Our first three weeks were nearly complete and though we were having clinic today, two of our team would be departing mid-day as they both had flights to Dar es Salaam this evening for the first leg of their trip to Gombe where they would be spending time with the chimps. I had done this back in 2019 with one my residents, Mike Baer, and our medical student, Leah Zuroff, who had accompanied us on that trip to FAME. It was one of the most incredible trips I have taken, not only because of the time we spent in the wild with the chimps, many of whom were members of the original group that Jane Goodall had been studied, but almost more so for me because of the history of Gombe and what it meant to science. For anyone who has watched her biographical movie, “Jane,” the significance of her achievements is obvious. For those of you who haven’t seen it, you must.

Morning report was the last time for everyone to say goodbye to FAME for Wells and Usha would be traveling with us to Arusha for their outbound flights tomorrow and there was no clinic. I think it was a sad departure for all the residents who had very much enjoyed working here at FAME and getting to know everyone. The FAME team is always so appreciative of the time we spend here and the work that gets done, not only patient care, but the educational lectures and the teamwork in general. For the residents, they’ve also had a chance to experience working in an amazing environment half-way around the world in a low resource setting that is as different from being at home as one can imagine. There are no “million-dollar work ups” here in Tanzania such as we see at home, but rather incredibly thoughtful evaluations with the resources we have at hand and developing a treatment plan that fits within the constraints we have here in Tanzania.

Though the weather remained cool and rainy with flooding nearby in Arusha, there were still patients coming to clinic. Mark and Anya were leaving around 1 pm for their evening flight, so we were not counting on them to be in clinic today. Thankfully, there wasn’t a rush of patients at the end of the week and given we’d be back working on Monday with the next group of residents, it was a generally quiet end of the week day. An 11-year-old Maasai girl came in from the Endulen region in the Ngorongoro Conservation Area who had been having daily seizures for the last month after running out of their medication (carbamazepine) with four seizures the day prior and who was very encephalopathic. Given her history and seizure frequency, it was not at all surprising that she was confused and sleepy and after evaluating her, it became clear that she was just post-ictal and only required restarting her medication. Unfortunately, we are unable to load carbamazepine, so she was placed back on a starting dose of medication with an up titration over the next week and her family was also counselled not to run out of her medication again.

Usha’s final patient of the day, and for that matter, of her rotation, was a small child who she said helped restore her faith in medicine. I find it hard to believe that Usha had actually lost her faith in medicine given the amazing doctor that she is, so I took her comment more to mean that even those who love the profession they’ve chosen can still use those subtle reminders that what they are doing has made a difference. This was a 3-year-old girl who had seen Dr. Anne in February with seizures and had been started on sodium valproate which had immediately controlled the episodes and she was doing well with no side effects. We checked her labs to make sure that she was having no metabolic issues with the medication, which she was not, and continued her on medication with instructions to follow up with us in six months when we return.

Finally, a twenty-something Maasai man walked into clinic with an incredibly interesting story and what turned out to be a significant problem. He had been working as an askari (guard) in Kenya where he was apparently attacked by thieves and hit in the forehead with a hammer in January. He had originally been taken to a hospital there where he was stitched up, given antibiotics, and then sent home. Once home, he had a seizure and was subsequently brought back to the hospital where he was found to have significant skull fractures, bone fragments in his frontal lobes, and pneumocephaly on a CT scan. He subsequently underwent extensive surgery with duraplasty and had returned home to Tanzania.

He was now presenting with a constellation of symptoms that was very worrisome – nausea and vomiting, fever, confusion, and a headache, all of which pointed to an intracranial process until proven otherwise. He absolutely needed a CT scan to rule out some underlying process as his symptoms also were concerning for an underlying infection given the fact that he had been manipulated (his surgery). I’ve attached some samples of this CT scan along with the preoperative study just for reference. We were considering doing a lumbar punction as there were no contraindications, though in the end, it was felt to be unnecessary as the new CT scan demonstrated an underlying abscess formation and probable cerebritis (an infection of the brain itself) requiring an additional procedure to wash out the infected area. We had started him on antiseizure medication as given the size of his injury and infection, there was little doubt that he had a significant seizure risk outside of the acute setting.

He was admitted to the ward to be placed on IV antibiotics and we began the process of referring him to Kilimanjaro Christian Medical School in Moshi where there is a neurosurgeon and ENT who could deal with taking care of his complex situation. Sadly, the following morning, the patient and family decided to take him home to a traditional healer despite our protests. We sent him home on an oral antibiotic course that we knew would be insufficient to cover the process that he had going on and hoped for the best. This is often the case here, that patients and/or families decide to go home rather than to follow our recommendations. Sometimes it is to go to a local healer for cultural beliefs, but often it is secondary to money. Even with Kitashu, who is Maasai and our social worker, it is very often impossible to dissuade families from leaving the hospital in these situations. As frustrating as this can be, one always must remember that we are guests here and working with vastly different cultural and economic paradigms than our own.

Mark and Anya had left for the airport around 1 pm, being driven by Dr. Adam, who just happened to be on his holiday and offered to shuttle them instead of having to hire someone they didn’t know. Considering that he was driving a nice BMW, they probably scored considering the long drive to get there. Upon walking home after clinic, though, I realized that I had forgotten to ask Mark to leave his key to the house which are an unusual type here that cannot be reproduced or copied. We tried calling Adam (though Mark had a new SIM card on his phone, they hadn’t turned it on, unfortunately), but he had just left the airport after dropping off. Finally, Mark contacted us and had actually realized he still had the key, but after Adam had left. I told Mark to ask around the airport to see if there was anyone, he could leave it with and, thankfully, the security office was willing to hold the key with my name and number as I would be at the airport the following evening to drop off Wells and Usha. I had a pretty good sense that this would work as there were no other alternatives to getting the key back to FAME in a reasonable timeframe.

The night was spent for packing for Wells and Usha and for Jill and me to bring whatever we needed for a night in Arusha. The plan was to leave sometime around noon for a leisurely drive to Arusha and a stop at the Shanga Shop, a very nice little shop that sells the wares made by disabled artisans using recycled glass for glass blowing, looms for textiles and beadwork for jewelry. It was a quiet evening at home.

With more follow up on the Marburg virus situation in the Northwest of the country, it seemed there have been no new cases since those initially reported. With the WHO involved there is a sense that the outbreak has been contained to a very small location and after speaking with those here at FAME, the sense is that the risk of travel to Gombe will be incredibly low, and Mark and Anya will be fine with their current plans to leave tomorrow for their trip. Flights to Kigoma, the town on Lake Tanganyika from which they will depart by boat for the last leg to Gombe, are not available on Sunday, so they will be departing from FAME a day earlier than originally planned and will be spending tomorrow night in Dar prior to flying to Kigoma. It is a true adventure, flying all the way across the country to its western most border on Lake Tanganyika, the second oldest, second largest by volume, and second deepest freshwater lake in the world, while also being the longest freshwater lake in the world, that sits between Tanzania and the Democratic Republic of the Congo, or the DRC.

Mere mention of the DRC can bring shudders to anyone remotely familiar with its past, but the greatest atrocity occurred more than 100 years ago when King Leopold II of Belgium decided that he deserved a colony as much as any other European nation. Under the guise that he was colonizing the Congo for its own benefit and to improve its standard of living, he proceeded to found the Congo Free State for himself in 1885 and, over the next 20 years continued to rule the Congolese population by force using a mercenary army to enforce his rule through violence and atrocities. He first began exporting ivory in massive amounts and, when the price of natural rubber made its harvest profitable, turned to having his mercenaries force the population to harvest it for export.

During this time, he had the backing of the US Government as he completely duped them into believing that he was doing good. While the exact number of Congolese killed during his reign is estimated to be between 1 and 15 million, a consensus seems to center on 10 million killed, making it one of, if not the, largest mass killing or genocide (some debate the definition of genocide) in the history of mankind. Despite this incredibly dark history, the atrocities that occurred in the Congo Free State were where not widely known until the publication of “King Leopold’s Ghost” in 1998 (a great read that I would recommend to anyone).

