Tuesday, March 29 – It’s all about localization…then off to Kambi ya Simba…

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It’s all about localization…

The case of the young girl in the ward yesterday evening had significantly affected each of us given the magnitude of her brain injury and the fact that we would never know exactly what had happened to her. Overnight, we had queried just about everyone we could think of to see if they had any good thoughts as there would still have to be a conversation with her family about the fact that any further care would be futile at this point. In the end, no one had any better guess than we did last night, but the clear consensus was that it was some type of infection that had most likely been what brought her to the hospital in the first place a month ago. Natalie planned to speak with the family as there hadn’t been a chance earlier after the CT scan as they had already left the hospital. This would certainly not be an easy task.

Dr. Anne informing the patients about what types of ailments we treat

This morning was one of the two mornings that we had been asked to give a neurology lecture to the staff and, as last week’s lecture had been given by Peter and Natalie, today it was Alex and Savannah’s turn to enlighten everyone on the wonders of neurology. Their chosen topic was “localization,” which is the art of determining where in the neurologic system a lesion might exist or exactly which part of the nervous system is affected in a specific patient. This is the essence of what we do as neurologists every day and purpose of our lengthy histories and physical examinations. In fact, I will often tell my residents and medical students that if you don’t have a good idea of what is going on after taking your history alone, then there is a good chance that we are going to figure out exactly what is going on. While taking the history, we are formulating what the problem is and designing our examination which is where we test our hypotheses, though sometimes have to redirect.

Natalie and Abdulhamid getting ready for clinic
Two of our exam rooms

Alex and Savannah gave a wonderful lecture that would have made Ray Price, their program director, very proud. This is a subject that isn’t the easiest to grasp unless you’re  incredibly interested, or otherwise a nerd like most of us neurologists. The FAME staff, though, were remarkably attentive and very much engaged with the subject which I was thrilled to see. After they went through the basics, they went over a few of the cases that we had seen at FAME to use as examples of how we think of localization as we’re evaluating our patients.

Alex, Natalie and Abdulhamid
Hear no evil, speak no evil, see no evil

Despite having completed our mobile clinics the week before last with two visits to the Mang’ola region and two to the Rift Valley Children’s Village, Kitashu felt as though it would still be good for us to return to the Mbulumbulu region and spend a day at Kambi ya Simba (“Lion’s Camp”). Kambi ya Simba had actually been the location of my very first neurology mobile clinic back in 2011, when I had been brought here by Paula Gremley and her partner, Amir, two individuals who had been an important part of coordinating FAME’s larger mobile clinics to the Lake Eyasi region in the early days. It was Paula who had suggested creating a smaller neurology mobile clinic and should really be credited with recognizing the need for these visits.

Peter and Anne working together

Mbulumbulu is an absolutely gorgeous region of lush farms that lies in the area between the top of the escarpment having risen from the Rift Valley and high mountain slopes coming down from the Ngorongoro Conservation Area. At the far end of this land, where the mountains meet the escarpment, you can travel no further and will find the village of Losetete. The region forms sort of a long acute triangle with the point being this distant spot where the land ends and the base being formed by the tarmac traveling from Rhotia to the village of Manyara. Kambi ya Simba sits at about the dead center of this triangle and the village of Upper Kitete, where we have previously held our clinics is closer to the point. The land in this region is very hilly and the roads very treacherous during the rainy season. Unfortunately, we would not be traveling as far as Upper Kitete today as this is the location of a wonderful overlook perched thousands of feet above the floor of the Rift Valley with an unobstructed 180° view of the valley below with Lake Manyara to the south and the approach to Lake Natron to the north.

Kitashu, Christopher and Nuruana sitting at our “pharmacy”
Peter and Anne working together

Several years ago, I was contacted by a gentleman who had worked for the Peace Corps in Upper Kitete back in the mid 1960s and had somehow found mention of the village in my blog. He sent me photos that he still had of Upper Kitete when elephant hunting was still a thing and there had been lots of attention to the area from the new government trying to start State operated farms as there had been much interest in by Nyerere in creating many socialist projects, farming one of them. It’s difficult to imagine what this part of the country must have been like in those days as they were in the process of creating a brand new government with more than 120 tribes to navigate, all of whom lived in their own villages and spoke their own languages. Imagine creating an infrastructure trying to build roads, a dependable supply chain and a system of policing. Somehow, though, Julius Nyerere managed to do all this successfully with but a handful of Tanzanian college graduates existing in the country at that time, and continued to lead his country, first as prime minister and then president, for 24 years. He is considered the father of the country and referred to as Babu (grandfather) and also Mwalimu (teacher), for that was his education.

Nuruana registering patients
Anne with one of our special patients

There had been rains in the recent days, though the roads were quite manageable on our way in the morning. Traveling along these rutted dirt roads that are bordered by huge, often luxurious, farms growing colorful crops, it difficult to imagine how this area has been more developed over time as it would have scooped up immediately by real estate investors had anything close to this existed in the US. The land is quite hilly, so we are constantly going up or coming down from the many ridges into the gullies where the streams flow and turn into raging rivers when the rain becomes more intense. As we pulled into the Kambi ya Simba health dispensary, a sprawling group of clinical buildings, wards, maternity rooms and more, it was unclear to most of us just what our work was going to entail here. There were a few patients already present, but not the numbers that had typically seen in the past when there may be crowds of patients lining the buildings waiting to see us on our arrival.

Some very tough critics…

Though there were only a handful of patients that we could see as we pulled up to the buildings, there were plenty more waiting for us in their homes who were soon called, coming to clinic on time. Several years ago, the president of Tanzania had visited Kambi ya Simba, dedicating the health dispensary as a model facility and promising to provide many new services at the facility. We had come to town within days of the celebration and all of the flags and flowers were still present from the original event making us feel incredibly welcome as if it were all for us, though we knew it wasn’t. Kambi ya Simba is one of the largest villages in the Mbulumbulu region making it a natural for this upgraded health dispensary, though it has never been entirely clear to that they have been able to utilize everything that was developed there given the amount of staffing they have been provided. I’m sure it will come in time, but for the moment, and over the last years, they have been very gracious to us for allowing us to come and utilized some of their space to provide the neurology services for the area.

We made due initially with three rooms to work in, though later Natalie decided to see one child outside on the benches as it was getting late for us. As in the recent past, we had Christopher along with us to run our “pharmacy,” dispensing medications that we had written scripts for. There were a number of epilepsy patients as would be expected and a great number of headache patients. Natalie’s final patient, though, was a very young child who had obviously had some type of perinatal injury and had a hemiparesis, but both of his parents, who had accompanied him to the visit, were incredibly attentive to him so that he was in fantastic shape in regard to have absolutely no contractures or significant spasticity. Natalie spent a great deal of time with the parents, as she always does, and when she told them that she was confident their child would be walking soon enough, the mother broke into tears of happiness as she had been told differently in the past by other care givers and to expect the worse. These types of interactions, that instill reasonable hope in parents and family, are very important as otherwise, the child could have been neglected, or worse, abandoned. These parents were so grateful that Natalie had shared this prognosis with them.

Natalie and Nuruana evaluating the young child outside with his parents

During our day at Kambi ya Simba, the skies opened up and there was a truly magnificent downpour that made it difficult to hear things underneath the tin roofed buildings due to the very distinctive sound of the large rain drops striking the metal. Hearing out of only my right ear (due to my episode of labyrinthitis six years ago and loss of hearing in my left ear that has never returned) can be a handicap even in the best of times, but downpours like these can completely incapacitate me. And not only my hearing, but I now also had to worry about the roads driving home that were sure to have become a bit soupy with the onslaught of moisture. Thankfully, though, the rains seemed have abated before it was time for us to leave and, in the end, though soupy they were, there were no close calls on our way to the tarmac.

And thankfully so, for we had been invited to have dinner at the African Galleria once again by Nish Dodhia, who had offered to cover the cost of our drinks for the evening. Given how delicious the food is at the Ol’ Masera restaurant, though, we were all more than willing to go for dinner on our own dime, or should I say Shilling, and opt for the drinks. Their cheese samosas are absolutely to die for and their pumpkin soup has got to be the best I’ve ever tasted. Ke had taken a taxi down from Karatu to meet us for dinner and it was a wonderful time of friendship and dancing in the open restaurant with the wonderfully clear night air of the African sky surrounding all of us. Our remaining days here were getting fewer and fewer and we certainly wanted to make the most of every one of them.

Monday, March 28 – Back to neurology clinic and a welcome break from those terrible tsetses…

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Just how much has FAME grown since 2008?? This is how much…

Though it had been a really wonderful weekend diversion from our normal schedule here at FAME and the lovely relaxation at the pool had been a real treat, it was now time to re-engage with our primary mission here. Having come to Karatu on my own for several years prior to bringing residents, the first in 2013, I had developed so many relationships not only with the staff at FAME, but also with locals and lodges throughout the community. The primary goal of bringing residents here was to have them partner with the clinicians, not only acting as educators, but also as students, for it was clearly a two-way street and what everyone would learn in the process could not have been accomplished had it been otherwise. The true value, though, was not merely in the two-way communication of the medical knowledge that was occurring, but rather, and perhaps more importantly, in the cross-cultural education that everyone was receiving passively. That is something that is not taught or learned, but can only be experienced and, without traveling here in person for the month, would be otherwise impossible to absorb. These relationships that are built will only occur when both parties are in the proper frame of mind and are both equals.

Developing these relationships with the staff at FAME is, of course, quite simple, for everyone is working towards the same goal, but spending time with Tanzanians whose only connection to FAME is that they live in the same city or region, is another matter. In the past, our entire group would spend the night with the Temba family in Arusha, but since the pandemic, the flight schedules have changed such that we now arrive in the morning rather than the afternoon, and are able to make it to FAME on the same day during the daylight hours. Spending that night in Arusha with the family was always something that the residents valued tremendously, and though we’re no longer spending the night, we still have the opportunity to visit and have breakfast with the family. Leonard and Pendo have been invaluable to the development of this program, having helped immensely with all of our logistics here, from housing everyone in the past, to arranging transportation and, perhaps most importantly, maintaining Turtle during my absence.

Dr. Anne and Savannah evaluating a patient
Abdulhamid, Peter and Nuruana evaluating a patient

When the team arrives to FAME and Karatu, there are many members of both communities who are ready and willing to make everyone feel right at home, whether it be for helping with a dinner out at one of the lodges or visiting someone’s home as in the case of Daniel Tewa. Teddy, our ready and waiting seamstress has always made everyone feel right at home, greeting us with a smile and her tray of pipi (candy) that she offers to us as we pull up to her shop in Turtle. She is now in an area of Karatu known as G-Arusha that is on the other side of town, exposing everyone to a new area here. Gibb’s Farm has been a staple from the very beginning of these trips, strongly supporting the volunteers at FAME by offering dinner and lunch at greatly reduced prices as well as the opportunity to spend time at their brand new pool. The attraction, though, isn’t only the food and view, but also its place in the history of this region and all of the employees who I have come to know over the many years. There are those I know only through my visits to Gibb’s and then there are those who have either been our patients or their children have seen us in clinic. Our team is always greeted not as guests, but as family because being a volunteer at FAME, even if only for a month, means that you are now part of this resilient and wonderful community and our goals are the same.

