Friday, March 4 – Sunday, March 6 – If It’s March, This Must Be Tanzania.

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For those of you who are not Class B movie historians (if you are, I am sorry), the movie If It’s Tuesday, This Must Be Belgium was a romantic comedy that starred Suzanne Pleshette and covered a group of American tourists traveling around Europe on a busy schedule. If you happen to have missed it, there are no worries as the title is surely enough to imagine the entire gist of the movie sans the love affairs.

Sunrise over Mt. Meru

Meanwhile, the significance of the time of year remains as we are all poised to begin another adventure to East Africa to provide neurological care to the population of Northern Tanzania and neurologic education to those caregivers at FAME who will continue to care for the patients we see in between our every six month visits. With the work that we have done to date and the help that we have received from FAME, we have developed a first class system for the delivery of neurological care, or any specialty for that matter, where there are no specialists and, more importantly, do it in a sustainable fashion. But it is undeniably clear that none of these successes would have been possible without the incredible infrastructure that is FAME and without the hard work of all those individuals on the ground in Tanzania. For that we will be forever grateful.

Our neurology program, bringing residents, medical students and additional neurology faculty to FAME has also continued to grow as would be expected over the last decade plus that we have been traveling to the Karatu region, and it is out of this growth that we have found other opportunities to improve the neurologic health of the population of Tanzania. As I have mentioned in the past, we have accumulated data on our patients into a database whose sole purpose was to provide the necessary internal information, such as medications and supplies, where patients were traveling from to see us, what types of neurologic illnesses we were treating and in which tribes, so that we could continue to provide the most efficient and cost effective care possible. What developed, though, was an incredible treasure trove of data that would apply not only to our beloved specialty of neurology, but also to many other specialties that had not yet developed a presence in the rural regions we were serving. Thus, began our “database project” that has now involved a number of researchers at the main government teaching hospital in Dar es Salaam, Muhimbili University, as well as those caregivers at FAME who have been working with us over the last years. We were poised to begin our work in earnest in 2020 when the pandemic hit which has merely delayed the project.

MUHAS Emergency Department

And it is through this relationship with Muhimbili University of Health and Allied Sciences (MUHAS) and Dr. Bruno Sunguya that I visited the medical school last October, only to discover that there were two neurology fellows there who were eagerly waiting for my arrival and were like sponges for as much information as I could humanly supply. Even though I had only been able to spend less than a week with them before heading home, it was incredibly productive and has now developed into what I hope to be a longer term relationship between Muhimbili, University of Pennsylvania and FAME. Next fall, I am hopeful that the two new neurology fellows will come spend the month with us at FAME, working side by side with our residents and the FAME clinicians. Inshallah.

MUHAS Drug Treatment Program

So, it is on the background of these new developments in global health involving FAME, Penn and Muhimbili University, that we embark once again to the now enlightened, “Dark Continent,” a term that I use only from the standpoint of its historical background. Where we are traveling and living for the next month will be not only the furthest from dark, but will be a journey of exploration and enlightenment, both individually and as a group, both personally and professionally. It is truly difficult to put into words just how meaningful this experience can be for those who participate, and I say that not just from the standpoint of what I wish it to be, but rather from the direct feedback of those 40+ residents who have accompanied me to visit FAME over the past decade. Practicing in a low-resource setting, such as that in East Africa, provides an education of its own, from the cultural differences in which we live and work here, to the decisions that we make with our patients and the unintended consequences that can occur if one is not careful. It is nothing short of an intense professional course condensed into a single month.

Mt. Meru in Arusha as we’re heading east to Kilimanjaro International Airport

With the restrictions placed by the pandemic on who could travel and who could not, we had to forego keeping a spot for a medical student this trip, though that opened up extra room in addition to the four residents. Whitley Aamodt, who had traveled to FAME in the fall of 2017. and who has now completed her movement disorder fellowship (think Parkinson’s disease for you non-neurologists) elected to come for a second visit now that she will be staying on as a faculty member at Penn. Meredith Spindler, another movement disorder faculty member at Penn, will also be joining us as she has been considering this return to Tanzania for several years, having spent some time during residency at Bugondo Medical School in Mwanza on Lake Victoria.

Mt. Meru in the distance

The residents who will be arriving a day later than us, allowing me time to get Turtle in order for our travels, include Savannah Quigley, Alex Pfister, Natalie Ullman and Peter Schwab. Natalie is our Children’s Hospital of Philadelphia representative and a very necessary addition to the team, while Peter has been to FAME previously as a medical student accompanying us. In fact, Peter was the very first medical student to come with us, having paved the way for this possibility.

Getting the jack to work changing our tire

Our flights from Philadelphia have been uneventful thus far considering my two previous trips. In March 2021, I was stuck in O’Hare Airport for two days with a passport that didn’t have a full empty page, eventually receiving permission to fly from immigration, and my last visit in September, having arrived to the Philadelphia Airport with a COVID test that had been too early after they changed the requirements from 72 hours prior to departure to 72 hours prior to arrival. Dr. Frank’s expression of “TIA,” which has an entirely different meaning than what most neurologists think and instead meaning “this is Africa,” pretty much sums it all up and apparently extends outwards to include one’s travel to and from. These types of plans with so many moving parts requires a combination of skill, luck, ingenuity, and the realization that we will eventually get to where we are going. But if all else fails, we must be confident that there is someone, or something, looking down upon us that is ultimately directing this great journey that is life. I am often reminded of a saying that I read in one of the mountaineering survival sagas that I am so found of: Good judgement comes from experience, and experience comes from bad judgement. A good example of this was having our tire fall off the Land Rover last March while driving in Tarangire National Park – the result of tightening the lug nuts with the vehicle on the ground after having had a flat tire. I will never make that mistake again.

Alex Gill lifting the vehicle after our tire has fallen off

We will be landing at Kilimanjaro International Airport in several hours and even thought this is my 25th trip to Tanzania, I can still recall the excitement of my first, something that I know each of the residents who are on their first trip will also have the chance to experience. Kilimanjaro International Airport, or KIA, is a tiny speck of an airport that caters to only two carriers arriving each day from off the continent, while a host of African carriers arrive throughout the day from such sites as Dar es Salaam, Nairobi, Johannesburg, Kigali, and such. Arriving on a widebody jet from off the continent such as we are today is a site to see as the airport suddenly becomes a sea of activity with lines forming everywhere for purchasing visas, moving through immigration and then through customs, and now, during the pandemic, having a rapid test done at the airport despite that fact that we have all tested negative just to board our originating flights. Thankfully, obtaining a visa has now become a streamlined process on the internet, though I will have to admit the TIA adage definitely applies here as it became a bit of group effort as the website was determined to take some credit cards and not others in a hap hazard fashion that left us relying on Venmo to send funds back and forth. This is Africa.

Mt. Meru coming into Kilimanjaro International Airport

The drive from Kilimanjaro to Arusha is an incredibly colorful one, traveling first along the foothills of Mt. Kilimanjaro that dominates the landscape at nearly 20,000 feet, though it is most often in the clouds and unseen, and then to the slopes of Mt. Meru that dominates the skyline around Arusha. At 15,000 feet, it is higher than anything in the continental United States. All the while, we’ll be traveling through the small towns of the Arusha district that saddle the highway, each with its own hustle and bustle of the daily life that goes on here. We’ll soon arrive to Leonard and Pendo’s home in Arusha, my Tanzanian family, who have feed and housed countless residents while in transit to FAME. Leonard was my safari guide in 2009 when I first came with my children and it is he who is responsible for introducing me to FAME and everything that has followed. Our lives have become hopelessly intertwined for more than a dozen years and through them I have learned much of the Tanzanian ways while watching their two oldest children grow to become simply amazing young men.  

“Lamp Bear” – the centerpiece at Hamid International Airport, Doha

 

Thursday, September 16 – Akash returns from Dar (finally), the Tarangire group arrives and a night at the Golden Sparrow…

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Revo and Emily with a patient

As I had mentioned previously, Akash had been in Dar es Salaam since last Sunday due the fact that he needed to renew his J-1 visa prior to being allowed to re-enter the United States. Normally, this would have been a formality, but because of the pandemic it required that a number of things worked in our favor. Thankfully, they all did and Akash had received his passport and renewed visa yesterday and had then taken a flight to Kilimanjaro, but it arrived too late for him to travel to Karatu, thus requiring him to overnight in the KIA Lodge. “KIA” is the name for Kilimanjaro International Airport and the lodge is not your ordinary plain vanilla airport hotel. The KIA Lodge has wonderful room and a very nice outdoor lounge where you can always find groups of climbers who had just conquered Mt. Kilimanjaro and were now waiting for their long flights home the following day to whichever continent they had originated from.

