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.

---

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.

---

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.

---

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.

---

---

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.

---

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.

---

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.

---

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.

Since it’s Tuesday, it another education morning for the doctors and we’ve asked to give this morning’s lecture again. Perhaps I should be clearer, though. The residents will give the lecture and since the neurologic examination had been covered last week, it was decided that giving a talk on the pediatric neurologic exam would be a worthwhile review for the doctors, all of whom are often called upon to evaluate children and, more specifically, neonates. Having our child neurologist here with the current group, this seemed to be as good a time as any to tackle this subject. Usha gave the lecture with Mark standing in as her demonstration “dummy” for the session. Needless to say, they both did a wonderful job and Mark now has another profession to fall back on should he sour on playing doctor.

Today had been set aside for us to see the group of Maasai that live near the Tarangire National Park gate and is a group that we have been seeing every visit now for several years. They live outside of the Karatu district which means that it would require of number of things to occur for us to hold a clinic there such as permission from the regional or district health officer and a formal site in which to hold the clinic. So, as an alternative, we have had the chief of the village bring us as many patients that can round up while driving around the village on his motorcycle. This is the same chief who had brought two teenage Down syndrome patients to me back in 2019, and though we had little to offer them medically, we were able to find vocational training for them at a rehab center in Usa River near Arusha.

With the help of a number of donors, we were able to completely fund their tuition at the school for two and three years, respectively, and now both Tajiri and Amani have both finished their education and are looking for jobs. Unfortunately, despite having training, getting a job in Tanzania is another matter, but hopefully with the help of their village and others in the area, they will find something that will work for them. There was never the hope that they would be self-sufficient, but rather contribute to the family’s income and make them less of a burden.

Chief Lobulu has been incredibly helpful in getting patients here who need to be seen by and many of them have had epilepsy that, once properly diagnosed, has responded incredibly well to the medications we have here. It is not easy for these patients to get to FAME other than the two times a year that we are here which does pose an issue not only for medication refills, or rather the cost of these refills, or to obtain laboratory studies that are sometimes necessary depending on the medication. Sustainability is the most significant issue that we have in treating our epilepsy patients as the cost of medication is the biggest factor by far in the overall cost of our clinics. Though we provide the doctor’s visit, any necessary labs, and at least a month’s worth of medication (often it is two or three months) for only 5000 Shillings (a little over $2 USD with today’s conversion rate), patients very often have a difficult time affording this small amount, let alone the cost of medications when they come back as these are not currently covered by our program.

Our ultimate goal has been to provide some further funding to subsidize this population of patients (epilepsy patients) for their medications. FAME’s philosophy, as well as my own, is that there always must be “skin in the game” for the patients, as this serves to prevent the perception that we’re a free clinic, which we are not and, for a dozen or more reasons, would be the absolute wrong thing to do in a country where access to health care is very limited. Doing so would immediately invite many of the sixty-million residents of the country to travel to Karatu for their free healthcare and the system would collapse instantaneously. With the help of both Kitashu and Angel, our social workers, we generally assess patient’s or family’s ability to pay for their treatment, whether it be a CT scan or medications, so very few patients are turned away without receiving the treatment that has been recommended. That being said, it is not uncommon for families to refuse treatment based on cost or to take patients out of the hospital early because of concern for the cost of treatment. Unfortunately, despite our best efforts and explanation, it often comes down to values and how a family or patient perceives the value of their health. This concept is also operative back at home where I commonly lecture the residents on differences in value systems and the fact that we cannot project our own values on those of our patients and though we may not always understand the decisions made by our patients, we must respect them just the same.

So, it is with this preamble that we began seeing our patients who came with Chief Lobulu from Tarangire, to be seen by our neuro team and many of whom have epilepsy. One of the patients, a young girl with primary generalized epilepsy who had been doing poorly on carbamazepine (as can often be the case with this medication and generalized epilepsy), returned to see us in clinic today. We had originally diagnosed and characterized her epilepsy by performing hyperventilation on her when she was much younger. Patients who have one of the primary generalized epilepsies, whether genetic or not, will often have hyperventilation induced absence seizures, or what used to be known as petit mal seizures, and appear as brief staring spells with loss of awareness and often associated with eye flutter. In the old days, we used to carry around a pinwheel with us when doing a Peds Neuro clinic, to help with hyperventilating patients, though now we just use a piece of patient and hold it in front of them to blow on continuously for three minutes. In my experience, they will typically have a brief seizure after about a minute of hyperventilation.

