Saturday, March 19 – A slow day in clinic, a power walk and a night at the Sparrow…

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We have been seeing a record number of patients in our neurology clinic, far outpacing even the busiest of the pre-pandemic clinics. There had always been a difference between our two clinics with the greatest number of patients always being seen in the fall months, a situation that had always been thought to be due to the planting season in March keeping people from clinic, though it was never something that we knew for sure. From day 1 of this trip, though, we have been steadily inundated with patients suffering from all sorts of neurologic diagnoses and that has included the mobile clinics. Having taken yesterday off to go to Manyara so that Whitley and Meredith would get their second game drive in, we were now going to be in clinic all day, and even though last Saturday had been very busy, today wasn’t looking quite the same.

Meredith and Whitley on their day of departure with Dr. Anne

With Whitley and Meredith having plans to depart this morning as their flight out of Kilimanjaro was scheduled for 5pm, there was no intention of having them work today meaning that I was now on my own staffing the four resident teams that we had been using so far. Not that I hadn’t done this in the past, but I had definitely gotten used to the luxury of having two fellow attendings available to staff patients with me. They had both decided to have a nice breakfast at the Lilac Café, our onsite cantina that had been built when the hospital came into being as there needed to be a kitchen to prepare food for the patients and a restaurant where visiting family could find food as many would stay in the area having often come from distant locations.

Peter and Abdulhamid, the dynamic duo, evaluating a patient in clinic

Sitting outside of Lilac for breakfast, or even a simple coffee, has to be one of life’s true pleasures for there is absolutely no sense of time and all of your troubles seems to melt away in the breezy sunshine that is ever present. The menu here has both Western selections for the volunteers and the stray tourists that end up there as well as local selections for the visiting families that may be staying in the area. Since it’s conception, Lilac has always been a staple here for the volunteers for either the weekend dinners that are not supplied by FAME or if one develops a hankering for food more familiar to them during the week. If you happen to miss breakfast at home, you can always catch a coffee or a samosa there to bring to clinic. Thankfully, though, lunch for the entire FAME staff is served every day of the week.

Natalie and Eliza evaluating a very cute child

Given the short clinic today that ended by around 3pm, we took the opportunity for a group walk through the nearby fields so I could finally show everyone the loop that we have used over the years that is around 3 miles and takes 45 minutes to complete. Since the very beginning, long walks or runs have been the best source of exercise while volunteering here at FAME. As some may recall, though, I did buy a mountain bike for my visit back in September 2020 during the pandemic when I was here all alone as travel had been banned for the medical students and residents. Biking here was a blast, but required sufficient time in the afternoon/evening and is difficult to do given our current schedule. Besides, I choose not to abandon the residents in the evenings as these are some of the best times we have to share our stories of the day and life here.

Alex and Anne evaluating a patient

On my very first visit to volunteer at FAME, I had decided to hike to a distant ridge, which I now know is within the Shangri La coffee plantation, to take some photos of the wonderful sunset we see every night here. I had told my two roommates, Carolyn and Joyce, where I was going and promptly set off on my expedition to reach that distant ridge I had my eye on. Unfortunately, I hadn’t planned very well at all, bringing only my camera and small backpack without a flashlight or phone, the latter of which wasn’t really a thing here back then. I reached the ridge after a good hour’s journey and managed to get a few, mostly disappointing, mediocre shots of sunset that didn’t do it justice and turned back for my return trip in the quickly fading light that is so typical here. When sunset happens near the equator, it is very much like a heavy, dark curtain suddenly falling and there is no dusk. In the quickly spreading blackness of the night, and without a moon to light my way I should mention, I suddenly realized the error of my ways and the fact that I had no means of illuminating my path home that would lead me through not only the coffee orchards, but also through some very sketchy, overgrown and dilapidated orchards I had walked through on my way up and had remembered being a bit weary and that was in the light.

Our power walk through the fields

To this day, I don’t recall most of that walk, during which time I had to suppress every fear my mind managed to drum up along the way, from leopards to cape buffalo, with every shadow and every bush looking like a wild animal. The walk back to FAME seemed like it lasted forever and when I finally returned and walked through the door of the volunteer house, Carolyn and Joyce were both incredibly relieved to see me, but equally furious with me for putting them through having thought that I had been eaten along the way. They both admitted that they had been very close to sending out a search party, but given the early days of FAME, were unsure of who to have contacted to arrange that. I learned many lessons from that experience that included not only hiking where I had no I idea where I was going or how far it was, but also never putting a roommate through such an ordeal. And yes, I travel nowhere without a torch, or flashlight, these days.

Relaxing after the walk

Our power walk this day served its purpose of getting everyone’s juices flowing well. The others had undertaken a few runs over the last weeks, though I had wanted to show them the loop we have used over the years and there was little question that I could use the exercise in the process. The fields next door to FAME in the direction of our walks are gorgeous and there are trails the locals take through them to get to their work or to school, though depending on when the fields were last plowed or when it last rained, the trails can be less than easy to follow or incredibly muddy to where your feet suddenly feel like they each weigh 10 lbs. after completely caking with the dense red clay. Thankfully, we were reasonable able to follow the path this afternoon as it coursed along the edge of the recently plowed field near the line of trees that separates one field from the next. When exactly to break away from the path is the tough part as otherwise you will end up in circles. We found the larger road to take next and then looped up along the top of the fields for the return trip home. The route is not entirely obvious to the uninitiated and my hope was that the others would remember the turns to take, but that isn’t always the case.

Sunset

We returned home in plenty of time for some rest and showers prior to all of us meeting for dinner at Happy Days, one of the local pubs here in Karatu, that had been arranged for a number of FAME who had been on a hike to the crater rim earlier in the day. Though Happy Day had been the ex-pat hangout for many years, there had been a number of management changes and I hadn’t been there in several years. It’s hard to judge whether the food served tonight would be representative or the same as just sopping there for dinner, but tonight’s meal was incredibly delicious – rice and beef stew, roasted chicken, coleslaw and salad. Everyone had a wonderful time at dinner and the foosball table served to bring out the killer instinct in even the meekest of my residents. I believe Natalie and Savannah may have been the most serious, but sweet Alex was definitely the sleeper of the group, winning several games quietly and inconspicuously. As for me, a single game played quite sloppily was enough to tell me that foosball would not be my road to retirement and that I should stick to being an observer and simply cheering on the others.

Foosball table at Happy Days

We had planned to finish the night at the Golden Sparrow as everyone was once again looking forward to the dance floor there. We loaded Turtle and made our way over to the Sparrow, taking back roads as it was only about a kilometer as the crow flied and our route was not much more than that. The club was pretty much empty other than us, with perhaps a local couple or two sitting in the shadows and the normally present DJ hadn’t arrived yet. Of course, that didn’t stop any of us from hitting the dancefloor and we were off to the races with essentially three hours of non-stop dancing. The best part, though, was that the club began to completely fill up with a whole array of locals, some of who also took to the dancefloor, joining us, and it was a super special time as even though we were visitors to this lovely country, there was clearly a greater sense of oneness that night.

The well-known phrase that we often use in the US has been modified here, though still fully applies. “What happens at the Sparrow, stays at the Sparrow.” I do know that many of the past residents and faculty who have accompanied me in the past very much appreciate this fact and it has been my duty to make sure that everyone returns safely after a night at the Sparrow.  

Friday, March 18 – A visit to Lake Manyara…

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A weary cape buffalo not sure what to make of us

Though our game drives have typically always occurred on Sundays (hence the term “safari Sunday” that I’ve used over the years), with Whitley and Meredith departing on Saturday, I took the opportunity to switch around the schedule a bit so they would be able to experience two game drives during their two weeks here. Two weeks is an incredibly short time to come to FAME, but with everything already in place for them, as well as the fact that Whitley had been to FAME previously and Meredith to Bugando Medical School in Mwanza during her residency, they had both experienced the culture here in the past and it was not a difficult transition for them. I was also so happy to have the two of them here to work with us as our clinics had been incredibly busy requiring four teams seeing patients at once given the volume meaning that there that many more patients to staff. I knew that I would be swamped for the upcoming two weeks and the little respite I had with them here was tremendously appreciated. It had allowed me to tend to some of my other responsibilities such as the fact that I am on the Board of Directors for FAME and we are currently working on our five year strategic planning.

A pair of bee-eaters
A male impala

The national parks on the Northern Tanzania safari circuit each have their own unique features making it worthwhile to see all of them if possible. The parks include the Serengeti, which obviously speaks for itself and is perhaps the finest of all experiences in Africa with its vast and never-ending plains and the draw of the great migration; Ngorongoro Crater, an ecosystem of its own with herds of animals that do not migrate for they have everything they need within their home range; Tarangire National Park, which is centered around a river ecology for the Tarangire River that runs the length of the park and dominates the behavior of the animals with them scattered in the wet season and congregated in the around the river in the dry season; Lake Manyara, a park that is center around the lake ecology and was once the home of numerous black rhino that were over hunted and are now gone forever in that location. There is also Arusha National Park on the slopes of Mt. Meru, a park dominated by the mountainous terrain where there are plenty of animals other than the big cats, but lots of monkeys including the large black colobus. There are also many other parks in Tanzania as well, a few much bigger than the Serengeti and are in the southern and central parts of the country, but they are much less visited as accessibility is much more difficult.

A baby baboon taking a ride from mom
Grooming

As I have mentioned previously, Lake Manyara was made famous by Ernest Hemingway in his book, The Green Hills of Africa, a less common non-fiction piece that was written about a hunting trip to Tanzania by the author and his wife in search of the largest rhino horns they could find with a number of friends. From a historical perspective it is quite good, but would obviously be quite frowned upon based on our current cultural mores and what is considered politically correct. Regardless, the book is a colorful collection of images from another era in the history of Africa and that of the colonialism that so dominated the land until it was all turned on end and independence became the norm. As many of you may be aware, the Nobel Prize in Literature was won last year by Abdulrazak Gurnah, an amazing author who was born and lived in Tanzania for his early life and then emigrated to England after his teenage years. His books tell the story of colonialism in East Africa and its effect on the population here. The stories are colorful and informative and well worth reading if you can find them.

