i.e. neurology education, we could establish a program for the residents that would introduce them to global health and health equities by practicing in a resource limited area with entirely different cultures and values than our own. Every trainee that has come to work here has left with an appreciation not only for what we have in the United States, but, more importantly, how you can help in a region where they do not have what we have, and where the value systems are often very different than our own. As a result of this experience, it is impossible not to become a better neurologist, scientist, person, and citizen of the world, as it forces one to think in ways far different than we often do on a daily basis at home and changes the perspective of how we often approach complex, or even simple, situations that arise every minute of every day.

Marin and Frances

In building the program, though, it was very clear to me in the beginning that it would be necessary for the trainees to experience not only the practice of medicine in a different region than our own, but to also understand a culture that is very often far different than our own. Therefore, in addition to our typical six-day a week working schedule, we also take time off to visit friends and get out into the countryside as this is a country with an incredibly rich heritage that is made up of well over 100 vastly different tribes, each of who speak a different language, and a country with perhaps the most spectacular and varying geography of any in the world, and that never fails to amaze me no matter how many times I visit. Clearly, in spending a month here, you can only scratch the surface of this remarkable country, but it should not be overlooked that I have three of my group this trip who have returned for a second visit, mainly because they have been bitten by the same bug that captured me over ten years ago and ended up changing my life for the better. All of Africa can be said to do this, and on my recent trip to Mali I can now vouch for this, but have chosen to place my roots in Tanzania and, for that, I am a much richer person.

Purple-breasted sunbird

Saturdays are typically a bit slower in general and, given that we had plans this evening to have dinner out (we are not supplied dinners on the weekend giving us the opportunity to go out and eat), we were looking forward a slower pace and earlier departure from clinic. We had no neurology patients to see in the ward today, though there was one interesting patient that we do typically see at home. Someone in the Ngorongoro Conservation Area had been attacked by a rhino (not a common even in Philadelphia) and had suffered a chest injury with fractured ribs and a hemothorax among other injuries. We didn’t have to see the patient as they had no neurological consequences of the rhino vs. pedestrian encounter, but it was certainly something to keep in mind for future visits to the conservation area.

White-browed robin chat

We had fewer patients first thing in the morning who were lined up to see us, but it certainly wasn’t a bust and patients continued to flow in throughout the morning. It finally gave us a moment to catch our breath which was good as we were all exhausted from the prior two days of huge volume. The spread of diagnoses that we saw were pretty typical of our standard patient population – headaches, epilepsy, numbness – with a smattering of children, but never to the satisfaction of Amisha who prefers a steady stream of little ones and reminds on every occasion about how much she enjoys seeing adults which is not at all. Thankfully, Marin is here, but she is really only to see children as her training is exclusively in pediatric neurology, unlike Amisha, who has done rotations in adult neurology back home as is required of all pediatric neurology residents and vice versa. There has never been hiding the fact, though, that there is a clear comfort level by each of the residents, adult or pediatric, in seeing patients that they hope to see for the rest of their careers and, for that, I cannot really blame them (though I will not admit that to Amisha).

Baglafecht weaver

The somewhat slower than normal day did give Dan and I some time to spend outside on the benches by radiology in our “office” as the day was pretty much crystal clear and gorgeous. This bode well for our plans later in the evening which was to go to Gibb’s Farm for dinner. I have spoken of Gibb’s so many times in the past, but it is a remarkable place where one feels that all of the weight of the world is slowly lifted from your shoulders for every minute that you spend there. It is an old coffee plantation that later served also as a lodge and its own village where all the food was grown locally, all the furniture was made on site, and it was essentially its own little village. Over the last decade, Gibb’s has been transformed into a destination resort that has still managed to retain its old world charm and not matter how many times you’ve visited, it never fails to impress you with its sense of tranquility nestled in the Ngorongoro Highlands where it borders the conservation area. The view from its veranda, overlooking Karatu and FAME in the distance and the acres of coffee plants hugging the rolling hills is just simply spectacular, though the view of the garden areas from the open air bathrooms as you walk in from the small parking lot are equally impressive and not to be missed. Gibb’s for me and the rest of the group is a must and something not to be missed by anyone traveling to this region.

Compact weaver

We were able to finish clinic at a decent time and all head back to the house to get ready for the evening out. We did need to head into town to pick up some supplies as we would be traveling to Ngorongoro Crater and were planning to make our lunches to bring as well as needing water for the trip as you never plan to travel anywhere here with an adequate amount of water as breakdowns and dehydration can occur with equal frequency. We would be traveling through town on our way to dinner as the shortcut that I normally take to Gibb’s Farm road can be iffy at best, and given all the recent rains, there wasn’t a reason to chance getting stuck and missing out on our plans for the evening of drinks and dinner at a wonderful resort. Remember, there is no AAA here, so getting stuck for the better part of the evening was not something I wished to consider.

Purple-breasted sunbird. Photo by Dan Licht

After a short visit to the market in town for our supplies, we were able to make it to Gibb’s quite early enough for everyone, save for Dan and me, to take a walk down to the vegetable gardens below as they are very lovely. We, on the other hand, made a bee line for the veranda with the excuse that we were going to take pictures of birds, but the intention was to immediately order our Moscow Mules, a drink that is incredibly refreshing wherever it’s ordered and, even more so, here in Tanzania. Dan and I strolled around the grounds looking for birds while our drinks were being prepared, and the others slowly filtered back up from the gardens in small groups until we were all back together sitting at our large table on the patio, overlooking FAME far below and taking in all that is good in the world, while everyone’s drinks seemed to miraculously appear for them. There are always several artists in residence at Gibb’s, including our good friend, Athuman Katonga, who has created paintings for so many of our team that have visited here. Everyone visited Katonga in his studio to look at his works in addition to the other artist there who also had wonderful pieces that would be worthy of bringing home and framing.

 

While we continued to enjoy our drinks and the sun slowly set in the distance, the soft glow of the evening light waned while the shadows transitioned into darkness. It was an evening well deserved given the number of patients we had seen over the last several days and everyone took full advantage of the opportunity to relax and share stories. Sometime after 7 pm, it was announced that our dinner was ready to served, so we all moved into the dining room where a large table for the nine of us had been set up. The dining room is formal, as are the place settings, but the ambience of Gibb’s is more relaxed and comfortable than one would imagine just by the sight of things, and, after the we were all seated at the table, the courses of food began to be placed in front of us. We did, of course, have to order from the menu as three of the four courses (salad/appetizer, main entree and desert) were to be ordered with nearly all of the delicious selections being locally grown and incredibly difficult to decide which one each of mouths was watering for at the moment. It was such a pleasant evening with hours spent in this relaxing and rejuvenating environment. When we finally departed sometime around 9 pm, we were all just simply fulfilled, both physically and mentally, and I don’t believe that any of us could have imaged a more worthwhile place to have spent the evening, nor group of friends that we would have liked to have spent it with.

March 6, 2020 – And an even busier day in Neuro clinic….