I recall my visit to Gombe as an amazing experience and often sat on the beach near sunset, with the mountains of the DRC looming from across the lake some 25 miles away, but clearly visible to us in the waning daylight as darkness quickly fell upon everything around us. It was haunting not for what I knew of its past, but more so for what I didn’t know about its present and the fact that it occupied essentially a black hole that sat just across the lake from me.

We had a young woman present today that was very similar to a case we had seen several years ago here at FAME. Back then, it was a young Maasai woman who was post-partum and presented with severe headache and focal deficits on her neurologic examination. Lindsay Raab was here at the time and had seen her in consultation and was worried about a cerebral venous sinus thrombosis (CVST), or clot that had occurred in the large venous sinuses of the brain that drain blood into the jugular veins. Indeed, her CT scan was consistent with this diagnosis – not only did she appear to have CVST, but she also had evidence of a venous infarct that was causing her weakness. The treatment that was indicated, though, was something completely counterintuitive to most as it involved anticoagulating the patient with heparin to help the clot resolve and effectively reduce the back pressure that had developed causing the infarct. With very little technology to go on (we had no CT angiogram capability at the time that we have now), we placed her on intravenous heparin and hoped for the best. Had she developed a hemorrhage on the heparin, one of the possible complications, we had no means of operating as the closest neurosurgery was more than two hours away.

I will have to admit that I relied tremendously on Lindsay’s and the other resident’s input regarding this case as they were all much more up to date with the neurovascular data that existed for this situation and, even though I was comfortable with the concept, it was their dedication and commitment, especially Lindsay’s, that allowed for the comfort level I had with the plan. In the end, the patient did amazingly well and returned to a normal neurologic exam. It was quite a triumph, and I was very proud of the team. The patient also had a history of prior miscarriages, as did her mother, which made us suspect some clotting abnormality such as anticardiolipin antibodies, but without the necessary testing available here, we were unable to say for certain what her future risks were. We felt quite strongly, though, that a future pregnancy would be an extremely high risk for her and counseled her against becoming pregnant again, which also had to involve her husband. A Maasai man’s wealth is his children and his cattle and telling them she could not get pregnant in the future could have been a problem. Low and behold, her husband told us that he loved his wife more than having more children, which was music to our ears.

Our patient today underwent CT scans with and without contrast demonstrating that she did not have CVST, or a clot, and we treated her headache conservatively. Thankfully, I did not have to make the same decision that we had in the past as I’m not so sure I had it in me to approve anticoagulation again.

The weather was continuing to change, and we were getting more rain and cool temperatures. We hoped that it wasn’t the change of the season with the monsoons coming as that is a particularly unpleasant experience that I was hoping to avoid.

We had a Maasai patient present to the clinic who was five weeks postpartum and was now severely psychotic with pressured speech and marked paranoia. She was impossible to reorient or redirect. She had no history of psychiatric disease, and this was her third pregnancy. She was so out of control that it required quite an effort to get her to the emergency room where she was eventually administered two doses of haloperidol mixed with diazepam that, unfortunately, had little effect on her. She was eventually admitted to the maternity ward due the fact that she was postpartum, and later given olanzapine which is the medication we were planning on using at least short term for her. The following morning, she was calmer, but remained psychotic and agitated requiring that she remain in the hospital.

Our last piece of business for the day was to visit the Golden Sparrow with the entire neuro team for a night of dancing as Mark and Anya would be leaving the following day. We were joined by the entire group of interpreters who had been working with us for three weeks as well as Dr. Anne even though she was well into her pregnancy. Konyagi, whose claim is that it is “The Spirit of the Nation,” is the local drink of choice here, and, mixed with tonic water, makes a perfect gin and tonic. Better yet, it’s very inexpensive and perfect for the club. Though the club was entirely empty when we arrived, and remained so for about two more hours, it did fill up with other patrons later in the evening so that we were not the only one’s dancing. Everyone enjoyed themselves immensely and even though I have included a few videos, it is still “what happens at the sparrow, stays at the sparrow.”

Yesterday afternoon brought the report from the Ministry of Health that an outbreak of the Marburg virus, a cousin of Ebola and also a hemorrhagic fever, had now been confirmed in Tanzania. The report was from the Kagera region, which is in the far northwest section of Tanzania adjacent to the Lake Victoria and Uganda and had originally been reported last week, but without confirmation of the virus. The report noted that there had been eight cases of Marburg and that there had been five deaths, one of which had occurred in a health worker caring for the patients.

Considering the previous Ebola outbreak that had occurred in West Africa with countless deaths and an international response that included the United States, this report of a possible hemorrhagic fever now being present in Tanzania wasn’t something that we could take lightly and there was an immediate response here at FAME that included stricter triage than we had already been using since COVID and heightened awareness by the everyone seeing patients, especially those who had traveled far to reach us. The fact that the virus had been first reported and now confirmed in a region of the country far away from FAME was certainly reassuring, though nothing can be taken for granted in this post-COVID world of ours.

It was reassuring, though, that in addition to the Ministry of Health, the WHO was also assessing the current risk of spread of the virus to other regions. There seemed to be little worry here in our little paradise of Karatu, but unfortunately, two of our team had plans to travel to Gombe Stream National Park to visit the chimps who reside in the mountains surrounding that area and where Jane Goodall had done her monumental work that totally mystified the scientific world. Gombe Stream, which is on the far northeast coast of Lake Tanganyika, though still far from the Marburg outbreak, was closer than Karatu to it, and in a much more remote and less medically developed region of Tanzania.

I had followed the outbreak over our weekend in the Serengeti, hoping to glean from the news any information that would make me feel more comfortable or, if not, more definite about having to cancel the resident’s plans to visit Gombe for safety reasons. There was almost no news in either direction, which, though frustrating, was not overly surprising. The fact that it had now been confirmed to be Marburg was at least some information, but any more details regarding further spread or additional cases was entirely lacking from any of the news reports. I had originally not wanted to stress either Mark or Anya regarding the situation, but they became aware of it not surprisingly. We would have to keep an eye on things, and it would be a moment to moment or game time decision once there was more information. They were scheduled to head to Arusha in two days, so hopefully we would know something shortly.

Clinic today included several interesting patients, one of whom had a relatively rare syndrome called Alice in Wonderland Syndrome, which I’ll describe shortly. First, though, we had a young Maasai patient who only spoke Maa, or the Maasai language, and was seeing us for seizures. “Maasai” actually means speakers of Maa, and it is often that Maasai patients who do not leave the boma, which are primarily the women, will not speak Swahili and will either require a Maasai interpreter or, at times, an additional interpreter if the first does not speak English. In that case, we do double translation, or Maa to Swahili, and then Swahili to English. Thankfully, we are usually working with Kitashu whose grasp of English is very good and is Maasai. This patient reported that they had seizures since 7 years of age following an episode of severe cerebral malaria. This is not at all an unusual situation and is one of the explanations for why epilepsy is so much more common in low to middle income countries – childhood infections including cerebral malaria as well as trauma and limited perinatal care.

The other interesting seizure patient we saw today involved a 22-month-old child who had been suffering from seizures with prolonged automatisms (automatic behavior like chewing) which are atypical in and of themselves, but more significantly had a seizure here in clinic for us and it was decided that it would be best to admit the child to the hospital here just in case they were going to have more seizures or, worse yet, go into status epilepticus which would put them significant risk of harm. The child was started on an antiseizure medication right away and stopped having seizures over night and was fine for discharge the following day.