Dr. Anne and Cat evaluating a patient

Knowing that we had clinic starting today at 8:30 AM, I had asked Prosper to have Akash picked up early from the KIA Lodge (6 AM) so that he could make it in time to see the pediatric cases that we had told to come back after he had returned from Dar. Today, we also had a number of patients (probably around 12) who had been brought to see us from near Tarangire National Park and this included a number of children, many of who had epilepsy. The morning began as expected and we had no word from Akash or where he might possibly be. It was not until near noon that Akash finally appeared, several hours later than expected. When I asked him where he had been, he simply explained to me that he was late because breakfast wasn’t served until 6:30 at the Lodge and he hadn’t wanted to miss it. Needless to say, I was a bit bent out of shape over the issue and had even considered causing him bodily harm, but then quickly realized that he was still our only pediatric neurologist and whatever pleasure I would have gotten from doing so would have paled in comparison to not having his around to see the pediatric patients. In the end, Akash quickly got to work seeing the children and all was forgotten once we had finished our day of patients.

Leeyan and Denise working together

We again had our educational lecture on Thursday morning which was given by Dr. Kerry once again as she and Dr. Sean would be departing this weekend and we would have other chances to lecture. This time she covered how to deal with traumatic head injuries focusing primarily on conditions such as subdural hematomas and how to manage them. She included several case presentations as examples which is something that we’ve always tried to do here as it is more often a very effective way to relay information that will be retained.

Working together on a patient

In addition to our regular patients who were coming to see us today (i.e. those from the Karatu region or follow up patients who we had called to come in), we were expecting a Maasai group from near the Tarangire park gate who were coming. They had been expected yesterday, but the van bringing them apparently had broken down delaying their arrival by one day. We have been seeing patients from this area now for several years and they are brought by a Maasai elder who we have just referred to as their “chief,” though he is really more their leader or elder. He has always brought patients in to see us with real neurological issues, such as seizures or migraine, rather then patients with joint pain or muscle aches and this was always very much appreciated as those are the patients who we are most interested in seeing here.

Denise and Dr. Leeyan evaluating a patient

It was last September, when I was here on my own working with Revo and Abdulhamid as my “residents,” that the two Down Syndrome boys, Tajiri and Amani, were first brought in to see us and I had spoken to Kitashu about trying to figure out a way to send them to vocational school so they might be able to contribute to their own support going forward. Kitashu did most of the leg work and we were able to find a suitable training center in Usa River that the two boys visited with their “chief” and Kitashu  and determined how much it would cost for the several years of vocational training for the two of them. Through the generosity of those who responded to my GoFundMe page, https://gofund.me/9d3e6a7b, I was able to raise enough money to send the two boys for several years and have hoped that I might be able to continue assisting other such neurologically impaired patients with their vocational rehab in the future.

Leeyan and Denise with a patient and mother

Last March, we were able to visit the two boys and their families in their village after a game drive in Tarangire. Their “chief” met us outside the park gate on his motorcycle, which was quite a sight to see as he is probably 6’ 3” tall , quite broad shouldered and dressed in shukas with his knife and Maasai club that are carried by all grown male Maasai, and we followed him on tiny trails between homes until we arrived at his home. There, both of the boys met us with their parents and despite the language barrier, exchanged pleasantries as well as a few gifts they had for me. Both boys came today as they were home on school break and I was able to review the “report cards” from school which were all good news as both of the boys were doing quite well in their vocational training. It is so unfortunate here for any children with disabilities as there really are no similar programs to what we have at home with things such as IEP (independent educational plan) or a 504 plan, both of which enable children with disabilities to receive appropriate accommodations that even the playing field for those children without disabilities. As I care for many patients with Down syndrome, or trisomy-21, at home, I am quite familiar with what is typically provided for them such as being able to remain in school until they are 21-years-old rather than just when they finish 12th grade. At least for Tajiri and Amani, we’ve figured out a way to enable each of them to contribute to their own future by learning a trade.

One of our younger patients

In addition to coming to see us today, it also enabled Kitashu to take both of the boys down to the “Double D,” or government dispensary in town so that they both could receive the Johnson and Johnson vaccine, which was now a requirement for them to return to the vocational rehab center. As I may have mentioned previously, Tanzania finally requested vaccine for the country and received one million doses, for a country of sixty-million, last month. Though nearly all of FAME’s staff have now been vaccinated as well as many others in the tourism industry, there has been a significant amount of vaccine hesitancy here in Tanzania, similar to what we’ve seen in the US, and all of it misguided. One funny side note to their visit was that after they had gotten their vaccinations and were waiting around for the others from Tarangire to be finished with their appointments, they had gone down to the Lilac Café to wait. The next day, when having a going away breakfast for Sean and Kerry and being handed my bill, there were charges for some sodas and snacks that I hadn’t recalled ordering and wasn’t inclined to pay. Though broken English and Swahili, it eventually dawned on me that it was for the two boys from the day before and I gladly paid it, knowing that they had all the right intentions.

Matilda deciding to bail on Cat

Sean and Kerry would be departing on Saturday, with Kerry leaving early to go to the Serengeti for two nights, so we all decided that it be appropriate for us to go out and enjoy ourselves for the evening. The options for this type of entertainment in Karatu are very limited and, in fact, there is really only one that would meet our needs. The Golden Sparrow is an eating establishment that also has an indoor disco with a DJ attached to it and has been the site of celebrations during past trips to FAME. I will have to admit, though, that the words, “what happens at the Sparrow, stays at the Sparrow,” have been muttered before, though every evening we’ve had here in the past has been quite civil with everyone making to clinic in the morning. The Golden Sparrow is relatively new on the Karatu scene, and is the successor to the club, “Carnivore,” where they served wonderful grilled chicken, chips (French fries) and drinks. Carnivore had dirt floors and plastic tables with a tiny inside bar and dance floor and though it had plenty of character, was nothing like the newer Sparrow that was opened by the same owner.

Denise getting ready for a run with her headlamp

The night was attended by all except for Akash, who was home finishing work on a paper he was submitting, and Emily, who decided to stay at home and keep him company. The rest of us, which included Dr. Anne, Revo, Leeyan, and Kitashu, all enjoyed dancing the night away to loud music, none of which I knew, and being with friends and colleagues who had shared in the work we’re doing here. There is a wonderful connection that occurs no matter one’s background or age or culture, when you’re working for a common goal that is to help those who are in need and to make the world a better place for all. Those who have participated in this type of work in the past will clearly understand, and those who have not should consider doing so when they have the opportunity.

Cat presenting Revo with his very own copy of the Penn Neuro JAR Guide. He was incredibly touched.

Monday, September 13 – A new week at FAME, Akash in Dar, the team hits the market and the ants go marching on…

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Patients waiting in our outdoor clinic

I had failed previously to mention that we were missing one member of team for our Tarangire trip yesterday as Akash traveled to Dar es Salaam for a visit to the US Embassy that was scheduled this morning at 9:15 AM. The reason for this unexpected visit to the coast is that Akash is an Indian citizen currently on a J-1 Exchange Visitor visa for his training at CHOP. With this type of visa, leaving the US means that you must visit a US embassy to have your visa renewed prior to re-entering the States. In normal, non-pandemic, times, this would not be a significant issue and was pretty much standard practice, but given the situation in the world, all of the US Embassies have been working with a reduced work force meaning that merely scheduling an interview was virtually impossible, not only here in Tanzania, but also in India. Originally, Akash had planned to travel home following our work, get his visa renewed and then travel back to Philadelphia. When he went online to schedule the interview in India, it was impossible to do so and became readily apparent that this was going to be a major problem.

Cat and Revo examining a patient with Emily documenting
Cat and Revo examining their patient

Thankfully, I was able to make a few inquiries regarding him getting an interview given the service he was providing to Tanzania by coming here as the only pediatric neurologist in the country and providing care to countless children. Though this did allow him to eventually schedule an interview, it remained touch and go along the way and we weren’t fully comfortable with him traveling until the very last minute as any hang up along the way would have meant that he would not have been able to return to the US after this visit. Trying to figure out how we would pay for the application process when the two methods were either to wire the money (there was no time) or to pay with M-pesa, their telephone payment system which could only be done in-country, was a major obstacle that required me sending money a friend that then paid it for us. That certainly would not have boded well for our program considering CHOP would have been down a senior resident. So, considering that his interview was scheduled first thing Monday morning, that meant that he had to travel to Dar on Sunday afternoon and could not travel with us to Tarangire. In the end, Akash made it to Dar as planned and even though his Airbnb he had rented had power issues causing him to relocate, he was able to make it to the interview, which was successful, and get his visa renewed. Of course, there was still the two day wait for his passport to be returned, meaning he had to remain in Dar until Wednesday, when he could pick up his passport and then fly back to Kilimanjaro and catch a shuttle back to FAME. There were still many moving pieces, but the first major hurdle was now over with and the focus was getting him back here to FAME.

