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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Despite having set the very conservative goal of 11 pm the night prior, and having stuck to it, it was still a bit of a chore to get up the next morning, though everyone did so with grace. It was another early morning for education and, with the large conference room being occupied by a nursing meeting, we all crammed into the education room in the administration building. Having seen the growth of FAME over the last decade, where in the early days we had a mere handful of clinicians attending this meeting, there are now literally dozens who attend and space for these meetings can be at a premium. Regardless, we all packed into the room, some on chairs, some on the floor, others two to a bolster and still more standing. As each person enters the room, everyone shifts to make room, until it becomes an incredibly cozy event.

This morning, Shama was speaking about rabies, a very important discussion here especially given the events of the last several days. Having arrived only days earlier, she essentially walked into a situation that she had been training for over the last years, and, given her background in infectious disease and epidemiology, was the right person and the right time to tackle the problem at hand. Rabies in low resourced areas such as Africa remains a deadly serious problem that has yet to be fully dealt with as it is an incredibly complicated task to eradicate it in such vast areas where the vector here, dogs, mostly run free and exposure to these rabid animals is frequent, especially in places like the NCA. Couple that with poor education and resources, it is can be a recipe for disaster. And, it can be a preventable problem even after exposure as long as the victim gets the proper medical attention early enough which means receiving immunoglobulin and vaccine prior to any symptoms developing. Unfortunately, the treatments are not readily available throughout the world, patients do not always seek medical attention, and the time from exposure to developing symptoms can be many months or even years.

Yesterday, Shama and Kitashu, along with a team of researchers from Arusha, had spent the day traveling to very remote areas of the NCA, far on the other side of Olduvai Gorge, a remote area in itself, to find the families and the other victims of the rabies exposure that occurred not only from the dog that had killed the young boy here at FAME, but also from exposure to another potentially rabid dog that had bitten other children. They were able to bring vaccine with them and administer it to those who had been exposed and, after an interview, determined to be at risk to develop this condition that is 100% fatal if untreated. The difficulty, though, is that they must receive a series of four injections over a number of weeks and making sure that occurs can be very tricky itself in a population that is constantly on the move looking for new grazing areas for their livestock. The solution certainly isn’t an easy one, but at the very least, the team that went into the NCA in search of these victims made a difference for these individuals and, along the way, made important connections with those in the region who can help educate the population in this vast region. Leaving something behind can be as small as saving a single life and it is always important to remember that.

We knew in advance that our day was going to be a busy one as Frank had been contacted by a local project here, Food for His Children, an organization that assists local families in obtaining the necessary assets such as food and medicines, who was interested in bringing any of their clients with epilepsy to see us. They had gathered at least 70 patients who would be coming and it was decided that they would come over three days with today being the first. This would be in addition to the normal volume of patients we see and, having gone back to the pre-pandemic practice of announcing our clinics to the local community, we had already anticipated a greater number of patients for this visit in general. Thankfully, we had already decided to have four examination stations yesterday as having Meredith and Whitley here to help with the staffing duties made it a very reasonable proposition. Each of them would work with one team, sitting in with them while they were seeing the patient, thus shortening the amount of time needed to staff, while I would manage the other two teams who were seeing patients. In the past, I have staffed four teams by myself and it can be a very hectic process for both myself and the residents.

The cost of medications, whether it be the anti-seizure medications, psychiatric medications, or those for Parkinson’s disease, has been one of the biggest issues we have had here from the very beginning. Though we have been subsidizing the neurology clinic visits in which the patients pay a flat fee of 5000 Tanzanian shillings (TSh), which is slightly over $2, that includes the visit, any necessary lab work, and medications for a month (though in reality it can be for several months), there is always the problem of whether the patients can afford the medications when they come back for refills. Though we try to discuss whether they will have this ability or not at the time of their visit through a meeting with Kitashu or Angel, it isn’t always as simple as that and when it comes to putting food on the table or buying medicines, the former will always take precedent in any part of the world, whether it be here or at home in the US. That being said, we did an analysis of these costs in September 2019 and found that for the incredibly reasonable sum of $36,000, we could supply all the necessary medical care, including medications, for the entire cohort of 407 patients we saw that month. It’s impossible to calculate an equivalent in the US, but by using Medicare costs for a year and even dividing it for the entire population, to provide the same care at home would be in the millions of dollars.