We see so many epilepsy patients here who have never been treated for their condition or have been treated with inadequate medication dosing and never went back to see the doctor because treatment had been ineffective. As I have mentioned so often before, the epilepsy treatment gap (those patients with the condition who are either not receiving treatment or who are not being treated effectively) is greatest in low to middle income countries where the greatest amount of epilepsy exists because of childhood infections, poor perinatal care, and head trauma. And this is exactly where there are the fewest neurologists to treat these patients, so it is almost a perfect Catch-22 scenario. Not only have we identified epilepsy as one of the most common diagnoses that we treat here, but it is also a diagnosis where many of the patients have previously sought medical attention but were placed on the wrong medication or too low of a dose. Therefore, epilepsy is the condition in which we can make the greatest impact here, not only providing treatment for the patients, but also providing the education for the caregivers at FAME to use in our absence when they see these patients.

Now for our most interesting patient of the day and, thankfully, one whose native language was English as I’m not entirely certain how her history would have been portrayed had we been translating from Swahili, or worse yet, Maa or Iraqw. This was a young patient with a history of headaches that sounded very migrainous but was now complaining of new symptoms that were very specific. She noted that recently she was having episodes of headache that were associated with abnormal visual perceptions in which objects or her own body parts appeared too large or too small. This syndrome, coined Alice in Wonderland Syndrome (AIWS), for fairly obvious reasons, has been well-described in the literature over the years, and though no unifying diagnosis has been confirmed, it mostly consistently felt to be migrainous in nature and most often in the pediatric population.

The syndrome is considered to be rather rare, though our patient today seemed to describe the necessary symptoms in a very unprompted manner and the migraine association in this particular patient seemed to be quite convincing such that it was decided to treat the patient with preventive therapy for migraine. Given the lack of a definite and unifying pathophysiologic process, though, we did recommend that the patient obtain an MRI scan of the brain once they returned home, which would be in the near future.

At the end of the day, we all had the pleasure of traveling up to visit a good friend who lives just below Gibb’s Farm and has a wonderful coffee business, preparing and roasting his beans onsite along with his numerous hives of stingless bees who pollenate his coffee plants. Phillipo and his family have always been incredibly gracious to the groups I bring there, demonstrating the process of preparing the beans and then roasting them fresh for us. From his wife, who sits tirelessly at her manual sewing machine making the kanga cloth bags for the coffee they sell, to his lovely children who are often helping when we are there as long as their school is not in session, everyone is just so absolutely pleasant that you just can’t help from having a huge smile on your face.

We stumbled upon Phillipo and his family somewhat serendipitously while on a walk towards Gibb’s Farm in the last few years and were visiting the woodcarver next door when he took me to visit his friend, who happened to be Phillipo. It was a quick friendship and we have not missed a visit with him since. The Ngorongoro Highlands is a premier coffee growing region where coffee plantations dominate the landscape, though most of the coffee from here has been traditionally exported to East Asia, just like most everything else that is produced in Tanzania.  

Phillipo describes the entire process of processing the beans from bringing them in off the bush, to pulping them and then fermenting them. Once they are then dried on screen racks, they are hulled by pounding them in a large container while singing “twanga, twanga, twanga kahawa, twanga,” in unison. The hulled beans are then separated from the chaff by tossing them in the wind with a winnowing tray and are then ready for roasting in a large cylindrical container over an open fire and turned by hand for 40 minutes to yield a medium roast. If you’d like your coffee ground, he then grinds it for you with plate grinder. Most of our coffee is purchased as who beans, but we also buy several bags of ground to use at the house or to bring home.

And then there is the honey he harvests from one of his many beehives he has hanging all around and are home to the stingless bees that pollenate his coffee bushes. He must have nearly two dozen hives hanging around his home and his coffee equipment, each hive yielding two honey harvests a year. He just happened to have honey available, and Mark was more than happy to have purchased some from him for he doesn’t drink coffee and he wanted to participate in the visit in some way. After more than an hour of having learned and participated in the coffee production, honey, and coffee tasting, it was finally time for us to head home and think about dinner.

Coming home from the Serengeti is always tough. You’re in the middle of this incredibly magical place, driving roads that are truly endless and go on forever with not another vehicle in sight for as far as one can see. And then throw in the millions of wildebeest making up the Great Migration, and event that is seen only one place in the world. Now we are back at FAME, itself a magical place in a much different way. Everyone’s happy to be here, but somehow there’s a longing for more of the Serengeti. There’s always the Nat Geo channel or Animal Planet, but somehow that’s not quite the same.

On our way home from the Serengeti, we had encountered a considerable amount of rain, and this continued throughout the night making things a muddy mess into the morning. This is a very good predictor of a slow day in clinic as the patients, many of whom would normally walk or take a boda boda (motorbike taxi) to clinic which is always a problem when the roads are as slick as ice due to the lack of absorption of the red clay here in Karatu. Similar to the issue that we had in Serengeti, it takes very little for a vehicle here to easily swap ends and wind up in one of the many deep drainage ditches on the side of the road. Riding on the back of a boda boda as a passenger can have an equally deleterious outcome with far less body protection and walking on the roadside even less so.

With everyone tired from the long days over the weekend, having a slow day in clinic wasn’t necessarily something that anyone complained about, though given the shortened three-week rotation now for the residents, I always feel badly when there is a day with fewer patients as their experience just isn’t the same. Regardless, there is very little that we can do about the situation when few patients show for clinic other than to just make do which typically means for the residents to do some didactic teaching with our Tanzanian clinicians.

At morning report, one of the patients being presented was in need of blood transfusions and there was a call for compatible volunteers to give blood that morning. Both Usha and Mark had the appropriate blood type and were more than happy to come into the lab to give blood which worked well given the slow day for us. I think Usha got a Fanta soda for her troubles, but Mark seemed to have missed the memo and didn’t receive one much to his dismay. Blood transfusions are an ongoing issue here give the fact that we don’t have the storage capacity for a full-service blood bank, though we will often have family members and patients donate blood for upcoming surgeries should they need a transfusion.

One interesting patient that did come in today was someone who had developed unilateral weakness three days prior to seeing us but had not sought medical attention to evaluate their problem or to receive treatment. It was pretty clear based on the history that this was a stroke as it had been of very sudden onset and she didn’t have a headache at the onset which would have made us worry about a hemorrhage, so at least we didn’t believe there was a significant concern for that process. Given her clearcut history and examination, there wasn’t a sense that she required any urgent or emergent treatment, and, in fact, it was debated as to whether there was even a need to obtain a CT scan as it was very unlikely that it would have any impact on their future care. In the end, we did obtain one that was entirely consistent with the infarct we suspected and explained the neurologic deficits that had brought them to see us. There was no clear reason to admit her to the hospital as she was perfectly stable, and no further evaluations were required. Certainly not something that would happen back home, but without the availability of further testing, having her as an inpatient would only increase the cost to her family and they were more than happy to bring her home.

The end of the day saw another visit to Teddy’s to pick up the clothes she had been working on over the last week. It’s always a joy to visit and now, with her little son, Allan, it is even that much more pleasure. We’ve been using Teddy to fashion clothes for the residents for several years now, ever since I was introduced to her by one of the long-term volunteers here at FAME. She has always done a great job for everyone and bringing home the clothes made of the colorful East African fabrics is something that seems to be very much appreciated by everyone. It’s an activity that I love given how much the residents enjoy it, but it has been some time since I’ve had anything made. I usually drive everyone there and then plop myself on a chair on her porch with my computer to type away on a blog or answer emails while I’m waiting.

Having completed our predawn departure yesterday and seen the sunrise on the road, today was the day for us to sleep in, or at least a few extra minutes of shut eye. As we would be leaving camp this morning, we all had to be completely packed either before breakfast or be ready to run home afterwards to do so. Everyone showed for coffee and a delightful breakfast on time except for Patrick, though he was usually the quickest of all of us to be ready for the game drive, and besides, it wasn’t very likely we were going anywhere without him, anyways. After a very full meal that even included an omelette station, pretty amazing considering we were in the middle of nowhere.