Savannah and Anne evaluating a Maasai woman
Natalie evaluating a young child

At morning report, we learned of a patient who had come in with very significant hyponatremia and was otherwise neurologically intact. Though one might not consider hyponatremia to be a neurologic problem, and you would be correct, it can very quickly become one if the sodium level is corrected too quickly, causing something that used to be called Central Pontine Myelinolysis, and is now referred to Osmotic Demyelination Syndrome as it affects other parts of the brain other than just the pons, a potentially devastating and irreversible process that can be easily avoided with proper monitoring. Not wishing this to occur and wanting to be diligent, I spoke up to inquire as to the patient’s location in the ward and making it known that we would simply look in on the patient to assist in their care.

Eliza and Alex evaluating a young school student
Peter looking a bit suspicious while Abdulhamid questions a young school student

There was also another patient that had come in over the weekend who had been involved in a boda boda (motorcycle) accident and had suffered a severe facial fracture with involvement of the maxillary region and orbit on the right side. Not being an expert whatsoever in the treatment of facial fractures, I listened intently in the discussion of which La Fort fracture this represented as there is a grading scale depending on how much of the midface is involved and, essentially, how significantly the midface is separated from the rest of the skull. Ke had already taken a look at the CT scan and was far more qualified to be discussing this than any of us were, but there had also been a finding of a small subarachnoid hemorrhage noted in the right basal cistern around the brainstem. Now this was just a bit closer to our neck of the woods and, so, there was another consult now for us to see in the ward and our Monday morning clinic had not yet even begun.

Anne and Savannah evaluating another of the school children

I had also failed to mention that we were now down one of team members, for poor Savannah, after surviving the weekend like a real champ, was now completely reeling from her battle with the tsetse flies, having been unable to sleep last night due the multiple bites she had suffered on her ankles and the amount of edema and inflammation that was causing. She was pretty incapacitated by the pain and it was clear that coming to morning report and clinic with the rest of us was not in the cards for her today. I suggested a good bolt of steroids for her inflammation and pain as I had them with me in my bedroom cabinet, never traveling anywhere without them as they are not only good for anything that ails you (I am only half facetiously saying that), but for anything inflammatory, they are what’s indicated, whether it be something like Savannah’s bites, a prolonged migraine, or any host of acute inflammatory musculoskeletal injuries. And, as you’ve seen in some of our neurology cases, they do wonders for brain vasogenic brain edema with tumors or infections.

Natalie and Nuruana evaluating a patient

Savannah must have been really hurting for she did not put up a fight when instructed to stay home and take care of herself for the morning and to take as much time as she needed until her feet felt better. In the end, she showed up at the clinic earlier than I had anticipated, but knowing her, it was probably later than she had wanted to be there. Alex was off seeing the patient with the facial fractures and small subarachnoid hemorrhage and Peter was dealing with the hyponatremic patient, so it fell on Natalie to begin clinic that morning with everyone else having been occupied. Thankfully, it was not quite as busy as some other Monday mornings had been so far this trip, but there were definitely patients slowly showing up to be seen and it wasn’t long before we had a steady stream of patient arriving for hour services. And it also wasn’t very long before Natalie began getting her baby consults in the maternity ward with the first one being a twofer, requiring her to see both mother and baby, and I being thankful that she’s equally comfortable with adults and children given her plans to most likely do an adult stroke fellowship it the future.

In between patients

We had finished with clinic relatively early for a Monday, but received a late consult from the ward for a child that had brought into the ward by their family and concerns that the child was having continuous seizures. What we found instead was a story that was completely tragic and gut wrenching as the child, who was a 15-month-old little girl, was not having seizures, but was rather having continuous posturing of her extremities, a sign of extremely severe cortical dysfunction and something that is referred to as “decerebrate posturing,” meaning that the cerebrum, the part of the brain excluding the brainstem, is not functioning for one reason or another, and it is most often due to a devastating and quite likely irreversible process.

Working on documentation

The story had been that her Maasai family had taken her a month ago to a hospital in Arusha due to fever and seizures, and that she had been admitted to the hospital where she remained an inpatient until the family finally took her out of the facility after a month as they were concerned she wasn’t getting better. They then took her to another hospital briefly as an outpatient, finally making their way to FAME. I don’t recall whether they knew that we were here or not, I don’t recall, but as soon as she arrived, she was admitted to the ward and we were called. There was some mention that a CT scan had been suggested sometime over the last month, but it had never taken place either due to cost or some other reason. Regardless, her family was now intently aware of the grave circumstances and wanted our opinion.

Subarachnoid blood in our trauma patient

On examination, the child looked horrible – she was not awake and had constant decerebrate posturing of her extremities that did not represent seizures. She was breathing on her own and did seem to have some bulbar responses, but really had nothing else. And, to add to the situation, she had very marked hydrocephalus with all of her cranial sutures separated and splayed wide. It was immediately clear to us that there was nothing we had to offer this child in regard to helping her get better, but we were still at a loss as to what had happened to her and given that, it would be very difficult for us to have a meaningful conversation with her family not being able to give them this information. At home, we would never have been in this position for a multitude of reasons, the first of which would be that we would already have had tremendously more information as she would have been scanned a gazillion times so we would not be sitting here without information for the family other than her clinical picture.

We sat and wrestled with the decision as to whether or not to get a CT scan on the child. It would absolutely not change her outcome, which we knew was dismal, and the only thing that it would help would be to give us information that we could convey to the family and, hopefully, some insight into what had happened to cause this. We would have to make it clear to them that getting the CT scan would only help us answer questions for them. Even with the small chance that this was merely hydrocephalus, the likelihood of there being any intervention after a full month in the hospital was essentially nil. Thankfully, the family agreed to obtaining the CT scan, knowing full well that it was not going to save their little girl, but would at least give them some answers that they had been searching for over the last month.

Near complete loss of the cerebral hemispheres and hydrocephalus in a 15-month old

The images were frankly shocking to all of us as they demonstrated the near complete destruction of both of her cerebral hemispheres with the additional features of what appeared to be trapped ventricles, while there was some preservation of the cerebellum and the brainstem. What could have caused this degree of devastation while not having proved fatal was something that was mere speculation to all of us and even those back home who we shared the images with in an attempt to gain further clarity. I equated it to trying to explain all the events of a high speed traffic accident by piecing together information from the skid marks and mangled cars. In the end, it was felt to have most likely been due to an infection that had caused the massive damage and had never been treated. Herpes simplex and tuberculosis were two leading contenders, though there were other possibilities as well. Regardless, it would matter little to her family one way or the other as they were losing their child and no treatment existed anywhere in the world to save her now.

Sunday, March 27 – No, not the tsetses again!…and striking out on cats another day…

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Our second night in the Simba Lodge had been as nice as the first though there had been some soft rains through the night as the ground was still wet in the morning. Savannah hadn’t been feeling well the day before with the long game drive and it was unclear what our plans were going to be for the day. We decided to meet for breakfast a bit later than our previous days 6:00 am sharp and it remained a game time decision as it took a fair bit of time for her to show up in the dining tent. Though we hadn’t planned to leave the park at the end of the day by way of the lodge, we could certainly have changed those plans to accommodate whatever she wished to do. We had also told the Tarangire Maasai chief that we were going to stop by her place on our way out, though he lived close to the main entrance and not the eastern one where the lodge sat. But, like the champion she is, or perhaps it was the FOMO, Savannah made her way to the breakfast table and elected to depart with the team on schedule. Having left her behind for the day would have been difficult, not logistically, but more emotionally.

Hanging on for dear life

So, with our crew complete, our baggage packed, and our lunchboxes stowed, we bid farewell to the Simba Lodge and began our long trek back to the river area, passing by  the smuggler’s tree on our way and, once again battling the tsetse flies that were a touch less dense today mostly because of the rains overnight. The interior of Turtle was now smelling a bit like a Tiger Balm factory after Alex’s claims of it being something like a force field against these nasty predators and she was so convincing that she even had me applying the stuff to my socks. Whether it worked or not on the tsetse flies, it sure had us all smelling pretty good.

Keeping a look-out – White-backed vultures at Tarangire
What pretty eyelashes

Instead of driving straight to the river, though, Vitalis had decided to take a few side roads in search of other game, one of which lead by an unoccupied camp and was also another way to cross the river, though in seasons where the river was not so full. Driving in front of the camp, we immediately noticed a group of vultures who were devouring something on the ground that they were quite pleased with as they barely budge with us driving probably three meters from them. It was hard to make out what it was, but there was also a largo troop of baboons nearby on the ground and in the trees above with neither members of the quite divergent species being disturbed by the others. Although baboons will certainly eat meat, you will not see them going after carrion and never when there are vultures snacking on the remains of something. We drove on to an overlook and the road down to the river, but turned around since it would not us anywhere and, on our return, right were the baboons and vultures were, was an impala carcass up in the tree.

A very young baby and its mom

It was impaled on the branches as a leopard will always do when it drags its prey into the tree to protect it from hyenas and lions, who will typically never climb into a tree to steal prey, but do sleep in the trees to get out of the heat. The abdomen had been opened first and it is very likely that the vultures had been eating some of the abdominal contents that had fallen and were then dragged away for them to picnic. The large baboon troop had chased the leopard away as a leopard would never wish to tangle with a large group of male baboons, whose canines can inflict devastating wounds. There is clearly a hierarchy for everything here in the bush and, though the big cats are clearly at the very top of the food chain, there is a time and place to stand your ground and suffering a disabling wound to defend your prey isn’t something that is conducive to a long and healthy life in Tanzania. Numbers often matter more here than might.

An itch on his leg
Happiness is a muddy elephant

Unfortunately, the baboon troop appeared to have absolutely no intention of moving anytime soon and as there was no way the leopard, most likely hiding in a tree somewhere nearby, was ever going to come back to its prey until they were gone. We backtracked the way we had come in and then made our way slowly down to the river. Descending towards the water, we had spotted a very large family of elephants in the water who appeared to by making their way up towards one of the “river circuits,” small loops of trail off of the main road that bring you quite close to the river, or will sometimes even cross it. Taking the river circuit, we drove until we knew we had a good vantage point that would serve us well as the family came up over the riverbank. Being incredibly patient will most often pay off and, sure enough, the family eventually came out of the river basin and marched directly towards us without a care in the world for they were quite dominant in numbers and everything they needed was right here in front of them.

A Nile monitor

They had the tiniest of babies with them, which was perhaps only a week or two old and though most often the mother will completely shield this young of a calf from us by keeping it on her other side, this was not the case and we were treated to a wonderful display as this huge family clearly took its time walking past us with a worry. There were several other babies and lots of adolescents with the group and they were all just magnificent. As I said before, the thought of taking aim and killing one of these animals for the mere sake of glory is something I cannot simply not understand and never will. They are our equals in regard to intelligence and sensitivity in the same fashion as the great apes, whales, and dolphins and it is not at all unreasonable to appropriately anthropomorphize them.

Female impala

There were still no cats to be seen in the park, nor had anyone reported any sightings on the radio. This is a park where, though leopards may be very scarce, I have never come and not seen at least a half dozen lions and a cheetah or two. I’ve seen a number of kills here in the past and have even seen the incredibly elusive African Hunting Dog here for first and only time in Tanzania when one year, a family had decided to take up residence along the river – they had a large den and there were pups in addition to the adults that could be easily seen with your binoculars. Though we had had our fair share of elephants this weekend, there was some disappointment in the lack of other wildlife and especially the cats. We drove out into the Small Serengeti for a good distance, an expanse of flat land and some rolling hills that obviously reminded the locals of the Serengeti and, hence, its name.