Standard

A view from our back porch. The trees have gotten big

As I have mentioned in the past, the March trip has traditionally been the less hectic and less attended of the two for reasons of weather and planting. That has not been the case based on the first two days of our clinic, one announced and the other not so, as the numbers have been on par with the fall trips so far and that will put is on target for a record spring volume. The other thing weighing greatly on our minds here is the Coronavirus-19 outbreak going on globally at the present time that has continued to spread and, from the very good sources I have communicated with in the last days, will continue to do so regardless of what travel restrictions will be implemented throughout the world. Things here are safe, though the Tanzanian Health Ministry did meet with FAME officials several days ago regarding protocols to care for patients who may show up here (don’t forget that we also care for many tourists on safari in the region) with symptoms and may require isolation and protective gear for those treating them. We would not be seeing anyone with those symptoms (I keep reminding everyone here that we’re neurologists), but having a patient here would certainly increase everyone’s risk. I think that likelihood is very low for the immediate future.

The neuro team in the morning before patients

Our patients waiting for us first thing in the morning

Waking up this morning reminded me of just how beautiful if is here as the sun was shining with few clouds in the sky and you could already feel the radiant warmth in the early hours after sunrise. The number of birds songs to be heard here is absolutely immense and I wish I could identify them all other than the morning dove whose song is so very distinctive. Walking to morning report in the bright sunshine never gets old and, even though walking to clinic in the light rains of the morning is still being in paradise, there is something about the crispness of those clear mornings that reminds you of everything good in the world and provides a reassurance that is so difficult to describe. I had a feeling, though, that this morning was likely to be an anomaly as I still believe the weather has changed and we’re in for the rains. In any event, I’d rather think that way and be pleasantly surprised rather than the reverse and be poorly disappointed.

A bright clear day at FAME (though a monstrous downpour later)

Angela playing “who’s got the reflex hammer” with a young patient

Now Amisha playing “who’s got the reflex hammer” with a young patient with Angela looking on

In morning report, we didn’t have any neurology patients to focus on, though there was a young man from Rift Valley Children’s Village who had presented with recurrent abdominal pain and they were worried he might have inflammatory bowel syndrome, needing to be referred to Arusha to specialists who could do a colonoscopy on him. Since both Amisha and Angela are pediatricians, we were asked to have them see him and weigh in with their thoughts. Mama India, the long-time director of RVCV, would be by after lunch and Susan wanted to have an update for her so our peds contingent stole away from clinic momentarily to take a look, and, thankfully so, as they felt the young man suffered only from gastritis after taking tons of ibuprofen. They recommended treating that and seeing how he did rather than jumping to a scope at the moment. India was quite happy to hear that it may not be anything more serious than overusing the non-steroidals and would likely get better on its own without more aggressive testing or treatment.

Alice and Anne evaluating a patient with Carrie looking on

Molly and Africanus evaluating a patient

We did hear about a young man who had come in the night before with fever and confusion and who they had possibly wanted our input in if it hadn’t been for the fact that he had a tremendous number of malaria parasites running around his bloodstream and most likely had cerebral malaria. Malaria isn’t a common condition that we see here at FAME given our altitude (a mile high) and weather that is much more moderate than Arusha. There is malaria in many of the areas that we travel through, though, so that everyone traveling her for a short time (meaning everyone on our trips) will prophylax with typically Malarone, or, for those allergic to it, doxycycline. Malarone tends to cause vivid dreams, though not nearly so significant as mefloquine, an older drug used to treat and prophylax for malaria, but still enough of an effect to be noticeable and distinct. There is little question in my mind that I have had very vivid dreams here in Tanzania over the years while taking Malarone, clearly more than I have back at home, and I would be the first to say that they are not disturbing, only vivid as billed. Meanwhile, the young man with cerebral malaria was doing much better the following day with treatment of his underlying condition and there was little need for our involvement given that.

Carrie doing her crossword puzzle by headlamp

Dan examining a patient

Walking into our clinic area, the old ward 2, it was clear that the trend over the last two days would continue over the coming weeks as there was already quite a queue waiting for us. Angel and Kitashu were working hard to get everyone registered as we needed to have their charts whether they were new or follow up. There is no electronic medical record at FAME, and even though they are working on one as I am writing this, it will take several years to get that in place. They do have all of the demographics online for every patient, though, as well as an accounting of all of their visits, laboratory testing, radiology testing, etc. that makes life much very much simpler for reception and the doctors caring for the patients.

One of Amisha’s pediatric patients

Amisha and Marin

We had been told that there was a group of patients coming today from the Tarangire region, a fair distance away, and would be arriving sometime around 11 am, but when they did finally get to us, and around the appointed time which was not at all expected, the group was far exceeding the 11 patient slots that we had reserved. We had decided in advance to keep our numbers around 30 patients for today, given the long day yesterday, but by lunchtime we had already exceeded that number in our log book as the group of Maasai from Tarangire ended up being more like 15 patients, all told. On the good side, the majority of those patients ended up being children, much to the delight of Amisha, Angela and Marin, who are all obviously in their zone seeing children and there is little else required to keep them happy. It was also quite interesting that there was a large contingent of trisomy-21, or Down syndrome, patients in the group that were of varying levels of function. In this group of patients, who, by the way, I manage many of at Penn who are adults, we typically do annual thyroid testing, given the high percentage of hypothyroidism, and cervical spine studies as they are also prone to cervical subluxation. We have little difficulty getting a TSH here at FAME, but even if a patient had cervical subluxation and myelopathy, there would be little that we could do them as that surgery is not something that could be undertaken here by any means.

Amisha with one our Down syndrome patients

A hearty downpour at FAME

One of the children that we saw very late in the afternoon was really quite interesting, though also quite sad given his problem. He was with the group from Tarangire, or really Babati to be more accurate, and had come a long distance to see us. He was seven-year-old boy who had not moved his lower extremities since birth for the most part and his father told us that he had a “rash” on his bottom that occurred recently. When Marin had the father pull down his son’s pants, what was really present was an incredibly large ulcer over the sacral region that appeared to have stool in it making her initially concerned for the presence of an enteral-cutaneous fistula, but it was really difficult to make the connection between his lack of walking since birth and this wound. Eventually, it was discovered that the wound had begun very recently and had first shown up as an abscess that had been drained at one of the local health centers. Once the wound was cleaned fully, it was determined not to be a fistula, and the wound, or now wounds, appeared to be just very large sacral decubitus ulcers that actually had fairly clean borders, though it wouldn’t be long before this entire mess became horribly infected and the young boy would become septic in no time. He looked as though he may have hydrocephalus, or at least had significant frontal bossing and was scaphocephalic (elongated front to back) making us quite suspicious for this condition. His chest was also poorly developed and, in the end, Dan was pretty certain that he had sacral agenesis , a congenital disorder in which the sacrum and other midline structures of the lower spine are not fully formed.

One of Amisha’s children

Even though the reason for the child’s visit was the fact that he wasn’t moving his legs, a problem that we had very little to offer for, we felt compelled to help with the now likely decubitus ulcers (bed sores) and after the father had cleaned them out to reveal no clear evidence of a fistula, rather just the two large ulcers, we asked if the nurses here could help clean them up a bit further. As the child didn’t need to be admitted to the hospital, we had very little else to offer immediately, but suggested that he be taken to Haydom Hospital, a regional facility much closer to the family, that could fully evaluate him treat his ulcers further. After his treatment by the nurses, he sat on his father’s lap waiting for everyone from their group to be ready to leave and was clearly a very attentive and cognitively intact child who needed no further evaluation or care from us.