Dr. Anne with the residents
Dr. Anne and Denise taking a history of a patient
Chatting with Dr. Anne

So, our Monday morning, most often the busiest day of the week, began with one less resident and the only one who couldn’t be replaced. Not having a dedicated pediatric neurologist with us is a major limitation as probably 1/3 of the patients we see here are children and their neurological assessments are often very difficult. Not only do we have lots of childhood epilepsy and cerebral palsy, but also developmental issues and muscular dystrophies. Even though I’ve taken care of children my entire career, I do not feel comfortable evaluating the youngest of children when one has to consider all of the genetic and metabolic disorders that can occur. I was probably the most relieved of all that he had completed and passed his interview, otherwise I would not have had his input on the multitude of children that we see here.

Revo, Emily and Phillip evaluating a Maasai patient
Revo, Emily and Phillip evaluating a Maasai patient with his son
Dr. Anne and Denise evaluating a young girl with a static encephalopathy from birth injury

The patients seen today were, I will have to say, all pretty basic as I can’t say that anything really stuck out to me. There did seem to be a large preponderance of musculoskeletal patients today, meaning those with back or neck pain, joint or muscle pain. These are really not neurologic problems, something the residents hear me say time and again in the clinic at home. The fact that pain is mediated by nerves does not make pain a neurologic condition. A ruptured appendix, a very painful condition, is not a neurologic problem just because it is manifested by pain. Regardless, since we’re here and these patients need to be seen by someone, we tend to be a bit more relaxed about our triage, unless, of course, we become overwhelmed and need to be more selective so we can get through the day. In addition to the MSK (musculoskeletal) pain we saw, most often treated with ibuprofen and exercise or physical therapy, there were the normal smattering of neuropathy and epilepsy patients, some who had seen us before and many who had not.

A patient who presented with seizures and concern for COVID getting CT scans of the brain and chest
Dr. Anne and Denise waiting on the CT scan
Onaely (CT tech) preforming a scan on the patient with seizures.

The day ended at a fairly decent time, though, allowing everyone, including Dr. Kerry, to head downtown in the company of Dr. Anne, to purchase some groceries (really Konyagi, the local spirit here) and cloth so everyone could have clothes made by Teddy, the tailor who we’ve worked with for several years now and who does an absolutely amazing job of creating just about anything you can show her a picture of or draw for her. The fabrics here are out of this world beautiful and very fairly priced so that between the fabric and Teddy’s cost to make a skirt, dress or shirt, each piece probably comes in at only $10 to $15. There are absolutely no large stores here in Karatu and all shopping is done in small little shopfronts or kiosks depending on what you are looking for.

Shopping for fabrics
A street in Karatu

There used to be a huge, poorly constructed vegetable market where you could find anything grown here, but with the dirt floors and leaky roof, it was always a muddy mess. You’d walk through the market, constantly hopping between the large puddles of mud that always dominated the aisles, hoping not to slip or fall along the way, while managing to find just the right vegetable or fruit you were looking. They have been building a new vegetable market over the last year that is now finally open and much less challenging to navigate with an intact roof and gravel on the ground. Though I will absolutely miss the incredible character of the old market that had provided many an amazing photo, I will certainly not miss the muddy shoes or the poorly selected vegetables or that occurred as a result of the horrible lighting of the place. Progress is not always a photographers friend.

The new vegetable market
The old vegetable market
Vendors outside of the vegetable market

I drove the entire group, less Sean, down to the market area and dropped them all off with the instruction to Anne to make sure they arrived home safely and each in one piece. I sat at home working as the sun slowly set and it quickly became pitch black outside. Though I still wasn’t worried in the least as I knew they’d eventually show up, I was getting pretty hungry and was therefore quite pleased to finally hear everyone outside. They had all taken a couple of bijajis home from town along with all their prizes and importantly including the Konyagi so we could enjoy some cocktails with dinner. We found that it mixed quite well with tonic water, mango juice and a lime. We all migrated over to the veranda at Joyce’s house to meet with Sean and Kerry for dinner as they are staying in one of the other volunteer houses and Joyce’s veranda is the best place for dinner given the seating. It is under a pitched roof that works well so the bats flying through in search of the insects attracted by our lights are high enough over our heads so as not to be too intimidating. When we built the Raynes House with its small veranda, I promised Joyce that we would always gather on her veranda for dinner and I was keeping true to my work even though she’s back in the States at the moment.

Sunset in Karatu
A street in Karatu at sunset

Meanwhile, I have to mention the incredible ant migration that has been going on just outside the gate to the volunteer housing that we walk past every day on our way to clinic. This truly represents a migration that far exceeds by number the Great Migration of the wildebeest that involves millions, but given their tiny size, go unnoticed. But not by us. We have watched their diurnal progress, coming out at night and still being present in the morning while completely vanishing during the daytime other than the faint trail they leave in the grass. On the third or fourth day, they began to form archways or tunnels made up of the perfectly still bodies of both the workers and the soldiers. There are worker ants going in both directions, or coming and going, while the soldier ants continuously guard their procession that is presumably serving some ultimate purpose, though it’s not so readily apparent to us at the moment. Regardless, it seems like it must be some monumental task given the sheer numbers that are involved and remains very impressive just the same. It is equally enthralling to me as a Nat Geo, Discovery or Animal Planet special and is occurring in our own back yard.

The Great Ant Migration
A tunnel of ants
Close-up of the ant migration

And finally, as if to add insult to injury, Akash checked in with us from Dar just to let us know how he was doing. After his first experience with the Airbnb and a second experience with an equally dumpy place, he elected to move to a hotel just north of the city that also happened to be on the beach. He sent us photos of the beach and, even though we were all still sad that he had to travel to Dar for his visa on his own, we did feel just a bit less sorry for him, and perhaps a little jealous, after seeing his photos. He would have to remain there for two days waiting for the return of his passport, but it now seemed to be that much more tolerable.

A view from Akash’s hotel. So sad, but someone had to do it.
A view from Akash’s hotel

Thursday, September 9 – Our first day of neuro clinic….

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Having arrived the evening before and fully moved into the Raynes House, everyone settled into life here. The Raynes House was built several years ago, through the generosity of Stephen and Lisbeth Raynes, as the fourth and final volunteer house on FAME’s campus and a home for the Penn Neurology team during our time at FAME. The house would be used by other volunteers at times that we’re not here, but will always be reserved by us during the months of March and September, as well as other months that Penn faculty and residents may come. The house is incredibly comfortable with four bedrooms (three double and one single, the latter for me), each with its own bathroom. We have a large living area centrally and a kitchen with the best view in the world looking out over the coffee fields to the west to watch the wonderful sunsets here. We have a small veranda in front of the kitchen windows with a beautiful garden courtesy of Annie Birch, a long time ex-pat resident here and jack of all trades. I have three hammocks set up across the front of the house for that occasional day we get back to the house early to enjoy the evenings. As I mentioned before, life is good.

The first day of school – Emily, Denise, Phillip, Cat, and Akash (left to right)
An ant colony on the move

Our daily schedule here is clinic from 8:30 AM through 4:30 PM with tea time at around 10:30 AM (a British colonial holdover) and lunch usually around 1:30 PM. Lunch is made by the kitchen for all the workers at FAME who eat together, though now it is outside during the pandemic where it used to be inside the small cantina at picnic tables. We have rice and beans complimented by mchicha (a spinach like vegetable) on every day but Tuesday, when we have ugali and meat plus mchicha, and on Thursday, rice pilau with beef (most everyone’s favorite, though I am partial to the rice and beans). Lunch is served seven days a week for anyone on campus. The kitchen prepares dinner for us on Monday through Friday, serving it in hot pot containers, one for each of us. The dinners are basic, though adequate, and after a long day at the clinic, we’re usually so tired that the dinners more than suffice. There are lots of vegetables, prepared in every way imaginable, with a smattering of beef or chicken complimented by occasional chapati. We are on our for breakfast, but are supplied all the basic groceries such as cereal, eggs, bread, veggies and fruit. Trust me, we are never wanting for something to eat here, that is for certain.