With his buddies in the background

The Small Serengeti was the site of a near disaster for me back in 2015 when, on our way to Arusha, we decided to take one last game drive despite the fact that we were leaving the following day. It was the wet season and I drove into the Small Serengeti taking the same roads I had always done, but with the wet ground, the grass kept getting higher and higher with the road narrower and narrower and, rather than turning back, I forged ahead. I was driving a Land Cruiser at the time and had the residents spotting ahead for me from pop top, when, quite suddenly and without any warning, our vehicle suddenly sank. We were in the middle of a park that normally has many lions as opposed to our current trip, completely stuck in the mud with no hope of digging ourselves out, our cell signal was very weak and it was beginning to rain. Walking was not an option and staying in our vehicle overnight with the hope that they realized we hadn’t exited the park and send a search party for us, would ensure that we’d all miss our flights the following day. Leave it say that miracles do happen as I got a single call outs to Leonard, who by divine intervention, just happened to be entering the park at that very moment with a group of clients and, with my description to take the Small Serengeti road a few kilometers, then turn left at the large herd of cape buffalo and drive another kilometer or so, then look for our vehicle out in the middle of the tall grass. He found us and we were able to pull the Land Cruiser out of the mud and be on our way back to Arusha with darkness setting in.

Nursery school for ostriches – there are two adult daycare workers, second from left and far right
Weaver nests in a tree

Not to worry those of you who are unfamiliar with the logistics of driving in these types of condition, or to give you the idea that these things happen commonly, but a year ago, we were in a similar pickle having come to Tarangire for only the day. We had suffered a flat before lunch which, with the help of Alex Gill, we were able to change, no small feat with a vehicle the size and weight of Turtle. After changing the tire, we had gone to lunch, and while driving along what is normally a main road, but in the pandemic reduced tourism had become a bit overgrown, the front tire wheel that we had changed suddenly fell completely off the vehicle with a sudden drop of one corner of the front end and the disc rotor digging a nice grove in the thankfully dirt road. Watching the wheel and tire continue rolling ahead as we stopped was rather comically, but then again not. Because if was worried about Turtle falling off the hijack, we had let the car down before completely tightening the lug nuts, allowing them to loosen and drop off one by one over the several kilometers that it had taken that to happen. Retrieving the wheel was the easy part and thankfully the undercarriage of Turtle was undamaged, but there was no way we could simply walk back on the road to find the lug nuts given we had seen lions along the way, so we cannibalized a lug nut from each of the other wheels and, along with the two from the spare tire, we were able to get the wheel back on and drive away, a bit shaken but unscathed.

Red and yellow barbets feasting on a termite mound
Waterbuck in the river

We had no such incidents this visit and, after searching high and low for a cat of any kind, we made our way to the gate to have lunch at a small coffee stand where there were tables and umbrellas. We still had a bit of time to explore after lunch (which by the way was probably eaten around 2:30pm, so we decided to explore a few more areas where we spotted some more elephants, birds and a group of waterbuck standing in the river. We had plans to visit the Tarangire chief’s home around 4pm so that we could check on the patient from last week with the finger infection, which was thankfully doing very well, and then were on our way home back to FAME. We had requested a bunch of cooked white rice on Friday as we were planning to make fried rice for dinner and Ke was dying to watch the Formula 1 race with me. The fried rice, cooked by Natalie and Peter turned out great, the race was a bit of a flop due to a number of logistical issues with the internet that seemed to block every plan we came up with. ESPN would let us stream to the TV, Comcast would let me stream the race as I was recording it at home, and, ultimately, the bandwidth was just not satisfactory to support the continuous feed. We watched, but the broadcast would freeze every several minutes and we missed late race events that determined the top scoring positions. Oh well, thankfully the rice was delicious.

Children at the Chief’s home
Happiness is a warm puppy
After the storm has passed

Saturday, March 26 – Battling the tsetse flies, elephants, elephants and more elephants…

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This morning was both rather special and sad for me as the weekend here brought memories of my prior trips to the Simba Lodge, one of them with Kelley and Laura, and the fact that I was missing Kelley’s wedding in Puerto Rico today. Both of them were close personal friends both prior to accompanying me here, but even more so in the later years of their residencies and fellowships with Laura having moved to the Bay Area and Kelley having returned to Penn after a short stint at NYU. We were all in the Napa Valley this last August for Laura’s wedding and when Kelley told me that she was scheduling her wedding at the end of March, I tried to think of anything I could do to make it, but, in the end, it was really the issue that there was no one else who could lead this program and it would not have been fair to the residents who had been scheduled on this trip. I know that Kelley understood completely, as did her now husband, Paul, but just the same it was a huge loss to have not been there in person not to mention having missed all the wonderful dancing with my wonderful friends. There was some solace in the fact that both Kelley and Paul were able to accompany us on the last trip in September and I was able to give them a memorable balloon ride in the Serengeti as part of my wedding present.

Smugler’s notch tree

Laura and Kelley’s visit to the Simba Lodge had not been the only memorable visit lest I not mention the visit there with Susanna, Susan, Mindy and Johannes back in the spring of 2018, when we had once again discovered the amazingly refreshing pool with its nearby bar, but also later in the weekend had encountered two male lions only to discover that we also had a flat tire and were in no shape to move until it was fixed. The lions were some yards away and there was another vehicle next to us, mostly shielding Yusef, or driver, as he worked on the tire, until one of the males decided that he would come investigate. Johannes was videoing the whole thing, but all I remember was Mindy, not so calmly shouting, “Yusef, get back in the vehicle.” Needless to say, it is extremely unlikely that the lion had anything in his mind other than finding his next shady spot, but the appearance of the whole thing was certainly up for some debate as to whether there was ever any danger, yet it makes for a wonderful story.

A motley crew – Peter, Alex, Savannah, Ke, Natalie and Vitalis

So, Tarangire National Park is known as the elephant paradise in Tanzania and for good reason as it is the home to countless families of elephants, some incredibly large, that can be spotted for many miles along the river pretty much year round. The other thing that Tarangire has become known for, though, is its tsetse fly population. This is not such a nice thing to be known for as these little beasts, which are incredibly vicious and will track you down like a miniature heat-seeking missile and pack a nasty two phase bite that can leave very nasty welts on their unsuspecting victims. In the worst of cases, they can carry trypanosomiasis, or sleeping sickness, which is caused by a small parasitic protozoan, but is thankfully quite rare in Tanzania with only 10 or so cases a year seen here. The disease, when presenting with neurologic complications is essentially 100% fatal, though there is a medication that can be used to treat it with the only downside that the treatment itself has a 10% fatality rate. I would imagine that you can gather from all this that it’s not good to contract sleeping sickness here and, though that is such an unlikely occurrence here, the issue of the bites still exists.

The nasty culprit following a meal with distended abdomen

The tsetse fly is most populous in densely wooded areas near water such as exists in many areas of Tarangire and it is impossible to avoid them as you have to pass through these areas on your way to the river. As we entered the park, we were very soon encountering them and they were following along at the same speed as our vehicle which is an amazing knack they have. When you bat one out, it just keeps flying at the same speed and lands on some other location. Don’t forget that we are traveling in a vehicle whose top is completely open so it’s not very difficult to begin to accumulate these insects in the vehicle and particularly in the rear of the vehicle. They also have a very dense exoskeleton, making them very hard to kill by simply smashing unless you make sure to crush them after swatting them. Simply giving them a firm whack with your hand will not do them in and it is amazing how often they will fly away uninjured after having just smacked them against the seat or the window with your hand. You can almost hear their little laugh as they fly away undeterred and are immediately ready for another attack. The best thing to use for this purpose is one of the two small wildlife guide books that I bring along and you have to do this again a firm surface like the window or a piece of bodywork. Striking them against a seat or a person with the book does nothing to their wicked little bodies.

An early morning family of elephants
Coming to check us out

If you’re really interested in the mechanics of a tsetse fly bite, there is a video online that I will not include here so as to spare those of you who do not wish to have nightmares of these beasts, but leave it to say that the tsetse has a very firm proboscis that is immediately inserted through your skin, as well as any piece of clothing such as socks, pants or shirts, nearly instantaneously upon landing. This is their test probe, and though it is painful and will leave a smaller welt, it is nothing like the discomfort that occurs when they remain attached and begin drilling for blood, which is their ultimate goal. Why anyone would ever do this is beyond me, but the video I mentioned above is of a volunteer allowing a tsetse to land on their arm and then, undisturbed, proceed to engorge itself with the volunteers blood taking several minutes to do so. The last point I’ll make about these insects is that they laugh at normal insect repellants. I think they eat DEET for breakfast. Alex, though, did bring Tiger Balm with her and based on our non-randomized, non-controlled, and simply unscientific study that was conducted, it does seem like she suffered far fewer, or perhaps, no bites during the weekend after completely slathering herself with it. Further studies will need to be conducted in the future.

So, despite the tsetse fly attacks, we continued on intrepidly towards the Tarangire River looking for game as most of the wildlife in the park focuses either on the river here or on the Selela Swamp, an immense body of grass and marsh that alternates between a shallow lake and a swamp throughout the year depending on the rains. Along the way, the Poacher’s Tree greeted us as it always has when nearing the river. The story goes that poachers used to hide their ivory here some years ago before the anti-poaching forces began to protect all the animals in the park. Ivory, of course, has been outlawed now for many years due to the decimation of the African elephant that reached its height during the early years of the 20th century when millions and millions were killed purely for their ivory. The population of African elephants in 1800 have been estimated at 40 million, while the current number is now less than half a million. Though the trade of ivory was fully banned in 1990, there has been a constant demand for this precious commodity that has been fueled mostly by the far east. And it also became very complicated as there were a number of countries who were exempted from the ban for assorted reasons, none of which made a lot of sense or had any legitimacy.

Just saying “hi”

Today, elephants continue to be poached at numbers of twenty to thirty-thousand per year and though there has been a slight decline in numbers in the recent years, researchers believe this has not declined in regions other than East Africa, where strong anti-poaching efforts have given the appearance of the overall decline in other regions of Africa. For those of you who have not read King Leopold’s Ghost, it is truly a must for it tells the story of King Leopold of Belgium who, under the guise of bettering the population of the Congo, instead perpetrated perhaps the greatest genocide in modern history while also first raping the country of its elephants and ivory, and then its natural rubber, all the while making millions upon millions of dollars in the process. This atrocity occurred in the late 1800s and into the early part of the twentieth century until it finally came to light what his intentions had been along. This dark secret continues to haunt the Belgium people, knowing that the vast majority of their public memorials honoring the Royal Family had been funded by a reign of death and mutilation masterminded by their King.

A male waterbuck

If one were to spend only a short period of time with these marvelous creatures in their natural habitat, it would be entirely impossible to think anything less of them than our equals in so many ways. The families we encountered were all incredibly healthy, with lots of adolescents and very small babies, some only weeks old, sticking very close to their mother’s sides, nursing at times, playing at others, and trying to imitate their older siblings. Families are dominated by a lead matriarch, whose children, sisters, nieces and nephews make up the rest of the group. Adult males do not travel with the families, but either roam on their own or in groups, usually made up of related males. Occasionally, I have encounter bull male elephants on their own and they have usually been in a bad mood when I have. They are not to tangle with and you are usually best to let them have their way as they will typically become bored and move on with not harm. Those encounters have most often occurred her in Tarangire.

A martial eagle
A juvenile martial eagle

For all the game we saw this day, there were no wildebeest or zebra herds that we ran across as it turned out that they were all out of the park on the Manyara Ranch, an area of open grazing land that sits between Tarangire and Lake Manyara, with some of the herds having been visible to us as we were driving to the lodge yesterday. There were some fairly large herds of cape buffalo that we saw, any many, many groups of impala with their large harems with a single male and their bachelor herds of males who have yet to be successful challenging a male for his harem. And then there were the Olive Baboons, whose large troops were very diverse as far as aging is concerned. There were ostriches and giraffe, waterbuck, and many of the tiny dik dik, who mate for life and can always be seen in pairs with their significant other. Crossing the bridge at the far end of the park on way to the lunch spot, we spotted two large Nile monitors, one warming themselves on the rocks and the other swimming along with the current. These large green, yellow and black lizards feed on fish, small mammals and birds, and, of course, carrion. There are no Nile crocodiles in Tarangire.