Acoma lizard

Thankfully, Manyara is the closest park to FAME as far as the time it takes to get into the park itself. Though Ngorongoro Crater may be closer as the crow flies, the time it takes to reach the crater floor considering the drive up to the crater rim and then down into the crater itself is tremendously greater as the route to Manyara is all tarmac the entire way. Starting out that morning, Karatu was essentially in the middle of a dense cloud making the visibility nearly impossible as we began our journey. Still worse, driving through Rhotia, higher in elevation than Karatu, visibility dropped to precipitously and without other vehicles on the road that early, there were no taillights to follow. As we made our way lower towards the village of Manyara, still high on the escarpment about Lake Manyara, the fog began to lift and we were finally able to see the lake down below. Thankfully, the weather only continued to improve throughout the day and remained incredibly gorgeous during our entire stay in the park.

One of our friendly elephants

There is a new entrance to the park with artificial waterfalls spilling down the sides and the entire gatehouse has been moved well inside where it was before. About seven years ago, there was a tremendous flash flood that occurred here with an incredible number of huge boulders that came tumbling down the stream that crossed the road into the entrance area of the park. The result was that the entire road and bridge were washed away and the entrance area inside the park where a number of buildings existed such as the bathrooms and small displays were entirely covered with over six feet of debris that filled in the entire area. No one was hurt as it occurred over night, but with the only highway connecting Arusha with Karatu and the Serengeti beyond now completely washed out, no vehicles could cross. This occurred three days prior to Danielle Becker and me having to leave and there was a question of whether we could actually get out or not. Safari vehicles and buses were trapped on either side and the washed out road became a waypoint where guests were passed on to waiting vehicles on the other side, either coming or going, with luggage having to be hand carried across the ravine. Amazingly, and somewhat to our disappointment, the road was repaired in time for our departure and other than having to drive across a part of the newly constructed road that was still covered in debris and water, we made it safely and were on our way to Arusha and Kilimanjaro International Airport for our scheduled departure.

A baby vervet monkey

Though there have been no flash floods lately, there were some extra heavy rains in February causing the level of Manyara to have risen to unexpectedly such that much of the area along the lakeshore is now completely underwater. Where we used to spend lots of time around the hippo pool looking at all the incredible birds, it is now an eerie sea of dead trees and our previous roads have now completely disappeared into the oblivion. It’s a very strange sight having been coming here frequently for the last twelve years and to now see the present landscape. The main road through the park is still completely intact and it drives along the cliffs that lead from the valley floor up the escarpment. The steep rise and incredibly lovely trees and undergrowth up the cliffs remains intact and the scenery remains spectacular, but the amount of dry land for all of the wildlife has been greatly reduced and the areas where I have spotted the prides of lions on past trips are now gone. Whether this is a sign of global warming or just an aberrant weather season is unclear, but either way, it’s disappointing to see as it looks like the landscape is suffering in some way.

Oxpeckers on a cape buffalo

There were plenty of impala in the foothills, with the large harems of a single male and many, many females as well as the bachelor herds made up of the single males hoping someday to have their own harem by either challenging a dominant male or stealing some females and growing their own harem. We saw none of the incredibly cute klipspringers, a small rock antelope that looks the part, stocky and heavily muscled for jumping from rock outcropping to rock outcropping. I had always seen them around the Magi Moto (hot water) lunch spot where the hot springs are, but now with the water level so high, the shore has taken them over.

A blue monkey

One thing was for sure, though, and that was the tremendous troops of olive baboons that seemed to appear at every turn and, whether in the trees by the roadside or merely making their way along the road, they are always an attraction. The little babies either riding on their mother’s backs or hanging on for dear life on their mother’s chest as they scamper along the ground. They seem to be thriving and though not visibly affected by the altered landscape, I am sure that in some way they must be. There are also smaller families of vervet monkeys and even fewer of the blue monkeys. These are equally cute and perhaps even more so for there are no large ferocious males lurking around dominating the actions of others. There is always something about the baby monkeys, though, for the emotion they stir in all of us. Other baby animals, such as the elephants and lions, are also tremendously cute, but they do not create that same emotion in us that the baby monkeys do and it is clearly understandable.

A baby vervet monkey
Some dramatic coloration of the vervet (not the blue) monkey

The big attraction today, though, was the elephants, which were initially few in number, but at the end of the day, began to grow in numbers as they were making their way to their homes for the night. Watching these huge creatures that are clearly so intelligent when you glance into their eyes as they are watching every move of ours. Parking the vehicle in the middle of a small family feeding along the road, they will slowly move towards us, initially with some skepticism, though once reassured that we are not dangerous, they become less tense and even allow their babies nearby. Despite reassuring everyone in the vehicle that as long as they remain quiet and make no sudden moves, it can still be unsettling to have these huge behemoths ambling only a foot or two from the car. I think this is one of my favorite things, to sit quietly almost as part of the landscape and to have at least some acceptance by these remarkable creatures that they are willing to relax (albeit somewhat) and for us to be in their presence. They are simply the most graceful of beings.

A blue monkey

Despite the severely altered landscape, we were able to spot other wildlife during the day and the weather turned out to be absolutely spectacular for us, something that has been hit or miss as you heard from the rains of the last days. We left the park fully satisfied that we had once again had a wonderful experience in this amazing country. After a quick stop at the African Galleria for someone to pick up something they had purchased earlier, we were back on the road to get Alex home in time for another interview, this one much shorter, and then it was out to dinner at Green Park, a local outdoor restaurant serving nyamachoma, or barbecue, as it was Whitley and Meredith’s last night here. They would be departing tomorrow and would be greatly missed by everyone, but mostly me, for their assistance in helping with the residents was a godsend for me during their time here. Now I would be on my own, and though I have done this for so many years, it is always wonderful to have a few partners in the process.

Whitley and Matilda

Thursday, March 17 – Back to Rift Valley Children’s Village and some very heavy rains…

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The rain fell heavily overnight making a terrible racket on the metal roof of the Raynes House, but all I could think about was the road to the Children’s Village as it would once again be incredibly challenging to get there. We have had to cancel mobile clinics in the past due to the road conditions and I have written before about the time I slid off the road and managed to get my Land Rover stuck axle-deep in the mud on the way to Mbulumbulu, making it not only impossible to get to the planned clinic, but also taking three hours to literally dig ourselves out of the predicament.

Veronica, Joel, and Kitashu before clinic starts

I got up extra early to drive Turtle down to Soja’s shop as he had told me to be there at 7:00 am, though I waited for over twenty minutes to no avail and finally walked over to his house to find him. The door was open, so I offered the appropriate response of “hodi,” which essentially means, “may I enter.” Hearing “karibu,” or “welcome,” I entered to find several of Soja’s children in the front room who told me that their father was there and they would let him know that I was outside. After a few minutes, Soja appeared and walked over with me to his shop where I had parked Turtle. To make the repair, it required pulling the floor coverings up and over both of the shift levers and then bending the transfer case lever towards the back so that the throw of the stick shift would now clear the dash. Having finished the work by 8:00 am, I asked him what I owed for the work and he said that there was no charge for the work. Given that I had dragged him out of his house at an ungodly hour, I insisted that I would pay him something for the work, but having no cash on me, that I would return later to make good.

Abdulhamid and Peter evaluating a patient

Kitashu texted me regarding the roads suggesting that one of the FAME drivers take us to RVCV in Turtle which I thought was a reasonable suggestion and something we have done in the past. As much as I love to take on a challenge, and especially one that involves driving a Land Rover through tricky and unknown terrain in East Africa, I have come to realize that it is quite unfair for me to risk our ability to get to a clinic for the small bit of machismo I would receive. Unfortunately, it ended up not be a decision that had to make as there were no drivers available given late notice of Kitashu’s request, so it was up to me to get our crew to the Children’s Village come hell or high water, and I had a sneaking suspicion that it would very likely involve both of those.

Whitley working

The road was now a bit worse than yesterday evening, though thankfully I had my full complement of gears with the transfer case now being fully functional, as I could take the downhill portions of the drive in the lower range, thus allowing the engine to brake our descent rather than utilizing the brakes. The lower range was also necessary on the uphill portions of the drive where the maximum amount of torque and maintaining RPM was a necessity. The drive was pretty amazing all in all, and I became totally confident in the abilities of my Land Rover, now with its full complement of gears, as well as to some degree in myself for it was a handful to keep the vehicle on the road and moving in a forward direction until we finally reached the village and prepared to complete our day of patients. As I was approaching the gate of the village, though, a very large squeal began that sounded like it was coming from one of the wheels and I was worried it was a wheel bearing. Thankfully, they have a full-time mechanic at the village and I was later In the morning able to hand over my keys to he and a driver, who determined that the noise was from mud having gotten collected and caked on one of the disc brakes. One cleaned, the squeak disappeared and it was another disaster averted as any major repair would have been difficult, though I’m sure they would have gotten it done for us in a timely fashion to have prevented us from having to overnight there.

Savannah and Eliza staffing with Meredith

Pulling into the village, I had a sense of real accomplishment having tackled what can only be described as a truly gnarly road and, I must admit, I also had a sense of relief as those memories of sliding off that road a decade ago have stuck with me all this time. How the drivers from RVCV do this all the time is quite remarkable and my hat goes off to them. There were many patients waiting for us to see them, of course, and it was now down to the job we had really come to accomplish. Starting clinic was a snap as everyone had already become quite accustomed to their rooms and the routine here.

Children playing at RVCV

We did have one very nice addition to clinic this morning and that was Abdulhamid, who had traveled from Dar to work with us for the rest of the month. Abdulhamid is from Karatu and first came to work with us when he was a medical student several years ago. It was actually complete happenstance as had just wanted to volunteer at FAME during one of his school breaks and we happened to be working at the time and in need of a translator. He quickly became interested in neurology (how could one not?) and during his time with us has become a topnotch neurologist whose histories and examinations are as thorough as any trainee I’ve worked with. In 2019, we were able to bring him to Penn for a month with the assistance of the Center for Global Health and he spent his time mostly with the inpatient neurology services. From never having been on a plane to traveling to Philadelphia for the month and even visiting NYC, I am sure that it was a life-changing experience for him.