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It appeared that we had all packed early and now, all that was needed, was to transport our bags to Turtle for the trip home. The camp staff did this for us, though I carried my own as I often do, always feeling quite self-conscious about having someone else carry it for me when I’m perfectly capable of doing so on my own. Though I must admit that I am one not to like attendants to carry my bags at the airport because I hate to worry about having to tip them, and not because of the money, mind you, but just because I hate to have to think about the situation. Regardless, our bags, which were all sitting at the main tent pending Turtle’s arrival, were all schlepped to the vehicle by the camp staff. Since we had eaten breakfast already that morning, we had lunch boxes packed in the car that we would eat later in the day, most likely at the Naabi Hill gate where we had eaten lunch two days earlier on our way into the park. We had seen quite a bit in the two days we had explored and still had a more of games drives to go this morning.

Our camp sat at the northern end of the Central Serengeti, and we first went north to look at the river that travels through that region, but found very little in the way of wildlife, so turned around and went back in the direction of the Seronera River looking for leopards. We found a few Nile crocodiles out sunbathing and a hippo here and there, but no leopards nor lions were to be found despite the conditions being excellent. Leopards love to sit up on the trees near a river or good water source where it can stealthily stalk its prey. With nothing much to show for morning drive and the threat of mutiny by the female members of our party, Patrick made the unilateral decision to head in the direction of visitor center, where there were very clean and very western toilets as opposed to the alternative, which was a squatty potty, or even worse, Turtle’s rear bumper.

Following the much-needed pit stop, it was time to begin our drive out of the park and head in the direction of the Naabi Gate, well, kind of. Patrick was still looking for more leopards or lions and though we did find some lions sleeping in a tree with other cars nearby, we didn’t spot any other big cats. We drove along on the Sopa side of the valley (nearby the Sopa loge) which is on the west side of the Central Serengeti and eventually leads into the western corridor of the Serengeti, a place I’ve never visited, but hope to someday as it is very different than the other parts and equally unique as things go here.

The drive was clearly the long way round to get to where we were going, but the views were spectacular as we were traveling along very small roads, often flooded, with no one else around for many, many miles, through endless stretches of low grasses broken only by the occasional small herd of antelope surprised to see our vehicle in such an out of the way place. As we drew closer to Naabi Hill, though, there began to appear in the distance massive numbers of wildebeest along with some zebra in small groups or alone, but stretching in all directions as far as the eye could see and feeding on the vital grasses that would maintain them on their long journey to the north eventually across the Mara River into Kenya. This was the Great Migration, the largest movement of land animals on our planet, and there were millions of wildebeest here that were participating in this event unlike any other and we were sitting smack in the middle of it all. It appeared as though Naabi Hill was ground zero or the center of a giant wheel with the wildebeest radiating outward for miles and miles. It would have been amazing to have seen an aerial view of this procession, though it was easy to imagine what it would have looked like. The scene was spectacular.

Departing Naabi Hill and leaving the Great Migration behind, I knew that I would be back to see these sights again, but not so for those accompanying me on this trip. For me, once I had visited Tanzania, I knew that I had to come back, and I have now for the last thirteen years. Some of those who have come with me over the years, have returned, but it is by far the minority. Just having that handful of individuals who have returned, though, is enough to justify what we have been doing here at FAME.

The drive home from the Serengeti is typically long and dusty, though for today, it was raining much of the way that certainly keep the dust at bay. The bumpiness of the road was just the same and left most of us longing to get out of the car. Over the last four years, we have always stopped on the Crater Rim at Kitashu’s boma to visit his family and often be lucky enough to share in a goat roast which is a real treat. Today was not different, and he was waiting for our arrival around 4pm as, once again, we had to be out of the gate by 6pm.

Kitashu’s family, and especially his wife, have been incredibly gracious to have us visit over the last several years. In addition to giving a tour of a Maasai hut, his wife has also made sure to dress all the residents and other guests in Maasai shukas and dress along with all the accoutrements such as jewelry, knives and rungu (clubs). I usually excuse myself from that aspect of the visit since I’m there every time, and then everyone participates in dancing for the women and jumping for the men. It’s quite a bit of fun, though I am more than happy to be the official photographer for the festivities.

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After the dancing, Kitashu’s male family members wanted to show us how they make fire without matches so we did that demonstration. I had participated in that a visit or two ago and it’s pretty amazing, I must say. Following this, we all went to eat some goat on a hillside with only the men. Men eat meat such as goat meat and beef without the women present usually. The fact that the women in our group were able to participate was primarily because they were not Maasai. Otherwise, they never would have been allowed. Usha, who is a vegetarian, was more than willing to participate in the ceremony, but of course, she did not eat the meat.

We all washed our hands with water and soap and then Kitashu brought the goat to us on long skewers that could be secured in the ground before slicing off chunks of meat from the legs and ribs. The meat is absolutely delicious and quite flavorful despite the fact that they use no spices or flavoring other than the natural juices and the charcoal over which they are cooking the meat.

It is a very special event to be sitting out on a hillside in the Ngorongoro Highlands beside the Crater eating freshly barbecued goat prepared especially for us and then sliced into small chunks by Kitashu, a good friend, who works with us during the week at FAME and then spends his weekends in his boma in traditional Maasai dress and lifestyle. Being part of this community, even if it is only for three weeks, provides an experience for the residents like no other.

Waking up in the Serengeti is an experience unlike any other. Though the animal sounds continue throughout the night with the “whoops” of the hyena or the low rumbling growls of the male lions trying to attract their females, there is a sense in things intensifying prior to sunrise. It reminds of one of my favorite musical pieces, Grand Canyon Suite by Ferde Grofé, written in the late 1920s and perhaps more familiar than people realize, but the opening movement, Sunrise, certainly captures the same sense of increasing intensity leading towards a crescendo as the sun emerges from below the horizon as an orange glowing orb and with its rays beginning to penetrate the coolness of the morning.

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We had decided to leave camp well before sunrise to experience those animals that are only out at dusk and dawn. Before we could even get out of sight of our tents, we ran across a large family of hyena around their den which was just off the road. In addition to the adults, there were many young hyena cubs playing with each other in the road and completely oblivious to the presence of our vehicle despite its size. We sat watching them for some time, with the sky slowly becoming more and more orange as we waited. Eventually leaving the hyena den and heading east, we could see in the distance several balloons that were slowly rising into the sky, their passengers undoubtedly in awe at the incredible sights they were experiencing and would continue to experience over the next hour during their flights.

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I had taken a balloon ride here some years ago on a trip with Danielle Becker and thought it one of the most incredible and exciting experiences of my life. Leonard’s brother, Jones, has been a balloon pilot here in the Serengeti for his entire career and offered to have us fly with him for a greatly reduced price as neither of us would have considered it. Sitting out on the Serengeti, after that flight, with its wonderful breakfast that was served to everyone who had flown together, I quickly realized that had we paid full price, it would have been well worth the cost. Floating silently among the thermals and only the occasional sound of the burner supplying what was needed to rise, there were herds of wildebeest and zebra running directly below us as well as the occasional hippo in a pool or elephant grazing through the acacia. This was paradise.

Shortly after sunrise, with the temperature slowly rising, we quickly ran across a mother cheetah and her adolescent child feeding on a recent kill, a baby wildebeest, common a prey during this time of the migration with the calves having arrived during the herds trip south from Kenya. Nearby, there was another mother cheetah with her two adolescents sitting in what shade they could find on the side of a termite hill, looking very satisfied and likely having recently eaten themselves. It’s not often that you see cheetahs this close to each other, so I suspect that they were related in some fashion.

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We eventually stopped for breakfast sometime in the late morning, simply parking the vehicle and preparing our picnic meal on the hood of Turtle. It was a smorgasbord of breakfast items – eggs, chapati, crepes, sausage, bacon, toast, bananas, fruit, coffee, tea, and juice boxes, though I’m sure that I’ve forgotten a few of the items along the way. Sitting in the middle of an endless plain with absolutely nothing around in all directions as far as the eye can see certainly brings things into perspective as you realize just how incredibly small and insignificant each of us are in this grand scheme of things, we call life. One can easily imagine simply being swallowed up, never to be seen again, and would anyone really notice?