A long-crested eagle
Leopard tortoise

The lunch area that we always stop at overlooks the Selela Swamp at the far end of the park. I have seen hundreds of elephants in the water here before, but there were none today for there was enough water in the river so that the elephants didn’t have to travel this far. Thankfully, there were far fewer tsetse flies here than in some of the other parts of the park as is much less wooded on the slopes overlooking the swamp, and we were able to eat our lunch with some degree of relaxation from the constant swatting of those incredibly pesky bugs. Since we were returning to the lodge in the evening, we were supplied with a wonderful picnic lunch rather than the typical lunch boxes that you receive when leaving camp for good. After enjoying our lunch, we made our way along the swamp heading over the hill in the direction of the balloon camp and the Sopa Lodge, meeting the river on the opposite side from what we had taken in the morning.

Vervet monkey guarding his post
White-bellied Go-away-bird (thanks to Dan Licht for the ID)

We were obviously looking for any of the big cats throughout the day, whether they be lions, cheetahs or even leopards in the trees by the swamp, but we had seen none and suspected that they had likely followed the herds out of the park. None of the guides we had met along the way had seen anything for the entire day and Vitalis had also been on the shortwave radio listening for any sightings of which there had been none. Heading back in the direction of our lodge, we stopped by the overlook lunch spot for a bathroom break and some great views in both directions of the river. One of the last times I was here at Tarangire, the river had been so full that the main river crossing was impossible and you had to drive all the way to the far side of the park towards the swamp to cross at the bridge. The main road that crosses does so on cement slabs that are only several feet about the normal level of the river requiring only a moderate downpour to make the crossing impossible. Though the Land Rovers are specifically designed for water crossings that can completely submerge the engine thanks to its snorkel, it is the current that is the problem, and taking chances when unnecessary will only leave one very disappointed and in need of a rescue. I will mention that Turtle is equipped with an electric winch on the front, though I typically tell people that’s mainly for rescuing Land Cruisers that get stuck and need our help. I guess that’s really a joke best told in Africa.

A pair of Bare-faced Go-away-birds

A family of elephants by the river

Having mostly survived the day amongst the tsetse flies, for Savannah ended up having her ankles severely bitten as we would learn later, we made our way back by the smuggler’s tree and home to the lodge where a dip in the pool sounded like the most amazing thing ever given the heat and the bug bites. As we arrived to the gate of park to head to the lodge, we ran into the very first zebra we had seen all day in a small area. It had been raining off and on in the area and there were some pools of water by the roadside. There had also been lightning and thunder overhead, but we seemed to dodge most of it and on our arrival, there was enough of a break and lack of any lightning for us to consider a dip in the pool.

Relaxing after our safari
Spotting wildlife from the tower

The cool water seemed to ease the itching and I’m sure that the drinks also helped, but in a different manner. After the pool, I had decided to try the outdoor shower, which was an interesting experience with the occasional flashes in the sky and drizzle that would fall. There were many more people that had showed up to spend the night, which was great to see considering how significantly the pandemic had impacted the tourist industry here with many tour operators going out of business and lodges closing. It did seem as though things were slowly returning to normal and for dinner, we had more of the standard buffet meal as most of the tables were full of guests tonight. One of the highlights of the safari camps is the fresh made soups that are so spectacular and have long been my favorite. A very heavy rain fell during our dinner, with the loud sound of the falling rain on the roof of the tent so that at one point it became difficult to hear. It was truly pleasant and we were fairly confident that the precipitation would be gone by morning when we were planning to head back into the park for our second day.

A white-headed buffalo weaver joining us for lunch

Friday, March 25 – A quite morning for the residents and heading to Tarangire for the weekend…

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Passing through Mto wa Mbu, Shama had to pick up some of her favorite red bananas

As we would be away for the weekend, everyone had decided to spend a leisurely morning and skip morning report. As much as everyone wanted to see patients, and you’ll hear later on how that continues until our very last minute at FAME, the thought of spending the morning at the Lilac Café having breakfast was just too much for the residents to resist and I think there may have been images of French toast with a cappuccino swirling in their brains making it far too difficult for them to resist. I was meeting with two other Board members, Ke Zhang and Frank Lee at 9:00 am at the Lilac and though there was little question that I would be ordering food, it was, in fact, a working breakfast for the three of us to catch up on things since face to face meetings of the Board had not occurred since 2019 prior to the pandemic. Ke and I each ordered a full breakfast of eggs, sausage, bacon, toast and fruit, while Frank, who was staying in town at the Kudu Lodge had already eaten and as good as our meal was, I would definitely wager that Frank’s had been much more luxurious.

Our arrival at the Simba Lodge – not the fresh juice glasses being offered

We spent a good hour talking shop with Ke and I enjoying our food at the same time, though I suddenly remembered a few minutes prior to 10:00 am that we were attending one of Diane’s meetings on strategic planning and I had recalled from the first one I attended that she did not tolerate tardiness in the least and it would not set a good example for the three board members to walk in fashionably late. Of course, despite her mandate and threats of bodily harm, there were several people who were running late for legitimate reasons, such as the operating room, and the meeting did end up starting just a tad bit after its scheduled starting time. Regardless, it was an excellent meeting for us to have attended as she was developing a list of things that had to get done and was assigning specific people to not only oversee the progress of each project, but also the additional folks involved and, perhaps most importantly, a deadline for each task. Neither Ke or I could stay until the end of the meeting, as we were departing for Tarangire shortly, and Frank has other work he had to attend to that did not involve FAME.

One of the spacious double rooms

I had turned over Turtle to Vitalis much earlier in the morning before everyone was up so that he could check everything out on the vehicle given we would be out for the weekend on game drives. Though Tarangire is much closer than the Serengeti and you never want to break down anywhere in Africa as there is no AAA or anyone to call, but the former is a smaller park and you are more likely to see someone else along the road. The Serengeti is an entirely different beast and the meaning of its name, “Endless Plain,” gives you enough of a sense of what it’s like there. You can easily drive for an entire day and see perhaps 2 or 3 vehicles, unless of course there’s a leopard in a tree in which case they are like safari car magnets and suddenly a dozen vehicles may show up before you know it. Be that as it may, a guide must be confident in his vehicle as breaking down is not an option. Trying to walk out in lion infested surroundings, not to mention the elephants and cape buffalos, is really not a consideration, so, if you can’t fix your vehicle, you must either hope you’re in radio contact with another vehicle or you spend the night where you are and wait for the next day.

Having just arrived, we had to check out the deck and the pool

Tarangire is a really wonderful park and is consider the home of the elephants in Tanzania. There are literally hundreds of them in the park and they all come down from the surrounding hills in the morning to make their way to the river and then head back at night. Tarangire National Park is the park where the Tarangire River dominates the landscape and, in the dry season, all life exists around the river for it is the only water for miles around. As this was not the dry season, though, and it had rained quite a bit just before we arrived three weeks ago, it was difficult to tell exactly what the situation in the park would be regarding the other animals such as the wildebeest and zebra herds. That remained to be seen. Vitalis arrived back to FAME just a bit after noontime with Turtle all spick and span and looking like a completely different car given the fact that we had completely coated her in mud from our drives to the mobile clinics the week before and then Lake Manyara last week. Believe it not, car washes are a big thing in Karatu given all of the tour company traffic here and everyone wishing to have a spotless vehicle for their game drives. To be honest, though, I’ve never been one to keep my car at home clean let alone a giant tank like Turtle who somehow looks perfectly appropriate with a good coat of mud all over including the runny boards, though they do get a bit slippery entering and exiting as it’s a big step up to get in.

The pool from under one of the umbrellas

As we had invited both Ke and Shama to join us for the weekend and with me not driving as we had asked Vitalis to take us, we had a nearly full vehicle with eight occupants since Turtle can hold a total of nine in seats, and twelve if we stretch it with soda cases in the middle aisle for seats as we have done on occasion. Vitalis, who has guided us in the past on numerous occasions, is a wonderful person and someone who really puts his all into guiding and really knows his stuff, especially birds, something that is often overlooked here in lieu of the more famous big game mammals like the big five – the rhino, elephant, lion, cape buffalo and leopard. The big five received their “honor” as being the five most fearsome and dangerous animals to hunt as a great many hunters were either severely or mortally wounded during their pursuit of these trophies that are thankfully far less commonly hunted now, but not entirely so. Though one cannot hunt in any of the national parks or the NCA, there are private game reserves where one can still hunt in Tanzania for a price. My preference is to stay completely out of the politics of this issue, but leave it to say that I have never been convinced of the benefits of culling these herds of wild animals for the sake of conservation despite my numerous conversations with those who have been involved in this process. If herds need to be culled for the purpose of preserving a species or a specific population, then so be it, but it should not be done to promote the sport of killing another animal, as this should occur only out necessity for one’s survival and there is little question that the vast majority of hunting is not done for that reason.

The drive to Tarangire will typically take about 90 minutes to the main gate, but today we were heading to the Eastern gate in the direction of Babati. This is a newer gate that was opened several years ago specifically to accommodate guests staying at one of the several lodges that were placed just outside the park for various reasons. I had stayed at the Simba Lodge there several times before and it has always been wonderful. A good friend in Karatu had worked on design and marketing with the company and in addition to knowing that her involvement was an excellent endorsement for us to stay, she has also been able to secure resident’s rates for us which are far better than the typical tourist rates. The lodge is what’s called a semi-permanent lodge for it has wooden platforms for all the structures that are otherwise soft-sided and essentially tents. This allows for nice level floors and different furniture in addition to a full bathroom and shower at the back of the tents that are somewhat more complete than those found in the tented camps in the Serengeti which move with the seasons and the migration. One huge plus for the group, though, is that the Simba Lodge has a lovely pool that, although not necessarily an infinity pool, is practically the same as it has an unobstructed view looking off into the distance towards Lake Burungi which lays outside of the park.

We turned off the main road that, had we continued, would have led to town of Babati in several kilometers, and proceeded along a rather circuitous route of increasingly smaller dirt roads, constantly looking for progressively tiny signs on even smaller poles directing us to the Simba Lodge. Thankfully, Vitalis had been there before as well and knew the way, otherwise, it would have been an interesting adventure on its own. Along the road, we passed by the homes of the local residents, some quite colorful, while others were but sticks and mud in the local fashion of the farmers here. As is always the case, children run out to wave as we pass, though many of their gestures are often with palms up indicating that they are asking for us to give them money or food, something which is just not possible as we’re passing through. Being torn by the obvious inequity between these young children on the roadside and those of us in the vehicle heading to a lodge that even at a reduced rate would be more than many of these families earn in a year can only be lessened a small amount by the fact that we have been volunteering our services to these same communities for the last three weeks. Regardless, it can be gut wrenching at times.