A father and one of our patients

Returning home, he has graduated medical school and now completed his internship. Most physicians in Tanzania, after finishing their internships, will go to work as generalists rather than starting residencies for the sole reason that one has to pay for residency here as there is no government health system like Medicare, which is what pays for our training programs in the US and allows residents to receive income. Here, one must be sponsored in some fashion or have the means to pay for their residency education. Until recently, all of the MDs at FAME have been generalists and we only recently hired a residency trained general surgeon to head the surgery program here.

A shopping frenzy

Then there is the problem that there are very few neurology training programs in Africa and, until recently, there were none in Tanzania. Even the program that currently exists at Muhimbili University, which now has two neurology fellows (neurology is a two-year fellowship here after one completes their internal medicine residency) only recently came into being and though the fellows that I met last fall were very good, they are lacking a faculty neurologist currently, making it very difficult to entertain a full program similar to our residency training at home. How do you create a neurology department and training program in a country that has fewer than a handful of neurologists  or a continent where many countries still have no neurologists?

One of the sewing machines for use by the Women’s group

In Zambia, a country that was in a similar situation only several years ago, two neurologists from the US have now helped create a bona fide neurology training program that rivals many in the US and they have now graduated fully trained neurologists in a country where there were few previously. Omar Saddiqi, who is on faculty at Harvard Medical School and is a neurovirologist, has been living in Zambia with his family for probably ten years now, has been working in the capital city and providing incredible research on HIV, TB and epilepsy. Deana Saylor, a Johns Hopkins neuroinfectious disease specialist moved to Zambia with her family just prior to the pandemic to create the neurology residency program and maintained it single handedly during the height of COVID as there was little in the way of international travel during that time. It is programs like these that will create the future neurologists for Africa and in low resource settings.

Meanwhile, our visit today went smoothly and we had a good number of patients to see, but with the four rooms going and help from both Meredith and Whitley, we were able to get everything completed. Of course, we made certain that we enjoyed another wonderful lunch with the RVCV volunteers and, at the end of the day, visited the duka, or shop, where all of the items made by the Rift Valley Women’s Group are on sale. In addition to the Children’s Village, the other activities of the Tanzanian Children’s Fund focus community empowerment and include microfinance programs and the women’s group, which in the latter, women are trained in making various crafts such as clothing, computer cases, bags, pouches and other useful things using cloth as well as jewelry. Similar to what many organizations have learned in the past, empowering women is tremendously more effective in supporting families as the income will go exclusively home where the same cannot be said for the alternative, empowering men. Nothing sexist there, just reality.

Shoes from one of the children’s houses

The visit to the duka is one of the other highlights of a visit to the RVCV and this group of residents were no different than any of the last that I have brought. The items to purchase are either incredibly useful or incredibly beautiful or both and everything is priced very reasonable. In the US, these items would go for multiples of what is charged in the duka. After completely their shopping, we all walked over to one of the houses where the children live, each managed by a house mama. The houses are grouped by the age of the children and by sex. The youngest child they now have is a local 9-month old baby who was recently orphaned when her mother was killed by a cape buffalo and the family couldn’t care for the child. As we were in the house, it began to rain heavily meaning the drive home was going to be another challenge for us. In fact, just making it to the vehicle can, at times, be a challenge.

Anne and Turtle

There is another way home from RVCV that I had never driven before and that was through the village of Odeani, where I had never been in the past. The road is supposedly better graded and there are none of the steep ascents or descents to content with. It is a bit longer, though, but knowing that we had a better chance of making it home was enough to sway the decision and it was off we went once we finished our tours. Anne and Eliza who had intended to ride home with the others and despite the fact that Anne told Kitashu that she’d kill him if he left, they were abandoned and had to drive home with us. The road was truly better which was apparent by the numerous vehicles from RVCV that we passed who were heading home after we had left. Navigating a tight one lane road in the mud with ditches on both sides can be a challenge in those situations, but all worked out well. When we reached the road to Mang’ola that we had taken days earlier and turned to head home to Karatu, the skies opened up and an intense downpour began that made it difficult to even see the road. The numerous culverts that cross the road repeatedly became raging torrents of water throwing a muddy bath entirely over the top of Turtle and our windshield, temporarily blinding us as we hit each of the crossings. Thankfully, though, the road was gravel and not the slippery mud of the other smaller roads, so I was confident by now that we were assured of making it home. We dropped Anne and Eliza in town and as we passed Frank and Susan’s house to get to ours, I received a text from Susan as she had been worried about us with all the rain. I was quite happy to home once again and tomorrow we would be heading to Lake Manyara National Park for a game drive as Meredith and Whitley were leaving on Saturday.

Wednesday, March 16 – A visit to Rift Valley Children’s Village…

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Eliza, Dr. Anne, and Natalie sharing the pediatric room

Rift Valley Children’s Village, or RVCV for short, is a very special place for so many reasons, though one of the most important for me is its connection with FAME. When Frank and Susan had made the decision to come to Tanzania and set up a health clinic, the exact location and nature of the clinic had not yet been decided. In the end, though, it was through their meeting and connection with India Howell, the founder of RVCV and its parent organization, the Tanzania Children’s Foundation, that was to be the guiding light and the determining factor when it came to FAME’s location and, in the end, its proximity to RVCV and Ngorongoro Crater. To be honest, I don’t know the full story behind how the location of RVCV came to be, but it preceded FAME by several years.

Peter and Daniel seeing a patient together. Daniel is now a clinical officer and one of India’s children

Rift Valley Children’s Village came to be when India, who had come to Tanzania with the tourist industry, quickly became aware of the vast number of “street children” here who were essentially homeless as they were either orphaned or their parents were no longer able to care for them. Rather than creating an orphanage, where the children would still lack a true home, she partnered with her Tanzanian business associate, Peter Mmassy, to create both the Tanzanian Children’s Fund and RVCV, the latter serving as a true home for the children living there who would all be adopted by India and Peter, growing up in the village with their family and eventually going away to college and making a life of their own. Over the last several years, the number of children has remained stable at around 100 and their ages have ranged from infancy through early adulthood.

Nuruana and Alex evaluating a patient

India and Peter also had the insight very early on that their children would need the best of medical care that could be provided in Tanzania and this is how the relationship with FAME came to be. Locating FAME in Karatu would not only allow for the much needed care of patients throughout the Karatu district and the NCA, but its location would also allow an opportunity for those tourists traveling through the area to give back to the communities they so enjoyed during their game drives here. Over the years, as FAME has continued to grow, the relationship between the two organizations has continued to solidify.

Savannah and Africanus

Something that India also realized very early on was not only the need for her to provide basic medical services for her children, but also for the surrounding community for the children from these villages would all be in the same school with her children and all going home to their families for the evening. Without having a healthier population in which the children of RVCV lived and played, it would be difficult to keep her children healthy. Thus, began the collaborative effort of RVCV and FAME in providing not only the clinics to administer the medical care, but also the funding to cover the cost of that care as the region surrounding RVCV is extremely poor with the only real means of support  picking the coffee beans during the very short harvest window. FAME doctors and nurses would travel to the Children’s Village two monthly for these clinics and, in the early years, neurology would tag along with the FAME crew and run a clinic side by side with the general medical clinic.

Lunch with the RVCV volunteers

For a number of reasons, the general medical clinics at RVCV ended as it was felt to be more efficient to have some of the care provided by a full-time nurse or clinical officer onsite and any patients needing further care could travel the short distance to Karatu and be seen at FAME as there are cares traveling back and forth all day long. The neurology clinics continued, though, and became part of our mobile clinic week where our team would travel to RVCV for two consecutive days in which we’d see all of their children and also provide continuity care to the neurology patients from the community. As such, it has remained one of the cornerstones of our neurological care here in the Ngorongoro Highlands and probably one of the favorite activities here for the residents as the Children’s Village is an absolute pleasure to visit not only for its facilities, but also for the incredibly uplifting sense of wellness one gets by just being there. If there truly is a Shangri La, this is surely one of the leading contenders.

Our lunch spread

The road to RVCV is entirely another story. In good weather, it is a bumpy and dusty trail that traverses several ridgelines and drops into an equal number of ravines along the way. Portions of the road are quite steep, necessitating the use of one’s transfer case and the low range gears when driving a large, fully-loaded vehicle such as Turtle. The problem was that they had done some repairs on Turtle while I was in the US, one of which included replacing the gearbox, and they had apparently not checked that the transfer case shift lever had enough clearance with the lower portion of the dash. It’s a bit of a long story, but Turtle is actually a Td5 Land Rover, but the engine and gearbox had been replaced with older 300 series units due to their better reliability. Though more reliable, the fit isn’t exactly perfect, hence the issue with shift lever and the fact that I had no low gears, not a problem for the morning drive, but as you will soon see, was an issue for the return trip.

Alex (in the middle) staffing with Whitley (L) and Meredith (R)

The first time one arrives to the Children’s Village, it’s an experience. There is a sense of calmness that comes over you as you enter the gate and only continues throughout the day. Driving up to the administration building, our patients are immediately visible sitting on benches out front waiting to be registered. Africanus, who I had worked with previously, is now the clinical officer there after having working for a brief stint at FAME. He is the perfect person to be running the health center there for a number of reasons that include his personality and the ease with which he deals with any situation and has also organized our visits there. All the support staff are there, charts have been pulled and we have separate stacks of children and adults needing to be seen. Including his office, which he has always graciously given to us, there are four examination rooms all ready for our use along with a room for the pharmacy. In addition to the translators we bring, any of the older children there can also help out as their English is impeccable.