Reducing the cost of medications would be one answer, but even then, it will very likely be more than the population here can afford. Though fully subsidizing these costs for the specific population of neurology and psychiatry patients that we see here isn’t an entirely sustainable solution, it would be one way of determining if that is the only factor impeding their health or whether there are others such as nutrition, living conditions and clean water, that are equally important. These are all questions that we are hoping to answer going forward and are working with Tanzanian researchers at Muhimbili University in Dar es Salaam as well as the caregivers here at FAME in this effort.

We saw many epilepsy patients today, many of who were on phenobarbital that they obtain for free from the government dispensaries. This is a medication that is used very little in the US due to its long term side effects and is used mostly in the pediatric population less than 2 years of age where it is better tolerated. For patients with epilepsy who we treat at FAME and keep coming back, a testament to the fact they have improved seizure control, we are using “newer” medications, though these can be very expensive and difficult to afford for when they return for refills. Phenobarbital is currently the WHO recommended anticonvulsant as it is effective and inexpensive, though comes with a cost of the long term intellectual side effects and simply something that we use rarely in the US for these reasons and the fact that we have better alternatives readily available to us. This is such a conundrum for us as we see these patients who have such poor access to medicines and are only able to afford them when they come from the government dispensary for free and that includes only phenobarbital. The patients we saw today from Food for His Children were, for the most part, already on phenobarbital that was either effective or needed minor adjustments, and it was decided that we would continue this therapy as switching them to something else was not a viable option. Had the medication been flatly ineffective or had the patient been suffering concerning side effects, the decision to switch them would have been without question, but that did not seem to occur today. Everyone was kept on phenobarb for the most part.

A gentleman was seen today who complained of carpal tunnel symptoms, which is usually a very simple issue for us to rectify, either with wrist splints or, in the event it is severe and involves motor dysfunction, a surgical release may be in order. When I went to look at the patient with the resident, though, he unfortunately had complete loss of his thenar eminence, bilaterally and absolutely no movement of his abductor pollicis brevis. The new surgeon here at FAME, Dr. Manjira, is actually able to do these procedures that are, for the most part, fairly simple, but in this case,  there would have been little reason as there was so little to gain and given the risk for even the smallest of surgical complications, the benefits were clearly outweighed. We recommended wearing wrist splints to help with his pain at night, but did not suggest pursuing surgery.

Meanwhile, the really interesting case of the day was a woman that Peter was seeing and who described a long history of infrequent episodes (monthly) of motor weakness that would develop over minutes and last a short while, but were not associated with any alteration in consciousness during the episodes. She did describe a headache that would occur often following the episode of weakness, but no headache at the onset or even during the event. He was initially thinking about conditions such as cataplexy associated with narcolepsy, but there were none of the familiar triggers associated with this condition. She had been having these episodes since she was 12, and they had never changed in frequency or quality during the number of years she had been having them. It didn’t seem like migraine and certainly didn’t’ represent a seizure disorder based on the history.

The episodes were actually very similar to what is seen in a condition called periodic paralysis of which there are two main types, hypokalemic (the most common) and hyperkalemic, and are rare genetic disorders that are related to the ion channels in the muscle membrane. The disorders can be debilitating depending on the frequency of the attacks and are typically investigated by lab work and an EMG. For treatment, though, one can take preventive medications such as acetazolamide  (Diamox), a medication often taken for altitude sickness, or abortive therapy that consists of taking oral potassium at the onset of an episode. We checked her labs, including a thyroid level, but there were no abnormalities there. I’m really curious how she will do with the therapy that’s been prescribed, but I’ll have to wait until the next time I’m here to see whether our treatments will help.

As we had about 40 patients today, the afternoon began to run long and it was not until after 5 pm that we finally finished up. This isn’t a problem for us, but given the fact that we cannot operate in a vacuum here, meaning there are many support staff needed for our clinical work – the doctors that we are training and who act also as our translators, others who are just translating for us, and then Kitashu and Angel, both of whom are the heart of our clinic – must stay late and help us take care of the last patients. FAME operates a small bus along with their Land Rovers to transport employees to and from town, which is about six kilometers away, but they only leave on schedule and missing them would mean having to catch a ride on one of the little boda bodas or a piki pikis (little three wheeled vehicles and motorcycle taxis, respectively) that are always parked in the lot waiting to take patients, visitors or employees down the road to town. In the end, I drove Nuru, Eliza and Anne down to the center of town to reach their final destinations for the evening.