Akash and Cat evaluating a child
A good view of our outdoor clinic
Revo and Emily

For our first dinner here, they had unfortunately shorted us on dinner, which was not a major problem as it included meat sauce and Akash is a strict vegetarian. Sean and Kerry came to the rescue, though, as they had been here for a few days and had some salad fixings that worked just fine for Akash. We all sat out on the next door veranda (Joyce’s house) which is much larger than ours and in between our house and the one Sean and Kerry are staying in. Thankfully, they also had some beer and wine to bring which made dinner that much more enjoyable.

Morning lecture on chronic subdural hematomas and burr holes
Dr. Sean demonstrating on wood

Perhaps it would helpful for me to introduce the cast of characters for this trip as that might be helpful for those of you who are not family members or unfamiliar with the group. The neuro team consists of three adult neurology residents – Cat (Catherine here as the nickname Cat is not well understood), who will be going into epilepsy; Emily, who will also be going into epilepsy; and Denise, who will be pursuing training as a neurohospitalist. Our pediatric neurology resident is Akash, who will certainly discover how indispensable he is, though we would never tell him that 😉. Phillip is our medical student, whose role it is to keep our database of patients current and, when he’s not doing that, work with us in clinic to observe as he’s not allowed to officially offer any treatment or touch a patient, a common rule for medical students going to foreign countries and imposed mostly by the home institution, in this case Penn, rather than the host country.

Dr. Ken and Dr. Sean

Sean (Dr. Sean Grady) and Kerry (Dr. Kerry Vaughan) represent an entirely new effort here at FAME and that is neurosurgery. Not to bring highly technical procedures to FAME, but rather to train the surgeons here how to do a rather simple, lifesaving procedure to treat a very commonly seen problem here in East Africa and other parts of Africa. Traumatic head injuries are significantly more common here in Africa (and all low to middle income countries) and often result in bleeding outside of the brain called a subdural hematoma, or, less commonly, an epidural hematoma. Having a CT scan available here at FAME, we’re easily able to identify when these events occur, but we have no mechanism to treat them effectively other than giving some medicine to reduce intracranial pressure and shipping them off to Arusha for a burr hole or craniotomy to remove the blood and relieve the pressure. The problem is that time is of the essence, as one can certainly imagine, and very often the patient may suffer significant injury or death prior to or en route to Arusha, where there is a single neurosurgeon.

Kerry preparing the femur

Sean has accomplished similar efforts in the past during his time in Seattle, Washington, where he trained general surgeons in lower Alaska how to do these procedures successfully so that these patients could be treated on site rather than having to be shipping down to Seattle with many of them suffering complications along the way. Kerry, who is actually a pediatric neurosurgeon and just about to start a new job after her fellowship training, trained at Penn under Sean and has done extensive global health work in many locations, including nearby Uganda. We are so excited to have them here with us and this will be a huge new step for FAME, equipping them to deal with these neurosurgical emergencies in the appropriate time to save lives. They will be here for two weeks and, though it would be an excellent opportunity if one of these patients presented during our time here, it is not entirely necessary as they will prepare the surgeons and the operating rooms either way.

Gabriel saving a femur’s life

Sean and Kerry had arranged to give the educational lecture today which would be an introduction to the hand drills that were brought here to use for this procedure. Not having a ready, or willing, volunteer to undergo a burr hole (essentially the same as trephination that was practiced by many cultures in both prehistoric and ancient historic times), they had arranged for Dr. Ken to boil down a few cow femurs to remove all the soft tissue and these would serve as surrogate skulls to provide the feel of drilling through the two layers of the skull – the harder outer and inner tables and the softer cancellous bone center. After some introductory slides for orientation, the practical exercises began and our two neurosurgeons instructing the FAME doctors on the fine points of using a hand drill, or brace, to bore a hole through the two layers and note the feel of the drill bit as it was about to perforate each of the harder layers, the outer leading to the cancellous center, and the inner leading to the cranial vault with the brain and the fluid collection that was the target.

Gabriel working with the drill

After the educational exercises, we had a brief morning report to go over the inpatients and any new patients that might need our expertise, as well as the maternity patients. There was also one patient in the COVID isolation ward that was being taken care of. Once finished with morning report, the first piece of business for us to take care of would be for everyone to be instructed on the reasonable new EMR used at FAME. This is a rather bare bones system designed to primarily capture the necessary data on patients, as well as to track medications and payments. In addition to orienting everyone on the EMR, they were oriented on the work flow of the clinic and introduced to our translators. Revocatus, or Revo, who has worked with us on multiple occasions previously, is a medical intern at Kilimanjaro Christian Medical Center and is a superstar. He is a fantastic clinician who has learned a tremendous amount about neurology working with us. He has reinforced the power of our program in regard to training those frontline clinicians who will go on to care for their patients now armed with a full complement of the knowledge necessary to provide basic neurologic care where there was little before. Dr. Anne would, of course, be working with us again as she has for the last eight or so years. She is FAME’s neurology provider in our absence and has done a remarkable job of this over the years. She works with us for the entire month each time that we’re here. Dr. Leeyan, who is Maasai and a relative of Kitashu’s, is new to our clinic and working at FAME for the first time. We will give him time to get up to speed and make sure everyone is comfortable as working as a translator is not always the easiest job.

Dr. Sean instructing Dr. Ivan

By the time we were finished with orientation for everyone, it was already tea time, and this is not something that is taken lightly here. The wonderful African tea, or tea masala, is served as well as coffee and bread. I’ve never totally understood the tradition of eating slices of white bread with margarine, but it seems to be well accepted by everyone here with employees walking from the cantina holding several slices in their hands. In a continent where caloric intake is poor at best, I guess it’s certainly a means of improving that issue, even if it isn’t terribly appetizing to me.

Dr. Sean working one of the FAME doctors

Our clinic began at around 11:00 AM when everyone was finished with their tea since, as I’ve mentioned before, this is not something that we would ever interfere with here. The patients who came today were mostly return patients who had been called by Kitashu or Angel, our clinic coordinators, to come see us for their follow up visits. There were a number of well controlled epilepsy patients on medications that were working well and merely needed to be renewed or a few may have needed lab work to make sure they were having no issues on their medications. There were also a few consults for us. One was a patient with a long history of quadriparesis from what sounded like Pott’s disease (Tb of the spine), though the history was a bit inconsistent and would require a bit more interrogation to make sure we had an accurate story. The other was an unfortunate baby who had a very problematic birth with likely HIE or hypoxic ischemic encephalopathy and then began promptly having seizures. Akash went to evaluate the child who was now very sleepy and on phenobarbital which was very likely contributing to the sedation and they hadn’t seized in some time. We elected to hold the phenobarbital and observe the child to get a better exam on them as far as a prognosis.

Our patient with carpopedal spasm

Just before we were finished for the day, Dr. Anne and Cat ran to the ER to see a very interesting patient for a neurology consult. It was a 28-year-old gentleman who had no past medical history and had been driving their family member to the hospital when he developed a bizarre posturing of his hands and feet that looked dystonic in nature. They brought him to FAME fairly quickly where he continued to have the same posturing that indeed appeared to be a dystonic posturing of the hands with flexion and abduction of the fingers and, to a lesser degree, the feet. He was given some diazepam with eventual resolution of the abnormal posturing. When Cat and Dr. Anne got there, he was back to totally normal with a totally normal examination. Thankfully, they had taken a video of the patient when he had first arrived and they brought this back to show me. The patient was clearly hyperventilating and I took one look at the video and was pretty certain what the diagnosis was. The patient was having carpopedal spasm in the setting of a panic attack! What a great case for the residents.

Meow and Charlie

We gathered for dinner once again on Joyce’s veranda and enjoyed a meal of curried vegetables and chapati. Matilda was once again pestering everyone in constant search of some morsel of food despite the fact that she is fed daily by housekeeping. The sky was quite clear tonight and Akash took some amazing photos of the stars. I was working late only to realize that I had an important Zoom conference scheduled from 11 PM to 12 AM that I had forgotten about. It was with the Center for Global Health at Penn meeting with the director and assistant director as well as others at Penn who are currently doing work in Tanzania. It was great to be on the call considering I was the only one actually in Tanzania at the time, but it was also very late and we had clinic the following morning. Thankfully, we didn’t have a 7:30 AM educational meeting so that I could at least get a few minutes more of sleep.