Dr. Anne and one of her patients

Natalie had the most appropriate of rooms in which to see her children as it was decorated as one would imagine a pediatrician’s office would be. She worked with Dr. Anne and they had a selection of patients that included epilepsy, headache, and learning disorders. The latter is always a challenge as the children don’t always come with collateral information from a parent or family member and most often we don’t have a teacher, just a report. Though RVCV does work with a psychologist, the visits are not on a regular basis and getting some more formal testing, such as neuro-psychological testing can be very difficult or impossible to obtain. Having the resources that we do in the US for these situations becomes eye-opening and trying to navigate the intricacies of educational accommodations here is typically an exercise in frustration.

Anne and Natalie seeing Valentine

One of the highlights of our visits to RVCV has to be the lunch that is provided for us that is served alongside all of the other volunteers there. The mamas that do the cooking are simply amazing and the lunches are an assortment of homemade items that typically includes freshly baked breads, incredibly fresh salads, and local fruits. Today’s lunch was a Tanzanian version of a burrito with thin chapati, hamburger meat, rice, fresh tomato salsa that we assembled ourselves and smothered in lots of hot sauce. Though I am constantly raving about the wonderful lunches at FAME (basically beans and rice with mchicha and pili pili sauce) that I miss terribly on my return home, I will have to admit that the lunches at RVCV are a fantastic diversion to the routine at FAME and, between the two of them, it is a wonderful balance.

Valentine’s incredibly infectious smile

One of the other highlights for me has been the opportunity to have cared for many of my patients over a number of years, and one such patient, Valentine, is a young boy who I have become particularly attached to over time. I began seeing him when he was very young and was having a great number of seizures as a result of his probable hypoxic-ischemic injury at birth and he also has a fairly profound spastic hemiparesis. His anti-seizure medication was changed and he has now been seizure-free for several years as a result. Though he remains significantly impaired from his birth injury, the fact that he has been seizure-free has allowed him to gain skills and the risk of SUDEP, or sudden unexplained death in epilepsy, has great decreased with the seizure control. In the past, he would always try to hide from me when I came in the room, usually under his mother’s arm, but would warm up to me as remained present. This time, he broke out into an enormously wonderful smile when he saw me and had no intention of hiding under his mothers arm, but rather was totally engaging from the moment I walked in. I realized that he was now growing up.

Valentine and me

One of the unforeseen issues of having senior residents come in the spring is the chance that it will conflict with their interviewing for fellowship programs. We have a similar issue with the March trip for medical students as it conflicts with Match Day, though I have never really understood how missing an incredible adventure to Tanzania could possibly be equated to being present for a single day in which you find out something that can’t be changed. This is often a day of celebration for most, as well as a disappointment for some, but in all honesty, the only reason to be present in the US would be if you didn’t happen to match at all and needed to scramble to find a last minute spot. That is a scenario that most would know well in advance or at least have some inkling of the likelihood. In any event, Alex had to be home by 5:30 pm tonight for a fellowship interview which was to begin at 10:30 am in the US and was to run for about 7 hours! She would be up until the wee hours doing her interview on Zoom interviews to which we have become accustomed.

Loading Turtle in the heavy rains

In the afternoon, though, it had begun to rain fairly steadily and continued raining for the remainder of our afternoon session. That was concerning as it now meant the road that we had taken in this morning would now become a muddy slip and slide and trying to navigate the steep downhill sections would be incredibly treacherous given the lack of low gears that I had discussed earlier. Descending these roads was challenging in the best of conditions and when briefly tapping your brakes to slow your downhill speed could mean the difference between maintaining control or starting to slide, having the engine slow your descent is essential. Additionally, the rear of the vehicle continually slides from side to side depending on the ruts in the roads and is quite exciting for those in the rear seats as they get to experience the greatest effect of this given the distance they’re traveling. Controlling your vehicle in these conditions is anything but easy and finally reaching the tarmac was met with a cheer as it meant the difference between digging ourselves out of a ditch and having Alex miss her interview versus enjoying dinner on time in our comfortable home. Thankfully, it was the former, and Alex made it to her interview with time to spare.

On the way home, I also saw Soja, our mechanic here in Karatu, walking along the road in front of his home/shop and was able to arrange bringing Turtle in at 7:00 am the following morning to look at the transfer case shift lever to see if he could fix it. We would be returning to RVCV tomorrow for another day of clinic and I was very concerned about our ability to even make it there given the condition of the road on our return this even and that didn’t account for the massive amount of rain we were about to receive overnight.

Tuesday, March 15 – Another visit to Mang’ola, but this time to Mbuga Nyekundu…

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Reception at Mbuga Nyekundu

Having survived our day at the Barazani dispensary with a clinic full of patients, it was now time for us to make the long drive again, but to a different dispensary in a somewhat more remote area. Thankfully, the Mang’ola road has been in great condition and the typical dusty conditions have been less with the small rains that have come. Our drive is along the same route save for the very end where we head away from the lake to cross a huge ravine and bridge that has served as a backdrop for many a photo in the past. These routes have become second nature to me over the years, though I will have to admit that I’ve had a keen sense of direction since childhood having studied maps when others were reading books. Traveling once to a remote location is typically all that is required to imprint the route in my brain forever, often at the expense of more mundane, though equally important facts.

 

Natalie and Meredith in front of clinic
Christopher, our nurse for the day

Regardless, we pulled into the dispensary at Mbuga Nyekundu to find a brand new building that we would be using instead of the previous wards. The new building was quite nice with a large central atrium and lots of fresh air, though the numerous rooms for us to choose from were completely lacking of furniture requiring that we raid the other buildings of any chair, desk or table we could find that would enable us to have four mostly outfitted examination rooms. It did take a bit of time to get everything situated, but once we did, patients were brought in for the residents to see with Whitley, Meredith and me staffing them as they went.

 

Alex in a Zen moment before clinic starts
Peter and Nuruana evaluating a patient
Savannah and Revo evaluating a patient

Once everyone was up and running seeing patients, Kitashu, Safari and I left to travel to the Barazani dispensary as we had to drop off medications for some patients who were told to come back today and we also wanted to complete our discussions with Dr. Damien. I drove and we took a shortcut that included driving across a huge dry riverbed with probably ten foot walls that must be incredibly impressive when the heavy rains come and it fills to the brim with raging water and would be totally impassable. I remember crossing one of these streams a number of years ago in the FAME bus when we were on the larger FAME mobile clinic. It was very late and sun had gone done, but we still a distance from clinic. The water was roaring down from the foothills and the drop off into the stream was far too large for even for our bus, which is an all-wheel drive vehicle and has very high ground clearance.

 

Meredith and Whitley staffing a patient with Savannah and Revo
Eliza and Natalie evaluating a patient
Dr. Anne and Alex

It took some effort from a number of team members using shovels and axes to break down the riverbanks in preparation for our entry and hopeful crossing as the water level began to drop. It took perhaps an hour or so for this to eventually happen, though not before an elderly Datoga man on a bicycle choose to ride across the river, looking at us with some consternation at the commotion we were making when we could have simply driven across.

 

Peter and Nuru evaluating a patient
Whitley and Meredith ready and waiting to staff patients
Peter administering an occiptial nerve block

Once back at the Barazani dispensary, we found the patients who needed the medications we had brought with us and again sat down with Dr. Damien to discuss what type of support we might be able to offer their clinic in the future. They have been so helpful to us by allowing us to come here and partner with them in providing the neurologic care that we do with their assistance. We eventually said our good byes and departed back to the dispensary at Mbuga Nyekundu where the rest of our team was diligently working to finish the patient load there. Shortly after, it was lunch time and we all gathered at the vehicles to again enjoy our lunch boxes from the Golden Sparrow that had more than enough food for each of us and I am sincerely doubtful that anyone of us was able to finish all of the food. We often eat in our vehicles or somewhere completely out of sight of the patients and their family members to be respectful of the fact that many of them may not have enough food to eat. When I had first gone to Kambi ya Simba many years ago and our team was so small, the village had prepared a traditional lunch for us. It was such a tremendous thrill for me at the time, to have been treated as such an honored guest out of their appreciation.

Lunchtime
Eliza and our little patient

 

The most interesting patient of the day, though was a very young child who had weakness of one of her legs and severe scoliosis that was easily seen on an x-ray that had been done in the past and which the mother brought to us. The child appeared otherwise neurologically normal in regard to its development and the other limbs, but the x-ray was very abnormal and not something we as neurologists would normally read. Using our WhatsApp neurology consult group that includes many residents as well as a pediatric neurology attending at CHOP and a neurosurgeon, we sent an image of the film as well as an image of the child. Unfortunately, it was a very difficult case for those who were reviewing it and it was decided to have the images reviewed by radiology at CHOP. Obviously, the question, depending on what’s going on, will be whether there is anything we can do about it going forward. If that is not clear on the x-ray, then we can always obtain a CT scan at FAME.

 

Our clinic was not nearly as busy as it had been on Monday at Barazani and our plan for the afternoon had been to visit Lake Eyasi as we had done last fall. Lake Eyasi is one of a series of shallow, elongated lakes that can be seen throughout the Rift Valley of East Africa and also include Lake Manyara and Lake Natron. These lakes are highly alkaline though manage to maintain a good supply of small fish that apparently produce enough of an income for them to continue their longstanding tradition. We had gone to visit the lake last September and it was an awesome experience as not only was the scenery incredibly picturesque, but the fisherman were also wonderfully generous in offering to take everyone out in the little dories. Of course, this sounded like a fantastic idea, though it was not until the boat left with about half of our team that they realized a steady bailing of the boat was required to keep it afloat due some serious leakage. Despite this serious flaw in our planning, the afternoon had turned out to be one of the highlights of our trip.

 

The beach at Lake Eyasi
Our drive to the beach

So, with this prior adventure in mind and the hope of a similar experience, we had planned to depart from Mbuga Nyekundu with time enough to get to the lake and enjoy the sights in a similar fashion as last September. As we were packing up, of course, one additional patient came who sounded like they had migraines, and rather than having her travel all the way to FAME for a relatively simple problem, Alex offered to see her and, thankfully, it did turn out to be a simple issue. So often, we’ll offer to see an add-on patient at the end of clinic and find that they are the most complex patient we’ve seen all day. My mantra is, “no good deed goes unpunished,” but the seems to portend a rather pessimistic view of the world, one that I certainly do not have. An alternative, and perhaps more positive, explanation might be that in offering to help, one must always accept whatever comes along, whether it be complicated or not.