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Over the next hours we saw many, many lions, some with kills and others just chilling during the heat of the day, looking for whatever shade they might find. One group of them consisted of four quite healthy males and we were told that this was the group that had recently killed a fairly famous dominant male who had lived and ruled in this region for many years. Bob, Jr., as the older male was known was killed last week by his sons in a very brutal attack that had been captured on video with the news having been big here in Tanzania and elsewhere. Whether these were his sons and killers or not, we really had no way to tell, but it was certainly a distinct possibility given the location, the circumstances, and the very healthy look of these four males.

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Throughout the day, we continually ran across vast herds of wildebeest, often with a small contingent of zebra in the lead almost guiding them. Wildebeest and zebra have a symbiotic relationship as they protect each other from the constant pressure of the big cats with the large numbers of wildebeest protecting the zebra and the sharp eyesight and hearing of the zebra acting as sentinels for the large herds should lions, cheetahs, or leopards approach uninvited for a meal. The scene was incredibly dramatic to see these herds stretching for such great distances and moving slowly in the direction of the greener grass.

We made it to the visitors center for lunch and the bathrooms as it had been some time for everyone and everyone was paying particular attention to being well hydrated, certainly not helping the issue. Patrick and I left briefly to refuel Turtle at one of the two fuel stations in the Seronera as even though we had used a surprisingly small amount of our fuel on board, it’s aways best to have more than you need never knowing what emergencies may arise during our travels.

After lunch, we started to look more seriously for leopards, hunting for them in the lines of trees that sit along the rivers, or sources of water in the area. Leopards live in trees when they are not in search of their prey, and when they find something and are successful, they’re dragged up into the tree, no matter how big they are for the leopard is not only incredibly strong but is also a natural climber. You can often spot old prey in their trees, but the best way to look for them is to spot their tails hanging down from the branch they are sitting on. Females will straddle the branch, with both their rear legs on either side of the branch, while males will have both rear legs on one side or the other for obvious reasons. Leopards hunt stealthily and will get very close to their prey, almost on top of them, in fact, before pouncing, or ambushing them in a very quick action. We saw several leopards, one of which was on one of the very many kopjes in the area, the rock outcroppings that are interspersed throughout the central Serengeti and where all life exists.

Late in the afternoon it began to rain very heavily, and the roads became incredibly slick as the water here has nowhere to go and the clay does not absorb it well. We were heading in the direction of camp, but suddenly, and without warning, Turtle decided to completely swap ends in a slow-motion pirouette that thankfully did not end in us flipping on our side. It took a bit to get us back on the road and in the right direction, but Patrick did eventually get us going in the right direction again. We were all just a tad shaken in the process, though I think was more so than the others as I had been stranded in the mud several times in the past and it is not a good feeling to say the least. There is no AAA here, and, in the low season, cars pass by very infrequently. Furthermore, though we did have a winch on Turtle, we had nothing on which to anchor, so it would have been up to shear muscle power to get us back on the road had we gone off in a bad way. Despite a bit of fishtailing here and there, Patrick kept us going forwards after and, even though we had planned to get back to camp earlier to enjoy some drinks and the sunset, we ended up continuing our search for leopards which put us back to camp just in time for showers before dinner. We did manage to enjoy the drinks, though, and after quite a long day (12+ on the road) of game driving, we all enjoyed a moment of relaxation. I’m sure that Patrick enjoyed it even more than the rest of us, though.

The Serengeti is one of those places that is known world-wide, and the mere mention of its name conjures up childhood stories and adolescent dreams, or perhaps in today’s generation it’s more thoughts of the Discovery Channel and Animal Planet. Regardless of how one first became aware of this natural wonder, it remains a place of awe with magical powers that justly deserves its reputation for it is a place like no other in the world. Serengeti National Park was founded in the 1950s, before there was even a Tanzania, as the need to protect this region was clearly recognized by the British who were in control of the country until its independence in 1961, and subsequent merger with Zanzibar in 1964 to create the country we know today.

The word “Serengeti” is believed to come from the Maasai word, “Serengit,” which means endless plain, though regardless of the origin, there is little doubt that the Serengeti has become synonymous with the vast and endless expanse of land that makes up the national park and even continues on with a small portion slopping over the border into Kenya as the Maasai Mara. The Serengeti is absolutely immense – by area, the park is larger than the state of Connecticut and slightly smaller than New Jersey, yet there are no permanent residents other than the researchers and workers for the lodges and camps. Although the Maasai can live and graze their livestock in the adjacent areas including the Ngorongoro Conservation Area, their cattle are not allowed within the park boundaries, nor can they camp in the park.

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The great migration of primarily wildebeest along with their friends, the zebra, with whom they have a symbiotic relationship given the latter’s fine sense of sight and hearing that helps to protect the herds from the always present threat of the lurking carnivores looking for an easy meal. The migration is the largest of any land animal and is the continuous clockwise movement of over two million wildebeest who are following the rain and the grass, calving from the north in the Maasai Mara, all the way to the Lake Ndutu region in the south. The massive herds seen crossing the Mara River in the north while avoiding the open jaws of hungry Nile crocodiles occurs in late August and Early September. I have now been to the Serengeti on countless occasions and have never once tired of seeing these incredible sights and experiencing this remarkable land for the Serengeti is much more than just the animals, the kopjes, the trees, the sky, or the place each alone. For it is about sum total of all that exists here and can be found nowhere else in the universe.

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As I’m sure the residents appreciated, we were not leaving at the crack of dawn to today’s expedition, but rather were being picked up by Patrick at around 7:30 am along with Turtle which he had checked out the day earlier. We had our lunches packed along with our snacks for the road and were on our way back through the Loduare Gate as the same route to the crater is used to get to the Serengeti. The weather was cool and especially so on the rim of the crater as we traveled back around as if we were going to descend into it, except this time that wasn’t on our agenda as we passed the entrance to the crater on the far side and continued towards Naabi Gate, where we would be entering the Serengeti later today.

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But first, we had a stop to make at Oldupai Gorge, which is Mecca for those of us like me who are anthropology nuts, and an incredibly important site even for those who are not. The Gorge, which was discovered by a German neurologist in 1911 who had been studying sleeping sickness, or trypanosomiasis, in the area and found numerous fossils of extinct animals here. When first publishing his find, he misspelled the word “Oldupai,” which is the Maasai word for the local sisal plant there, and called it instead Olduvai Gorge, which unfortunately has stuck ever since. Following WWI, with the British control of East Africa, further exploration discovered what were believed to be stone tools which eventually lead Louis Leaky to the site in 1931, and his wife, Mary, in 1935. Together, they spent season after season working here until, in 1959, Mary discovered the skull of Zinjanthropus, or Australopithecus bosei, who Louis later nicknamed “Nutcracker man” for the large molar teeth used for its diet. Zinj dated to 1.75 million years ago and was the oldest homonid, now homonin, that had been found to date.

When I first came to Tanzania in 2009, there was absolutely no way I was going to miss visiting Oldupai Gorge and, so, I dragged both of my children here to see what was so important to their father. I know they both appreciated the visit we made there as they have told me so since, and it is for this reason that I have brought almost every group of residents here on our way to the Serengeti. When we first came here, the museum was a one-room affair that looked like it had been put together on a shoestring, but several years ago, a new and incredible museum was built that would be worth a visit on its own.

Driving up to the gorge, it’s a dry and very desolate place that’s not at all imposing until you walk to its edge and realized exactly what you are looking at. In front of you is something akin to the Grand Canyon on a much smaller, though no less significant, scale and consists of multiple layers of sediment that are the result of erosion and volcanic activities over the millions of years it took to create such a masterpiece. From the viewpoint amphitheater, the Leakey’s camp is still visible and is now a living museum. I had first visited there before it was open to the public and it was a magical place. Mary Leakey’s original Land Rover sits there exactly as she left if in 1986, her last season at Oldupai.

