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

Standard

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….

Standard

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….

Standard

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.