 

Loading the first boat

We were on our way at an earlier enough hour to head to the lake and took the shortcut to Barazani that we had taken earlier, thought the dry riverbed and then turning off the main drag in the direction of the lake. The route took us through areas that are not typically traveled by large vehicles and, at times, they were simply not wide enough leaving the vegetation slapping at the sides of our Land Rover with a sudden “thwack.” We eventually came upon the very same beach that we had visited last September and I’m sure that we were remembered by the fisherman as we pulled up onto the beach and parked the two vehicles. Everyone was excited to dip their feet in the water and it was a gorgeous day with the sun shining bright and the temperature not too hot. The small waves of this large, shallow lake were continuously slapping against the sandy shore in an almost mesmerizing rhythm.

 

A definite Titanic moment
Natalie, Peter and Nuruana

Far out into the lake, the small dories of the fishermen plied, setting their long nets and then paddling back to shore to begin the process of hauling them in by hand. Each of the fishermen has his own harness made out of old burlaps sacks that he steps into, places it around his bottom, hooks into the line and then very slowly walks backwards as the net inches towards the shore. Multiple men will hook into the same line and as the first one has walked as far as he can on the beach, he unhooks from where he is and walks back to the water to hook back in and start anew. Given the weight of the catch and the length of the net and lines, this process will take quite a long time. I haven’t been there when one of the nets was completely brought ashore, so I can only imagine what the catch must be based on the resistance I felt when helping to pull the nets in.

 

Nuruana on board
Our little sandbar

Meanwhile, Kitashu once again spoke with the fishermen on our behalf to see if they would be willing to take a boatful of people out onto the lake for fun. About half of our group immediately volunteered to go on the first boat ride, including Eliza, who I don’t think knew what she was getting into initially. The boat had barely gotten out when it returned to drop her back off on sure as she became nervous. Now, I will have to admit that these boats were really not for the squeamish or risk adverse as it became immediately apparent upon launching that the boats required constant bailing to remain afloat. So, you might ask, why would anyone in their right mind get into a boat that is sinking even before the voyage begins. Though that is a very good question and I wondered the same thing last trip when I chose to remain on shore and take photos instead of getting into a boat, I don’t have any excuse this time as I was caught up in the excitement and jumped in the second boat without a thought.

 

Our group on the sandbar

With everyone onboard, we weighed anchor (not really, but it sounded good) and began to make our way to a little island that seemed so far away when looking from shore, but when we made it out there and then looked back, it was clear that we really hadn’t traveled very far at all. As we approached the sandbar, a lone flamingo and albatross were initially lurking around, but they quickly took their leave on our arrival not wishing to share their little piece of real estate with us. We spent some time exploring this tiny island, which took all of a minute, looking back at shore and realized that the other boat with the second half of our group had now decided to come out as well. Not wanting to disturb their experience, we chose to shove off head back to shore first. Like passing ships in the night, we each took the opportunity to photograph the other, while headed back to wait.

The other boat photographing us and vice versa
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The visit to the beach was one of the highlights of our visit to the Mang’ola region, an incredibly remote corner of this wonderful part of Tanzania that we have all made our home, for some of us much longer than others, and we jumped in our vehicles for the trip back to Karatu. One the way, the other vehicle carrying our support staff chose to stop at one of the onion fields, their local crop here, to purchase a supply as the price was much better there than in town. Certainly not something that would happen in Philadelphia.

 

Monday, March 14 – Our return to Mang’ola…

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Peter, Whitley and Dr. Mike arriving to clinic

Our neurology mobile clinics have been a part of FAME since first traveling to the Mbulumbulu region in 2011 with Paula Gremely, who had then been in Tanzania for many years providing access to health services through her own non-profit and who had partnered with FAME to provide services on their larger monthly clinic visits to the Lake Eyasi region. It had been Paula (pronounced “Paw-oo-la” as Swahili pronounces every vowel) who had first suggested traveling to some of the smaller villages in the Karatu district to provide our neurology services with advance notice to the villagers. FAME had been providing a weeklong monthly clinic for all services to the Hadza and the Datoga, two tribes in the Lake Eyasi region, as part of a grant from Malaria No More, and I had traveled on several of these which were very successful (and very often, exciting), though after our first visit to Kambi ya Simba (“Lion’s Camp”), it became quite clear that there was a role for these smaller, dedicated neurology clinics.

Registering patients at the beginning of clinic
Dr. Anne informing patients on the conditions we treat
Sorting through our pharmacy

The very first clinic was in a single Land Cruiser and consisted of me, Paula, Amira (Paula’s associate and driver), a clinical officer, Patricia (our nurse) and myself. We brought all the necessary medications and held our clinic outdoors as there was no health dispensary that was available to us for space. This first clinic was a great success and we managed to see a number of patients who were unaware that there was any treatment for their condition. I have always said that most often it is not a matter of the patients at these clinics being unable to get to FAME, but rather that they may be completely unaware of the fact that their condition is treatable so they don’t bother traveling to FAME. It is not uncommon at all for us to see an epilepsy patient at one of the mobile clinics who has had seizures for many years and had never seen anyone for their episodes or been on a medication.

Nurse Christopher taking our patients vitals
Whitley, Alex (mostly hidden), Shama and Natalie getting ready for clinic
Peter and Eliza checking emails before clinic

So, for one of the four weeks we spend at FAME, we dedicate it to our mobile clinics, traveling to different villages throughout the Karatu district to provide neurology assessments for the residents of those villages. Just to be clear, though, these villages have government dispensaries that are typically staffed by a clinical officer, or, in the very least, a nurse, who provide routine medical services for the residents. Our role is solely to provide neurologic services and we’re very  careful not to cross that line or step on anyone’s toes by our presence. We are guests when we visit these locations and will only come as long as we are invited. The district medical officer has become well aware and very supportive of these clinics over the years, though there have been times when our efforts have been misinterpreted by village elders as somehow being a money making activity and we have been asked to pay for each patient we see. We have explained to those villages that this is not the case and have simply left it at that as there are many other locations where the clinics have been appreciated and we’ve had fantastic partnerships with those villages.

A secret from Anne?
Savannah and Alex evaluating a patient
Anne and Savannah staffing a patient with Whitley and Dr. Mike
Natalie and Nuruana getting ready to see patients

This is obviously our mobile clinic week or I would not have prefaced this entry as I have. Since Meredith and Whitley were only here for two weeks and I wanted them to experience these clinics, I moved the week from our normal third week, to happen in the second week. Our team has increased in size from the single small Land Cruiser to now involving two vehicles and a host of other participants. Our group of seven, of course, with four clinicians/translators who would partner with each of the residents along with Kitashu, who would be the main organizer of the expedition, Christopher, our nurse, and a driver for the extra vehicle that would be required to help transport our team. We bring along a large container with all of the medications that are needed for the day and include not only our neurology meds, but also medications for blood pressure, in case they’re needed, antibiotics, antidepressants, antipsychotics, and whatever else we can think of. We also bring all of our old records from these clinics as we are not computerized, instructions for back exercises and whatever other paperwork we can think of that might help during the day. Oh yes, we also have to bring lunch with us and, for the last several years, have been in search of the best and equally affordable lunch box to bring with us. Today’s lunches would be coming from the Golden Sparrow, which we haven’t used in the past, and I, for one, was very enthusiastic to see what they would put in our lunch.

Safari, Revo and me during a break
Natalie and Revo evaluating a patient
Peter and Eliza evaluating a patient with Shama and Meredith looking on
Savannah, Alex and Anne evaluating a patient

We were planning to visit Mang’ola, which is about a 75 minute drive from Karatu when the packed dirt and gravel road is in good condition and it is not raining as there are multiple gulley crossings that completely flood in a heavy rain. Given the distance to the clinic, it was decided that we would leave at 7 am,  a not quite ungodly time to get two car loads of travelers together, but close, as there is typically much for us to do in preparation when we arrive. We have been traveling to the Barazani dispensary in Mang’ola for the last three or four years and it has been a very successful clinic both in the number of patients seen as well as the types of cases that we see. The dispensary is well-established and the clinical officer there, Dr. Damien, has been there for the entire time we’ve been visiting and has been incredibly happy to have us there seeing his patients.

Savannah examining a patient
As our patient load continues to grow
Natalie and Nuruana evaluating a child
Meredith, Eliza and Alex evaluating a patient

We walked through the building to see what rooms we could use, and though we had originally chosen to use only three exam rooms given the number of patients, it wasn’t long before the “waiting room” completely filled up with patients and we quickly maneuvered to create four rooms so that things would move more smoothly. Thankfully, we had brought four translators to work with everyone and it was quickly off to the races for the residents. Whitley and Meredith did most of the staffing for the day and I supervised, which means I sat and tried to work on my blog as much as possible. In addition to our regular crew, Shama, our infectious disease volunteer at FAME, has come along to join us and see what the mobile clinics were like. One of the patients we were asked to see today was a young girl with a reported heart problem and since both Shama and Natalie were there, it seemed like as good of time as any to tackle the problem.

Peter and Revo examining a patient
Alex and Eliza evaluating a patient

As is typical here, what is billed never seems to be case, and the plot thickened as her mother told the story. When she was much younger, she had reportedly contracted TB, though the therapy her mother described didn’t seem to be adequate if that was indeed what she had been treated for. The child was clearly small for her age and had been born prematurely, but her mother also gave the history that she had a heart condition but did not specify exactly how that had been determined or whether she had ever received a specific treatment for it. So, we essentially had a very young child who needed a very thorough cardiac and infectious work ups that were clearly not going to occur at the Barazani dispensary and the fact that needed to come to FAME to have a number of lab studies as well as an echocardiogram was clearly evident. Her mother did not have the necessary bus fare to get to Karatu (5000 TSh, or slightly more than $2 each way for each mother and child) so it was given to her by Kitashu (from me, of course) and she would come on a specific day when all of us would be there to direct her care. Where was the neurological problem, you might ask? There wasn’t one, but as it had been Dr. Damien who had asked us to look at the child, it was perfectly appropriate for us to facilitate the medical services that this young child would need.