Another provocative maneuver that can be used is photic stimulation, which is a rapidly blinking light at various frequencies, though the seizures that it provokes can often be generalized tonic-clonic events and very scary for both the patient and family. This is typically done during an EEG to record more subtle events that can be captured and be of diagnostic utility. This is the basis for patients having seizures while playing video games as it has to do with the exact frequency of the flashing that is being presented, but only occurs in patients with underlying epilepsy whether previously diagnosed or not (i.e., a normal, non-epileptic patient will not have a seizure playing video games).

One of the young children was found to have bilateral cataracts that appeared to congenital. She was referred to Sehewa, who is one of our long standing nurse anesthetists who also doubles as our optometrist here at FAME and has been doing eye exams and refractions for glasses for a number of years. Glasses that have been discarded in the US have been sent over here for years through donors with the matching prescription for the lenses present, and then distributed for no cost to patients.

The number of patients coming from Tarangire was about 17 or 18 and kept us quite busy for the day as we had other patients that just happened to show up for the day or those who were sent to us from the general OPD. It was a quiet evening at home with our FAME dinner of macaroni and cheese with zucchini and lots of garlic. We had obtained some pili pili for the house which was also a nice addition.

From the very beginning of my time in Tanzania, I have been involved in mobile clinics to the smaller communities of the Karatu district. The first mobile clinic that I participated in was a very large, campaign-style effort that involved a large portion of the FAME staff traveling to the remote regions of Lake Eyasi and providing a weeklong clinic in several of the communities there. These clinics served primarily the Datoga and the Hadza tribes, both tribes living in this region and the latter tribe representing the last hunter gatherers living in Tanzania. The Hadza are the bushmen of Tanzania and one of the click language speaking cultures of the world, incorporating different click sounds representing consonants into their normal speech. They are a very unique tribe in Tanzania and, unfortunately, are decreasing in numbers due to loss of their game because of outside pressures placed on the land by other tribes such as the Datoga who graze their livestock on land previously used only by the Hadza. At approximately 1500 individuals and declining, it is unclear how long they will continue to exist. Here.

Our trips to Lake Eyasi were always a monumental experience for a number of reasons. We represented a very big crew of individuals that included not only caregivers, but all the support staff necessary to travel into a remote region where there were no facilities other than the shells of brick buildings for us to sleep in and use for our makeshift exam rooms and for our mobile lab (blood smears, malaria, syphilis, brucella, etc). We often set up shop in dirt floored, brick schoolrooms that could house several clinical teams each. We would eat our meals as a group and the same cook, Samwell, who continues to serve meals today at FAME, cooked our meals on these trips, along with a Paula Gremley, an American social worker by training who had her own non-profit for helping out in Tanzania and traveled with us on these clinics.

It was Paula who first brought up the idea of our traveling to the local villages on the outskirts of the Karatu district to provide neurological care to these residents, not only because they could not get to FAME, but also since they more often didn’t realize that they had an illness that we could treat and improve their quality of life. My very first mobile clinic was to the village of Kambi ya Simba (or Lion’s camp) where we had no facility to use and instead placed several desks out in front of their church and began seeing patients. Our nurse, Patricia (who still works at FAME) came along with a large storage box of medications that served as our pharmacy. Kambi ya Simba was in the Mbulumbulu region of Tanzania, a very fertile land that has been settled by the Iraqw tribe who farms throughout the area and is quite the polar opposite of the Maasai when it comes to their livelihood. Quite simply, the Maasai are pastoralists whereas the Iraqw are farmers, and their culture is solely based on agriculture, growing numerous crops on the land they tend and plow.