Angela and one their pediatric patients

One of Amisha’s patients

The other child from the Babati group with an interesting problem, albeit non-neurological, was an incredibly cute 3-year-old young girl who was presenting with a very large vascular malformation of her lower lip and a large protrusion of her abdomen (which later turned out to be just a simple ventral hernia). There was little question that neither of these issues were neurological in nature, but given Dan’s vascular background, there was no way that he was going to allow anyone else to see this child. Once it was determined that her AVM was limited only to her lower lip, meaning that she did not have more extensive involvement, it was merely a matter of documenting the extent of the lesion and then determining if there was anything we could do about it, which meant contacting specialists back home for recommendations. The lesion was very limiting for her causing issues with her speech and ability to eat properly, not to mention the risk of ulceration or infection as time goes on. The fact that it was limited just to her lower lip meant that it would not be incredibly difficult to deal with, but would require specialized services not likely available here in Tanzania.

Our cute young child with the AVM of the lip

We ended up seeing 36 patients today which, combined with the 35 from yesterday and the 20 patients from the day prior, meant that we had seen 91 patients in our first three days here. And that did not include the inpatient consults that we had seen along the way which would have brought our total to nearly 100 patients in only three days of work, only two of which had been announced to the community. There had also been an incredibly heavy downpour during the midafternoon, an event that usually brings most everything to a halt here, but since most of patients had already arrived, we had a steady stream during that time, of both patients and rain. The downpour was so heavy and lasted for so long, that during this time you could hardly hear yourself think, let alone communicate with others which is quite necessary when the residents present patients. One special patient who came this after was a Maasai woman and her husband who I have treated now for many years and who comes back to see me every visit and he thanks me every time for having taken care of his wife. A few years ago, we had visited his boma and his four wives who live on the far side of Lake Manyara, where they had honored us with a goat roast that was amazingly tasty, though it seemed that I was the only one in our group who was partaking in this delicacy as the others were either vegetarian or just not enthusiastic about eating fresh goat roasted over the open flame on wooden skewers.

My friend whose wife I have treated for many years

Regardless, it was the tastiest barbecue that you could ever imagine and, since that time, I have been to several other goat roasts that have been equally incredible on every occasion, not only for the taste of the meat, but also for the significance of the event as it is very meaningful in the Maasai culture and carries a tradition of true honor and friendship when it is presented in this manner. Each time that our group has participated at the boma in this affair, everyone has left with a sense that they have been part of something very special. I have felt this every time I have visited this country with its very special and resilient people; a sense of unity and oneness in the world with the knowledge that love and tolerance can overcome any differences that may exist and, most importantly, hope for the future.

Molly playing the “skittle game” with Amisha (and losing – sorry, Molly)

 

Thursday, March 5, 2020 – A very busy clinic….

Standard

Yesterday had gone well with a fair number of patients and today was going to be our first day of an announced clinic in which the community had been made aware of our presence . It had been raining for days which often has the effect of decreasing our patient volume given the difficulty of getting around for both pedestrians and vehicles on the rain soaked and muddy roads. For this reason, it is often much quieter as far as patient volume in the spring or rainy season, when it is either due to transportation issues or because there is planting going on and everyone is in the fields. For whichever reason, though, our numbers have been consistently lower for patients in the spring, or wet season, compared to the fall, or dry season. If yesterday’s clinic, though, was any indication of what we were to expect, this could be stacking up to our most robust spring clinic that we’ve had.

Carrie charting and Dan working at the central station in clinic

It was also an education day so that we all gathered in the administration building for a lecture, this morning given by Dr. Joyce, our resident laboratory scientist extraordinaire who has been here since the beginning and has built the lab here at FAME. The doctors at FAME have been unable to do cultures due to the significant safety concerns and the equipment requirements that include an isolation hood, which up until now have obstacles that were unable to be overcome. After much fanfare, they are finally ready to begin doing cultures as everything is in place, though not until after having to wait 9 months to have the hood repaired. Joyce went over what the expectations should be for everyone ordering cultures and what things they could culture and what they couldn’t. It will be a new era here as we will have full information on sensitivities and resistance as well as an ID on the bug in most instances. Being able to finally narrow antibiotics will mean that patients will be on fewer unnecessary antibiotics and possibly for shorter courses. This will be a major advance in therapy here at FAME.

A father and son

I had left at the beginning of morning report to get clinic up and running, leaving Amisha to listen for any potential neurology consults in the ward that we would be requested to see or for those that had some neurologic flare to their presentation and who would be prudent for us to see at some point during their hospitalization. Dan and Marin had gone to the ward early to see their two young children who were very sick (i.e. ICU-sick) which seemed like a very good thing to do prior to our neurology clinic. In addition to the children, we did have a consult in the ward who was women admitted after a head injury with an aphasia who had also had an CT scan demonstrating multiple hemorrhagic injuries. We arrived in clinic to find a great number of patients waiting for us, all of who needed their vitals taken, but once that was done, we were pretty much rolling with three translators to help us in three examination rooms.

Patients waiting in clinic

Dan and Marin spent much of the morning working on the two children who, unfortunately, both succumbed to their illnesses later in the day despite providing everything possible short of intubation. The one young child who Amisha had done the lumbar puncture on yesterday and quite likely had an initial bacterial pneumonia that progressed to sepsis, but hadn’t responded to any of the antibiotics that she had been placed on. The child continued to have respiratory distress throughout the morning with worsening O2 saturations and increasing work to breath. Not that it would have made a difference in this case, there are no ventilators available to use in these situations, meaning that the best we had to offer was the CPAP machine which was no longer providing the benefit it had yesterday. The baby received some morphine to provide some comfort and passed quietly in the presence of her mother, who had been told that she was not going to survive. The other young child presented with what was likely pyloric stenosis and presented after prolonged vomiting and hyponatremic dehydration with renal involvement. The young boy eventually succumbed to multisystem failure.

Patients waiting in clinic

Meanwhile, what had been our decision to see perhaps 30 patients for the day, quickly was abandoned as more patients were sent our way, many of who had come from very long distances making it impossible to ask them to return the following day. We saw many patients with complaints of headache and many patients with epilepsy, both adults and children, so that everyone was happy, though the volume of patients did get a bit worrisome in the afternoon as we were approaching 4 pm, when the clinic usually stops, and had many patients still to see. We continued seeing patients as long as was necessary and finally finished our day somewhere around 6 pm, quite late considering the number of support staff required who must stay late to help us. We still had a consult to see in the ward that we had known about earlier in the day, but hadn’t had a chance to see her given the volume of patients showing up in our outpatient clinic.

Three Maasai women

One very interesting patient that Alice saw in the late afternoon was a young man who stated that he had developed abnormal movements of his right side less than a week prior to coming to clinic. He had never had the symptoms before and noted that he had been drinking alcohol excessively, but had stopped at least a week ago and prior to the movements starting. He was not encephalopathic, had no eye movement abnormalities and was not ataxic so it was quite unlikely that this was thiamine deficiency. Since the movement was acute in onset and there were very few things that could cause a movement like this to start suddenly, we were very suspicious of either some metabolic derangement or possibly something structural. We decided to send him off for labs first and they were normal we would consider getting a CT scan with contrast. Surprisingly, we found that he had a blood sugar of 599 and a hemoglobin A1c of 12.9, both very elevated indicating that he was not only hyperglycemic, but had been so for some time. He was eventually admitted to receive treatment for his blood sugar and by the following day, his movements had completely resolved!