I had the luck to meet a wonderful anthropologist several years ago who is still currently working at Oldupai, Professor Paulo Masaki, and each visit, he gives a very nice presentation to the visiting residents about the gorge and its importance for the history of man. When I had first met him, we had visited Leakey’s camp and a fossil storeroom there which contained only non-hominid fossils, but still had amazing pieces that were an archeologist’s dream. Professor reached into one shelf and pulled out a three- or four-foot section of a mammoth tusk and all that I say was, “don’t drop it!” Walking the same ground as the Leakey’s that day was something that I’ll never forget.

Everyone went through the museum at their own pace (I think Anya was the slowest as she was the one most excited about visiting here) and we then visited the gift shop, where Mark posed with the sternest of face with a Maasai shield and spear. After the gift shop, the residents found a few close by giraffes that they could take photos with before we decided to depart for Shifting Sands. The route to this incredible display of volcanic force took us down into the gorge, across the river that runs through it, and then up the opposite side. The road is not particularly marked well, but there are multiple paths heading in the right direction though not incredibly reassuring to one who doesn’t know the area. Finally, in the far distance, we could see the mound of volcanic sand that was ejected from Ol’ Doinyo Lengai hundreds of thousands of years ago and is slowly moving across the plain traveling some 3-5 meters a year blown in one direction by the wind. The miraculous thing is that the sand stays together due to its magnetization and, therefore, doesn’t lose much, if any, of the pile along the way. It’s a sacred site to the Maasai and many were there when we arrived.

After leaving Shifting Sands, we traveled by way of a small, out of the way road that bypasses the main road with the benefit being that you miss the horribly wash boarded section of gravel with vehicles passing the other direction at high speed and the risk of shattering your windshield like we did last year. This road, if you can call it that, as it is more of a trail, travels on the far side of the gorge for some distance until it peters out at the point where you meet the main road again. We eventually arrived at Naabi Gate in time for lunch, but before getting there, we were able to appreciate the huge number of wildebeest that were aggregating around the gate and on the other side. They were as far as you could see in all directions and pretty much everywhere.

After eating lunch, we officially entered the park and, within minutes, found a pride of lions that were spread out in several groups. They had obviously been feeding on the wildebeest herds that existed nearby. There was also a mating pair of lions that were a short distance away, though they didn’t seem to be in the mood given the heat, or either they were a bit shy as there were several vehicles sitting with us hoping for a show. As I’ve mentioned in the past about lions who are mating, they do so every 30 minutes for about 48 hours and each mating is literally seconds. The persistent mating for 48 hours is to ensure that the female is impregnated as the male’s penis is very short requiring the frequent copulation to achieve the desired outcome. I can allude to the many funny comments that I’ve heard along the way when encountering a mating pair of lions, though the best were from Kelley Humbert and Laura Mainardi when we came upon a male mating sequentially with three females in his group.

Shortly after leaving the lions, we stumbled upon a cheetah with a fresh wildebeest calf kill very close to the roadside. Cheetahs are unable to take down a full-grown wildebeest on their own, though they are quite capable of managing a calf along with their normal diet of the smaller antelopes – Thompson, Grants, and impala. We left the cheetah to enjoy its meal on its own and slowly made our way in the direction of our camp, about an hour away. We encountered some rain which necessitated putting our top down and it seemed that every time we put it back up, it would rain again for a short spurt. We eventually made it to camp just before sunset so there wasn’t any difficulty in everyone knowing where we were.

I’ve stayed at this camp many times before and it is very comfortable. We were met with warm washcloths to clean all the dirt off we’d accumulated throughout the day and fresh mango juice to quench our thirst. It turned out that in addition to a single couple staying there, we were the only others in camp for the evening. The camp has fourteen tents in total, but given it’s the low season, there are far fewer traveling now. The meals at the camp are typically buffet, but given the small number of guests, it was going to be ala carte tonight, so we chose from the menu what each of us wanted as well as when we were going to meet back for dinner. Hot showers were available as well which I believe all of us took advantage of before dinner. There were zebra and Cape buffalo roaming around in front of camp and as the night went on, you could hear hyena in the distance. It was decided at dinner that we would be heading out before breakfast for a pre-dawn departure for a full day of game viewing. Animals are most active in the morning and the evening, so getting on the road early is always a plus.

Overall, it was a quiet day for us and, with everyone very excited about leaving for the Serengeti tomorrow morning, it was a welcome break. Preparing for the Serengeti, we all had to pack for three days and two nights that we would be spending in luxury at one of the many tented camps that exist within the park. Getting there is another matter as it usually takes several hours of driving on one of the bumpiest roads anyone could image, so much so that it feels like any dental fillings that you had prior to traveling on it will be long ago fallen out once your journey is complete.

We had to make sure we had enough supplies to make our lunches for the journey in the morning heading to the park – typically peanut butter and jelly sandwiches, hardboiled eggs, fruit – essentially what we had brought to Ngorongoro Crater for lunch, though this time the eggs would be adequately hard boiled, of that I was certain as Jill had promised. We’d also be providing lunch for Patrick, our driver/guide, who would be coming today to pick up Turtle and get her ready for the journey. Driving to the Serengeti is no small undertaking, and breaking down while there is another matter altogether as services in the park, even if you could get to them, are very limited. Last year, we spent the entire weekend game viewing in the park with a completely shattered windscreen held together with duct tape as there was nowhere to have it repaired and the only other option would have been to return home, which none of us was interested in doing. There is absolutely no option to leave your vehicle and walk anywhere given the amount of deadly wildlife that would like nothing more than to make a meal of you.

Even though Turtle goes out on only several occasions each year, she has been getting very long in the tooth and has been requiring more and more upkeep over the years making it even that much more important for Patrick to take the vehicle and check it out for our journey. Land Rovers, despite being the absolute best vehicle for driving in Africa, or any other similar terrain, do require more TLC and upkeep than their off-road cousin, the Toyota Land Cruiser, but are tremendously less expensive to operate as the repairs are simpler and parts much more affordable. Land Cruisers operate longer between repairs, but when they break down, it becomes a major hit to the wallet. Most safari companies have turned to using Land Cruisers for these reasons, but having driven both for the last dozen years, I would take a Land Rover Defender over the Land Cruiser any day of the week for a number of reasons. The Land Rover is more comfortable, has a wider stance and better stability, and is far less likely to get stuck in the mud. And then there is the sentimental part of me that would choose an old Defender over anything else, though I’m sure if you put a gorgeously restored 1960s F40 Land Cruiser in front of me, I wouldn’t turn it down.

Clinic today was a bit slow, but there were numerous cute children to be seen making Usha quite happy in particular, but all of us enjoyed seeing them. Prior to coming here, I had been asked to give Grand Rounds for the neurology department at the University of Virginia, my alma mater, and had set this up to be done virtually since it was obviously impossible for to fly back for the day. I hadn’t realized that it was actually the Distinguished Alumni Grand Rounds, and I was incredibly honored to be given the opportunity to speak to a department that I hold in incredibly high regard for the training that I was provided there. They had asked for me to speak about the work we’re doing here at FAME and about the accomplishments that we’ve made over the last decade plus. Giving Grand Rounds virtually, which is how most have been done since the pandemic, would not have been a concern had I still been in the US, though doing so from a country where all the internet access is cellular based, and the power grid is about as stable as a cerebellar ataxia (sorry, neurology joke).