Tomorrow, we’ll see another group of seizure patients from Food for His Children along with our normal clinic volume and try to finish at a decent time for we have reservations for dinner at Gibb’s Farm. We’ll share more that later with you 😊

It’s simply amazing just how much an extra half an hour of sleep can make you feel, but I’ll have to admit that one does look forward to those days without an educational meeting. I think it’s more a mental thing, though, as I have become accustomed to getting up extra early in the mornings to finish my blogs and get them posted. I have set a goal on this trip to not fall behind with my writing, as has happened so often in the past, leaving the last days unfinished. I will do my very best to stick with this plan and see if it lasts.

This would be our first full day of clinic and we were already a bit handicapped in that I knew that Kitashu would be heading back into the NCA to complete their search for the rabies exposed children and to continue their work of contact tracing. We would not be without a clinic director, though, as Angel would be working with us today and, as social workers go, she is a gem both from the aspect of keeping the clinic running smoothly as well as helping with the patients when access issue would arise. Having them both with us is always the best, but Kitashu does have the benefit of having been raised in the NCA and still has his family there, hence the need to have him leading the rabies contact tracing expedition, and that clout is often very welcome in our clinic when it comes to these patients. FAME’s catchment area in Northern Tanzania throws an incredibly wide net over approximately 2.9 million people living in these regions, many of whom are Maasai from the NCA, and it is frequently necessary to have someone who not only speaks their language, but also understands the complexity of their lives. Kitashu brings all of this to the table and more.

Having an outdoor clinic certainly has its advantages and, in addition to all of the fresh air and openness, one also quickly realizes how busy the clinic is as the “waiting room” sits adjacent to us so that it is readily visible just how many patients are waiting. And, in addition to seeing the volume of patients that need to be seen, we now have the EMR that also displays the patients waiting to be seen by us in neuro clinic. When patients come to FAME for our clinic, they are registered and segregated for us in a separate area and today we discovered a small issue with the standard process of triaging and taking vitals in one area. When we’re here seeing patients, these are in addition to the normal volume of the clinic and with seeing nearly 100 patients per day, adding nearly a third more to that can be very disruptive to the patient flow. Starting tomorrow, we’ll make sure that the normal clinic patients are triaged first to get them moving as seeing a neurologist tends to be a lengthier and more thorough process so that our patients can be triaged much more slowly given our pace. Thankfully, everyone here working is here for the same purpose and there are never issues in working these situations out.

So, it became readily apparent once we started clinic that it was going to be a very busy day for us as the patients were quickly piling up after we opened for business. There are no appointments here for the most part, and most patients will show up at around 8:30 am (2:30 Swahili time) to be seen with the knowledge that they will most likely be spending the entire day here. The EMR has made it much easier to keep track of the patients as seeing someone out of order can create an issue and when we see those who come in with special situations, it must be done quite discretely. It is always a bit of an educational process for the residents when they get started here as their normal workflow from home may not work depending on the patient and the volume of patients that we have in clinic for the day. We had planned to have three examination stations originally, each staffed by at least one resident and doctor or translator, but it became very clear quite quickly that we would need to have four stations given the volume of patients that were showing up to be seen. We can’t control the number of patients who come to be seen on a given day, but we can control how many patients we can see in a day with the overflow having to come back the following morning to be seen at the head of the line.

Natalie, our pediatric neurologist, had more than enough kids to keep her busy through the day, including one young child with hydrocephalus who I saw along with her. The child did have a shunt that had been placed shortly after birth but had a very large head despite this and though mom reassured us that her head had not grown in size over the last year, her prior CT scan had been done elsewhere and we therefore had nothing to which to compare it. Furthermore, she had a very broad opening in the back of her head where her sutures had not fused and, though this did not pose any immediate concern, this was something that would normally have been addressed with a cranioplasty. The child was also on very low dose phenobarb for a history of seizures and it was recommended that she continue on that given the high risk of recurrence based on her abnormal examination and the focality seen. It was unclear as to whether or not she was cortically blind based on our routine examination, but Natalie recalled  that Meredith had brought along an optokinetic strip (OKN), a tool that is used less commonly these days, but certainly something that could help us determine whether she had vision as drawing this striped band in front of her eyes would produce movements, or optokinetic nystagmus. And sure enough, she had some vision, which was very reassuring to us. We had discussed obtaining a CT scan now, but in the end, the decision was to hold off, both for financial and clinical reasons, and we would see her back in three months.