Our busy clinic

Alice and Carrie went off to evaluate her in the ward and found a pleasant 55-year-old woman who had been struck by a bijaji (the little three wheeled vehicles from India that have slowly populated East Africa over the last several years), lost consciousness for several hours and had initial difficulty with her speech. She had gone to an outside hospital, but her family had taken her out and brought her here for a second opinion. When seen here, she was noted to have some difficulty with her speech and underwent a CT scan of the brain prior to our being consulted to see her. Her scan was quite impressive, demonstrating a right posterior cephalohematoma, a left posterior parietal epidural hemorrhage and a left temporal subdural hematoma with parenchymal hemorrhagic contusion. For those of you who are “neuro-nerds,” I am sure that you’re quite familiar with the urgency of an epidural hematoma as these are usually associated with a skull fracture and most often require surgical evacuation to prevent rapid deterioration of the patient. Given the fact that we don’t have a neurosurgeon here at FAME with the closest one being over two hours away, having a patient here with a potential surgical lesion isn’t the most comforting.

The epidural hematoma of our ward consult

This patient looked remarkably well given what her CT scan looked like and after we saw her, the first question from the family was whether or not they could take her home as they lived very close and promised to bring her back should anything change. It is so different here given the fact that patients and families are paying for their hospitalization as families want to take their family member out of the hospital as soon as possible so they don’t continue to run up a bill. In the States, the discussion is tremendously different and it requires a team of social workers to find the appropriate placement for patients, often delaying their discharge by days or weeks. True, that many patients are sent to acute level rehab which doesn’t exist in Tanzania, but family members here are taught the various exercises and stretching that would benefit a patient and then they are done at home. We had given instructions that it would be good to watch the patient for another night perhaps to make certain that she didn’t worsen suddenly, but we found out the next morning that her family remained very persistent through the night and she had been discharged home after remaining stable for the evening.

The parenchymal hemorrhage of our ward consult

I did not leave that night until after 7 pm with the ward consult having been finished and then locking up our ward for the night after housekeeping finally finished mopping the floors as there was quite a bit of dirt that had been carried in through the day. The final tally of patients was 36, not including the inpatient children that had been seen nor the ward consult of the woman with the head injury. It was quite satisfying to have seen that many patients and everyone had felt some sense of accomplishment for our first day. Given the number of patients seen today, it was clear that this spring was stacking up to a busier time than prior spring visits. Dinner tonight was the Tanzanian version of mac and cheese, spruced up by Chef Amisha with the local gouda cheese and peppers that she added to make quite a gooey and tasty concoction. That and a cold beer completed quite a successful day and the rest of the evening was occupied with work on the computer for me and various activities for the others. We each fell asleep with the anticipation of the coming day and what new experiences it would hold.

Wednesday, March 4, 2020 – Welcome to FAME….

Standard

Setting up before clinic starts at the Ward 2 nursing station

Waking up at FAME is a beautiful thing. The mornings are soft and quiet, other than the sounds of the many birds outside and the soft rain falling on our metal roof. Our house is nearly full with the six of us and Dan and Marin are in the Neill House which is one of the original volunteer houses here that I have stayed in many times before until our Raynes House was built three years ago through the generosity of a donor. It again rained through the night, but as heavy as before and remained as only a light rain through the morning, not even enough to have us put on our rain jackets for the five minute walk to clinic. Everyone grabbed something for breakfast and it was off to clinic for us. Our room and board here includes not only our housing, but also dinners made for us during the weekdays (we fend for ourselves on the weekends), lunch for everyday that we’re here, groceries for the house for our breakfasts and whatever else we would need, laundry done every day and wireless serve in the house (when it’s working). All FAME volunteers pay a daily fee for room and board no matter how long you’ve been coming or whether you are on the board of directors or not. It is the only way that FAME can operate and is necessary for the volunteer program to run as close as possible to a zero balance sheet.

Dan and Marin adapting the CPAP to a young child

Morning report begins at 8 am daily, and we usually do our very best to make every report as is often the place where you learn about patients that came in overnight and any possible neurology patients that may be in the ward for us to see. On Tuesdays and Thursdays, we have education at 7:30 am, which we are usually responsible for when we’re here, so those are early mornings. Morning report is run by the night call doctor, which each of them take on a weekly basis in rotation. During our month here, though, Dr. Anne, who has worked with us for several years now and is training to be our community neurologist at FAME, will again work with us for the entire month and will have no call scheduled so as to make sure she remains available for us.

Checking the child’s pulse ox

Today’s clinic would be unannounced, meaning that we would see mainly patients referred by a physician here at FAME, or one that they would have called to come in for follow up with us. Tomorrow would begin the busier announced neurology clinic meaning that our advance team has gone to the community and made announcements about our presence and what conditions we treat lessening the chance that we have non-neurological patients in our clinic. One problem that we run into over the years is the fact that our neurology clinic has been subsidized, meaning that the patients pay a flat fee of 5000 TShillings (a bit more than $2.50), and for that they will receive our consultation, a month’s worth of medication and any labs necessary for their evaluation. As this is far less expensive than most people will pay for a visit, many patients will do their best to be seen in our clinic even if they do not have a neurological problem. We have worked on triaging patients for this reason, but somehow that doesn’t always work effectively and patients will slip through.

Alice reviewing a chart with Carrie and Africanus looking on

Our clinic staff is coordinated by Angel and Kitashu, both social workers by training, who have worked with us for several years now and have a perfect understanding of the needs of the clinic and our purpose here. When seeing patients, it is necessary for us to use translators, and sometimes two depending on the languages spoken, as there are many patients here who do not speak Swahili. I have always strived to use translators with a clinical background such as the MDs or clinical officers here, as then we are leaving something behind in the neurological knowledge we’ve conveyed, but that has not always been possible given the growth of FAME over the years. As I’ve mentioned, Dr. Anne is the clinician that we are training and, in addition, we’re working with two new clinical officers who do not yet have jobs to help us. Though they are hired as translators, they are also clinicians and it would be impossible for them spend this time with us without absorbing a great deal of neurology. I am in the process now of finding a fourth translator so that Marin would be able to see some patients on her own with us, but finding a well-trained translator here can be quite difficult. It can be very frustrating at times as the patient volume continually grows along with the need for qualified translators which just don’t seem to exist here in any overabundance.

Dr. Anne doing a fundoscopic examination

Patients are seen on a first come, first serve basis as there are no appointments here and patients will often spend the entire day waiting to see us. We try to separate the children for our pediatric folks as this is the most appropriate, but we have no control over the mix of patients that will be seen on any particular day and often there can be a disparity in either direction. Patient visits can either be rather simple, such a neuropathy or a well-controlled seizure follow up, or they can be incredibly complex for us and this is not helped in any way by the lack of documentation available when we see our patients. They have very often been seen somewhere else and may have even received medications, some of which may have worked, there is no record to refer to and often the patient is completely unaware of what had been done in the past. On occasion, showing the patient a selection of tablets, such as anti-epileptics may spark their memory, but more often it is a guessing game in which you must weigh how confident you are in the history you’re receiving and decide going forward. Considering all of the obstacles that are encountered throughout our day, the residents do an incredible job with the patients that are seen in both regard to diagnoses and treatment plans.

Carrie, Molly with Anne examining a patient

During this visit, we are also very lucky in that we have a physical therapist working with us who is from Ireland and has a huge interest in neurological cases. Frances Marron had found out about the work we’re doing through the FAME website and my blog and, after spending some time in New Zealand, decided to come to Tanzania and coordinate here visit here with ours. What a luxury of having our own physical therapist who can sit in evaluation with the doctor when it looks like it’s someone who might need her services and then she can work with the patient and family after our visit. She’s also happy to see our dizzy patients to help with vestibular therapy which is a great advantage for us. I am quite certain that we will have many patients for her to help during her time here and, better yet, that’s what she is looking forward to.