We would also travel out to Upper Kitete, another village in the Mbulumbulu region that was populated by the Iraqw and was even more remote than Kambi ya Simba. Upper Kitete also has the unique distinction of being one of several sites where an attempt was made to establish socialist camps, or government farms, following their independence in the 1960s when Julius Nyerere, the first president and father of the country, began to plan for the future of the country and which direction they would head. The socialist camps were never successful, and the country is a now presidential democratic republic, but the camp in Upper Kitete remains as an historical monument to their past experiences in developing the country that exists today. Several years ago, I was contacted by someone who had found my website while searching the internet for he had spent several years in Upper Kitete with the Peace Corps back in the late 1960s and had fond memories of the place. He still had some photos, in both black and white as well as color, of the village and life as it was there shortly after independence. One of them pictured local villagers posing with elephant tusks and was a chilling reminder to the one of the many dark pasts that exist here in Africa.

It’s always exciting traveling with the team for mobile clinic given the group effort that occurs to put it together. Doing so would never be possible without the help of our outreach coordinators, Kitashu and Angel, both incredibly experienced at organizing these types of efforts and also fully in tune with the needs of the patients we see as they are also both incredibly competent social workers. I have worked with each of them for several years now and have come to rely on them completely for the success of our clinics, both at FAME as well as our mobile clinics. Preparing everything necessary for a day in the field requires skill to make sure we have everything needed for traveling well over an hour on dusty and bumpy roads only to find out that we forgot something is not a happy feeling. Our medication box must be stocked with all the possible medications we might use for the trip, though in a pinch, we have sent medications later by bus for the patients to receive them.

Our team consists of either Kitashu or Angel, a nurse to dispense medications, four FAME translators/clinicians, an extra driver (I typically drive Turtle), myself and the residents. Often accompanying us will also be the volunteer coordinator here at FAME who make be documenting the trip and taking photos. We will typically bring the lunchboxes that are similar to those supplied on game drives along with lots of water and some snacks. Depending on the volume of the clinic, our drive home can be in the dark, though we do our very best to avoid this as driving the back roads, or even the main ones, can be very treacherous in the dark and is best to be avoided at all costs. And, of course, there are always the inevitable breakdowns that will occur when driving vehicles that are subjected to the conditions that exist here day in and day out.

The old dispensary at Kambi ya Simba was promoted into a full-fledged health center a couple of years ago following a visit by the former president and lots of fanfare. Driving up the day after his visit, we wondered if all the flowers and signage was for us, but alas, it was not. No matter, though, it still made us feel special just to see all the brightness and hope. What did not exist when I first came is now a complex of at least a dozen buildings including several wards and maternity. The center is managed by a clinical officer, as are most in Tanzania, along with a nurse. On occasion, our clinic coincides with their well-baby day when all the local mothers bring their young children to be seen by the nurse. This includes them being weighed which takes place using a meat scale hanging from the ceiling with each baby using their own brightly colored harness made by their own mother or grandmother (Bebe). Despite the crying babies, it is a joy to witness as each mother is so proud and happy when their baby is being weighed and deemed healthy by the nurse. I have always admired this sense of community that exists here for the support systems that exist for these mothers is something very special, indeed.

Our patient load here typically varies quite a bit and may be related to the time of year and whether it is harvest season or not. When it comes to tending their crops, there is little else that takes precedence, including their healthcare, for without this gift from their land, there is no life, and the family will fail. For the Iraqw, their crops are their existence, and their existence is their crops. It is not seen as a struggle, it just is. And it just is as it has been for several hundred years since their coming to Tanzania from the north.

Our clinic proceeded without a hitch, and though the numbers of patients were perhaps less than we had hoped for, it was still a steady pace and kept everyone busy for the day. Our lunch break, which is taken back at the vehicles so as not to eat our lunchboxes in front of those who may at times not have enough food, was relaxing, though the sun was hot. On my first visit here back in 2011, our group was small, and we were provided a more traditional meal of pot roasted chicken, ugali and vegetables that the village mamas had cooked for us. I remember that day very well, for it was the first of my neuro mobile clinics here that now number close to 100, or possibly even more. It was such an honor to have been served our meal as we were, though I have since come to understand that providing a meal or food to someone visiting is not something that is taken lightly and, perhaps even more importantly, the honor is not for the guest, but for the host.