The heavens above (photo courtesy of Akash)

Wednesday, September 8 – The team arrives to Kilimanjaro

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Having finally made my way to Tanzania and recovered from my jetlag and two sleepless flights, it was now time for me to drive to the Kilimanjaro International Airport to pick up my team of four residents and one medical student who were arriving this morning on the same flight I had taken days before. I had been in touch with them back home to alert them all to the frustrating issue with the COVID test needing to be done within 72 hours of arrival and the timing of getting it tested. It proved to be an issue for one of them, necessitating having a rapid PCR done at the airport for a rather princely sum, though it was all taken in stride and just another reminder of how the pandemic has affected our lives. Thankfully, the five of them were all able to travel on the same flights, making it far easier for me having to make only a single trip to the airport and having a vehicle large enough for all of them and their luggage was equally important.

Success. Everyone made it as did their luggage

I got there shortly after their arrival, but still managed having to wait well over an hour given the many hoops that are now necessary for entry into the country with the pandemic. After leaving the plane, you must first check in to receive your COVID rapid antigen test (which cost only a very reasonable $10) that surely seems superfluous given the requirement for a PCR within 72 hours of arrival and not departure. After that, you must then go through immigration with your online visa paperwork so your passport can be stamped. Once you’re through immigration, then you get your bags, or not, as has happened to us a number of times over the years. Once you have your bags, it is then through customs which requires your bags to go through X-ray to make sure that you’re not bringing in any items that you should have been charged a customs tax for. This is typically a crucial point for me as I am often shuttling supplies for FAME, though the residents were only bringing their own gear which would be permitted without questioning or any further discussion.

Tetris

The entire group finally emerged from the arrivals hall which is always a hectic scene of almost exclusively safari drivers waiting to pick up their clients, either holding signs with their names high aloft above their heads or against their chest if they’ve been lucky enough to secure one of the front spots and readily visible to exiting passengers. It’s always fun to watch as they exit looking for their names, something I recall quite vividly from my very first visit here in 2009. Meeting your guide and loading your bags into your Land Cruiser or Land Rover is the very first experience you have before heading off into the bush and experiencing this amazing continent and it is a very formative moment.

Cat (upper) and Emily (lower) finding something to do at the Doha airport

After their 24+ hours of flights, they all appeared to have weathered the travel well and were excited to get on the road, though not until I got a picture of the group, their first of many that I would get over the next month. We were soon on our way to Leonard and Pendo’s for a short visit and breakfast, something that has become a tradition for our visits here. They have always been insistent on providing a meal or accommodations for the residents on their arrival as their way of giving something back for the work we’re doing. I have tried time and time again to reimburse them for their troubles and they have refused me every time, simply insisting that they were just doing their part and would think of doing nothing less. That’s the way it is here as the Tanzanians so appreciate the fact that you traveled such a distance to help them because it’s something that you want to do, not something that you have to do. Little do they know, though I’ve told them time and again before, but what we get out of the experience far exceeds anything that we’re providing and is something that gives us some meaning to our lives. That is what it’s all about and why we continue to return year after year.

Breakfast was a wonderful spread of small roasted potatoes, chicken sausage, small pancakes, pineapple, watermelon, fresh watermelon juice and Pendo’s amazing African tea or chai masala, which is a wonderful cacophony of spices including cardamom, ginger, and everything nice. I have attempted this tea at home, but have never been able to perfect it and always dream of my return just for the tea (as well as most everything else I eat here). My Land Rover, named Turtle, had needed a few last minute services performed and so Leonard had taken it, but it was much needed downtime at the house with several of the residents closing their eyes on the couch prior to our departure.

Cat above and Emily below. Not sure whose hand that is 😉

We were finally all packed and had Turtle back from the shop, ready to say our goodbyes to everyone and finally make our way to FAME. With the new bypass, we were thankfully able to avoid driving through Arusha, which was once a sleepy, sprawling town with only one stoplight that has now become a massive tangle of traffic from the moment the sun rises and is worth avoiding at all costs. A quick trip to town during any of the daylight hours is no longer a possibility. The bypass, on the other hand, is not really heavily used and, as a result, we were able to scoot out of town and be on our way heading west in no time. As I’ve mentioned many times, the drive from Arusha to Karatu takes one from the green slopes of Mt. Meru through more arid lands that are occupied primarily by the Maasai and their many boma, eventually arriving to the Great Rift Valley and Lake Manyara. Here is the village of Mto wa Mbu, or Mosquito River, that sits at the entrance to Lake Manyara National Park, the site in the 1930s of Ernest Hemmingway’s hunting trip for rhinos that unfortunately no longer exist from over hunting. From here, we wind up the escarpment of the rift valley that ascends over 2000 feet to the Ngorongoro Highlands, famous for its coffee plantations and the many luxury lodges for those safari goers so inclined.

Matilda, our volunteer house cat, who makes Cat and Emily quite happy. Me, not as much as she constantly meows. Or is that Emily? (photo courtesy of Akash)

Each time I travel here, I am reminded of just how truly lucky I am to have found this place. Even during the current dry season, traveling out of the valley and up onto the escarpment with its vibrant and lush vegetation makes one realize just diverse the ecology is here. As we reach the highest point of our drive, at Rhotia, its valley below of fertile fields stretch before us and high on the opposite side sits our destination, Karatutown, where FAME has existed since 2008 and I have been coming since 2009.

Karatu is frontier town, the final stop on the tarmac, or paved road, before the gate to the Ngorongoro Conservation Area, the Crater, and the Serengeti. If one is planning to get to the Serengeti, you must travel through Karatu unless, of course, you’ve chosen to fly between location, which, in my mind, defeats the entire purpose on traveling to this amazing country. At one point, there had been plans to build a paved highway across the entire Serengeti to allow trucking to make the journey more easily at the expense of the wildlife there including the potential disruption of the wildebeest and their great migration. Thankfully, environmentalists rose to the occasion and blocked the continuation of the project which fizzled out without much fanfare.

I’m sure that traveling up the FAME road must have been incredibly exciting for the neuro team and they were probably also wondering what to expect at the end of this incredibly bumpy and dusty road. FAME is about three kilometers out of town and up a few hills, but you reach it, you know that you are home and have arrived. It is a place of great goodness and the nearby coffee plantation by the name of Shangri-La seems to say it all. The smiling faces and shouts of “Karibu” from all who see us driving through the gate and up to the administration building are all that it takes to wipe away any stress or troubles that you’ve brought with you to this wonderful place. We met up with Prosper, our volunteer coordinator, who gave the team their tour of FAME, then headed off to the Raynes House, our home for the next month. If the expression “Life is Good” ever had a more appropriate place to use, I can’t think of it.

Friday, March 12 – Day 2 of Neurology Clinic…

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March is the wet season here in East Africa, meaning everything is very green and the weather can be iffy at times. It has been nothing but bright sunshine, though, since our arrival several days ago and we’re hoping that this trend will continue. When it does begin to rain, it can be very treacherous getting around on the roads whether you are driving or walking due to the extreme muddiness and slipperiness. Early on, while driving to one of our mobile clinics, the Land Rover that I was driving managed to slide off the heavily crowned and muddy road into a drainage ditch, leaving us completely stranded for the better part of the afternoon and required that we be pulled to safety by one of FAME’s Land Rovers that had been unable to get very close to us for fear of their becoming stuck as well. Each wheel had to be individually jacked up, dug out and backfilled with stones and debris before moving on to the next and, finally, when the vehicle was raised up, it was jerked and pulled free. We finally made it back onto the road, but then there was the problem of not slipping off again and, much to my chagrin, no one else there was capable of driving a stick as for the first time in my life I would have been more than happy to have handed over the driving duties to someone else.

It has been absolutely gorgeous for us so far with total sunshine, not a cloud in the sky and incredibly comfortable temperatures hovering around 80° F during the daytime. The nights have been equally comfortable, though it would be nice if it cooled off just a bit more for sleeping. We’re almost exactly a mile high here at FAME while atop the crater rim, it reaches over 8000 feet and can become quite cold at night, but mostly in our summer months of July and August.

Normally, our daily routine here is a bit different as we would typically all be attending morning report at 8:00 am, but with the pandemic and social distancing, it has been decided that the smallest number necessary would be present for the meeting. The conference room used to be packed with doctors, nurses, and volunteers, all sitting around the perimeter of the room and at the large conference table in the middle, but now the attendance is appropriately sparse for everyone’s protection. What was an incredible daily meeting to discuss inpatients and interesting out patients here at FAME, is now a very abbreviated and sparse session that is more to pass on information to the oncoming coverage team. Over the last year, there have been essentially no volunteers, other than me, that have come to FAME due to the travel restrictions caused by the pandemic. Teaching sessions, often run by whichever volunteers happen to be here at the time, have also been put on hold to limit the number of people present at all gatherings, though a number of us have continued to make these available from the States using Zoom.