Angela and Amisha evaluating a patient with Kitasu translating

We started the day with morning report and quickly found that the ward had a number of extremely sick children or, more accurately, intensive care level children, who were in dire need of Dan and Marin’s care as that is their specialty. One of the children in the ward appeared to be septic having not yet responded to antibiotic therapy and was having serious difficulty breathing. We have no ventilators to use here, or course, but we did have an older CPAP machine with a host of masks there were able to be sized for this child so that her struggle breathing did seem to improve once it was placed, though how long this benefit would last was anyone’s guess. When they had originally seen this young child, Dan’s comment was that he didn’t think the child was going to last the hour, but after getting the CPAP mask on, the child seemed to stabilize and look a slightly bit brighter. Regardless, it was going to be an uphill battle. There were also other children who, unfortunately, were equally critical such that Dan and Marin spent most of the morning and part of the afternoon working in the ward service non-stop to assess them and come up with a game plan for each that would hopefully help.

Alice and Africanus evaluating a patient

The rest of the group spent the morning seeing a few patients and becoming acclimated to the system here that is very different than what they are used to at home. The clinic was actually to begin in the afternoon, but given that patients were there and ready to be seen, we took the opportunity to begin early and possibly lighten the load for the day. Carrie, the medical student accompanying us spent the entire day, but beginning tomorrow, she will take each morning to work on the data bases, entering all of the patients into it along with other data from demographics to specific diagnoses and medications that they were prescribed. In keeping this type of information, we have already accumulated a plethora of information that has helped us to recognize the distribution of illnesses seen in the various tribes we treat, the distribution of gender and ages that we treat, and, finally, the medications that we use most frequently. In addition, a very high percentage of the patients we treat here at FAME have an underlying diagnosis of epilepsy and we have shown that these patients are more likely than any other to follow up with us and are most likely to be adherent on their medication. They have also reported that their seizure frequencies have either improved or remained the same for by far the majority of patients that we’ve seen.

Dan and Marin with Dr. Lisso

Our clinic today was a steady stream of patients, though by no way unmanageable. It gave everyone a chance to get fully oriented with the clinic flow and the system here without becoming overly stressed by the volume. We were able to get home at a decent hour and in plenty of time to relax before sunset, some with a hammock, some with a beer, and others with just the comfort of our home away from home, the Raynes House. It was an awesome start to the month, similar to what I have done many times in the past, and I very much look forward to sharing this wonderful experience that is FAME with the rest of the group.

Amisha performing an LP with Marin looking on

 

 

Tuesday, March 3, 2020 – It’s off to FAME…eventually

Standard

D’Arnaud’s Barbet. Photo by Dan Licht

While Dan and Marin were waking in Tarangire with plans to meet us at FAME later in the day, the rest of my group was still in Arusha with me, waking for their first of many mornings in Tanzania. It had again rained all night, though not as heavy as the night before. Still, there was a heaviness to the air as a result until mid-morning when suddenly, the temperature dropped as did the humidity and it became lovely and cool outside. Today we would be heading to FAME, our final destination and soon to be home for the next month for most of us. I slept well, under the mosquito netting, of course, and was up and ready by 7 am as there were still a few last minute things to take care of on Turtle and would need to be finished by late morning as I had hoped to depart by then. We have an expression here which is “TIA,” something that has a far different meaning to most neurologists as this stands for “transient ischemic attack” in our world, but here it stands for “this is Africa.” The latter meaning is more than self-explanatory as it represents much of the essence of time here; that it takes on a different level of importance to time than in the west. Things get done, of course, but not necessarily tied to a schedule as we are in the west. We speak of projects in relation to when they will be completed rather than when they will be completed.

Eurasian Roller. Photo by Dan Licht

Given that Turtle was still in need of a few last minute repairs, I was pretty certain that we would, once again, be delayed in our departure from Arusha. Given that this situation has been a recurring theme, along with my knowledge of “Africa time,” it would seem reasonable for you to ask why would I even challenge myself with making such plans? Well, in reality, I have no intention that we will be keeping to our schedule other than to know that things will likely happen in any day…hopefully. So, Turtle drove off in the morning with someone for the necessary additional fixes, that also included getting a snorkel, now a necessity given the heavy rains of late, and would hopefully return in time for us to leave for Karatu and FAME.

Carrie with Patricia and Gabriel

Gabby

Exhausted from all their travels, everyone awakened at different times throughout the morning and enjoyed coffee and Pendo’s wonderful cardamom tea until breakfast was served around 10 am. The meal consisted of eggs, pancakes, delicious potatoes fried with onions and peppers (Amisha’s fav), and large plates of fresh watermelon, sweet bananas and pineapple, and was, of course, well enjoyed by all. We had little to do all morning, other than play with the children or enjoy a short nap for those who hadn’t had enough slumber the night before. Thankfully, Carrie and Molly seemed to pull the greatest weight when it came to the babysitting chores as that has never been one of my major skill sets and especially not while waiting for the return of my vehicle so that we could get out journey under way.

Molly and Patricia taking a selfie

Carrie and Gabriel on the front lawn

Leonard had gone over to his sister’s home for the day as the entire family was still in morning for his other sister who had passed away from Cancer the day before my arrival. Funerals here are a multiday affair in which the entire extended family, as well as friends, come together to meet at someplace for to exchange thoughts and to discuss particulars such as who will now take over that person’s responsibilities. It is also a time for those who may have been owed something by the departed , to show up and make any claims necessary. I had gone to Leonard’s mother’s funeral several years on the slopes of Mt. Kilimanjaro, where the entire family had already spent two days eating and drinking together and reminiscing They had even built a temporary structure to house many of the people there during this time. I spent the entire final day there greeting everyone and, of course, eating and then attending the final meeting where there were many speeches from those who had known her during her life. Despite the fact that all of her children were fully grown with families of their own, much of the discussion would focus on who would be responsible for their care in the future. A far cry from the discussions that are had at our funerals. Leonard’s sister was much younger, or course, and these discussions regarding her children would therefore become much more significant.

Selfie with Molly,

Turtle finally arrived back home and we were able to get all of bags packed into the boot and the back seats so there was still enough room for everyone to have a seat. Turtle fits 9 passengers comfortably, or 11 in a pinch using soda crates as seats set in the aisle. Leonard’s family had been waiting to see me at their gathering and, because over the years I have become part of it myself, I had no intention of leaving town before visiting them to pay my respects and greet each of them in doing so. The family gathering was being held at one of Leonard’s other sister’s houses in the village of Sakina outside of Arusha. This is an area quite familiar to me as Leonard and Pendo had lived there for a number of years prior to moving to Njiro. I have fond memories of this area as this is where I first became familiar with Tanzania and it’s wonderful culture. I still remember every little dirt alleyway and turn necessary to reach their first house that they had later turned into a day care center and could probably still find it in a pinch if I tried to do so. We turned off the main highway and then took a narrow path that hugged the east side of a narrow creek that was down in a gulley below. Several turns were quite tight and, given that this was their first ride in a Land Rover, I’m sure that everyone was quickly questioning the decision that had made to join me on this adventure. Thankfully, we didn’t end up in the bottom of a ravine nor did we drag down the clotheslines that we just barely cleared as we drove below them each time, though a few residents sitting in front of their houses did have to move as we drove through some of the skinnier sections of the road.