With our clinic finished for the day, everything was packed again into the vehicles, and we began our drive back home along some of the most incredibly picturesque scenery that one could ever imagine. The fields were lush and gorgeous and full of crops ready for harvest before the oncoming rains of late April and May. These are, without question, the loveliest people on earth, and we are the luckiest people on earth to be here with them.                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                           

(most photos courtesy of Jill Voshell)

The rainstorm last night was intense, but thankfully did not persist into the new day and the skies were clear as we all awakened early for our trip to Ngorongoro Crater, a world heritage site and one of the crown jewels of the safari circuit, not only in Tanzania, but in all of Africa. The Crater, which I have described numerous times on this website, is actually a caldera, or a collapsed volcano, and happens to be the largest dry caldera in the world, remnants of a mountain the size of Kilimanjaro that imploded some 2-3 million years ago. The crater itself is about ten miles across at the widest and its walls are 2000 feet tall and very steep. There are only three roads that traverse the sheer cliffs of the inner rim wall – the descent road, the ascent road, and the two-way road, with the two former roads now being paved to prevent issues in the rain getting into or out of the crater. I have climbed out of the crater on the two-way road in heavy rains and challenging is putting it mildly.

Inside the crater exists one of the greatest populations of animals that are unlike most in this region who migrate every year. Those wildebeest and zebra who live in the crater do not migrate as they have everything they need here and are able to exist year round without the need to be constantly following the grasses as they do in the Serengeti. In addition to these two species of mammals, the crater also contains virtually every other species of large mammal that resides in Tanzania other than the giraffe, as the walls of the crater are too steep for them to navigate. The other animal that is missing here is the Nile crocodile as there are no running rivers within the crater, though there is a large alkaline lake in the middle and a river that runs in one corner, but it not sufficient to fully sustain these huge reptiles. The crater also contains one of the densest concentrations of lions in Africa, mostly due to the numbers of non-migrating animals that exist here.

Another very unique feature about the crater is its association with the highly endangered black rhino, which in the past had been widespread throughout Tanzania, but is now limited to a few protected areas where they have made a huge comeback and are now thriving though still at risk. Though I’m not sure of the exact number of them in the crater, there are now close to thirty of them and the number is increasing every year thanks to the firm protection of the government and the rangers of Ngorongoro Crater. The black rhino is very near-sighted and relies almost entirely on its hearing, which is why they are very difficult to find at times given the frequent windy conditions in the crater. The rhinos spend the night in the protected foothills of the steep inside crater rim walls. It taken me three trips to the crater before I was ever able to see one the rhinos. Thankfully, I have seen many in the years since, both here in the crater as well as the Serengeti.

Whenever I am asked by the residents what time we should leave for a day of game driving, my answer is always the same. “So, just what would you like to see?” Animals are always the most active in the early morning and the late evening hours and if one hopes to see as much as possible, getting there bright and early is always a must. The Loduare Gate, which is the entrance to the Ngorongoro Conservation Area that is the most accessible and, from which, one can immediately access the crater by way of the long, winding, uphill road to the rim and the overlook and one of the most incredible sights anywhere in the world. It’s also important to realize that this little two-lane dirt road that ascends over 2000 feet in a very short distance is the main highway that crosses this country from east to west along the northern sectors. Buses, trucks, and local traffic ply this road that passes through the gate, around the crater and then across the Serengeti. It is a long a dusty trip that has remained the same for years. Several years ago, there was a proposal to pave this highway across the Serengeti, which would have completely disrupted the migration, but it was thankfully defeated by several environmental groups.

So, with a departure time of 6 am from our house that was surprisingly accomplished within several minutes of the actual time (have I ever mentioned about herding cats here), we were all happily on the road with lots of excitement for the residents and Jill, none of whom had ever been on a game drive in the past. We were the first to arrive and after only a few minutes in the office to make payment for a day in the crater, we were off and quickly heading up to the crater rim along the very windy and narrow road with lots of very tight harpin turns often barely passable at times for two vehicles. On most of the tight turns, the cliff has been gouged out by elephants who come at night to eat the soil which is rich in trace minerals they need to stay healthy. Up and up we went until we finally reached the crater rim at the overlook, a point on the rim with the best overview of the entire crater with its intact rim. Turn right and you will head in the direction of the Sopa Lodge before leaving the rim en route to Empakai Crater, a smaller version of Ngorongoro where you hike to the bottom, though this requires a Maasai guide for protection from animals. Instead, we turn left and in the direction of the Serengeti, though today we’ll only be traveling far enough around the rim until we reach the decent road into the crater.