Every time the power goes out here, which is quite often, our router in the house takes about five minutes to recycle, meaning that there is no internet during that time. Being on a Zoom as the presenter can be a bit nerve wracking as you’re waiting for the power to go out after which the router must reset. I thought I had perhaps outsmarted the issue by having my computer use my phone as a hotspot which would avoid the power issue, but I had counted on the cellular service on my phone waxing and waning like the aurora borealis. I signed on early to make sure things were working well which it seemed that they were, but then everything froze as the signal on my phone dipped to below a sustainable level for the presentation. Sitting in my room, halfway through my presentation, there was a bit of despair, but I was able to switch to the WiFi in the house thankfully and finish the presentation.

It was now 8 pm and I was starving, but I discovered that they had planned for me to speak with the residents separately in a question-and-answer format which was on a different platform than zoom. Still needing to pack for the Serengeti, not to mention eat dinner, I linked up to the necessary website to speak with the residents. Unfortunately, the bandwidth necessary for me to actually see the residents wasn’t present, so I was mostly talking to a black screen for much of the talk. At some point, my power went out and I was again at the mercy of clumsily reconnecting the internet and the WiFi once our router had recycled, but everyone was patiently waiting for me to come back on. I finally finished the session with the residents just before 9 pm, starving and still needing to pack for our long weekend trip.

Meanwhile, Mark had scheduled one of his virtual fellowship interviews for today since he knew that we wouldn’t be leaving for the Serengeti until tomorrow. My talk was only an hour plus the question-and-answer session, but Mark’s interview was probably the better part of six hours or so. When we got home from clinic, he was already well into his interview and in between sessions, he came out dressed in his suit and tie wearing flip flops. We were all grateful that he was at least considerate enough to be wearing pants as I’m sure all of us have thought about going bottomless, at one point or another, while on a Zoom call during the pandemic. One highlight, for me at least, during his interviews was that he was meeting with Caitlin Loomis at Yale. Caitlin had been a resident at Penn who spent a month with me in my office prior to my having joined the Penn faculty full-time. She then went on to complete a stroke fellowship at Penn and then to Yale where she has been on faculty there ever since. It was great seeing her and I’m sure Mark enjoyed the short break in his otherwise lengthy interview session.

Earlier in the evening, Jill and I had gone into town to run some errands (mainly to pick up snacks for our trip this weekend) and while there, visited the new vegetable market that had been constructed during the pandemic. The old market was a very large structure that was essentially a dirt floored partially covered mass of vendor’s stalls, mostly all carrying the same produce as the next, but somehow everyone knew which of the vendors they were looking for. There were hundreds of stalls and in addition to the produce, there was a fish section where fish from the various lakes in the region and as far away as Lake Victoria were sold. It was a photographer’s dream, and I had taken a few nice photos there in the past. The new market has a solid floor and cinder block stalls for vendors to display their produce. Jill and I walked around, most looking as we were leaving for the weekend and weren’t in need of anything, but still enjoyed exploring.

Tomorrow, we would be leaving early, but not so early as I had made everyone leave for Ngorongoro the week before. The plan was to first go to Oldupai Gorge and Shifting Sands and then make our way to the Serengeti, having lunch at the Naabi Hill Gate. We had heard that the migration was mostly hanging around Naabi Hill and into the Central Serengeti, so there were plans to see as many of these wildebeest as possible. With this huge number of animals and especially all the wildebeest calves, there would also be a significant number of large cats looking for an easy meal and that was something that we were interested in seeing.

I had mentioned yesterday how the road to Rift Valley Children’s Village can become treacherous when it rains and how our drive had gone well since the roads were dry. Well, it rained very steadily overnight, and everything was still quite wet in morning as we departed for our second day of clinic at the children’s village. We had seen a good number of patients yesterday and we weren’t sure how many would show up given it was the second day and also that it had been raining which typically reduces the number of patients we see in any of our clinic as most patients walk and doing so through the mud can be very difficult.

Sure enough, the roads were a tad slippery heading out to RVCV, and it was time to shift Turtle into low gear for both going down hills and up hills as well. The necessity for this going downhill is to prevent having to use your brakes at all as a simple touch can often cause your vehicle to begin sliding and that is a very unpleasant sensation. The need for low gear going uphill is more related to the necessary power to get started when traveling slower due to the slippery roads. Regardless, Turtle in low gear becomes somewhat of a tank that can tackle pretty much any terrain. For those of you who aren’t familiar with a four-wheel drive operationally, there is a transfer case just behind the transmission that has both high and low range for all the gears. This takes a 5-speed gearbox and effectively gives you 10 speeds to use. There is also another function of the transfer case in which you can put in 4-wheel lock which means that all the wheels receive power equally. This is used specifically for those situations that require the extra muscle this setting produces but it is only to be used when there is very poor traction.

The drive went well, at least from my standpoint as I can’t vouch for how everyone else felt about it. Jill was coming along with us today and acted as co-pilot for me in the front seat. At least there is never a dull moment when traveling these roads in the back country as a small mistake can definitely ruin your day. Having a winch on the front of Turtle does give me a little more confidence as there were plenty of trees in the area that we could anchor should we get into any real trouble with the need to extricate ourselves. Down, down, down we went through the deep gullies and then up, up, up out of them until we finally reached the plateau on which the children’s village sat.

As we drove through the gate, there were no patients to be seen sitting outside on the benches as there were yesterday, though we were soon to find out that that they were all sitting inside the gymnasium to stay dry, and the registration process was now being conducted there instead of outside in the somewhat nasty elements. A good crowd having already accumulated, we decided it was time to get started seeing patients as were hoping to depart today at a slightly earlier time than yesterday. The plan for Jill was to spend the day touring the village, checking out the sights, and then also possibly visiting with Peter and India. She ended up having a wonderful time and was obviously incredibly impressed with what had been accomplished at the village to date as well as with their plans for the future.

It was a steady group of patients that we saw throughout the day that included many patients with epilepsy, some new and some return, as well as patients with headache, numbness and tingling and the like. There were no patients needing to be seen at FAME right away, but had it been needed, there were always RVCV vehicles traveling back and forth to Karatu throughout the day. The drivers that do this are pretty amazing considering they tackle these roads in all conditions and, although there is a back way out through the town of Oldeani that one can take should the roads become unpassable, it is unusual for them to do this. I remember struggling to keep my vehicle on the road on trip while they were driving a van, albeit a four-wheel drive one, that was keeping up right behind us. It is a special style of driving in this mud – avoid touching the brakes, feather the gas and turn the steering wheel into the slide and you’ll be fine, most of the time.

Lunch was again a delicious affair, this time with spaghetti and meat sauce (a vegetable version was also available for the vegetarians present) with salad and fruit. It’s very difficult not to go up for seconds with this type of food and most of us took advantage of this opportunity. After lunch, we sat for a bit while Arturo (now the CFO) described for the us the amazing success that the TCF has had with their community education programs, not only in the primary school where they started, but also now with the secondary schools in the region. This has all been borne out in the children’s success taking the national exams that allow them to continue with their education, going to secondary school and beyond. He also described the efforts they have made in creating school lunch programs. Prior to this, some students would have to walk 2 hours to school in the morning and were then expected to walk home for lunch and then back again which was obviously impossible for them to do. They would usually just not return to school after lunch. Also, during walks to school and back, there were issues of abuse that could occur, particularly with the girls.

They now have developed a program for providing school lunches with a contribution by the families (there always needs to be that skin in the game), and students can now remain in school for the entire day. To further improve the educational experience and atmosphere, they have also created the option for students to board at school and have built a dormitory building with the help of the government who has donated the land for these projects. They are now working with the other secondary school in the Oldeani Ward to create all the same programs including the school lunch and boarding options. Through these efforts, the Tanzanian Children’s Fund has not only changed the lives of India’s children, but also hundreds, if not thousands, of children’s lives in Oldeani who would otherwise not have had this opportunity for a meaningful education and success in life. Through their programs – RVCV, Rift Valley Women’s Group, educational initiatives, and health programs – the TCF has changed the direction of an entire community and region of Northern Tanzania.