The view from the upper deck

Passing in front of the entry gate to the park, the lodge was a just a short distance away and immediately outside so we didn’t have to worry about having to enter and pay a fee for the day. Our plan had been to get to the lodge early enough to enjoy the pool and some relaxing time around sunset, hoping for a sky full of stars shortly after. We had reserved three rooms, a triple for the three boys and two double for the four girls, which worked out perfectly as the rooms were incredibly large and there was more than enough room for the three of us. I believe it was I who called “last one in the pool is a rotten egg,” but I certainly will not give up the name of who was last though it was not me. The pool was gloriously fresh and invigorating after the several hour journey to get here and we had absolutely nothing left to do for the evening other than eat dinner, which we had requested for 7:30 pm. The sun was bright, but there were umbrellas for us all on the deck and there seemed to be no one else other than our group staying there, or at least no one else wishing to partake in a swim in the late afternoon. Peter and Ke had gotten out before me and took advantage of the outdoor shower immediately behind our room, while I was the last to get out and by the time I was ready to shower, it was dark. Not wishing to battle the low flying bats nabbing insects attracted to the light, I chose to use the indoor shower and to avoid any possible rabies exposure despite the fact that I’m vaccinated. The vaccine only protects you from needing the immunoglobulin immediately and I chose not to play the odds on that one.

Jim, the friendly warthog who was the last of his family left and now lives at the lodge

As there was only one other couple staying that night at the lodge, dinner was not the usual buffet, but rather served to us so as to avoid setting up all the serving trays. We were not disappointed, though, as all of the main courses were superb and we all spent a relaxing time at the table thinking of what the following day would bring for each of us. We had planned for breakfast at 6 am the following morning so that we could get a reasonably early start. One thing that I think only I and Vitalis were keenly aware of was what the tsetse fly situation was going to be like because we had been the only ones to have experienced this phenomenon previously. These incredibly vicious flies with a painful, blood sucking proboscis can be incredibly thick in the woodland sections of Tarangire and I was not at all looking forward to discovering what they’d be up to tomorrow.

Sunset

March 24, 2022 – A lecture on epilepsy and Teddy’s for fittings after work…

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Peter and Natalie delivering their epilepsy lecture

With the internet still out and my life somehow spared from having been murdered in my sleep by one of the residents, everyone was up bright and early for our first neuro educational lecture for the staff of this trip. In the past, we have always given at least one lecture a week, and sometimes two, but much of the schedule had already been made prior to our arriving. We always offer to lecture on whatever neurologic topic might interest the group of physicians here at FAME and over the years, we have collected a vast library of lectures that remain available for reference should anyone wish to look back at them. With only two slots for us to use, and Whitley and Meredith now having already gone home, the residents had decided to divide and conquer with Peter and Natalie covering seizure disorders this morning and Alex and Savannah deciding to something more neuromuscular related since the two of them are both pursuing that for their careers.

A happy patient on the ward

This morning’s lecture was held in the education room in the administration building which, being tremendously smaller than the normal conference room, allows for a much more cozy and somewhat cramped time among the FAME medical staff. Unfortunately, the room has far fewer chairs than are needed given the growth of the staff over the last several years and when adding in the often difficult transportation to FAME in the morning, with many individuals arriving late not because of tardiness, but just because their ride was delayed, it gets pretty congested at the door with others pointing out a sliver of room on one of the cushions to those who are entering. Be that as it may, once the lecture got going, everyone was paying close attention given the high prevalence of epilepsy in Tanzania and the need for each of the caregivers to be aware of how to treat it.

Nuruana and Alex evaluating a patient
Typical resident with two phones

What Peter and Natalie didn’t discuss this morning, as there was little need to do so, was the fact that 90% of the world’s epilepsy occurs in low to middle income countries and that is exactly the place where there are no neurologists. The reason for this, the high prevalence rather than the lack of neurologists, is due to the number of childhood infections, head trauma and birth injuries that occur here compared to the high income regions of the world. The lack of neurologists is a bit more complex, but in Africa in general, there are very few specialty trained physicians as most of the care here is delivered by generalists who have not done residencies following their internships, but rather have gone out into practice. Our postgraduate medical system (i.e. residencies) are wholly funded by Medicare in our country, a government program that doesn’t exist in most African countries and, at least in Tanzania, nor does a solid government health plan that everyone pays into. So, in a region of the world where by far the majority of epilepsy exists, there are no specialists to treat it.

Natalie, Anne and Eliza evaluating a patient
Natalie, Anne and Sue, our communications specialist

There are only a handful, and I mean literally, of neurologists in Tanzania and none in the regions of the country most needy such as the area around Karatu and the Ngorongoro Conservation Area, where I have been working for the past twelve years. Though we have gotten the word out to the communities, it is common for us to see patients in early adulthood who have been seizing their entire life because they either didn’t know it was treatable or had seen someone once who put them on an anti-seizure medication at a sub-therapeutic dose, or the wrong one, and since it didn’t work, they stopped it and never saw someone again. We also have patients who tell us they took the medication and it worked, but when they ran out of it, the seizures came back, clearly not understanding that the medication, very often, must be taken for life, or at least for several years. It is an issue of education both for the caregiver, as Peter and Natalie were doing this morning, but also of the patient and family.

Our efforts here at FAME in treating neurologic conditions and, specifically, epilepsy have seemed to make a difference in the health of the population here in the Karatu district. Patients with epilepsy come back to see us in follow up at a tremendously greater rate than any other population of patients and we have a great many patients who have remained seizure-free or their seizure burden has been greatly reduced. Through the data we have collected at FAME, we’ve shown that our efforts have made a significant impact, but the problem is more complex than just a matter of simply educating the patient and the caregivers here as placing patients on the proper (and that term can obviously have very different connotations) anti-seizure medication may not be possible due to the cost of treatment, and that means primarily the medication. Sustainability is the buzzword that you cannot help but think of nearly every moment of every day. How to make this all work is the million dollar, or billion Shilling, question that everyone thinks of every moment of every day.

Natalie and Anne evaluating a patient
Eliza, Abdulhamid and Peter evaluating a patient

Now back to Peter and Natalie’s lecture. Simply put, it was great. They went through the basics of epilepsy, what it is and why we need to treat it and then, using a case based discussion with several of the cases we had already seen here, covered all of the information necessary to effectively treat the epilepsy patients we were seeing at FAME on a regular basis. It is usually a bit difficult to get group participation here, especially at 7:30 in the morning, but they did manage to get some involvement by the group and there were some excellent questions which is always a good sign that people were listening. I should also tell you that it has been an absolute rule enforced by Dr. Frank since I came here on day 1, that we use no brand names, which is totally appropriate as those brands are only in the US and are not used in most other parts of the world. Using generic names like levetiracetam (Keppra), lamotrigine (Lamictal), sodium valproate (Depakote) and carbamazepine (Tegretol) can be very difficult at times if not only to spell them correctly and certainly gives you a sense as to why drug companies like you to use their more simpler brand names. I will typically go through their presentations ahead of time to make sure there are no digressions to Frank’s rule. Another good sign as to the veracity of their lecture was the fact that when it came to the 45 minute mark, I didn’t see Dr. Ken getting fidgety and he allowed the questions to continue on.

Nuruana, Alex and Savannah with a patient
Kitashu translating for a patient speaking Maa with Natalie, Anne and Alex

The start of clinic was a bit slow and most everyone decided to run up to the Lilac to get coffees before things got out of hand, which typically happens once we get rolling. Alex, when checking on her patient with the leg weakness who had presented earlier in the week, found that she was vastly improved and, although she didn’t have all of her strength back, she was able to stand and walk with a walker after several days of steroids which was a good sign that she would continue improving. Her examination had also evolved and she was clearly looking more like a patient with transverse myelitis rather than one with Guillain-Barre syndrome. Without going into too much details, these exams are vastly different as one is an upper motor neuron problem and the other is a lower motor neuron problem. Alex’s patient had come in with a somewhat confounding examination as she initially had spinal shock and it required days for her exam to declare itself. I’ll apologize in advance to those of you who would rather not have heard that explanation.

Teddy at her sewing machine
Fitting Alex

Clinic did end a bit early for us and we were all able to head out by 4:00 pm which was good as we had scheduled with our seamstress, Teddy, to go over to her place for the residents to get fitted for some clothes they wanted to have made. Peter had decided to excuse himself and remained home to relax and do some reading, while Alex, Savannah, and Natalie hopped in Turtle along with Anne and myself to head to the other side of town and visit Teddy’s. I am sure that most of you are aware that the fabrics here in Central Africa, both East and West, are incredibly gorgeous with their vibrant colors and patterns. When I first came to Tanzania, I couldn’t help myself and would just bring the folded fabrics home to give as gifts or keep for myself. Several years ago, though, and probably under the influence of Anne, it became clear that we could buy the fabric and then have it made into all sorts of clothes. I know that this sounds pretty obvious, but with Anne’s help, none of that would have been possible as you can imagine walking up to a small shop where no one speaks English and trying to navigate the intricacies of having a piece of clothing made to your specifications. Having an interpreter along to help with that process is not only crucial, it is a necessity, and Anne has served in that role for us for at least six years that I can remember, ever since Kelley Humbert and Laurita Minardi accompanied me here in October 2016.

Typing on the porch

Several years ago, though, I was introduced to Teddy, a seamstress who can do amazing work and can do it quickly if needed as there are times that we can’t get to her early in our trip and may need things done over a weekend. She is the most incredibly pleasant person you could possibly wish for and she can create most anything including sport coats out of Kitenge cloth, men’s pants, shorts, shirts, not to mention the standard dresses and skirts. Even though I have long lost the idea that I could ever find a piece of clothing here that would fit comfortably on me (no need to go into detail on that matter here), I still love my visits to Teddy’s shop and look forward to taking the residents there. And despite the fact that everyone was getting something made, and I won’t tell you who had the most (don’t worry, Alex, I won’t rat you out), I think we were there for only a bit over an hour, which in Africa is a quick visit. I had brought my computer to catch up on work and emails and it was a relaxing time for me.

Anne with a little visitor to Teddy’s shop
Charlie inviting himself for coffee

After Teddy’s, it was home for everyone as tomorrow we would be heading to Tarangire National Park in the middle of the day and we had no clinic in the morning. Normally, we fit in a trip to the Serengeti, leaving early in the morning, but with three of the four residents heading to the Serengeti (and Zanzibar, I might add) at the completion of the rotation, I had decided to switch things up and go to Tarangire for two nights instead as it was a much less expensive proposition owing to the high cost to travel through the NCA and to enter the Serengeti compared to Tarangire National Park. As we were taking the day off and not going to morning report early, it was a perfect night for a movie and popcorn, so we set up the projector and watched the Borne Identity.

A very happy Charlie

Wednesday, March 23 – A very slow clinic and a visit to Daniel Tewa’s home…

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AUTHOR’S NOTE: I do apologize for the delay in getting these blogs out, but due to our busy schedule, both clinic and social, I have fallen behind. Do not fret, though, as I have notes and will be getting them out over the next week to complete the visit

With no educational lecture for the morning, the extra 30 minutes of sleep was much appreciated by everyone. The image of Africa as that of the “dark continent” is not too far off the mark for a number of reasons other than why it was originally used which was to convey mysterious and unexplored regions of the earth. Though the Congo very likely still deserves the use of that term for it remains off limits to outsiders, the rest of Africa does not. But it is otherwise a very dark continent in much of its midsection, where the equator broadly traverses just below its waist. For it is here that the days do not change throughout the year and darkness comes quite quickly shortly after 6 pm every day of the year, like clockwork as they say, and sunsets are more rapid than we know at home, falling in almost exactly the same place day in and day out. There are no seasons here as we know them, no summer, spring summer or fall, but rather there is the rainy season and the dry season, and months are known only for their relationship to planting and harvest. We are approaching the heavy rains of April, when the skies open up and the ground literally turns to a soupy mix of water and clay making travel difficult and dangerous. In the dry season, the dusty roads, though easy to travel, leave a thick coating of red ocher over everything for several meters on either side and walking on a heavily traveled road should require a respirator in the best of circumstances.