Another patient who had presented today was a young man who was originally seen last month with new onset focal seizures and was found to have a rather large left parietal enhancing mass on CT scan. His seizures involved his right arm and on examination now, he was found to have mild right sided weakness. In reviewing his CT scan, the mass was quite evident and quite large with some surrounding edema and was somewhat cystic. It had been read officially as a meningioma, which is a reasonably benign tumor from a pathological standpoint, but when very large can produce problems based on its mass. Based on the fact that it was producing a mild hemiparesis, it was producing enough mass effect that it would most likely be amenable to at the very least resection, though depending on its ultimate pathology, we may also have other options such as radiation. Regardless of this, we adjusted his carbamazepine to achieve a more therapeutic level for him.

Our other incredibly interesting patient of the day was another gentleman who had been having focal seizures for about five years and was on carbamazepine with incomplete control. He had come to FAME about a week ago and had been sent for a CT scan here that was felt to be diagnostic for neurocysticercosis. He was started on albendazole, an anthelmintic used to treat tapeworms which is the parasitic agent that causes cysticercosis, and had returned to see us a week later. His seizures were still under poor control on his carbamazepine dose, which obviously needed to be adjusted further, but there also issues with him taking the albendazole as patients with a high lesion burden can have severe reactions with brain swelling and hydrocephalus.

Neurocysticercosis is actually the number one cause of epilepsy in the world and very prevalent in South America where there are many pigs, and therefore pig tapeworm. Small cysts develop in the brain that cause irritation (through immune reaction) and lead to patients developing focal seizures. In addition to the numerous cysts in the brain, patients can develop hydrocephalus that complicates the treatment as the patient will require that a shunt be placed prior to any parasitic treatment for the reason that I mentioned regarding reaction that can occur with the death of the organisms and a massive inflammatory response. For this reason, patients are also given high dose steroids when ready to initiate treatment to prevent this reaction and will most often have placement of the VP shunt prior to treatment if there is any concern for hydrocephalus developing with treatment, or they have already had it placed for hydrocephalus that has developed before treatment has been started. In addition to a great many cystic lesions (i.e. high lesion burden), this patient already appeared to have some hydrocephalus. Given the significant possibility for a severe reaction with treatment, he was place on steroids, his carbamazepine was titrated higher for better efficacy, and his albendazole was discontinued until he could be fully evaluated at a tertiary center where a neurosurgeon could weigh in regarding whether he would benefit from a VP shunt. As you can see, he was also a very challenging patient regarding his management.

Clinic was fairly busy as I mentioned and, in the end, the residents had seen approximately 29 patients throughout the day, all of whom were very interesting, whether it be from a medical, social,  or cultural standpoint. Managing patients in such a resource limited setting can be incredibly challenging, though also quite rewarding given the lack of neurological care in the entire country.

As we travel here every March and I have done so for the last 12 years but one, I have also had the pleasure of celebrating my birthdays here with the residents and FAME staff. As my family will tell you, I am not one to naturally accept such attention, and I have done my best to typically avoid drawing any attention to the fact that another year has passed for me. I’ve come to the realization, though, that birthdays are more of an excuse for those who care about you to show it than they are for the one who’s gained a year and, with this in mind, I have slowly accepted this philosophy. As tonight was my birthday, it was another time for celebration and arrangements had been made for us to go to the Golden Sparrow, a local Karatu club that just happens to serve the most amazing roast chicken. It also has an indoor dance club that is a throwback to the discos of the 70’s (at least in my limited view of the dance scene today), though without the Donna Summer disco music.