Lunchtime
Shama and Natalie enjoying lunch
Anne and Whitley looking on while Savannah examines her patient

There were quite a few patients for us to see here, but the patient that really stuck out for me was a young 25-year-old gentleman that Peter was seeing who had been suffering with epilepsy since he was 12 years old and who was having several generalized tonic-clonic seizures a month. And throughout this entire time, he had never seen a doctor and had never been put on any anti-seizure medication. During the visit, the patient had one of his typical seizures with his typical semiology of a focal onset and then secondary generalization. The seizure lasted for over a minute during which time he was rolled on his side and his head was protected. He had clearly bit his tongue as he spit up some blood and was then post-ictal for probably 15-20 minutes during which he was initially a bit combative and then confused. All in all, though it was unfortunate that he had the seizure, it was incredibly helpful to us to have witnessed the onset of the event as it confirmed his seizure type and on which of the anti-seizure medications he would be started. He was placed on carbamazepine, a very common and inexpensive medication here and one used primarily for focal onset epilepsies.

Natalie examining a child
Natalie and Nuruana evaluating a young patient
Natalie and Nuruana evaluating a child

It was not until all was said and done and the patient had left clinic after receiving his medication and epilepsy education that Peter informed me that the patient and his father had traveled 5 hours on a boda boda (motorcycle) to come to our clinic after having heard that we would be there from one of our announcements. Though there is little question that the work we have all done here at FAME and in the surrounding communities have made the difference for countless individuals over the last twelve years, it is still stories like these that impact me the most. Knowing that had we not made the effort to continually return to Mang’ola and the Barazani dispensary, this young man would never have been brought here and would still be suffering from an entirely treatable condition with little hope in his life.

More children

Our day had been steadily busy and it was now time for us to pack things up and begin the drive home. We had seen a total of 40 patients between the four residents with Whitley, Meredith and me staffing (supervising) them. Dr. Damien met with Kitashu and me for a few minutes before our departure to discuss our future clinics with them and we were thankful for being invited back to a dispensary where we could make an impact on the health of the community. Tomorrow, we would be visiting a different dispensary in Mang’ola, but would also drop off some medications that we hadn’t brought with us and were necessary for patients. We bid everyone in Barazani goodbye and began our journey back to Karatu, arriving home around sunset. Tomorrow, we would be making the same journey to another village nearby.

Our pharmacy
Shama, Kitashu, Natalie and Nuruana evaluating a young girl
Revo, Meredith and Peter evaluating a patient
Our team before we depart Barazani

And more Ngorongoro Crater photos…

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Here are the top picks from the team that were taken by everyone using the better SLR cameras. All the photos in the previous blog were shot from iPhones.

And now for the winners…

An auger buzzard taking flight – photo by Natalie Ullman
A male grey crowned crane courting
The cory bustard – largest flying bird in Africa
The Meeting of the Minds

Sunday, March 13 – A lovely day in the crater…

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The crater floor from the overlook

Within the boundary of the Ngorongoro Conservation Area lies the crown jewel of the Tanzania, if not the entire African continent’s, wildlife parks. Ngorongoro Crater, which is a UNESCO World Heritage Site and the largest intact dry caldera in the world, is the remnant of a giant volcano the size of Mt. Kilimanjaro that erupted several million years ago and a reminder of the tremendous volcanic activity that still exists in the Great Rift Valley here in East Africa. There are several other smaller craters that exist just north of Ngorongoro Crater, but neither provides the immense habitat for animals that Ngorongoro does. The crater is a massive enclosed wildlife zone that is 12 miles across at its widest point and the crater rim is a steep 2000 feet that must be descended to get to the floor. Within the crater lives every species of animal in the region other than the giraffe, who cannot descent the steep crater wall, and the crocodile, as there are no flowing rivers within the crater.

The neuro team from the overlook in the morning
Our super explorer ready for action

One of the most treasured of all the species of animal in Tanzania lives here which is the rare and endangered black rhino, hunted to near extinction, but now making a comeback thanks to a tremendous effort to prevent poaching throughout the country. The population of rhinos living in the crater have been growing over the last years under the protection of the rangers here who monitor the whereabouts of every animal here. The black rhino also live in the Western Corridor and northernmost regions of the Serengeti where they are also very protected and growing in number. Their eyesight is extremely poor and they rely primarily on hearing and smell for protection, so they are very difficult to find if there is any significant wind in crater as they will remain in the protection of the lower wooded slopes out of sight of any visitors. It took me several visits to the crater before I was finally able to see a rhino so it is a very good day when one is spotted and they are most often far in the distance.

Elephants in the swamp near the hippo pool
A pair of grey crowned cranes

Ngorongoro is by far my favorite park in which to drive and guide. Aside from the animals, the sheer beauty and magnificence of the place is simply breathtaking. At this time of year, everything is green and the alkaline lake at the center of the crater is full and flocks of flamingo abound. One could never be disappointed by a visit here and it is not to be missed for some many reasons. Though the NCA is a dual use area with many Maasai living within it, grazing their animals throughout, no one lives within the crater itself and no animals are grazed there. The entire expanse of the crater is reserved for wildlife and the volume of visitors is constantly monitored, though I don’t believe they have yet to place restrictions on the number of vehicles allowed at one time. Thankfully, as today is Sunday, there are far fewer visitors due to the normal schedule that the safari companies follow, most often finishing their trips on the weekend and starting on the first of the week.

To get to the crater from Karatu is simple. You drive the only paved road out of town that is the main thoroughfare through this region and the only road to the Serengeti and across Northern Tanzania to get to the city of Mwanza that lies in the northwest corner of the country on Lake Victoria. The Loduare Gate, less than 30 minutes away, opens at 6:30 am and it is always best to get an early start on a game drive, so we’ve set a departure time of 6:00 am, full knowing that it will be closer to 6:15 by the time we’re moving. There is an orange glow in the sky of the coming sunrise and it is quickly apparent that there is not a cloud in the sky meaning that it will be an excellent day in the crater with no rain. As the crater rim is 8000 feet in elevation, it will often sit up in the clouds for the entire morning meaning that we’ll be driving in pea soup fog until we descent, but thankfully that was not to be this morning. After quickly making it through the gate with all the necessary paperwork, and having avoided a run in with the overly aggressive baboons here that love to jump into any vehicle whose window has been left open even a crack, stealing a lunchbox in a flash, we were on our way to ascend up to the crater rim.

The tarmac ends at the gate and the narrow, winding road serves not only as the only route to the crater, but also for any trucks that are heading across the Serengeti. There are many hairpin turns that are barely passable with an incredibly steep drop off to one side,  and though I’m sure one of the many huge trees here would likely break your fall, I’m quite thankful that I’ve never had to test that theory. The massive trees reach far to the sky for their tiny bit of sunshine in the high canopy and vines hang down from the heights to reach the ground below. This is the primordial forest of my dreams and it would not shock me in the least if a T. rex suddenly appeared, pocking its head out from the heavy undergrowth. There is a sense that we are traveling back in time as we continue to ascend until we finally reach the rim and the crater, in all its splendor lies before us from the overlook. With binoculars, you can see all the herds in the distance and the lone elephants, meandering through the swampier areas after having left the safety of the foothills where they spend their nights. Life here is as it has been for thousands and millions of years and their struggles for existence are the same. We are but visitors here, hoping for a glimpse of what has been forever before us.

Once to the overlook, the magnitude of the crater becomes readily apparent to all those fortunate enough to experience it. The crater floor spreads out before us, a vast expanse of just absolutely incredible splendor that everyone would soon be seeing up close. There are only three roads into the crater from the room. There is one descent road, one ascent road and one two-way road that is used to reach the tented camps. The descent road has been under repair for well over six months as it was out when I was here last, so at the present time everyone is using the ascent road to descend in the morning. As the crater wall is so incredibly steep, the ascent road was paved a few years ago to prevent vehicles from becoming hopelessly stuck on their way out making our way down today that much easier and, other than the grade, the numerous switchbacks and the repeated 180° hairpins, it was a slow, steady descent to the bottom.

On the crater floor, our first stop was the bathrooms that are next to the Lerai Forest. Normally this is our last stop before heading out of the crater, but we’ll start our game drive from here having come down the ascent road (I guess this would be the opposite of Up the Down Staircase for those movie aficionados reading this). Within several minutes, Whitley immediately spotted a small group of rhinos (remember, seeing any rhinos here is a chore, so seeing a small group of them is very close to a miracle) off in the distance that were easily seen with the naked eye and even better with our binoculars. I have seen the rhinos closer up on several occasions, though it is surely hit and miss and totally dependent on luck. They come out from the lower slopes of the crater wall in the morning to graze out in the open and hurry back in the late afternoon as long as the winds don’t kick up and send them back to hiding earlier. The black rhino is a magnificent animal, though quite odd in appearance as one can imagine. Despite their immense size, they are still only half the size of the white rhino of southern Africa, but are much fewer in numbers.

Having watched the rhinos for some time, it was off looking for other animals and, in particular, big cats. There were tremendous herds of cape buffalo, wildebeest and zebra as well as some unexpected number of Eland, the largest of the African antelope. There were also huge numbers of both Thompson and Grant’s gazelle as we traveled along. I decided to check out the hippo pool and, on the way, learned that there were some male lions on the way there, so we slowly drove in that direction and came upon the two male lions sleepy in the grass. We watched them for a bit, along with several other vehicles, moving slowly forward until we were about leave the area, when the two decided to seek the shade of one of the other vehicles. It was a bit of a maneuvering game and thankfully, we were in the best position for a completely unobstructed view of them probably ten or so feet away. After some time, though, the vehicle providing the shade decided to move away leaving the pair of brothers exposed to the intense sun once again and within a few minutes, they were once again on the move looking for the new shade of another vehicle. By this time, there were perhaps twelve vehicles slowly tracking these two brothers who were merely trying to get out of the hot sun. We eventually decided that we’d seen enough of the pair and made our way to the hippo pool.