Alex, Peter and Anne ganging up on a patient

The darkness here, though, is also related to the complete lack of light pollution and the fact that shortly after sunset, the blackness becomes so entirely dense that it is difficult to see your hand in front of your face as the cliché goes. Dusk would not have been a term invented here for it almost doesn’t exist, and twilight is so brief that the popular teenage vampire series may have never been written if it had been left up to an African writer. The lack of light pollution makes for the absolute most incredible skies full of more stars than one could possibly imagine living on the East Coast, though they are readily available in parts of the west at altitude and away from the cities for I have seen them many times in the High Sierras and the Rockies. So, once the sun is down and we have finished our dinners, served in their little individual plastic pots to each of us, there is time to relax and catch up on the days activities. As we have been collecting data on our patients here at FAME for the last five years, it is crucial that all this be entered into the spreadsheets each day as trying to do it at the end has proven difficult in the past. Often, we’ll have a medical student accompany us on these trips for this purpose alone, but with COVID, that has been off and on, given the restrictions that have been placed on travel. Hopefully, this will open again soon for everyone’s sake as it is a big chore and provides an opportunity for a medical student to travel with us that wouldn’t otherwise be available.

Eliza, Savannah, Abdulhamid and Natalie enjoying a slow morning

Other than the nights that we have watched a movie here at the house, which have been minimal, or the nights that we have gone out to the Golden Sparrow to dance, also really only once, the residents are in bed by around 9:00 pm and probably get tremendously more sleep here than they do at home. I am usually left alone at the dinner table, typing away on my blogs or catching up on emails until at least 11:00 pm, and though I do miss their company, having the silence in the house is a bit more conducive to putting pen to paper as the expression goes. When I was here on my own in September 2020, as the residents were not allowed to travel due to the pandemic, I was able to keep up on the blog throughout the entirety of my visit, but often we have other social plans that keep me from this work. Today was a good example, as not only were we going to be visiting with a close friend of mine, Daniel Tewa, later today, but the internet was also out for the entire day, meaning that we had to all go up to Frank and Susan’s house where Ke was staying as he did have it up there and I was afraid that the residents were going to kill me if they were unable to get access at some point during the day.

Alex walking out of Daniel Tewa’s Iraqw house
Daniel in front of his Iraqw house built in 1991

For whatever reason, our clinic was incredibly slow during the day, which was probably a blessing given the internet situation that existed. We amazingly had time to get tea and follow up on inpatients that needed to be seen well before lunch. It felt as though we had stamped out neurologic disease in Karatu and the surrounding areas over the previous two weeks and were now seeing the results of the incredibly hectic sessions that we had experienced previously. With the quiet day, it gave us plenty of time to finish up the day, get some work done and plan to leave for Daniel Tewa’s home early enough for him to give everyone a proper tour of the replica Iraqw home that he had built back in 1991. Though in the past, Daniel had always had our entire team over for dinner, given the events of the last couple of years, we had changed to having his wonderful African kahawa (coffee) outside where we could hear his wonderful stories about Tanzania’s past in the days of independence and prior to that exciting time.

Peter getting a lesson in defense with a spear from Daniel
Sleeping platform on top and rocks for cooking fire below

I had first met Daniel by chance in 2009 when I had first come to Tanzania on safari with my two children and had been asked by our tour operator, Thomson Safari, if we would like to do some volunteering as part of our trip. I had chosen Thomson for exactly this reason of promoting responsible tourism and also because of their reputation as one of the top operators in Tanzania for many years. Our volunteer time had been scheduled for three days at the end of our trip and we were assigned to help paint a primary school in the village of Ayalabe, just outside of Karatu, which, importantly, is where FAME is located. Leonard Temba, our guide and now my family, spent the days with us in Ayalabe and Daniel happened to be one of the village elders of this Iraqw village. Each day, we would have an early breakfast and head out to the village of Ayalabe, where Daniel would be waiting for us to begin painting at the school. It was really just the four of us painting, but I remember so vividly Daniel shaming any of the teenagers who happened to stumble by to the see the three wazungu in their village working. In this manner, he would not so subtly recruit them to work with us, cleaning and painting the window frames a lovely sky blue.

Corral for animals
Checking out the roof design

In this manner, we proceeded to paint much of the school buildings, though not nearly all, with the help of Daniel and our literally captive audience. On the last day, the entire school came out to thank us for the work we had done, which was quite frankly minimal, but it was the really about the effort that we had made to help. Afterwards, we went to Daniel’s house, where we met his wife, Elizabeth, and heard stories about the Iraqw way of life both prior to and after independence, and learning the dances and songs of their culture. It was truly a remarkable experience and I was so happy for my children to have the opportunity to meet such a remarkable man. It was during this same time in Karatu while we were volunteering, that I had asked Leonard to take me to a Tanzanian medical facility, thinking that he would bring me to some local practitioner of medicine, but rather he brought me to FAME, where I met Frank and, as they say, the rest is history.

Natalie ready to defend the house from atop
Another view of Daniel’s Iraqw house

Having returned home, I struggled through a number of personal setbacks over the next year, including the death of my father, but I knew that I was somehow destined to go back to Tanzania and FAME. When things were finally in some sense of order, I made arrangements to return to FAME in the fall of 2010, the first of my now two dozen visits back to this remarkable place. I recalled our visit with Daniel and Elizabeth so fondly and, wanting to meet up with them again, I obtained his phone number from Thomson Safaris and took a stab at calling him. Not only did Daniel remember me over a year later, but he immediately asked how Daniel and Anna were by name without any prompting from me. Calling half-way around the world to someone I had met over a year before and not having any idea of what to expect, I was very quickly put at ease and even more so when he kept repeating karibu (welcome) to me. It was if I was speaking to someone who I had known for my entire life. And that is how it has remained.

Despite having met with countless visitors over the many, many years of providing his cultural demonstrations for the safari companies as well as college students and researchers who stop by to see the unique Iraqw house that he has built on his property, when I returned and sat in his living room with him eating dinner, he told me that I was the very first visitor to have ever returned for a visit to see him on a personal basis. I was so incredibly touched by his generosity and warmth and, as I sat with his entire family watching his granddaughter, Renatha, eat the leftovers from his plate, an honor here, I quickly realized that we were to be lifelong friends. It was clear to me that he and I had been cut from the same cloth and it had been meant to be that we would encounter each other on opposite sides of the earth after so many years.

And it has remained so. I have visited with Daniel and his family on each of my return trips to FAME and, perhaps equally important, he has shared with my residents and friends who I have brought here, his family and his remarkable strength. Each time we have come, Daniel will have us over for dinner, or even just coffee, during which time he will share his stories of Iraqw life as it was in the past and is now, answer any question that one wishes to ask about world politics, or he will amaze everyone with his knowledge of US geography by giving everyone the capitol of their state, the square miles, date of statehood, and a multitude of facts that no one present was aware of, though should have been.

Unfortunately, with the internet down at FAME, Ke was unable to join us as planned, and Shama was also detained with work at FAME, so it was the five of us plus Abdulhamid, who we had asked to come along at the last minute. Arriving to Daniel’s is always an experience of warm greetings for everyone and it always seems like I had just seen him yesterday even though it’s been six months. Daniel’s farm is on the Gibb’s Farm road right at the Ayalabe Road junction and very easy to find. He is always waiting for us, waving his arms up and down and practically dragging me out of the car as I open the door. The lovely, though invasive, eucalyptus trees shade his home and the surrounding area including where he has a table and chairs set up for us to have coffee and snacks.

After the introductions, he wanted us to go see his traditional Iraqw house that he had built in 1991 because, as he puts it, his children had always accused him of losing his mind when he told them that he had grown up in an underground house. For years, the Iraqw had built their homes mostly underground, covered by a large dome of dirt and grass to protect themselves from the Maasai who would steal their cattle for, as the Maasai believe, cattle are God’s gift to them and belong to no one else. By living underground and brining all of their animals in at night, they could hear if there was any intruder walking across their roof and then defend themselves. The Maasai and the Iraqw remained enemies until a truce was finally signed in 1986.

A cup of Daniel’s incredible African coffee

Meanwhile, when independence from the British came to Tanganyika in 1961 and then they became Tanzania after uniting with Zanzibar in 1964, Julius Nyerere, the first president and father of the country, had a true dilemma of how to develop an infrastructure in a country that had over 120 individual tribes living separately in their own villages and speaking their own languages. Realizing that the only way to unite his country would be to bring all of the population into the villages together, he banned traditional housing such as the Iraqw homes and others so that everyone would hopefully live together and they could begin to develop roads, water supply and energy grids. Add to this the fact that Tanzania had eleven (!) native college graduates in the entire country, Nyerere had a challenge of epic proportion in front of him to make things work. Having been continually doubted by his children that he had actually grown up in an underground house, in 1991, Daniel choose to build a small version of the type of home he had grown up in, one built for a young family with a handful of cows and goats. It took him three years to build it, but once he did, it has been utilized by researchers from the universities to see an authentic Iraqw house, built to the exact dimensions and of the very same materials he had learned in his early adulthood.

Chicken and vegetables with chipsi on the side

Standing in this original Iraqw home and hearing Daniel tell stories of Iraqw culture, you can practically hear all the commotion that would have been going on; the livestock being present through the night before being put out to graze, guarded carefully from the Maasai, the sleeping arrangements with men and women separated by the wide center row (“how babies are made is top secret,” says Daniel), the cooking area of three stones where a pot of porridge would be placed. Listening to him tell of how the house was built, having to gather the perfect y-shaped logs from the proper trees, using shrubs with natural pesticide properties underneath the grass and dirt root, and making everything perfectly watertight as his house was until just a few years ago when several elephants walked across the top. It was very easy to imagine what life was really like for the Iraqw only 50 years ago at the time of independence.

After touring the house, Daniel demonstrated the fine art of spear throwing for everyone and each gave their best shot, except for me as I was photographing the event and probably wouldn’t have been very good. Peter hit a bullseye with his first through, but others took several tries to get there. We eventually all sat down for coffee brewed in the traditional African style – boiling coffee with milk – which is an amazing treat, and even though Daniel forces us always to drink both thermoses of the drink, I don’t think anyone really minds. Then Isabel, his oldest daughter whom I have known since the very beginning and usually serves us dinner at her house, brings out an amazing pot of cooked chicken and vegetables for us to all share. This is the tradition here when visiting someone’s home, that you cannot leave without being fed, and I should have known that Daniel would never have let us go without feeding us. Thankfully, we hadn’t had dinner yet and there was no difficulty for anyone to enjoy the meal we’d been offered. During dinner, Daniel dazzled everyone with his knowledge of US geography and we also tackled many of the world’s problems. Sitting outside, with the coolness of the evening setting upon us, in a land as distant as one can get from home, it was truly hard to imagine how anyone could possibly hate another human being, or ever consider going to war for any reason other to defend one’s family. Describing the scene as idyllic would not do it justice.