Ultimately, the mission of FAME is to create a completely self-sufficient hospital and health center that will be run by all Tanzanians and require no outside support other than financial. Another of those silver linings of the pandemic is that FAME has successfully proven their mission as there has been essentially no outside clinical support from volunteers over the last year and, despite this, FAME has not only weathered the COVID storm successfully, but it has also served in a leadership role for other government health centers and hospitals in the Karatu district. Amidst the turmoil and stress of the pandemic that has changed our lives forever, there have been many triumphs, even here in rural Tanzania.

Without morning report, we don’t have to be at clinic until 8:30 am which is a welcome half an hour in the morning to finish breakfast or to exercise (residents only 😉). Usually, neurology has been a completely separate clinic space where patients check in and vitals are taken, but with the new screening process for COVID symptoms, all patients are seen first for screening and vitals in the same area and are then directed to where we are seeing patients in our open air clinic. The pace we’ll maintain at clinic for the month will be dramatically slower than our normal mob scene that we encounter every day during our normal clinics. We most commonly hand out numbers to patients and those over our quota will be seen the following day first, but it is typically impossible for us to see all of the patients that show up each day. By the end of the clinic, we are typically caught up and have been able to see everyone.

Part of the Neuro Team ready for work – (from left to right) Dr. Anne, Jess Fan, Revo, Alex and Jess Saunders

As expected, there were several patients waiting to be seen by us on our arrival this morning and even though the numbers were small, they remained steady throughout the day. Most were follow-up patients who had been called by Kitashu or Angel the night before to come to clinic for visits, though several were new patients who had either heard that we were here or had been referred to us by the other clinicians at FAME. As we have found in the patient data that we’ve kept over the last years, it is our epilepsy patients who have had the greatest likelihood of returning to clinic for follow up visits which is most likely based on the impact we’ve had on their health and quality of life. Many of the patients who we see here have never been evaluated or treated for their epilepsy and the impact of having their epilepsy controlled for the first time is truly life changing in so many ways.

Having finished our clinic at a respectable time, it was home to the Raynes House and a quiet evening enjoying some gin and tonics and eventually dinner. Darkness falls quickly after sunset and given the incredibly low amount of light pollution, the stars come out quite early for some serious star gazing and an incredible milky way that looks like a wide, twinkling, diamond-studded belt stretched completely across the sky. The constellations and planets are all easily visible to the naked eye while slow moving satellites intermittently show themselves as they progress on their appointed trajectories and shooting stars appear randomly throughout the night. We’re south of the equator so we are seeing all of the southern constellations, though I must admit that I’ve never been much of an astronomer beyond the big dipper and the North Star. I remember fondly each of the nights on our original safari back in 2009 when we overlapped with another group at the camps who had one of those fancy star spotting scopes that would identify each star and constellation and being totally enthralled with the technology. Now, with a simple app on my iPhone, it’s easy to identify each and every celestial body in the night sky and given the incredible weather we’ve had, the nights have been clear and inviting.

Tomorrow, we have a half-day of work as it is one of two of the resident’s “wellness” afternoons for the month. Though I’ve argued that the entire month is made up of wellness days, I’ve been asked to include these as part of the resident’s work schedule. We also have plans for dinner at Gibb’s Farm tomorrow night which has become a tradition for each group coming to FAME.

Thursday, March 11 – FAME Neurology clinic is open for business….

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To say that it had been an interesting journey for me to get here would be a bit of an understatement, though we were all finally here in Karatu and together, ready for another month of neurology clinic. Due to the uncertainties of the pandemic, we had made the decision not to fully announce our clinic to the district, but would rather see return patients who needed to be seen for their continuity of care or new patients who were being referred by other clinicians at FAME and had been seen in the recent months. In addition, we would not be traveling to the villages where we normally hold our mobile clinics, again because of pandemic concerns and not knowing fully what the situation would be at all of the locations. That part would be unfortunate, as the mobile clinics have become a significant part of our program here, not only for the communities that we serve, but also for the residents as it enables them to see more of the culture here as we are usually visiting rather remote areas that have fewer and fewer resources. For this trip, though, we will be restricting our clinics to FAME proper save for two days at Rift Valley Children’s Village (more on that later).

The vast majority of patients we see in the Karatu district, as well as those from surrounding districts, are members of two tribes, the Maasai and the Iraqw. These are not the largest tribes, that honor is held by the Sukuma tribe of Northwestern Tanzania on Lake Victoria, but they are both very prominent in Northcentral Tanzania. The famed Maasai also live throughout Kenya and this region of East Africa is often referred to as Maasai-land given the colorful heritage of these pastoral people, well-known for their large herds of cattle, goats and sheep. As I have mentioned before, they mostly live in small enclaves, or bomas, that consist of a number of small mud and dung, thatched huts, each built by one of the number of wives of the husband/father who lives there. Children remain in the boma until they are old enough to be married and move on, sons or brothers often building a boma nearby. In addition to each of the wives huts, the boma is often enclosed by a short loose shrubbery fence along with another small corral inside for their cattle. Younger animals will often be housed in the huts along with the children of each wife. Each hut has a small cooking fire inside and separate elevated beds for children and adults to sleep.

The Iraqw on the other hand, are very organized agriculturalists and have been for many years. They also keep cattle and farm animals necessary for their existence, though this has been a point of contention with the Maasai for many years as it has often by said that cattle are God’s gift to the Maasai, or at least that is how they have felt. The Maasai and Iraqw have been at odds for many years leading to many small conflicts, typically over ownership of cattle, and it was not until 1986 that a treaty was finally signed between the two tribes to preserve the peace. The Iraqw have many small villages and farming regions in the district of Karatu and through the Great Rift Valley. The villages that we have visited in the Mbulumbulu region to hold our clinics are all in the heavily Iraqw-populated regions and are typically the most common patient that we see there. Our clinics in the Mang’ola region on the shores of Lake Eyasi is also almost exclusively Iraqw. Unfortunately, these clinics will not be occurring this trip and it is sad to think of the patients who we see there going without our care for any period of time as I have also visited them for the last ten years. The pandemic has created unforeseen issues that will affect the health of this community in unanticipated ways.

We knew, though, that our clinic was going to be far smaller than it has been in recent years when we have seen 300-400 patients on each trip, many coming from distant regions of Northern Tanzania through our announcements and word of mouth. We would only be seeing those patients we contact for follow up visits or those who may have heard that we’re here. As in September and October, when I was here alone, FAME has taken steps to lessen the concerns of COVID similar to what we have done in States. Everyone wears masks on campus and anyone coming to be seen is screened prior to entering the clinical areas. Hand washing stations have been set up at every possible location and antiseptic lotion is on every table in every room. Our cantina, typically bustling and bursting at the seams during chai time and lunchtime, has now been emptied out of its picnic tables to promote social distancing and everyone is eating outside under the trees. I’ll have to say, though, that it has been incredibly pleasant given the wonderful weather we’ve been having here.

Having arrived rather late last evening, there was no time for Phoebe, FAME’s volunteer coordinator, to have given her usual tour of the campus with any light, so we had planned to do it in the morning instead. We decided to delay the start of clinic until later that morning and, since everyone here goes for chai midmorning, Phoebe took everyone around to familiarize them with the campus here which has grown quite large over the last years. While everyone else was on tour, chose to circulate to a number of offices to get things in place for our clinic. Space for our clinic has always been an issue and, now with the pandemic issue, it was even more of an issue as Ward 2, that had served us well over the last two visits, had subsequently been dedicated for use as a COVID-19 isolation ward and was no longer available to us. The good news, though, is that Kitashu, our amazing outreach coordinator, and others had worked to set up a more than adequate space for us to use that was actually outdoors on the backside of the outpatient clinic. They had hospital beds, room dividers, desks, chairs and computers set up for us that gave us more room than we’ve ever had before and, best of all, it was outside and covered, with loads of fresh air and cool breezes.

Despite the fact that there were far fewer patients than normal today, mostly due to the fact that we were running rather incognito given the lack of announcements, we did have the opportunity to evaluate a truly unusual patient that had not been previously diagnosed. Though I have always seen children throughout my career, those who know me are quite aware of the fact that I draw the line on the numerous metabolic disorders that affect children as I much prefer to treat problems such as epilepsy, headache and Tourette syndrome. Jess S. had just finished seeing a child with epilepsy I believe when I spotted a young boy sitting out in the waiting area that I knew she would be excited to see as he clearly had one of those genetic disorders that I have chosen not to focus on in my practice.