We all enjoyed drinks and some food, but the highlight was Dr. Anne’s birthday cake that she brought for me and was amazingly delicious. It had red frosting (my favorite color), a big blue frosting flower on top (my second favorite color), both of which made it look just a bit like something out of a Dr. Seuss skit. After having cake, we all made our way inside into the dance hall and enjoyed non-stop dancing for about 1 ½ hours, fueled of course by some Konyagi, which is the local gin and half decent when mixed with some tonic water or ginger ale. Whitley seemed to have good handle on making sure that the DJ was playing just the right songs for us and I was happy to have at least recognized one or two of them. As we all had to make the 7:30 am educational lecture in the morning, I was fairly intent on making 11 pm the witching hour and, in the end, had little resistance from any of the neuro team and they all went quietly. Once home, it was quickly to bed and ready ourselves for another wonderful adventure in clinic.

Our first night at FAME was a quiet one. Having just arrived to the country, the residents were surely exhausted and were all in bed well before 9 pm. Whitley and Meredith are staying in one of the other three volunteer houses – Dr. Duane’s house to be exact – and so I’m not certain as to exactly when they went to bed, but I suspect it was very much later than the residents. I had hope to stay awake and get work done, but found myself fading fast as well and made it to no later than 9:30, though decided to get up well before dawn to take care of unfinished work. Even though we were scheduled for orientation in the morning, I was sure that it was likely to be a bit of a crazy start to our clinic as is most often the case. As it turned out, they had a young boy die of rabies the night before we arrived (more on this shortly) as well as a young six-year-old girl that very likely has an untreatable brainstem tumor and came in the end of last week – the latter case one that they were waiting for us to arrive for our assessment. And even then, we were messaged on our drive here regarding a young man with epilepsy and non-epileptic events who was possibly having some side effects from his medications. Such is life in the fast lane here in Africa.

Despite my planned early awakening, it had been a good night with a lovely and quite soothing downpour that came shortly after getting into bed and lasted for only fifteen minutes or so. These are very common here and tend to clear the air with little in the way of suffering the following morning from any mud as the rains are far too short to produce anything concerning. During the rainier seasons, though, when it may rain through the entire night, the roads the following morning are like a slip and slide making both driving and walking difficult. The deep red clay here will cake to your shoes until your feet each feel like they are encased in cement. This morning, though, it was incredibly clear with a slight chill to the air and simply gorgeous for everyone’s very first walk to clinic, which was on the earlier side as there would be an education session this morning. It was led by Amanda Williams, an OB/Gyn from California, who has come to FAME in the past to volunteer. Her talk was on the cardiovascular complications of pregnancy and was quite interesting throughout. It was held using a synchronous two-way Zoom session and the quality was very good despite the bandwidth over here and the fact that we were just a mere 11 time zones around the world.

We had set aside the morning for the residents, as well as Meredith and Whitley to each undergo a training session on the EMR (electronic medical record) and clinic in general, so patients weren’t scheduled until noontime and, even at that, there were only a few patients who had been scheduled for us to see this day. Best laid plans, though, is one of my mantras (the other, by the way, is “no good deed goes unpunished”) and no matter how hard you seem to plan on things happening a certain way, they never seem to cooperate. During morning report, it became clear that there were several patients in the inpatient ward that needed our assistance which included the young girl with the likely brain tumor as she desperately needed our assessment from the standpoint of prognosis so the family could make some decisions about care. In a six-year-old girl, this was not necessarily going to be an easy task.

My schedule was also a bit of a work in progress as FAME is currently undergoing work on creating its five-year strategic plan and as a Board member, I had hoped to attend as many of these meetings as possible during my time here. We have a consultant here for several months who is directing this process which essentially means working with all of our Tanzanian staff to create this framework. FAME is run by an all-Tanzanian staff, many of whom have been with us for years, and it is they who are the best situated to determine exactly where FAME should be headed and what is necessary for the Karatu community health going forward. The meeting this morning was an intense two-hour session that focused on further developing our surgery program at FAME and I was so glad that I attended the meeting as I was so incredibly impressed with the work that was done. Having not been a part of this process when the last five-year plan was created, it was incredible to see in person and reminded me of just how lucky I am to be a part of this organization, let alone able to contribute. During this visit, I’ll be wearing two hats – one supervising the neurology team in caring for our patients and continuing to educate the Tanzanian staff while the other is as a  Board member and trying to take in as much as possible as to the inner workings of FAME and to ensure that we continue with our mission and vision.