Hamerkop. Photo by Dan Licht

When we arrived, I went in and greeted everyone, many of who I had never met before, but they all knew me through Leonard and Pendo and I was honored to be there and share at least this short moment with them. Unfortunately, it was impossible for us to remain there much longer as we still had our drive to FAME for which we would need at least 2-3 hours given the possible weather we’d encounter. The rest of the group was also asked to come in and say hi to Leonard’s family which was also very nice that they were able to experience such an event as it is not often that visitors are invited to such an affair. We eventually all said our goodbyes and I navigated the Land Rover back through the tiny alley ways, under the clothes lines and next to the ravine. We were eventually back on the main road and heading north on the Nairobi road before turning onto the new bypass that connects it with the road to Karatu and the Serengeti heading to the southwest.

Jackal in the grass. Photo by Dan Licht

Once on the open road, it was pretty much of a straight shot to Karatu, other than the frequent slow truck or dala dala (the local vans that travel between towns and are packed with travelers). The trip was dry through to Makuyuni , the junction where you head straight on to Tarangire National Park, or turn right towards Lake Manyara and the Serengeti. The drive from Makuyuni takes us across the Great Rift Valley where the views of Lake Manyara and the escarpment are spectacular. With the recent rains, the lake is very full and there are areas along the shore that are normally dry are now quite flooded such that I’m sure the game drives must be quite challenging there. We travel through Mto wa Mbu (mosquito river) which sits at the mouth of the lake with rice patties throughout, quite likely creating a perfect condition for these pesky insects. Passing by the park entrance there are tons of storks nesting in the trees and baboons alongside the road.

Lake Manyara

The escarpment is about 2000 feet in elevation, all told, and the views from the top of Lake Manyara and the Rift Valley before are magnificent and go on forever. The Great Rift Valley, which cuts across East Africa is a geologic formation that holds tremendous historic importance as it is the birthplace of man, and especially here in Tanzania, where Olduvai (or Oldupai) Gorge was made famous by Mary and Louis Leaky for finding oldest man here back in the 1950’s. This region is truly the Mecca for all anthropologists and it has always been special to me from my late childhood as my heroes then were individuals like Heinrich Schliemann who had discovered Mycenae and Troy. I guess you can say that I was pretty much of a nerd.

Roadside camel

Rising from the escarpment to Karatu is an amazing drive, especially now with lushness of the recent rains making the hillsides everywhere a green as one could imagine. We could see rain and thunderheads moving our way and even though we encountered some downpours on the way, by the time we reached Karatu and FAME, it was incredibly bright and sunny. It is always special to arrive back home at FAME for me, but even more so this trip as it is my twentieth volunteering trip here not including my very first trip when I “discovered” this miraculous place. FAME has grown so much over the ten years that I have been coming, but it has not lost that initial character that had attracted me in the beginning. There are many who have worked here the entire time I’ve been coming and they continue to grow, now serving nearly 30,000 patients a year. It is our hope that FAME will continue to grow and provide quality healthcare to this region of Tanzania and that our partnership that has been so successful over these years will continue to prosper as it has in the past.

Monday, March 2, 2020 – Day two in Tanzania, the rest of the team arrives….  

Standard

The weather here has been very wet over the last weeks and I have held on to the hope that it’s not the big rains starting, but rather just a small blip rather than the monsoons that occur every fall. It was fairly wet on my arrival yesterday, but with the fact that it rained heavily all night long, the roads have now become a bit more than just wet. Several years ago, I had traveled here in April, the normal month that the big rains begin, and had managed to become stuck in a Land Rover (not a simple task) en route to one of our mobile clinics prompting me to immediately move my spring trips to March in an effort to avoid a similar fate occurring once again. I have had other experiences in the mud and they are not exciting to say the least as there is no auto club here to call in an emergency. You are essentially left to your own resources and that is not a good thing when there are lions and leopards roaming about.

One of Alice’s strange sleeping positions during her travels

One such incident occurred very deep into the Tarangire National Park back country when the road I had driven numerous times before, but in obviously better conditions, suddenly disappeared and we became hopelessly stuck in the mud such that we had sunk to our axles. It was becoming dark and a light rain had begun and we had made no advance in any of the efforts to extricate ourselves from the mud. The tall grasses around us could have concealed anything save for an elephant or a giraffe, and a pride of lions could have easily slipped into our area without us even knowing about it. I barely had a signal on my phone, but somehow was able to send a message to Leonard (my family here in Tanzania ever since he was our safari guide in 2009), who was miraculously just coming into the park with a group of clients. I had taken the Little Serengeti Road and made several turns off, but somehow was able to describe to Leonard where we were by using directions such as, “turn left when you encounter the small herd of Cape Buffalo before you run into the trees.” Having been on many a game drive with Leonard in many different weather conditions, I had total confidence that he would not only find us, but would also be successful in getting us back on the road. Sure enough, despite the fact it was like looking for a needle in a haystack (yes, the grass was that high), he not only found us, but we were able to eventually pull the vehicle out of the muck, much to the joy of his safari group as they had now rescued another vehicle. I made sure to thank each of them personally, as well as give them money to buy a round of drinks at camp that night for the inconvenience of having had to take the detour it entailed. Of course, that wasn’t necessary, but it seemed only appropriate given the circumstances.

Turtle’s new coat of paint – a matt green

I had been up very late as I didn’t have an internet connection after arriving until Pendo loaned me one of hers, and had not gotten to sleep until nearly 1 am, hence having heard the rains beginning in the late evening. I did take the opportunity to do something I rarely do and slept in a bit until it was near breakfast time, but luckily was able to enjoy Pendo’s wonderful cardamom tea beforehand. Regardless of what I have tried at home, nothing has ever come even close to this tea and it is the first thing I go for upon arriving here each trip. Even though I rarely have breakfast at home, Pendo has always insisted on providing a wonderful first meal of the day, typically consisting of pancakes, eggs, and lots of fruit. It is a meal that is well worth the effort, certainly on my part, as it miraculously appears on the table each morning that I am staying at the Temba residence. My main chores today, though, were to get my sim card for my phone working , as they have gone to a biometric registration here recently, and to get to the airport by 2 pm which is an hour drive or a bit more depending on the amount of slow moving trucks on the road.

There is a wonderful Swahili word that I use quite often and it is, “shida,” which means trouble or problem. You can combine it with anything and people will often hear me saying, “hamna shida,” which means “no problem” when they’re asking me to do something for them. This morning and, for that matter, since I’ve been in Tanzania, I’ve had nothing but cellphone shida. There are several companies here and they have different geographic coverage, but basically the two companies are Airtel and Vodacom. Since there are no land lines here in the country, virtually everything goes over the cellular network meaning that the cell towers can get overloaded during times of the day when everyone is on the internet or their phones. Just to reiterate, there are no cable services or cables here, just cellular so that everything, phone calls and the internet, must go over the air with the cellular service. When each company decides to run some special deal, everyone begins to use that company and everything bogs down. Most people here have sim cards with both companies and switch between using them depending on who has the best deal. I have several numbers since coming in 2010, but have had my current one now for probably six years meaning that everyone here knows this number and calls me on it. It has been a struggle, though, and hence the cellphone shida, to keep my number active. Originally, it was the wild west and you just paid 1000 TSh (Tanzanian Shillings), or the equivalent of about 50 cents, to get your sim card and phone number. You needed no ID, no forms, no nothing.