Our plan had been to eventually make our way to Engitati Hill, a striking mesa that overlooks most of the crater floor, but more importantly, my friend Leonard Temba had been to the crater only days ago and spotted one of the lion prides there with a number of cubs. We drove along the shore of Lake Magadi, where there were many flamingoes feeding in the shallows along with a number of other water birds. We also spotted another hippo out of the water (we had seen one earlier in the day as well) which is always a sight as it’s just hard to believe how fast they can run and how deadly there are as hippos kill more people in Africa than any other animal on the continent. We eventually drove up Engitati Hill, but were never able to find the lion pride there, unfortunately, and decided to head to lunch afterwards at the normal lunch spot that is by a lovely lake which also contains its own family of hippos.

Lunch is eaten in the vehicle for one of the main sports is watching unsuspecting guests, who haven’t been warned by their guides, eating their lunches out in the open where they fall prey to the attacks by the black shouldered kites who divebomb with incredible accuracy, snatching whatever someone is eating as they are putting it into their mouth. The kites patrol the skies looking for careless safari goers and when they spot someone, the game is on. I made the mistake once while eating lunch up on the crater rim, not thinking that the kites were up there, but alas, one of these large birds divebombed me and grabbed a piece of chicken out of my hand only inches from my face without ever touching me. It was very impressive demonstration of marksmanship on the part of the kite and I’ve made sure to be more careful ever since.

Seeking the only shade available

After lunch, we headed back towards the area where we had first seen the rhinos earlier in the day, and, while on the way, spotted two pair of rhinos once again off in the distance. They were very likely to have been some of the rhinos that we had seen earlier, but it was still fantastic to see them again as they are just so amazing. We looked for the two male lions later and did find one of the pair, once again lounging in the tall grass and making sure to create as much of a traffic jam as possible even though there wasn’t very much to see other than the occasional paws in the air as he rolled over. We made our way around Lake Magadi to head through the Lerai forest on our way back to the ascent road and our departure from the crater floor. In the forest, though, we ran into a nice family of elephants that were making their way home to the well-protected crater wall where they spend their nights. There were dozens, if not hundreds, of elephants all making their way home that evening and we were watching as much of the elephant population here in the crater were heading home for the night.

At the lunch spot

We made it out of the crater by around 4pm or so which was quite a full day considering that we arrived so early and didn’t have to drive all the way around to the normal descent road, probably saving us around 30 minutes. We had made plans to visit my good friend of mine, Ladislaus, who is now one of the managers at the Ngorongoro Crater Lodge. The Crater Lodge is probably the most exclusive lodge in the NCA and perhaps all of northern Tanzania. Needless to say, I have never had the opportunity to stay there despite the fact that Ladislaus has continually offered for me to stay using one of his “company” nights for family. It’s just never been that convenient, but one of these days, I’m sure I’ll take him up on it. The Crater Lodge is on the site of a very old hunting lodge from the 1930s when hunting in the crater was still allowed. I’m sure that Hemingway must have stayed there during one of his African adventures, but hunting has not been allowed in the park since independence in 1961.

A very muddy Turtle
The lake at the lunch area with little weavers enjoying the view
Savannah at the lunch area

The views from the lodge are simply the best, but it is the lodging that is spectacular as there are three “villages” each consisting of only 6-12 little bungalows for each guest and one main house for each village where there are sitting lounges and a central dining room to accommodate all the guests staying at that village. They are very keen on privacy considering the type of guests that stay there as many celebrities and politicians come to be away from the public eye. Ladislaus started as a receptionist here, then became their sommelier and later their general manager. He still manages their wine cellar of approximately 1500 bottles of wine from all over the world, though he is a specialist on South African wine.

A rolling hippo

We had tea and coffee outside on the deck as Ladislaus told the others stories of his childhood and interesting stories about the lodge, though our time was short and by the time we departed, we had just enough time to get to the gate, which closes promptly at 6 pm, at which point you must find someplace to stay overnight in the NCA, most often your vehicle, before you can get out the following morning (and pay another fee for the day). Meredith sat up front with me and hadn’t realized why I was driving so fast until we made it to the gate at which point the others cheered as we had just three minutes to spare. I made sure she realized that I don’t always drive like a crazy person, though she did get a wild ride that I’m sure she’ll never forget.

The Ngorongoro Crater Lodge
The view from Ngorongoro Crater Lodge
Whitley, Ladislaus and me at the Crater Lodge

Saturday, March 12 – A very busy Saturday…

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Saturdays tend to be the quieter day of our work week, though we still had to see the last third of our patients from Food for His Children to be seen today and, along with the regular patients to be seen, it would make for a busy day for us. We can regulate the number of patients that we see in a day as the majority of patients are coming from Karatu and having them come back the following day typically isn’t a huge chore for anyone. For those patients coming from a distance, though, returning another day can be a hardship and therefore we try to do our very best to see them that day, but if we can’t, they will usually stay in town overnight with relatives as everyone seems to be related in East Africa and a place to stay is never an issue for that reason.

Whitley and one of our young patients for the day

Alex went up to the hospital this morning to see the patient in the ward who we had been consulted on and unfortunately, he had died overnight. He had looked extremely bad the night before with a significant change in his exam that had worried us about worsening increased intracranial pressure and even possible herniation so it did not come as a complete shock perhaps. Be that as it may, I don’t think Alex had necessarily expected to have found that news on her arrival to the ward and gathering a detailed breakdown of what had happened is not always as simple as one might think given the complexities of these patients. The most important thing, though, is for everyone to regroup and process the information with the hope that we would all learn something from it. Ultimately, it is unclear that we could have done differently in this case other than to have put him on anti-seizure medication when he arrived, but it’s not even entirely that was his problem at the end.

Charlie and Meow resting comfortable by the lunch tables

There is no morning report on Saturday as the staffing at FAME  is much more streamlined on this weekend day, allowing everyone a much needed additional 30 minutes of sleep (except for Alex, of course) . We had been out last night at Gibb’s Farm for dinner and, though it hadn’t been a late night, it had been late enough and all of us took a few extra minutes to get ready for clinic. Once clinic was up and patients were being seen, I had an errand to run as Turtle’s engine temperature gauge hadn’t been working properly and I had wanted it repaired prior to heading to Ngorongoro Crater tomorrow or for our week-long mobile clinic the following week. Driving around East Africa without a working temperature gauge is not a smart thing to do given the fact there is no Automobile Club here to rescue you or even service stations once you leave the tarmac, which encompasses the majority of roads here throughout the region.

Meredith’s sunglasses making the rounds

I have a mechanic here in Karatu who has worked on my vehicles over the years and who I was introduced to by FAME. He has literally come to my rescue on numerous occasions during my visits here – such as completely rebuilding the clutch plates in a Land Rover the day before we needed to leave for Arusha or driving all the way out to Mbulumbulu to install an alternator in our completely incapacitated vehicle as the sun was going down. Soja has been available to me at a moment’s notice, always managing to do the necessary repairs despite our always needing the vehicle back right away for some new expedition, whether it be to mobile clinic, for a game drive, or just to take our group to dinner at one of the local lodges. Today was no exception as he tested and replaced the temperature sensor, topped off the engine oil, checked the other fluids and made sure that Turtle was in tiptop shape for tomorrow’s game drive to the Crater – and all for 50,000 TSh, or about $21.

Natalie with a colorful patient

Once repaired, it was back to check on everyone in clinic at FAME and to make sure that things were running smoothly, which they were. As our waiting room continued to expand throughout the morning and it became increasingly clear that it was going to be another blockbuster day for us, one of our patients promptly decided that it was time for them to have a convulsion on one of the benches. As one can probably imagine, advertising throughout the community that we will be holding a neurology clinic, when you cast your net so widely it will be very likely that you will land at least one patient with an active seizure disorder. As I learned many, many years ago in training, the first rule of epilepsy is that epileptics seize and that the second rule is that if you don’t take your anticonvulsants, they won’t work. So, putting a bunch of epilepsy patients into the same confined space, there is at least one who will have a seizure waiting to see you whether they are taking their medication or not. Once the commotion was over with patient now postictal and stable, everything settled down with everyone getting back to the work at hand – more and more neurology patients.

Savannah and Meredith with one of our young patients for the day
The three siblings seen by Natalie

Natalie evaluated three young children (a set of 9-year-old fraternal twins and a 3-year-old sibling), all of whom were clearly affected with the same syndrome manifesting as cognitive delay and functional impairment. One of the twins was paraplegic and the other had a spastic hemiparesis. The 3-year-old also had a spastic hemiparesis and had been born prematurely. They all had a similar syndromic facial features with almond eyes and macroglossia. The mother had normal older children and a normal younger baby. We explained to the mother that the children most likely had a genetic syndrome affecting the three children, though she informed us that the reason for their problems was that she had had a fight with her in-laws prior to the birth of the twins, but had eventually made up with them after the first of her 3-year-old which was why the younger baby was not affected. Other than providing recommendations for therapy, there was little else for us to do here as there is no access to genetic testing here, which is not surprising as it would not change our management.

One of our rock star patients

Though we had plans to head out early for dinner again tonight, our clinic ran longer than expected and we had to depart later than anticipated. We were heading down to the African Galleria and its new Ol Mesara restaurant that was designed and build just prior to the pandemic, but has really only been open over the last year due to the decrease in tourist traffic. The food is simply amazing and everything is wonderfully cooked in traditional Tanzanian style with just a little bit of flair to make it that much more interesting. Though all the food was to die for, I think it was the cheese samosas that were everyone’s favorite for the night. The drinks, though obviously not traditional, were equally delicious and very creative. The night was finished off with the entire staff dancing around our table singing “jambo bwana,” then happy birthday while banging just about every item from the kitchen you could imagine in a wonderful cacophony even though my birthday had been several days prior. I guess there’s no harm in celebrating one’s birthday over a week.