So, while attended my meeting, our team was prepped on how to use the EMR, which by the way had been rolled out just as the pandemic was gaining steam worldwide, impacting medical care everywhere. We had used paper charts here for some many years, but the need to go to a basic EMR that would allow data extraction was clearly necessary considering the growth of FAME and the 30,000 patients that we see every year. Unfortunately, to have access to the EMR, there was a definite need for WiFi where we were seeing patients which was just outside the main clinic under an overhanging roof. Though it’s an idea place for us to see patients as it’s outside and lovely, the thick brick walls of the building are not overly conducive for the WiFi signal to get to us. Despite this, we were able to carry on by shifting some of our tables and stations and everyone was eventually seen with their charts completed.

The heart of our neurology clinic here, and what allows us to complete our necessary work, are our two social workers, Kitashu and Angel. It is there role to survey the communities and make the announcements of our clinic in advance of our arrival and it is they who create the patient flow for the clinic. Every patient we see here comes from a community that has diverse needs and though it is certainly necessary for us to evaluate the patients, without having them to assess the social needs of the patients along the way, it would be a work in frustration. Patients need services and assistance very often, and it is they who work tirelessly in the background to make things happen. Angel has worked with me for many years here and is the lead social worker, but she wears many hats at FAME. Kitashu, who has been with us for the last four or so years, is someone very connected to the Maasai community of the Ngorongoro Conservation Area (NCA) where he is from. When it comes to how things get done in the NCA, he is the most knowledgeable by far.

As I had mentioned earlier, a young boy of 12 had been brought to FAME the night before we arrived and who had died almost immediately after his arrival of rabies as he was symptomatic when he came. There were several other boys in the NCA who had also been bitten by the same rabid dog, but were not yet symptomatic, at least by report, and needed to receive the rabies vaccine and/or immunoglobulin. Arrangements had been made to bring the boys to FAME to receive treatment, but when the transport arrived this morning, there were only two boys and the report was that there were two others who had missed the ride and were still in the NCA. The two boys who made it both received the immunoglobulin immediately and will be receiving further therapy, but it was clear that some action needed to be taken to find the other two boys in the NCA and to bring them back for treatment. Given Kitashu’s knowledge of the NCA and his familiarity with everyone there, he ended up organizing a party to go in search of the other children and brought one of the other volunteers, Shama, who is an infectious disease specialist and epidemiologist, with him. Though it would be a loss for us not to have Kitashu with us for the day, clinic was light and we would make do considering the importance of the other mission.

The group spent the afternoon in the NCA trying to track down the two other boys, but they had turned out to have moved further away from where they were supposed to have been and there wasn’t enough time to get to them until the following day. But, as chance would have it, they ran across two other boys who had been bitten by a completely different, and most likely, rabid dog and were in definite need of treatment. So, the group came back to FAME in the early evening, as one must do from the NCA, with the two new boys and brought them back for treatment here where they were admitted into the ward. The reason one must leave the NCA by dark is that the gate closes there at 6:30 pm and if you’re stuck behind it, you’re either going to spend the night in your vehicle or find an expensive lodge to sleep in. Thankfully, they required neither, though I imagine they could have made it back to Kitashu’s boma and slept there. I should also put into perspective just what the challenge of their mission was, and will be tomorrow, in search of these young boys. The NCA is a completely undeveloped and incredibly vast swath of land that is nearly equal to the entire Serengeti National Park and contains the famous Ngorongoro Crater which is perhaps one of premier spots for game viewing in the entire world. Trying to find these boys could be like looking for a needle in a haystack, but with the help of Kitashu, their odds will be greatly increased and it truly a matter of life and death for the two boys with their friend having died several days ago.