Our young boy with scaphocephaly

He was six years old with reportedly normal cognitive development, though this was not entirely clear. He had a very large head that was greatest in the AP dimension (front to back) and which we often refer to as scaphocephalic. His facial features were extremely coarse and he had significant frontal bossing, or a very wide and tall frontal bone. He was of very short stature and on further review, he had a very large ventral abdominal hernia that was, in fact, the largest Jess had ever seen. His parents also reported that he had a nasal polyp, which, upon further inspection, was definitely present. There was little question in our minds that he had one of the disorders seen in children that are often referred to as the genetic storage disorders of which there are many and they are usually diagnosed with genetic testing that would certainly not be available to us here in Tanzania. Not certain of exactly how we should proceed and given the fact that the boy lived in Karatu, we decided to email Dan Licht at CHOP and would then bring them back for testing once we had a definite plan moving forward. He will most likely return next week once we’re able to organize the visit to ensure that everything will be available on the day that he is here.

It was slow first day, of course, which was much appreciated as I think we were all still a bit jet lagged from the long travels and even more so for Margo and I, who had spent two extra days sitting on egg shells in Chicago, not knowing for sure whether we were going to be able to meet up with the residents or now. Despite this, we had all made it here in one piece and with all of our luggage which is not always the case. With the change in equipment to the smaller plane in Doha, I was definitely worried that they would have just decided to send our bags with the next flight, but thankfully that had not occurred. Settled comfortably in the Raynes House, I was home again and looking forward to the coming month, even with the fewer patients and slower clinics. We would see whatever patients come and continue our training of the staff at FAME. One other silver lining is that with the current somewhat slower pace at FAME, we would be given two doctors to work with, Dr. Anne and Dr. Adam, while Revo, who has worked with me over the last two years and is now an intern in Moshi, would also be joining us. This would mean that the residents would have lots of opportunities to teach, and learn, and there was no question that their experience would be great. Satisfied with the day, we took the short walk home after clinic and readied ourselves for a relaxing evening.

Tuesday, March 9, and Wednesday, March 10 – Finally on our way to Kilimanjaro….

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After having spent two full days at O’Hare Airport and, with all of the stress concerning whether we were actually ever going to be able to fly or not, we were on our way to Doha to connect up with the residents for our final flight to Kilimanjaro. Our initial thirteen hour flight seemed to go much quicker than we both had thought it would be, but perhaps that had more to do with the circumstances than the actual time that transpired. We actually bumped into the residents after our arrival, something that would never have happened during normal times given the size and congestion that is typically seen there. At least we were now all in one place and it was merely the matter of one more flight until we reached our final destination, though for Margo and me, it was a two day delay in our plans that had included a visit to a local lodge near Arusha National Park and two days of relaxation. We’d have to find another opportunity to get away so as not to lose the money we had, but we had time to figure that one out.

The delay in Chicago had also now meant that I’d be spending my 65th birthday for the most part in the air which, even though I do not normally make a big deal out of the day, often not even making others aware, was certainly not what we had intended when making our plans for the two days at the lodge. Thankfully, I have access to the business class lounge in Doha given the amount that I fly on Qatar Airways, and that evening before I next flight, we enjoyed a wonderful meal of the freshest sushi, a huge buffet, and a dessert bar, from which I chose a lemon merengue tart that turned out to be scrumptious and just what the doctor had ordered though by the end, I was quite full. The lounge also offered showers for both of us and comfortable chairs for us to relax in during the nearly eight hour layover we had there.

We met up with the residents again at the gate (they had been in another club that Alex had access to with his Amex card so I didn’t leave them out in the cold entirely) and discovered at boarding that they had switched to a smaller aircraft given the limited number of passengers that were traveling. This meant that all of our seats had been changed, though at this point, that was of little concern as we were all exhausted, and particularly Margo and me, and just getting to Tanzania was the primary objective. The flight was actually busier than I had thought it would be, but regardless of that, we all still had decent seating and, after landing in Dar es Salaam for those passengers that were disembarking there, the plane was virtually empty with almost no passengers left on board. We arrived to Kilimanjaro International Airport (or KIA) in the morning and smoothly moved through immigration as we had all purchased our visas online in advance of our travel and, despite the lack of an empty full visa page in my passport, we promptly moved through to find our baggage, all of which had arrived safely, not always a normal occurrence when flying this route and especially considering the change in aircraft that occurred.

Now that six of us had all arrived together with all of our luggage, it would likely be an exercise in frustration to fit everyone into a single vehicle, even considering the size of Turtle, so Leonard had also arranged for a second vehicle to transport us all to Arusha, where we would regroup and relax for a few hours prior to departing for FAME. Pendo had also wanted to prepare a nice meal for us and spent the better part of the morning and afternoon cooking in the kitchen to present us with a meal fit for royalty and was very much appreciated given the amount of time we had all been traveling. We finally departed for FAME at 4pm with plans to arrive around sunset anticipating an uneventful journey that I have taken dozens and dozens of times now over the last ten years plus that I have been coming here.

I’ve described this drive through the Rift Valley so many times, but I can never imagine it getting old, especially to someone like me who is an armchair physical anthropologist. Arusha is the largest city in Northern Tanzania and has been growing rapidly even since my first coming here in 2009. It is a huge sprawling city of numerous neighborhoods and a central part of the city where there are now numerous multi-story buildings where previously there had been few. There is always traffic despite the fact that the vast majority of people here do not own vehicles and walk or take the dala dala (their local transports that are little minivans with 20 seats in them) everywhere. Following the Rwandan genocide of 1993, the United Nations had a huge presence in Arusha as part of the International Criminal Tribunal for Rwanda that provided many jobs beginning in 1994 and all were western wages. This facility closed in 2015 and, along with it, those jobs went away, many of which had been held for nearly two decades by residents who had now depended on that income. The city has continued to grow and now one can avoid the traffic with a western-style bypass that takes one around through the less congested outskirts, though at a very slow 50 kph (32 mph) pace rather than the 65+ mph we’re used to in the States.

So, we traveled the bypass from Leonard and Pendo’s to meet up with the main highway heading west towards Karatu and, eventually, the Serengeti, before it reaches the modern city of Mwanza, on the shores of Lake Victoria hundreds of kilometers in the distance. Through the many towns in the Maasai region where their bomas abound and large herds of livestock are seen at close intervals from the road, typically being shepherded by the youngest of children who do much of the work. It is wet season here meaning that everything is the most pleasant green and lush as opposed to the brown and dusty landscape of the dry season. We finally reach the little village of Makuyuni that signals our turn off the highway and is the first fuel station we have seen since leaving the environs of Arusha. Continuing straight and we would reach Tarangire National Park, home of the elephants in Tanzania, a wonderful park centered around the Tarangire River. It is important to remember, though, that animals here roam the country at will and the parks were created where the animals are most dense for reasons of water and food. The herds can move from park to park during the seasons and the in the Serengeti, the great migration is a year-long event where the wildebeest move in a large circle from Kenya to the Southern Serengeti and then back again in their search for the grasses that sustain them. Calving occurs in Kenya during our winter months and then they move to the south.

Our turn at Makuyuni allows us to continue west in the direct of Lake Manyara, the famed location of Hemingway’s The Green Hills of Africa chronically his visit there in the 1930s hunting rhino with his wife. Unfortunately, the rhino of Manyara have long ago disappeared from overhunting and are now found only in Ngorongoro Crater and the Serengeti. These are the rare black rhino as opposed to the larger and far more numerous Southern white rhino that inhabit the more southern countries of Africa. The Northern white rhino is now essentially extinct as they are represented by only two females living under protection in Kenya with no hope for survival of the subspecies due to overhunting for many years. Their story is a tragic one, but the black rhinos of Tanzania have made a wonderful comeback after years of protection here by the government.

Making our way towards the town of Mto wa Mbu (mosquito river), we descend slightly into the Great Rift Valley where Lake Manyara sits and is a huge expanse of water now protected as a national park. It has a wonderful array of wildlife though is one of the smaller of the northern safari circuit parks. Only thirty minutes from Karatu, though, it is one of my favorite parks to visit and drive as it is virtually impossible to get lost or disoriented with the lake on one side and the steep cliffs of the rift on the other. Mto wa Mbu is a true frontier town that sits in the Rift Valley and is the intersection of several cultures. Heading north from here and you will take one of the most amazing drives towards Lake Natron and the district of Loliondo that lays close to the Kenya border. But we continue to travel west and begin to climb the massive escarpment leading out of the valley in the direction of Karatu, our final destination on this leg of our journey.