A rare view of Kilimanjaro leaving the airport.

About three years ago, they decided that all the sim cards needed to be registered requiring some form of ID such as your national ID card for Tanzanians or your passport for the rest of us. I had taken care of this and things were going along smoothly until recently when they have decided to use a biometric ID in addition to your national card meaning that they record your thumbprint to register the sim. Given I was in the US, this would be rather difficult for me even if I had known about it, which of course I didn’t. I popped in my sim on arrival here yesterday only to find that it said it was suspended. More cellphone shida! Pendo and I spent almost an hour this morning at both Vodacom (trying to switch my number to them though discovered that portion of the network was not working) and Airtel, where even though we went through the whole biometric thing, my sim still wasn’t working by the time we had walked out of the shop. As of tonight, I am able to use it to send calls and messages, as well as for the internet, but am still unable to receive calls as the caller hears a message saying that my number has been suspended. Such is life here where very little is simple in these matters of technology, that is, when the technology exists. When there is no technology, of course, things are much simpler. I’m sure there was no registration required for rock art.

I left from the Airtel store to head to the airport as Pendo and I had driven separately for that express purpose as the traffic driving in Arusha can be brutal at times and there was no need for me to go back to the house before picking everyone up. The airport is about an hour away along the main highway between Arusha and Moshi. Most of it is two lanes with incredibly slow trucks, speed bumps through the towns and 50 kph speed limits in the towns as well (that’s about 30 mph for those of you metrically challenged). It can be a rather boring drive and perhaps the most exciting thing you encounter is the traffic police, who are stationed along the road in areas of predictable passing over the solid while line or speeding. Those of you who are familiar with my driving will quite shocked when I tell you that now I always drive the speed limit here in Tanzania. My record of being flagged to pull to the side of the road three times in less than 24 hours remains a record that I’m not very proud of, though each was for a different offense. Passing over the solid white line was one, doing 57 kph in a 50 kph zone was another and the final one was for not wearing my seat belt as I had just pulled out from a restaurant and wasn’t quick enough putting it on when I had seen the police and was too honest when they asked me if I had indeed been putting it on as they had spotted me. Very often, though, the stop is merely random and for a safety check, making sure that you have all of your safety equipment in the vehicle and all of your insurance stickers. They usually just let me go as I don’t speak much in the way of Swahili and it becomes an exercise in frustration for them. In the old days, they very likely pocketed the fines, but now they must give you a receipt for the fine which is then written into a receipt book so it’s all accounted for, or at least that’s the idea.

Marin’s tsetse bitten feet after a day in Tarangire

I arrived at the airport after their plane had landed, but given the amount of time it takes to get through immigration, get the bags and then through customs, which has now become more of an ordeal at times, I still had nearly half an hour before they would emerge. The scene at the airport is always hectic as there are typically at least 50 or more guides waiting for their guests, each holding a sign up with their names on it, while each traveler exits the airport into the bright sun looking for their guide and name. This has become quite familiar for me as I have picked up and dropped off countless residents and others over the years I have been coming. Today, and for the first time I have ever seen it, one of the safari companies for a group of travelers from the Philippines has brought a contingent of Maasai to perform their traditional song and dance for them. Obviously, everyone there was able to also enjoy them which was an added benefit since we still had to wait for Angela, our friend and colleague from Ghana, to arrive on her separate flight. As always, despite the thousands of miles and multiple flights that everyone has traveled, they all arrived safely and were excited to begin their journey to this new locale.

Our first stop, though, once everyone and their baggage had been loaded into my Land Rover, or Turtle as it is affectionately known, would be to the Temba household in Arusha. It is an hour drive, back through all of the villages, with their 50 kph speed limits, and the slow trucks to drive behind, though no one cared as they were all new sights and sounds for everyone save Amisha who was returning for her second visit here. It never gets old, though, even for me as this is my 21st trip here and I’ve driven this road countless times. There is so much life here that one can never see it all and I have never tired of it. Pendo always insists on feeding us when we arrive back to their home, regardless of the time, which becomes lunch as there is another meal later that is our dinner. They are both incredibly delicious and most appreciated after the long days of travel for everyone. Their youngest children, Gabriella, age 5, and Gabriel, age 3, are both incredibly excited to see everyone as they have their undivided attention for an entire evening of horseplay until everyone, residents and children, finally pooped out and were ready for bed. It was a well-deserved rest given the effort required to make it here and everyone was incredibly excited for tomorrow we would be making the trek to FAME and traveling across the Great Rift Valley on the way. FAME will be their home for the next month and the staff, their family. And each of them will have changed, in some small manner, for the best for having made the effort to help others and make a difference in the world. And, most of all, each of them will have also left a small part of themselves behind with each of those they have interacted with along the way and the world will have become a better place for it.

 

Sunday, March 1, 2020 – Our journey to back to FAME begins….

Standard

For the first time in many years, I will be traveling to Tanzania with our group rather than my normal protocol of arriving several days in advance of everyone else to prepare things. As many of your know, we have been traveling on Qatar Airways (a wonderful airline for any of you who haven’t flown it) since they came to Philadelphia as it saves us from having to schlep our way up to NYC , never a fun proposition. In addition to flying directly out of Philly, we have a long overnight layover in Doha, Qatar, that enables us to spend the night in town using their Discover Qatar program that provides five-star hotels for a fraction of the normal cost (like the ridiculous rate of $23!). The residents for this trip, Amisha (yes, her second time to FAME), Molly and Alice, all decided to spend two nights in Doha, with our medical student, Carrie, following a day behind them to meet up and all travel down to Kilimanjaro. Dan and Marin, our pediatric neurologist and pediatric neurology nurse practitioner, respectively, left Doha with me this morning while the others stayed behind, and will be traveling to Tarangire for a two night adventure before arriving to FAME the same time as the rest of us on Tuesday. It sounds a bit confusing, but trust me, everything worked smoothly in the planning phase and, so far, it has worked in reality.

The Souq Waqif

We all left Philadelphia, save Carrie, on a cold and blustery winter day from Philadelphia and had an uneventful, albeit 12 hour, flight to Doha, Qatar, arriving at about 4:00 in the afternoon. Amazingly, the six of us were able to fit into a single small SUV taxi to shuttle to our hotel at the Souq Waqif, or the marketplace. Amisha, Molly and Alice did have to get their checked luggage since they were staying an extra night, but the rest of us did not have to which was quite fortunate since I have two large duffels checked and they never would have fit. The ride to the hotel was cramp though quick and we all looked forward to settling in our rooms, showering, and getting ready for a nice dinner at a restaurant we’ve frequented before. There was only one hitch to that plan. In booking their rooms, Amisha, Alice and Molly had mistakenly booked at a different Tivoli hotel that was actually on the other side of the airport from where we were. As they had been booked through Discover Qatar, there was no way for the hotel to cancel and rebook without incurring a significant loss. Thankfully, the hotel had facilities for them to get showered and cleaned up so it was decided that we would all go to dinner and walk around the marketplace after which they would take a taxi to their hotel and get checked in.