Our clinic, though seemingly insignificant considering the search for these children exposed to rabies, went smoothly and was thankfully small given that everyone was just getting use to the system here. Knowing what medications we have at FAME as well as the other protocols does take some getting used to as it is far different than in the US mostly in regard to what is available to us. We were finally free to see the young child with the likely brain tumor at the end of the day, though I should reassure everyone that there was absolutely no issue of our weighing in on treatment as she had been receiving antibiotics for the possibility of an infection since admission despite the fact that it was very unlikely. We decided to go back over to radiology and look at her CT scan once again and, while doing so, contacted one of our colleagues in the US, Dr. Dan, who’s been here on two previous occasions, to go over them with him. Using a video link on WhatsApp, we scrolled through the images and were even more impressed with the severe and most definitely irreversible damage that existed on the scan, as well as the likelihood that this represented an entity known as diffuse interstitial pontine glioma, or DIPG, which, given the extent of the lesion burden, would be universally fatal in this case. Natalie and Meredith, with the help of Dr. Anne, went back to talk to the family and to give them our final prognosis which was, of course, very grim and not survivable. They were thankful and somewhat relieved as it was clear that they had been bracing for this information given her the terrible condition that she appeared to be and the fact that she had no improvement despite having received all of the treatment she had been given.

We came home after a long day of training, meetings, patients and the residents just getting their feet under them, to enjoy our little home away from home in the Raynes House, with its gorgeous views and the sounds of the many birds in the trees surrounding us. Relaxing with some gin and tonics, such a natural and refreshing drink here in East Africa, we all relaxed and told stories of the day with Shama eventually joining us after her travels throughout the NCA in search of rabies exposures. Being here at FAME is a gift for each of us and the ability to give back has made it so.

Sleeping in Arusha, and more specifically in Njiro, where Leonard and Pendo live, is an adventure of unknown sounds for those who have not spent the night here on a regular basis. OK, perhaps the dogs barking through the night may be something heard worldwide, but here, everyone has a dog, or even more likely, dogs, whose job it is to remain out of sight during the day and to roam the walled property (everyone here must have walls around their home for security and gates to enter) during the night looking for intruders. Of course, that is not a common occurrence at all, but the dogs don’t know. Several times a night, we are serenaded by a cacophony of barking dogs as they practice for that rare time that some may try to enter, and though it may never occur during their lifetime, they are ready and waiting. Pet dogs that are part of the family do not exist here and, for the most part, they are not friendly. The other sounds through the night are less familiar to probably 95% of those back home and, I suspect, all of the readers of this blog.

If you’ve grown up with that illusion that roosters somehow only crow when the sun is coming up, you’re sadly mistaken, at least for the population that lives here in East Africa. They crow all morning long, usually several hours prior to the sunrise, and although not at all unpleasant to the ear, they are not something that we’re used to hearing during our deepest of sleep such that they often manage to break up your dreams at the most inopportune times. And then there is the call to prayer that, depending on your proximity to the mosque or one of the loudspeakers, will also be loud enough to awaken you from your slumber at least once during the morning. Today, I believe that occurred at approximately 4:38 am, or thereabouts. Despite these oft somewhat annoying interruptions to your rest, though, it is usually, at least for me, not difficult to fall back asleep give the otherwise pitch black and restful nature of this place. When the sun goes down, everything is the blackest of black and, other than the moon, there are few lights to be seen. Far different than home in Philadelphia, where the PECO building (our electric company) is partially visible through my windows with its bring moving messages all night long.

As the four residents were arriving around 7:40 am, we’d have to leave Arusha to pick them up rather early. Of course, having some tea before we left was crucial and thankfully, there was a batch made up in the house quite early and ready for us to drink prior to our departure. The drive to the airport is mostly a pleasant one, at least on the bypass around Arusha, for once on the main highway across Northern Tanzania, which is a mere one lane in each direction, it can be a slow trip with the numerous trucks who slow to a snail’s pace on those numerous uphill sections of these roads that have no passing lanes. Added to that the 80 kph speed limit slowing to 50 kph (32 mph!) through the numerous towns, makes for drive that can be frustrating for those in a hurry, which is never a good thing here and a recipe for a lesson in futility. If one plotted out the frequency of which I received citations from the traffic police here, it has dropped precipitously since the time I finally came to terms with this fact. Having written about these experiences in the past, I won’t belabor it any further to say that I have now become Zen with the schedule here and it has done wonders. The sooner once accepts “Africa time” the happier one will be.