Up and up we climb to the village of Manyara that lays intermediate on a plateau atop the escarpment and before we make the final push up to the village of Rhotia. There are several high end lodges and camps that sit along this amazing geologic feature, a two-thousand foot cliff that overlooks the entire Rift Valley in this region, far north towards Ol’Doinyo Lengai, or Mountain of God, that is sacred to the Maasai, and far south to the far end of Lake Manyara. It is a remarkable view that never fails to amaze me no matter how many times I’ve seen it. The hills are incredibly green as we approach Rhotia and the Rhotia Valley with its lush vegetation and large areas of planted fields where an incredible amount of produce is raised. From Rhotia, it is another steep drop and then a final short rise into Karatu.

The sun is near the horizon and directly in our eyes as I drive though this dusty town once again, my home for two months out of the year for the last eleven years and a place that has welcomed each of my residents for the last seven. It is yet another chapter in our wonderful saga here in Tanzania and at FAME where we have now treated well over three thousand patients and counting and have trained many, many of the doctors and nurses at FAME how to recognize and manage neurologic disease in a region where there are no neurologists. And on our side, we have many, many residents and students who have now had the opportunity to experience the many cultures of Tanzania while practicing medicine in a low resoufdrce setting, but most importantly being exposed to these amazingly resilient people who have welcomed us with open arms and nothing but love and respect. FAME, as well as our neurology project here, has enabled us to greatly improve the general and neurological health of the residents of this district in a sustainable manner that will continue for many years to come, inshallah.

 

Saturday, March 6, through Monday, March 8 – An ill wind blows in the windy city….

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I had made the last trip in the fall on my own as there had been a near complete ban on any University travel save that which was deemed essential. Though I had been allowed to travel, the residents were unfortunately still banned as the pandemic continued to rage throughout our country, and the world, with many more months of a rising death toll before there was finally some hope in sight. Thankfully, with the vaccine becoming available in January to those of us in healthcare, meant that there would be a much greater degree of safety, such that the powers that be were willing to allow my residents to travel given the safety that this amazing breakthrough would provide. Still, given the new strains of the virus turning up throughout the world, the trip wasn’t completely without risk and we would all continue to practice the very same precautions we had at home. A strict ban on medical student travel did remain, though, and we would be once again traveling without them, as we had done for a number of years until more recently a single medical student would travel with us to provide support for our database in addition to having an observational role with the team.

After a number of formalities were completed with various University offices, both at Penn and at CHOP, to ensure our full compliance with their training programs, the time had come for us to depart Philadelphia and make our way to Kilimanjaro International Airport and then to FAME for our spring 2021 neurology clinic. Flights had been purchased, our trip had been registered with Penn which would provide us with full health coverage abroad along with evacuation insurance home should it be needed by any of us, our business visas had been purchased, and, finally, in-country evacuation insurance for each of us should something happen in the bush. Thankfully, this was all old hat for me given the number of times I’ve traveled to FAME, both on my own as well as with a full complement of residents, and most of this was routine for me. I had met with the residents on several occasions to go over things, such as their passports being good for at least six months after our travel and bringing American dollars printed only after 2006, and their fellow residents had also met with them to share information on what to bring with them, something much easier for their colleagues to do than for me.

The time had finally come for us to depart and, as was usually the case, I would be leaving several days in advance of the rest of the team to prepare things for their arrival. Turtle, my trusty stretch safari Land Rover, that has taken us there and back on so many adventures, would certainly need a looking over, though Leonard and Pendo had made certain that whatever needed repair had been taken care of after my last trip. Turtle, as many of you know, has managed to show her age on several occasions, though, in the end, has eventually come through to bring us home, often with the help of a few spare parts or a jump start. I would be leaving on Saturday, March 6, along with my traveling companion, Margo, on our journey via Chicago and then on to Doha, Qatar, and finally, Kilimanjaro. Booking my flight, I had thought long and hard about flying through Chicago in the winter, given its propensity for horrible snow storms and interrupted travel, but the forecast was for unseasonably good weather for the weekend, so I knew that we had little to worry about on that front. Oh yes, I failed to mention that the Delta/KLM flights which we had originally purchased had been abruptly cancelled two weeks prior to our travels necessitating us to purchase the Qatar flights quite late in the game.

It had been smooth sailing checking in at Philadelphia International Airport despite several overweight duffels including my carry-on baggage, so much so that I should have been overly suspicious that there was something lurking that might throw us off course. In Chicago, while traveling between terminals, I received a phone call asking us to go to the Qatar Airways ticket counter to get new boarding passes, which seemed innocent enough, but in the end, it proved to be the unravelling of a perfectly planned trip that would have allowed us a few days to relax at one of the country lodges outside of Arusha prior to the residents arriving. While issuing us our new boarding passes, the Qatar agent carefully looked through my passport and, in a very matter of fact manner, simply announced that I could not fly before moving on to Margo’s passport and then asking her whether she was still planning to travel without me. After several minutes of discussion, during which I was told that my passport did not have a completely blank page remaining on which the word visa was written at the top and that I would have to get a new passport before I could travel, it became readily apparent that this was going to be a problem of rather epic proportions and not one that was going to be easily remedied.

Lesson one in passport etiquette: This is NOT an empty visa page

I spent the next hour pleading with the station manager for Qatar Airways in Chicago, who, in a very polite yet firm manner, proceeded to explain that there was no way that I could travel to Tanzania with my passport as it existed given the current regulations from immigration in Tanzania. The regulation related to the fact that the visas used to be pasted into your passport and took up a full page, but they haven’t done that in a number of years since going to online visa applications, and they are now merely stamped in your passport and are the size of any other passport stamp, no longer requiring the full page. Despite my explaining this interesting piece of history that was clearly not appreciated, it was made clear that I could not board the plane and, in very short order, our duffels were taken off of the plane, stranding us at O’Hare International Airport on a Saturday night in need of a new passport, knowing that no one would be open on Sunday, and that many offices were only partially functional during the pandemic.

Lesson two in passport etiquette: this is a visa page with enough room to place a visa stamp

Exhausted from my hour plus of pleading our case, not to mention the fact that we were both starving having had a slice of pizza each back in Philly before our flight, we made our way to the O’Hare Hilton to look for a room and figure out what the hell we were going to do stranded in Chicago, knowing that the residents would be leaving shortly and very much in need of someone to supervise them. If I were unable to figure something out and in rather short order, it could jeopardize the entire trip. Even before we had left the terminal, I had already begun to make calls to Tanzania to see if we could figure something out, even though it was the middle of the night in East Africa. It became immediately clear to us, though, that nothing of any substance was going to occur that night given the time differences, so we settled into our 10th floor hotel room at O’Hare International and ordered some dinner to our room shortly before they were closing the kitchen for the night. To say that we both had just a bit of concern over the future of our travels as we settled into slumber that night would be putting it mildly and it was readily apparent that we would spending the next day figuring out just how we were going to rectify this seemingly hopeless situation.

And finally, lesson three in passport etiquette: These are NOT visa pages!

To add insult to injury, Qatar Airways was requiring that all travelers have a negative COVID PCR test within 72 hours of starting their travel and, despite the fact that we had taken care of this for our trip in its original configuration, we also realized that regardless of what happened, we would have to get new PCR tests done in time for us to fly even if we could figure out the passport issue. There were now so many moving parts that it became difficult to keep track of just where things stood with any of them, but somehow over that Sunday, we were able to put things in motion that would resolve all of the issues as long as everything fell into place as we had planned. We both got our new COVID tests, that had to be done on an expedited basis due to the incredibly tight timing and, which cost an arm and a leg, had our travel agent rebook all of our remaining flights, which, by the way, included a “no show” charge from the airline even though we had actually showed but were not allowed to fly, and simply waited for the stars to align. Though we had missed our two days of R&R, if we could make the Monday evening flight, two days later than originally planned, we could hook up with the residents in Doha for the final leg of our journey to Kilimanjaro and salvage the trip.

Spending two days at O’Hare had very little in the way of silver linings, but we were introduced to Giordano’s deep dish pizza and chopped salad, which we had delivered to the hotel on Sunday night. If you’ve never tasted these amazing dishes, I would highly recommend them as they were a definite redeeming benefit of an otherwise incredibly stressful two days stranded in Chicago. Monday morning came as we waited for our COVID tests to return, which they eventually did and were negative, and we were finally allowed to board our flight to Doha, looking forward to hopefully somewhat more uneventful travels in the future while promising to do my best to make up for our lost days of relaxation one way or another.