My favorite restaurant in the market

I had discovered this simply wonderful restaurant (Shujaa Restaurant in case anyone happens to be passing through the Doha Souq Waqif in the future) that serves skewers of the most delicious lamb and chicken that are simply to die for and it seems to have become a staple of our overnight stays in Doha since that time. The six of us ate very generous helpings of meat along with humus, tahini, eggplant, and yogurt with mint and lots of bread for a grand total of 97 Riyals, or just under $27 USD, total. We continued to stroll the market picking up lots of dried fruits for our stay at FAME along with some bags of candy that you really can’t find anywhere else but here. Dan and Marin decided to head back to their hotel early, but not until we had a hoot watching Alice order some ice cream from one of the street vendors. They are incredibly comical, scooping with a long spatula that really sticks to the ice cream as they proceed to spin and twirl it all the while teasing your outstretched hand waiting for the cone. It’s finally delivered, but not until after several minutes of outright laughter from everyone watching and a few smudges of ice cream on Alice’s nose, all without a single dropped scoop or other unfortunate mishap. Though the ice cream probably wasn’t worth the nearly $5 that she paid for it, but the show certainly was.

Enjoying our meal at Sujaa

Dan at Sujaa (there wasn’t enough room on the bench)

Amisha, Alice and Molly wanted to see the falcon shops on the outskirts of the market, so I took them over to the falcon market and we walked into a few of the shops. They are beautiful birds that are bred for falconry which is a hobby of the rich here and elsewhere in the Middle East. They are certainly pampered and not mistreated to the best of my knowledge, but they weren’t meant to remain captive for the entire lives so it is also difficult to see them tethered on their perches, many wearing their leather hoods to reduce the amount of stimulation and stress that they experience. It’s not much different than having a dog or a cat, I guess, but those animals are domesticated and were never meant to live in the wild, having been bred simply for our pleasure and companionship which is much different than these birds or any other exotic pet for that matter. After the falcons, we walked over to the Royal Stables where their Arabian horses are kept. The stables are open to walk around while you pet the various horses, mostly housed by themselves in the stables unless they are out in the sandy corral where they can visit with each other. Amisha had a particular love affair with one of the horses, a grey mare who seemed to be as intrigued by Amisha as she was with them. Amisha would cock her head to the side and the horse would promptly follow suit with its huge head and neck extending out the window in its stable. They were absolute speaking the same language for some time and had totally bonded by the time we decided to head home.

Amisha and her Arabian buddy

Alice admiring the falcons

I had to show them my room at one of the boutique hotels, which was the same one as Dan and Marin were staying in. My room, though, was on the third and top floor and was really fit for a king. There was a couch and desk and many chairs on which to sit along with a lovely upholstered bench or chaise at the foot of my bed. I had views of both the distant city skyscrapers and their lights as well as to the west with the setting moon and the tall tower of a distant mosque. It seemed a waste that I was staying for only one night and perhaps I’ll do in the future as the residents were doing this trip by staying for two nights or even more. Qatar is definitely a country worth exploring more than I have so far.

View of the city from my window

A room fit for a king

Our flight was leaving early in the morning so that Dan, Marin and I had decided to meet at 5:30 am to catch a cab to the airport. I slept horribly this night, waking up repeatedly and then finally getting up at 4:30, only to discover that neither Dan or Marin had discovered restful sleep and had gone out at 4 am for breakfast in an all-night diner not wanting to wake me. The trip to the airport was quick and after a few cappuccinos and a stop at the duty-free shop for some much needed libation during our stay at FAME, we were at the gate and ready to board. I will have to confess here that I had taken Qatar Airways up on their discount offer to upgrade to business class on this leg of the flight, so I boarded first and made myself cozy in my little cubby while the flight attendant brought me fresh squeezed orange juice and my menu for the ala cart dining during the flight. I will have to say that I have never booked business class as the cost is many multiples of the economy fare, but if you ever have the chance to take them up on an upgrade for a fraction of the regular price, it’s well worth the splurge as being pampered from takeoff to landing can be quite an experience and is almost a vacation in itself. I typed for the entire flight, other than my meals, of course, which is when I took advantage of the extra-large monitor to watch a movie while eating several meals.

A few horses in the corral in the moonlight

The bread cart

I should make some mention about the corona virus as there were many walking around the airport in Doha with masks on, even though we have been made well aware that the normal surgical masks do little to protect anyone from getting the disease and I saw only a handful of the more tight-fitting N95 masks that may be more protective (I can’t wear one due to my beard), though are probably still not worth the effort in these situations. Amisha texted us today from Doha to tell us that Qatar had it’s very first case confirmed, but I think that is going to be standard fare for our trip and other than staying vigilant to avoid those individuals visibly coughing and hacking, we will have to trust our common sense and the authorities to managing the situation. Of course, having listened to recent interviews by a certain individual back at home has done nothing to instill my confidence that the latter part of that statement will, in fact, take place. On arrival to Kilimanjaro, other than being led single file by a disinfectant dispenser where we were told to wash our hands and a quick one-over glance by an airport worker to see if we looked like death warmed over, there was little in the way of containment going on here for the moment.

The multicourse lunch at the museum

The multicourse lunch at the museum

The multicourse lunch at the museum

The multicourse lunch at the museum

The multicourse lunch at the museum

The multicourse lunch at the museum

The multicourse lunch at the museum

Unlike past trips, we made it through immigration and customs quite quickly, and Vitalis was waiting outside for us to drive us into Arusha. I have known Vitalis for several years now and he is one of the best safari guides and would be taking Dan and Marin to Tarangire for two nights after dropping me off at the Mt. Meru Hotel where Pendo was waiting for me. I’m sure as I type this that Dan and Marin are settling into their safari lodge just outside the park and preparing for a wonderful day of game viewing tomorrow. Vitalis is an amazing birder, which is really Dan’s favorite focus, so I can imagine the two of them together for the day. Marin will learn more about birds tomorrow than she had ever dreamed of. They will meet up with us at FAME on Tuesday after lunch.

Amisha, Alice and Molly

Molly, Amisha and Alice

I received word that Carrie arrived safely in Doha and, more importantly, connected up with Alice, Molly and Amisha and that they were heading back to the market to spend the evening. I was also told that the three of them had gone to the National Museum earlier in the day and had spent two hours for a tasting lunch that they said was spectacular. I’ll include a few of their photos, but it sounded amazing and I can’t wait to hear more. From what I am told they spent for their lunch, though, I suspect they may be going to back to Shujaa for dinner tonight or perhaps they’ll even fast given how much it sounds like they ate. I was told that the bread cart itself was worth the price of lunch, so I have a suspicion that they ate their fill. Hopefully they’ll be nice to Carrie and make sure she gets something to eat.

Items in the museum

They will be flying out of Doha on the same flight we took today so that I will be picking up the four of them along with another member of our team, Angela Osei-Bonsu. Angela is a pediatrician from Ghana who had spent a month at Penn over the summer as a global health scholar and given her interest ultimately in pursuing child neurology, she had spent a great deal of time with our department. She had asked me about joining us for some of our time here and, thankfully, we were able to work things out with FAME and Penn to coordinate a visit and the opportunity to spend several weeks with our team. Given that we will have three pediatric neurologists with us, it was perfect timing for Angela to come so not only could she get a taste of working with us, but our peds folks could also have the opportunity to work with her. You never know where these situations may lead and it is only through networking such as this that you can take full advantage and make things happen. Abdulhamid spending the month at Penn last October (please read my previous post on that) was a similar life-affirming opportunity that had been born out of a simple meeting with little in the way of expectations other than the desire to do your best and the graciousness and forward thinking of those in a position to make these things happen.