Having left later than I had planned, we still reached the airport with plenty of time to spare as the group had to go through the entire process that we had the day before – COVID test, immigration, luggage and customs – which, for a large jet and tiny airport, is often not something that is a model of efficiency. With that being said, though, I will have to give much credit to the authorities here as they do move a great number of people through a rather complicated process in less time than one would imagine. Our four residents finally emerged from the exit, a place where I’ve waited on so many occasions over the years, with the expected awe and excitement for having arrived after such long flights to this unknown continent. That is, at least for three of the four, as Peter had been her before in 2018 as a medical student with me and was now returning as a resident. None of the other three had ever been to Africa before and, despite their jet lag after over 24 hours of having left the US, were excitedly taking it all in. The majority of the passengers arriving here are meeting up with their tour companies, ready to head out on safari or to climb Mt. Kilimanjaro over the next weeks. I remember so well the same event for me back in 2009, having arrived for our safari with my two grown children, not realizing that it would change my life forever and send me down a path that would lead to my returning now a total of 24 additional times and considering it my other home.

A visit to Pendo’s, even one that is merely to regroup and pack the vehicle, can never be truly short as they will always involve a meal. Visiting a home in Tanzania and not being served food is something that is unheard of and it can be no more evident as our visits in Arusha with the Temba family. Prior to the pandemic, the flight schedule was such that we would arrive late in the afternoon with not enough time to travel to FAME as it is extremely dangerous to drive at night here due to accidents and animals on the road. Pendo would put our entire group up in their home for the night, serve us a fantastic home-cooked dinner that night, and see us off the following morning. The flight schedules have changed now and we arrive early in the morning with plenty of time to make it to FAME, but a stop at their home is still required both to get organized and to allow them to meet everyone. The three of us who arrived yesterday did stay with them last night and had a wonderful dinner, but she would make sure that everyone was well fed this morning and would have the opportunity to experience the true hospitality that is so essential to their culture here in East Africa.

Our breakfast was comprised of eggs, sausage, incredibly delicious fried potatoes and onions, pancakes, toast, fresh papaya and watermelon, spiced tea and fresh mango/watermelon juice. To say it was one of the most incredible breakfast spreads I have seen would be an understatement. After the long flights and the inflight meals, which by the way are very good on Qatar Airways, we were all so incredibly pleased to sit down to such a wonderful meal and it was a fitting beginning to everyone’s visit here in Tanzania.

After breakfast, though, it was time to hit the road and the rest of our luggage was shoe-horned into Turtle with just enough space for the seven of us. There was one little cubby remaining in the back corner of the vehicle and Peter volunteered for the job having been here before and seen the sights of the drive to FAME. The drive takes us through some incredibly picturesque countryside as we travel out of Arusha and into the regions of Tanzania that are dominated by the Maasai with their bomas (homes) and their herds of livestock easily visible across the landscape. The Maasai lead a pastoral existence that centers around their animals – cattle, sheep and goats – that are grazed throughout the land, often traveling miles in search of grasses on which to feed. Watering holes can be seen throughout at this time of year while in the dry months it can be a long walk to find them.

We travel west for some distance until we reach the Great Rift Valley, a geologic formation that cuts diagonally from north to south across East Africa with its many lakes and volcanic activity that is the essence of this region and comes to define it. It is also the cradle of mankind as I have spoken of on many occasions and will probably mention again in the coming blogs. We depart from Makuyuni and in a short time descend down to Lake Manyara, famous as the location of Hemmingway’s The Green Hills of Africa, written in the 1930’s about a rhino hunt with his wife. Sadly, there are no longer rhinos in this region, having been overhunted and now gone for probably 40 years. They still exist in the Serengeti and Ngorongoro Crater, but are no longer seen outside these parks. We then travel from the bottom of the valley, up and up until we reach the escarpment and then travel higher to the Ngorongoro Highlands alongside the Ngorongoro Conservation Area where the crater exists (more about that later).

We arrive to FAME, so familiar to me and my home, and it is incredible to be back here. It will be new for four of my fellow visitors and the second trip for two of them, Peter and Whitley. Meredith, Savannah, Natalie and Alex, though, have never been here before and about to have the experience of a lifetime. One that is so full in ways far beyond the medicine that we’ll practice and teach. For it is the Tanzania people who make this place so special in ways that are beyond words. There is such a beauty and warmth in everyone here that glows in ways so rarely seen. That is why I am here and why I continue to come back again and again, though at times I wonder where my true home lies, here or America. That is a question that remains unanswered and a problem that I am grateful to have.  

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

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

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

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

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

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

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

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

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

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