A very happy Natalie

Arriving home after Daniel’s to discover that the internet was still out at the house and not wishing to be murdered in my sleep by one of the residents (no names will be given), we all went up to Frank and Susan’s house to use the internet there at Ke’s invitation. Oscar, their Rhodesian Ridgeback, and sweetest, most cuddly dog of any size, spent the evening on the couch with Natalie as she soon discovered just how demanding he was for as soon as you stop petting him, a huge paw comes your way just a subtle reminder. We all made it home earlier enough as Peter and Natalie were presenting the following day at 7:30 am, so it was early to bed and early to rise…

Tuesday, March 22 – A visit from our friends in Tarangire…

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One of our many young patients

Our morning started early with an educational talk that had to do with treating tuberculosis and was given on Zoom by a government health worker. The talk had to do with treating TB in a setting where anaerobic cultures, or any cultures for that matter, are unable to be done and starting therapy is often based on the patient’s symptoms rather than any specific testing. The treatment for TB lasts many months and there are patients who may not respond because they have drug resistant TB. Save it to say that it’s a complex topic and one that probably shouldn’t be tackled by a general neurologist whose internal medicine training took place over 35 years ago.

Natalie and Eliza evaluating a child
Announcement of our upcoming epilepsy lecture

Educational talks are typically held on Tuesdays and Thursdays at 7:30 am and have always been a mixture of volunteers and FAME doctors delivering them with more of an emphasis on the former given the fact that FAME has relied on their volunteer doctors from day one. I have always expected the residents who come with me to give as many lectures as the FAME doctors have requested during their time here and that plan has always gone incredibly well. After the pandemic hit, though, there was a question as to whether or not volunteers would be coming back on regular basis and, if they did, when. I was here with a group of residents in March 2020 when the pandemic hit and, following that, we decided to begin giving neurology educational lectures by Zoom. Though I had returned in September/October of 2020, I had no residents with me and given all of the social distancing, there were no large gatherings taking place indoors, or elsewhere for that matter.

One of the children seen to be evaluated
Eliza, our Tarangire chief and a patient from their village

The main issue with the Zoom lectures, though, was the time difference as the education lecture here at FAME always occurs at 7:30 am which is either 11:30 pm or 12:30 am the night before for us at home. Staying up until midnight to deliver these lectures turned out to be a real challenge for those of us doing them. We had a similar program in Puerto Rico that was incredibly more successful given the convenience of the same time zone. Meanwhile, having started our program back up in March 2021, we were able to do the lectures once again in person, though the potential for delivering educational services and lectures in this manor was not lost on us and there remains plans to develop a more robust virtual problem similar to what others have done in this arena. Though the pandemic was an incredibly horrific and devastating event, there were many silver linings such as this that have now become part of our normal way of life.

Natalie and Eliza with a pediatric patient

In addition to our regular patients today, we were expecting a visit from the group of patients who live near Tarangire and are brought by their Maasai chief every six months. Many of them are return patients and a number of them are new. By far, the majority of these patients have a diagnosis of epilepsy which is often the case here. It was in September 2020, during the time I was here without the residents, that he brought the two Down syndrome boys to see us and following that visit, Kitashu and I began searching for a vocational rehab center for them, finally locating a great program in Usa River. The two chose their eventual occupations, one to become a tailor and the other a welder, who are now each in their second year and doing incredibly well. I get regular reports from the school as to how they are doing and am thankful to all those who helped contribute to my Go Fund Me campaign that raised the necessary money to cover their entire education.

One of the patients that the chief brought to us today who had well-controlled epilepsy and was being seen in follow up, also had another pretty serious problem that was a bit out of our normal range of expertise. The gentleman had suffered a crush injury of his index finger about five weeks ago that had also caused a laceration and was now significantly infected such that not only was his finger swollen, warm and tense, but so was his arm to just above his elbow. This was all very concerning and needed to be managed today as any delay could risk his infection worsening or possibly developing osteomyelitis. We discussed sending the patient over to the general medicine clinic but were informed by Kitashu that the chief had brought only enough money to cover the clinic cost for his patients (5000 Tsh or a little over $4) and no extra. There was a discussion of admitting the patient to the ward where he could be properly treated by the Dr. Manjira (our new surgeon) after receiving IV antibiotics. In the end, though, Dr. Manjira offered to treat the patient without admitting him and could debride the wound that afternoon.

Savannah had been treating the gentleman in the clinic and so she, Natalie and I watched as Manjira injected the man’s finger with a boatload of lidocaine and then proceeded to open the wound, remove the fingernail and basically open up the digit so that it would heal from the inside out. It was a pretty brutal and rather bloody affair and at one point, one of the nurses asked Savannah if she felt OK, but in her defense, she looked just fine to me and promptly declined any help or to sit down. After pouring a ton of iodine solution over the finger, it was time to wrap the wound as the patient would be heading back to his boma where there was certainly not going to be anything close to reasonable hygiene. The good news was that we were planning to be in Tarangire National Park over the weekend and could stop by on our way out on Sunday and evaluate him to make sure that his finger still looked like it was healing properly.

Thankfully, we finished with all the remaining Tarangire patients as well as our own regular FAME patients in time for me to attend the monthly FAME Board of Directors meeting that I was actually in charge of as the chair of the Board. The meeting was to begin at 4:00 pm our time, though we do have Board members scattered across the time zones including the west coast meaning that it was 6:00 am for them. As the meeting was only to last an hour (and we were able to finish it on time, we were all looking forward to a quiet evening and maybe a movie.

Ke Zhang, another member of the board had also arrived today, and would be here for our two remaining weeks at FAME. Ke has been a fixture here at FAME since even before my time, having been introduced to Frank and Susan while doing volunteer work in the area on a college trip. Over the years, he has been responsible for designing and maintaining all of the IT infrastructure, which I should say is very impressive in itself given our dependence on having an intact network over the years that now supports our EMR (electronic medical record), but when you consider that he’s managed to graduate from MIT, finish an MD/PhD, and is now an interventional radiology resident in Boston. How he has managed to get all of this done while staying so involved with FAME is beyond me.

Monday, March 25 – A busy Monday clinic without Whitley and Meredith…

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A happy picture from yesterday – Savannah getting “stickered” by the children at the coffee farm
Another happy photo from yesterday – Alex enjoying breakfast in one of the hammocks with Matilda lurking behind

I have mentioned that having Whitley and Meredith here over the last two weeks was a real treat for me as it significantly reduced my normal duties of staffing essentially four examination teams by myself. Mind you, there was still all of the coordination that must happen to make the neuro clinics run smoothly and, even though Kitashu and Angel always have everything under control, it still requires my oversight for things such as the number of patients we can see in a given day or other more logistical concerns. Despite the need for my presence, though, having them with us for the last two weeks allowed me to break away and attend several meetings as well as work on my blog during clinic when I wasn’t needed. For the next two weeks, the duty of staffing all of the patients will now be mine alone.

Natalie and Eliza evaluating a child
The all-important head circumference

Mondays are always the busiest day for us in clinic and today we are also expecting to have more patients from the Food for His Children organization that will be in addition to the normal patient load. Sure enough, patients were already lining up to be seen well before we arrived from morning report and the day continued on like this. In addition, there was a patient in the ward who had arrived the night before and was clearly a neurologic case who would need our assistance in further evaluating before any consideration of treatment. We were all completely rested after the wonderful Sunday we had just had the day before, though thankfully, we were all now well rested for the coming day of patients.

Dr. Anne and Alex with a concern for TB in their patient
Natalie and Eliza evaluating a Maasai patient with Kitashu as they only speak KiMaa

Given the consultation in the ward sounded like they were quite possibly a neuromuscular patient (we were all thinking Guillain-Barre syndrome during morning report), it was decided that one our two soon to be neuromuscular fellows should see the patient, and Alex won the honors. We had been told that the patient had presented after developing numbness and weakness in her lower extremities that had come on over a period of about six hours the day before and, thankfully, she hadn’t decompensated overnight and though she was weak, she was still breathing.  Alex took a very good history from the patient and family and performed a thorough examination that demonstrated the patient had primarily proximal lower extremity weakness with no reflexes in the lower extremities, normal to decreased tone, and subtle sensory changes in the legs with definite sensory level.

Peter and Abdulhamid evaluating a patient
Dr. Anne and Alex without their masks

We discussed the case and there were some atypical features with Guillain-Barre syndrome that bothered us and, so, we asked Sehewa, the nurse anesthetist at FAME who has been there forever, to perform a lumbar puncture that would be primarily for protein and cell counts as we are unable to check anything more sophisticated than that at FAME. They had already done a CT scan of her thoracic and lumbar spine the night before that was reviewed and felt to be essentially normal, though obviously wasn’t the necessary study as that would have been an MRI scan, a much more costly and difficult to obtain study here. Unfortunately, we would have to wait until the end of the day until the lumbar puncture could be performed, and though we were unable to initiate treatment prior to obtaining these results, she did not worsen throughout the day.

Savannah and Nuruana evaluating a patient
Natalie and Eliza evaluating a very cute child

Meanwhile, we had a busy outpatient clinic to get through with both our regular patients and those from Food for His Children. Midmorning, a women was brought into clinic by her family who clearly had a significant neurologic problem that has been present for several weeks and had been progressive. She had to be helped into clinic by two family members holding her up and helping her walk and when she was examined, she was encephalopathic and had a mild right hemiparesis. This presentation was worrisome enough, but then we were told that not only was she HIV positive, but that she also had not had a recent CD4 count or viral load performed, test that were only available at the government dispensary and not a FAME. Given this situation, our differential had drastically changed from what it had been, though either way, we knew that she would need an urgent CT scan of the brain. Thankfully, her family had already anticipated the need for this study and were totally on board with getting it sooner than later.

There was little question in our minds that she would have a very abnormal scan and it was just a matter of which one of the neurologic complications seen in HIV patients that we were going to find. There were several that could present this way and though it wasn’t 100% that it would turn out to be a complication, the odds were in favor of that being the case. Dr. Anne and Alex, the team who had seen her in clinic, were right on top of things and had gone to look at her scan after it was completed and had then asked for my opinion of the findings. She had marked edema of the left frontal and parietal lobes and, on post contrast imaging, had multiple ring enhancing lesions that were present at the grey white junction. The findings were very suggestive of CNS toxoplasmosis, a condition that is very prevalent in patients who are immunocompromised, such as those who are HIV positive, though typically patients who have very low CD4 counts and are not responding their HIV medications.

Toxoplasmosis of the brain in an HIV positive patient

When the findings of the CT scan were discussed with the patient and her family, it turned out that not only did she not have her recent CD4 count or viral load checked, but she had also no been longer taking her medications meaning that she was essentially untreated and fully immunocompromised, capable of developing any number of complications that can be seen. This pretty much cinched the diagnosis after hearing that piece of very helpful, though unfortunate, information and treating her became a more straightforward process at least from the standpoint of what we were dealing with. Had she been in the US, she would have been admitted to the hospital immediately, and most likely at least an intermediate stepdown unit, but the decision was made for her to go to the government dispensary where her treatment would be free as it was related to her HIV. It was a joint decision made with the family, Tanzanian staff and social work and relied heavily on something we don’t have to consider in the US – cost. These are the lessons that can be very difficult and unsettling, and though they will hopefully change for the better in the future, it is the reality now and we must recognize those boundaries.

A lovely patient returning to see us with his grateful mother

Towards the end of the day, we were greeted by a truly lovely patient who we had seen last September who had presented with abnormal movements of I believe several weeks duration. The confounding part was that he had a history of mild cerebral palsy and if one looked at him without taking a good history, they would have just attributed the movements to his CP and left well enough alone. The movements, though, were very much of recent onset and he had never had anything like them before. The resident was a bit stumped at first as we don’t see this condition in the US and, even when able to describe the movements as choreaform occurring in an adolescent, still had trouble coming up with the diagnosis. This was Sydenham chorea, a condition caused by a group A beta-hemolytic Streptococcus infection, the same that causes rheumatic fever, and the neurologic manifestations are typically self-limiting and treated with tapering steroids. The problem is, though, that these patient quite often have sub-acute bacterial endocarditis, an infection that can have many complications, among them being severe cardiac valve disease and, if not treated aggressively, can lead to the need for a heart valve replacement.