It was another lovely night out and as we drove home in the dark, plans were made for our game drive to Ngorongoro Crater the following day and the necessary preparations. We filled Turtle with diesel fuel and picked up two cases of bottle water for the day. At home, the residents worked on preparing our lunches for the day out – peanut butter sandwiches with either jelly or banana, hard boiled eggs, sliced cheese and whatever else we could dig up from the kitchen. We would be leaving at 6 am in the morning as the gate to the NCA opens at 6:30 am and it’s always best to get to the crater floor as early as possible.

Friday, March 11 – Some welcome rains overnight…

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For a land that is so often thought of as dry and dusty, the heavy rains that come in April and May are a welcome thing, as are the often earlier rains that may pop up in March and even February. Lives depend on the rains coming on time, for without them, the spring planting season would be bust and fields would go unintentionally fallow and the harvest would suffer. I’ve been here in the heavy rains before and they are sight to see as everything turns to a sea of soupy mud where all transportation is brought to a standstill. The roads become so slippery that making it to our mobile clinics becomes impossible and patients also have a hard time even making it to FAME. In the Southern Serengeti, where the great migration gently pauses momentarily with all of its new wildebeest calves, much to the pleasure of the predators that depend on this, the level lands, that are for the majority of the year as dry as one can imagine, become like a shallow sea trapping anything that dares to challenge it. Having your Land Rover stuck in this mess is not what one envisions for their game drive, though having been there on several occasions, it can generate its own excitement, if not fear of being swallowed up by the complete emptiness of the landscape here.

Natalie, Nuruana and their patient

It rained heavily last night with lots of lightning and thunder, much to my pleasure for those who know me well, and we could not help but stand on the back veranda looking off into the blackness that was briefly shattered by sudden displays of nature’s fury. There is nothing quite like the sound of heavy rain on a metal roof and ours was no exception as it’s almost impossible to even think at times. Sitting in our house at those times, the rain is all that one can focus on for it is that loud and that intense, occupying your entire focus. Conversations come to a standstill and reading is even difficult. These are the opposite of the soft rains one often thinks of when trying to relax or meditate as these rains are all consuming. They are life preserving, though, and are a reminder that the steady rains will soon be here next month, if not sooner, and that the circle of life that is nature will continue as it has done for millions of years.

Savannah providing a patient with occipital nerve blocks while I serve as assistant

Walking to clinic in the morning, the ground was wet, but we knew that it would quickly try given the completely clear skies and the intense rays of the sun that were already pouring down upon us in the early hours. During the dry season, Karatu becomes a dust bowl with the fine red clay seeming to be equal parts aerosolized and on the ground. Everything within several meters of any nearby road dons a lovely coat of red-orange ocher dust that remains until the next rainy season. We are thankfully spared that pleasure during this season as the light rains of January have managed to wash it all away. Our walk this morning, other than the dew on the grass, was unimpeded as the wetness from the rains last night had already evaporated into the warm rays of the sun and, thankfully, there was no mud to impede anyone’s travel.

Savannah performing occipital nerve blocks for a patient who had benefited from them before

We again had a hybrid patient population for clinic with the group from Food for His Children coming again to see us. Once again, we had many challenging patients mostly from the treatment side and mostly from the standpoint of cost of medications. A young teenage girl came to see us today who had a history of epilepsy that had been poorly controlled, though quite infrequent, in the past, but she was unable to attend school as the teachers had said that she could not return until her seizures were completely controlled. This is often the case here concerning epilepsy as there are a great many children who are unable to attend school for their most formative years for this reason. One such patient I had originally seen in 2011 as she was continuing to have seizures secondary to a perinatal stroke and had been repeatedly send home from school. We were able to place her on a simple treatment regiment, maximizing her medication and she has remained seizure free now for many years. More importantly, she was able to not only attend school, but graduated from primary school high in her class and has gone on to secondary school where she continues to excel. Neither her hemiparesis nor her seizures have ever been a problem since her first visit with us over ten years ago.

Arriving at the Gibb’s Farm gate
The best bathroom view of all time
The vegetable garden at Gibb’s Farm

More significantly, though, was the young woman we saw today who continued to have seizures and was not on medication at the present due to the fact that her family felt as though they were not helping her. Additionally, she was now 15 years of age and we had to consider the fact that we could not use valproic acid for her given the issue of teratogenicity, and specifically neural tube defects, which are disastrous when they occur.  Because we wanted to make sure to control her seizures while also not causing any harm, it would be best to place her on lamotrigine, our anti-seizure medication of preference when it comes to women of childbearing age.

Walking up to the main house

The issue, though, becomes complex when we look at the cost of the medication and its availability here outside of FAME. It is a drug that one can obtain in many pharmacies (a duka la dawa), but access is not universal and starting and stopping this medication is not something that is good for reasons beyond being unprotected for seizures. Lamotrigine must be titrated upward slowly due its propensity to cause a rash and, in extreme cases, a Stevens-Johnson reaction that can be life-threatening at its most extreme. Therefore, patients much have ready access to the medication even if they can afford it. A target dose of 100 mg twice daily, therapeutic in the majority of patients, would cost 1000 TSh per day, or 30,000 TSh per month, the equivalent of $13 USD per month, is typically out the question for many patients here. As I have mentioned previously, though we cover the cost of medication for a month, or maybe two, the patient must still cover the cost of the majority of their medication in between our visits here. She had been on phenobarbital previously with inadequate control and was unable to attend school, so hence the conundrum that exists here.

The main house
The women of Gibb’s Farm – Annie, Alex, Savannah, and Natalie

Another, much simpler, case for us was seen by Natalie later in the day and consisted of a lovely young 15-month-old child with a mild left hemiparesis since birth. She was very alert and attentive and clearly had normal cognition while she had a mild increase in tone on the left that was also mildly weak. Her condition was most consistent with a perinatal stroke or injury that was static. We spent a great deal of time explaining to her grandmother, who had brought her, that she was a gorgeous child who would most likely overcome these deficits and begin to use her left side much more over time, but would need to receive physical therapy to maximize her functional status. Her grandmother suddenly began to cry, at which point I took the child from her so that she could be comforted, but her tears were those of joy as she explained to us, for she had been told that the child would likely never walk by others who had evaluated her in the past. One could not help to have been overcome by gratitude over witnessing this scene and, though it was such an incredibly simple thing for us at the time, having required no imaging or other testing, yet had we not been there to reassure this grandmother, she would have continued with her concern for who knows how long. The impact and significance of one’s care is often not measured by the sleuth-like detective work we do or the number of tests that are ordered or even the severity of one’s condition, but rather by the amount of reassurance and comfort we can give. I have little doubt that the grandmother of this little girl now believes Natalie to be one of the greatest people on earth, which, of course, she is, but measured by her compassion and not solely by her clinical acumen.

The view from the veranda

At the end of the day, we were summoned to the maternity ward to evaluate a 10-day old baby that had been born at home with an encephalocele. Natalie went to evaluate the baby, who was neurologically intact as far as the exam was concerned, though we did not have any imaging to fully evaluate the nature of her encephalocele. These are an outpouching of the back part of the head that are covered in skin and may contain various other components such as the meninges and even parts of the brain. The trick is to determine exactly what is inside as the ones that contain brain are obviously tremendously more complex and trickier to deal with, though regardless of whether they do or not, the encephalocele itself serves as an incredible nidus for infection with a very short distance to the brain. Whether we did an ultrasound here or not, the baby would ultimately need to be referred to the only neurosurgeon in Northern Tanzania at KCMC in Moshi.

Alex admiring the trees

As our plan had been to finish early with the idea of cool drinks on the veranda at Gibb’s Farm firmly in our minds, we left clinic and all headed back to the house to get ready – that is everyone but Alex and Meredith who were planning on visiting one of the inpatients who we had seen two days ago and had been vacillating clinically, but never really turning completely around. He had come in agitated and combative with a significant alcohol history and a CT scan that looked mostly like diffuse edema with loss of sulci bilaterally. He was covered with antibiotics and we were concerned about doing a spinal tap given the likelihood of increased intracranial pressure. We were unable to give him thiamine as all that was available was PO and he wasn’t taking anything orally with consistency. Alex, Meredith and Shama thought about his case long and hard, at least until I tore them away as there was little that we could do that required our presence and we would just be a phone call or text away if they came up with additional recommendations. It was not the best of starts to an evening at Gibb’s, but unfortunately, puzzling cases like this are all too common here.

Dining at Gibb’s Farm

Our evening at Gibb’s Farm was, as expected, a lovely affair. Gibb’s Farm is an old coffee plantation that has transitioned through multiple owners since its original German founding at the beginning of this century, then followed by the Gibbs family who later purchased the working farm, owning it for many years until the last decade when it has been transitioned to a destination resort by the owners of Thomson Safaris. Completely independent of its history, though, is the magical place that the Gibb’s Farm holds in the memory of those who visit. I had first come in 2009, when I believe it was still owned and operated by the Gibbs family and prior to the extensive renovations that make it the resort it is today with a world class restaurant a view looking out from the Ngorongoro Highlands that is beyond description. Sitting on their veranda in the late afternoon and early evening breeze looking out across what seems like all that is important in the world at that moment, one cannot help but forget every ill they arrived with.

We sat for quite a long time on the veranda sampling the many delicious drinks that I am sure were made that much tastier by the incredible surroundings and eventually made our way into their amazing dining room and table that was set so beautifully with more glasses and silverware than I thought existed in the Karatu district. Dinner is a fixed price affair with several choices of dishes that are either farm fresh or come from local regions and all were presented in most lovely manner. Edible flowers covered everything and complemented each dish appropriately. Needless to say, everyone was very happy with their selections and dessert was an equally delicious affair. We finally left after 10 pm, a very late night here in Africa and were all thankful that morning report doesn’t occur on the weekends, though we would have a full day of clinic and the last of our Food for His Children contingent.

Author’s note: When preparing to post this blog with its photos, the contradiction in terms between my discussion of the financial hardships of our patients here who cannot afford their medications and our dinner out at Gibb’s Farm did not escape me. These are conflicts that are self-evident each and every day that we are here. Though the solutions are complex, it does not go without recognition by each and everyone of us.