Though we weren’t able to leave early enough to get everyone home by 5 pm, we were able to finish up a second day of 38 patients and arrive home in time for sunset. Jill and I had an invitation to have sundowners with a good friend, Annie Birch, and a guest of hers to discuss our upcoming trip to Zanzibar after the rotations were through. Annie, a travel consultant who has been here for over twenty years, and her guest Helen Ingvarsson, herself a travel specialist and who has lived on Zanzibar for the past ten years, were the perfect pair for us to speak with about our trip. We met at a relatively new lodge, Baghayo Garden Suites, which is a stone’s throw from FAME and is a wonderful place to watch sunset. I was very surprised when we went in to find Annie and Helen as the lodge is a little oasis that you would never have imagined existing where it sits. The sky was ominous with lightening in the distance from dark clouds and thunder that boomed all around, though we sat pleasantly at poolside sipping our gin and tonics and chatting about Zanzibar. Their recommendations were priceless and more than we could have hoped for given that our trip was only a month away.

Our visits to the Rift Valley Children’s Village, affectionately known as “Rifty,” have always been one of the highlights for the residents during their time here in Tanzania. The Children’s Village, which was first opened twenty years ago by its founders, India Howell and her business partner, Peter Leon Mmassy, began with a small number of children and has now grown to include over 100 children, all of whom now call RVCV their home and India their mother. It is the furthest from an orphanage that one could ever imagine as none of these children will ever have to worry about leaving their home. Early on, it was clear to India and Peter that their children would need good medical care and it was this need that led to FAME being located where it is in Karatu, only about 45 minutes away from the village of Oldeani, the location of RVCV. Prior to the opening of FAME Medical, now FAME Hospital, Frank had been practicing in Usa River, near Arusha, honing his tropical medicine and primary care skills, and it was their becoming friends with India that let them to the Karatu district. The ex-pat community here in Northern Tanzania is very small and very tight knit.

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In addition to having medical coverage for their children, it quickly became very clear to India and Peter that sending their children to the local school the other children from the local village, whose health was less than optimal, would become an issue. From a very early time, FAME began providing medical clinics at the village every other week that were attended not only by India’s children, but also members of the surrounding village and all the care was being provided essentially free of charge. In this manner, the general health of the surrounding village improved, and her children also became healthier being exposed to fewer illness while at school. This situation continued in this manner for several years until it seemed that many patients from outside the local village were also coming for treatment (i.e., those who were not intended to be there) and it became simpler to just send patients to FAME.

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When I began bringing larger groups of residents to Tanzania, we chose to have a neurology mobile clinic at RVCV that ran side by side with the FAME medical clinics, until they stopped and since then we have continued to have the neurology mobile clinics as a stand-alone event there each visit to Tanzania. The plan this week was to spend two days at the village seeing both India’s children as well as those neurology patients from Oldeani, many of whom have been seeing us for several years. Africanus, the clinical officer who runs the dispensary at RVCV and had previously worked with me at FAME with the neurology program before having been hired for the dispensary job, contacts all the neurology patients prior to our coming, so now driving through the gates of the village, we see a great number of patients waiting to be seen by us each day.

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Preparing for our mobile clinic at RVCV is essentially the same as when we do any other mobile clinic, except we don’t have to pick up lunch boxes as the kitchen there prepares a wonderful lunch for us to eat alongside their volunteers and is usually one of the highlights of a visit to the village. The drive to RVCV is a gorgeous one, albeit a bit rough and well-known for what becomes of the road in the heavy rains – essentially a slip and slide. We attended morning report as usual at 8:00 am with plans to depart for the village at 8:30. There is often a patient for us to follow up on or to see in the ward that may delay us a bit, but this morning, we were able to get a pretty good start other than having to pick Annie and the others up in town at the Mushroom Café, the best place to pick up Tanzania breakfast pastries – samosas, chapati, vitumbua (deep fried rice flour cakes), and small little bites that are like hush puppies with veggies inside.

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Once we had everyone loaded, we were on our way towards the Ngorongoro Conservation Area gate as the turn to the road leading to RVCV is just before that. Perhaps the sign on the side of the road, “African Massage Road,” provides some clue to what’s ahead, but it doesn’t take long for anyone unfamiliar with this route to realize that they’re in for a treat. The first part of the drive is along a gorgeous ridge with plowed fields on one side and a steep hill on the other where there are scattered the homes of the local Iraqw who farm here. Eventually, though, we reach a point where, after a sharp right turn, we begin our descent to the bottom of the valley before ascending to another ridgetop. The second descent is even more fun and once we cross a tiny bridge over a small stream, we make a sharp hairpin to the left and quickly ascend to the top of the ridge, through acres of coffee plants and finally arrive to our destination, Rift Valley Children’s Village.

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The road today was very decent and even though there had been some rain in the recent days, there were no issues. A year ago, we had traveled to the village in the midst of heavy rains, requiring the use of four-wheel drive low for most of the journey, not so much for traction, but more to prevent hitting your brakes on the downhill portions of the road as doing so is at your own risk and typically leads to an uncontrolled slide. This is all a bit nerve wracking considering that the majority of this road on a hillside with a steep drop off being present on one for much of the way. Today’s drive was much more uneventful, and we make it to the village in no time to begin our clinic.

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As I mentioned, driving through the gates, we’re immediately met with the sight of dozens of patients sitting on benches waiting to see us and, had it not been for the steady rain that began shortly after we arrived, they would have all been sitting there for much of the day while we worked through the high stack of paper charts. Instead, when the rains began, they moved all the patients into the nearby gym where they could all be registered and wait for us in a more suitable environment. By the end of the day, I think we had seen about 35 patients in total with many, many epilepsy patients, but also quite a few patients who had neurologic complaints that we were unable to attribute to anything and either had to consider treating them symptomatically or not at all. There was little that we had to investigate further, though if someone needed labs or a CT scan, we could always send them to FAME on another day to obtain the necessary studies.

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Annie and Usha worked together seeing the pediatric cases in one of the examination rooms that has animals painted on the walls and has always been used for this purpose specifically. There were quite a few pediatric cases, so they were kept busy while Anya, Mark, and Wells each worked with one of the other translators seeing either adults or an occasional child if the pediatric room became a bit busy. Both charts and prescriptions are all handwritten and, at the end of the day, the notes are all copied so that we have a full set of the notes for our binders at FAME. Joel, a nurse who has worked with us many times served as our pharmacist, both dispensing medications as well as giving patients detailed instructions and information that also included the need to remain on the medication, especially for patient with epilepsy, as chronic disease is not a concept that many patients are familiar with here. Infections, such as malaria and worms are well understood and require only a course of medication that is then discontinued. Not so for epilepsy medications, which must be taken long term and consistently, if not indefinitely.

As I mentioned, the highlight of the day, at least for those of us who live to eat, rather than vice versa, is lunchtime. The number of people working at RVCV has grown over the years, volunteers, and staff alike, and all eat together in the kitchen building where a wonderfully delicious meal is prepared daily by the kitchen staff and consists of all fresh ingredients, usually a main course, salad, and fresh fruit. Though I love the rice, beans, and mchicha that is served five days a week at FAME, I will have to admit that the lunch at RVCV is a welcome change for us. Today, the main course was open face ham and cheese sandwiches on freshly baked bread. Needless to say, it was well received by all.

After lunch, the residents were taken on a tour of the village and a visit to the duka (store) for the Rift Valley Women’s Group, another facet of the Tanzanian Children’s Fund, the non-profit that funds not only the RVCV and the Women’s Group, but also their education efforts in the area that I’ll discuss more in tomorrow’s blog, for during lunch, Arturo, now the CFO of TCF described at length with us during lunch.

For now, it was just a matter of finishing up with all the patients that had come today to be seen by us. We are typically shooting for a return to FAME around 5 pm, but today we were still seeing patients late into the afternoon and well past 5 pm. Thankfully, it hadn’t rained during the day, so the drive home would most likely be uneventful for any trip one takes here always has the possibility of being more of an adventure than one had bargained for.