As I mentioned, this diagnosis is rarely seen in the US due to our often overly aggressive and, at times inappropriate, use of antibiotics, though this is the third case that I’ve seen here at FAME. Each of the cases have been incredibly rewarding as the patients have all done incredibly well. This patient was continuing to receive his monthly IM injections of penicillin that he will be required to take for a number of years and this is to lessen the likelihood of suffering further damage of the heart valves from an infection. Seeing him today was wonderful, not only because he is doing so incredibly well and his mother is so grateful, but also because he is someone who lights up the room the minute he walks in. The residents who saw him last fall, as well as those who have seen our other cases of Syndenham chorea in the past, will never forget what these patients look like and never miss this diagnosis.

Our clinic ended after having seen a good number of patients, the bulk of them with epilepsy, and, thankfully, none were as complicated as the two I’ve spoken about, one in the ward and one that should have been in the ward, but was sent home to be seen at the government dispensary. It was later that evening that we learned of the lumbar puncture results, which were totally normal and, though they did not differentiate between our two main diagnoses, it did help us to exclude the likelihood of this being a purely infectious process. This was important as we were interested in giving the patient high dose steroids with the possibility of an inflammatory process such as transverse myelitis, though the differential for this condition is very different here than it is in the US, as it would include such things as Konzo, a toxic condition related to consuming improperly prepared cassava, among others. Guillain-Barre syndrome was still not off the table either, but we have neither of the therapies here to treat it, those being plasma exchange and IVIG, both very resource extensive and equally expensive treatments. So, we started the steroids and planned to re-evaluate her in the morning with the hope of having additional information as time went on.

A young child who had seen us in Mang’ola coming back for follow up at FAME

I think everyone was thankful for another quiet night at the house with the possibility of downtime, though all were fast asleep, save me, by probably 9 pm, a time where I am usually starting my evening of work at home while, I do my very best to stay away and do some plinking on my computer keyboard.

Dr. Anne and Alex working together

Sunday, March 20 – A very relaxing day in Karatu…

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Gibb’s Farm

A day of rest is a rare occurrence for us here at FAME. We are typically working six days a week seeing patients either here on campus or on our mobile clinics to the surrounding villages and the days are long. I also make sure that we get out an evening or two each week to feel a part of the community and share in the activities here. We had originally scheduled today to be a full day of clinic, but given the number of patients we’ve seen to date, it was felt to be unnecessary and the decision was made that we would start again on Monday. I must admit that we were quite aware of this change of schedule well in advance of our decision to go to the Sparrow last night and it just may have played a role in that decision, but regardless, the late morning awakening for everyone was a much appreciated luxury as it was sadly needed. Everyone in the house was a bit on the slow side this morning.

Our lunch table at Gibb’s Farm
The pool at Gibb’s Farm

We had made plans to pick up Annie at around 11 am for a short trip into town to buy fabrics as everyone (other than me) had plans to have clothing made by our friend, Teddy, who has been a great resource over the last several years. Unfortunately, she was out of town today for a funeral and wouldn’t be back until the middle of the week, but at least we could take care of purchasing the fabrics with Annie and would then go to visit Teddy with enough time to have things made before everyone went home. I had been introduced to Teddy, who is an incredible seamstress and has provided a wonderful service to my past groups, by our FAME’s previous social media director, and she has remained the only person we have used ever since that time. A visit to Teddy’s is like a social event for all. She now has her own shop on the other side of Karatu and even though I’ve had little interest in making clothes for myself along the way, I have always looked forward to my visits with her.

Pool at Gibb’s Farm
Natalie and Alex in the infinity pool

Having Annie along with us for any visits to town or with Teddy, though, is essential given the language barrier that exists is most situations including these. Having skirts or dresses made requires more than just a cursory knowledge of the language, otherwise things can come out much differently than one anticipates. Despite my having now spent over two years of my life here in Tanzania, my Swahili remains only words and phrases and I am nowhere near being conversational. I have often said that I am language handicapped and I am convinced that the older one gets, the more difficult it is to pick up a new language. I am either living proof of that hypothesis, or it is just another excuse of mine for being totally inept in something. Either way, having Annie along makes all the difference in the world and not just for that reason alone.

Synchronous swimming at Gibb’s??
Savannah and Anne lounging at the pool

After taking care of our shopping spree for fabric in town, during which time Peter and I hung around Turtle as neither of us were having anything made, we departed up the Gibb’s Farm road as we had made reservations for lunch there today. The Gibb’s road leads up and up out of Karatu into the hills above town and ends at the Farm which borders the NCA. In fact, hikes into the NCA, either to the elephant caves or even further to the crater rim, leave from just next door to Gibb’s. I had given a little history of the farm previously, but it remains a working farm with large plots of every fresh vegetable and fruit one can imagine in addition to their acres and acres of coffee plants. It also has a dairy and manages its own livestock, builds its own furniture for the rooms and, of course, grows its own coffee.

Grinding coffee nearby Gibb’s
Anne grinding coffee

Just before the Gibb’s farm is the village of Tloma where there is a very dense population of the Iraqw tribe, not a huge tribe as they go in Tanzania (there are 120 tribes in Tanzania), but one of the main populations here in the Karatu district, making up probably close to half of the patients we see during here during our FAME clinics as well as our mobile clinics. Most of the staff at Gibb’s Farm are Iraqw and, early on, most of the workers on the farm were all Iraqw as well from the local villages before it became the resort it is today. Traditionally, there have also been a number of woodcarvers who have had shops along the upper parts of the Gibb’s road. These carvers are all from the Makonde tribe of southern Tanzania and are the traditional wood carvers here, having been making masks, bowls and utensils for many years and now carvings of animals and similar more popular items for the tourist trade.

Peter utilizing the spread leg crouching
Coffee beans before roasted

One of the wood carvers, George Bias, had been here in my early days at FAME, though he apparently went home a number of years ago and his shop has been abandoned since then. Mbuga is the carver who I have dealt with during my more recent visits and his shop is well stocked with lots of carvings and even some paintings. Walking from FAME through the brick quarry and along the Tloma village road, it has often been quite convenient to stop there and check out his many carvings. We stopped today and, though Mbuga wasn’t there at the time, we did manage to each find aa few things. Next door to Mbuga is our new coffee supplier, who we had met last September during a wonderfully informative visit that took us from the coffee plant to the roasted bean with an extra bonus of stingless bees and their special honey. Lunch was awaiting at Gibb’s though, and the thought of our visit there was far too powerful to delay us any further.

Stingless bees
Honeycomb in the stingless beehive

Not wishing to be redundant, I’ll refrain from repeating my flowery descriptions of Gibb’s Farm and telling you that it is one of the most remarkable and peaceful places on earth and rather tell you that on our arrival, we were led to the mostly lovely outside table already set for the six of us (Dr. Anne was with us). In the past, Sunday brunches were buffet style, though during the pandemic, brunches were changed over to a fixed menu for safety reasons and have remained so despite the relaxation of restrictions throughout the country. Our table was set with more silverware than I’ve ever seen for a lunch and we sat underneath an incredible pergola with hanging plants and flowers all around us. Lunch was a delicious as you might imagine and each course was truly scrumptious including dessert that consisted of a rice pudding, fruit compote and two small scoops of homemade coffee ice cream.

The football pitch at Black Rhino Academy
Heading a corner kick
Our fearless leader

We sat for the longest time, completely relaxed and bathing in the wonderful ambience of such an incredible place as Gibb’s Farm. It is truly impossible for me to fully convey the experience of being in such a place other than to say unforgettable. I wish everyone could have the chance to experience such an afternoon as this as I have no doubt that it would surely cure most of the world’s problems. And if this wasn’t enough of perfect afternoon for us, Natalie and Alex had brought their swim suits with the hope that we would be able to take a dip in the new infinity pool built here a few years ago and after checking with management, they were fine with them using the pool with no charge.

William going after the ball

The pool looks out over the very same view that you see from the veranda, with the endless coffee fields stretching as far as you can see and the distant mountains towards Mang’ola. Though the pool was reportedly very cool (I was sitting in the shade the entire time talking with a friend), it was clearly refreshing as both Natalie and Alex enjoyed their time in the water while Savannah sat on the edge with her feet dangling. That is until a spider decided to threaten her life, or at least it seemed so with the scream she let out, jumping up in a flash. Yes, there are some big bugs here in Africa and I’m sure some of them seem even bigger than others. It was again a great ending to a simply lovely time at Gibb’s.

Valence
Quick footwork

We were heading to a football match that was being held at the Black Rhino Academy in Karatu, but it wasn’t starting until around 4 pm meaning that we still had time to stop and visit the coffee supplier on our way home. We had only planned to stop for a few minutes, but it was impossible not to be totally captivated by his home and his children as we all looked around his very simple operation, all powered by hand. We ordered our bags of coffee, twelve half kilo packages in total with nine of them whole bean and three ground. His coffee grinder is the absolute best, being powered by hand and collected on a sheet of brown paper, then put back in the same plastic bag and sealed. The consistency of the grind is amazing and far superior than anything you can achieve with a store bought power grinder, brewing the most flavorful of coffee considering also the beans from his fields.

A goal for the home team

We also tasted the honey that he collects from the numerous beehives that are hung along the front of his home and contain a variety of stingless bees whose honey is twice as expensive as that of the African bee. His two young children won over Savannah almost immediately as they were coloring stickers and placing them on her arm. After a bit, this evolved into a game of stuck in the middle with a soccer ball, and though I think Savannah had just a bit of a height advantage, she managed to make the game quite even as it should have been. During this entire time, his wife was inside the house madly sewing very cute kitenge cloth bags for each of our half kilo portions of coffee so they could be given as gifts. We had found this gem of a coffee supplier during our last visit here while walking to Gibb’s and they are such pleasures to deal with. When I later mentioned this to Leonard in Arusha, he told me this is the only person he buys coffee from given the quality of the beans. I should have guessed this was not a new discovery, even though we liked to think it was.

With the football match underway, it was now time to make our way to the Black Rhino Academy, where one of the very best pitches (fields) exists in Northern Tanzania. The Black Rhino Academy is an international school in Karatu that was the dream of Caroline Epe, who has been an integral part of FAME since the very beginning, having initially served as volunteer coordinator when I had first come in 2010, but moving on quickly to development and then finance within the organization. Her dream, though, had always been to build an international school in Karatu that would rival those found in Arusha and it sure does. She also created a sports center, hence the football pitch, that has hosted important matches in the recent past. It is a truly amazing facility with locker rooms, stands and the most amazing grass.

Dr. Adam and his quick footwork

The game tonight was between the FAME staff and a team put together from the coffee plantations. There were many fans in the stands, though we ended up sitting near the team benches and obviously cheering for our FAME team, who ended up winning the game 4 to 1. I left the game a bit early with Alex, Savannah and Anne as one of the fabrics that Alex had purchased ended up having significant slices through it that had apparently come from the factory like this as we found out when we returned it to the fabric shop, who gladly exchanged it as this seems to have happened before. We made it back home shortly before Natalie and Peter made it home after walking back from the stadium. It had been a wonderful 24 hours that had started at Happy Days the night before, foosball, The Golden Sparrow, sleeping in late, buying fabric, The Gibb’s Farm, coffee purchases and ending up at the football match. Though we had packed in quite a lot, it really didn’t seem so and we all spent a quite evening as tomorrow we would be starting another week of clinic.