The weather was gorgeous with a few low-lying clouds that quickly dissipated and, on arrival to the descent road, the view was crisp and clear as we began our journey back in time and to the bottom of this magnificent natural resource. Once on the bottom of the crater, we began our drive with a quick sighting of a small pride of lions that were a bit off the road, but easily visible to us. Of course, they were either sleeping or not very active as is usually the case with lions during the daylight hours. Lions, who typically hunt at night or in the early morning, sleep all day as opposed to the cheetah, who hunt during the daylight hours. Cheetah, though, have been very difficult to spot in the crater over the last several years for various reasons and, as expected, we didn’t see any today. We did see large herds of Cape buffalo, wildebeest, and zebra, along with the other usual characters that included Thompson gazelles, Grant’s gazelles, eland, Cooke’s hartebeest, hyenas, jackals, warthogs, ostrich and many, many other birds. We spend time at the hippo pool before lunch and saw elephants from afar. We actually spotted a total of six rhinos and, even though they were all from afar, you could still easily make them out with our binoculars or the long lenses we had on our cameras.

One of the funnier sights of the day was the number of unfortunate guests who were led astray by their safari guides and allowed to sit outside eating lunch while being dive-bombed by black shouldered kites who are notorious for being able to steal even the smallest morsel of food right out of the hand of an unsuspecting victim as they’re in the process of putting it into their month. Now, mind you, these are not small birds in any sense and having suffered the consequences of this years ago when having a picnic lunch up on the rim, I can tell you firsthand about their accuracy and the surprise one gets when a bird of this size deftly swoops in front of your face. In addition to the kites annoying several groups of guests today, there were two large marabou storks strolling through the picnic site looking for handouts and being very aggressive if they sensed there was anything edible to be had. It was definitely some very good entertainment while we all sat in Turtle eating our sandwiches and semi hardboiled eggs (there had been a malfunction in the preparation of these though I refuse to throw anyone under the bus for this). The lunch site in the crater is a lovely setting with a large lake of the deepest blue surrounded by marshes on the far side and just as pleasant as can be. Having now visited the crater dozens of times, this is a picturesque spot that never becomes old or stale.

After lunch we had more game viewing including flocks of flamingos on the alkaline lake and a rare hippo out of the water during daylight sighting. We drove around the lake in the direction of the descent road where we had started our day and then turned towards the Lerai Forest where we would find the single ascent road heading back to the rim.

We had planned to visit my friend Ladislaus at the Ngorongoro Crater Lodge as we usually do for coffee and to relax before heading home. The lodge is one of the finest in Tanzania and it’s an incredible treat for everyone to stop there and be taken care of even if it is just for a visit and not to stay. Ladislaus was on his holiday, so instead, one of the other camp managers, Joachim, helped to host us and was a delight. There is never a dull moment when it comes to these visits and the group gets a tour of one of their rooms, each of which has an unobstructed view into the crater, not only from the bedroom, but also from the bathtub!

One hard and fast rule in the Conservation Area is that the gate closes at 6 pm sharp and there are very few exceptions. Arriving late pretty much ensures that you’ll either be spending the night in your car or trying to find on the spot lodging at one of the very expensive lodges (there is no such thing as Motel 6 here) surrounding the crater. We left the Crater Lodge at about 5:30 pm with no time to spare, jumped in the vehicle, said some quick goodbyes, and hit the road as it was going to be very, very tight to get to the gate in time for us to get through. Turtle is not a race car, or anything close for that matter, and her engine is in dire need of a rebuild anytime soon. Summing that all up, we drove a behemoth vehicle with an ailing engine like a race car and made it down to the gate with a whole three minutes to spare.

It had been a fantastic day and a wonderful game drive for everyone’s first. We were now on our way home and decided to go to the downtown Lilac Café, which has a bit of a larger menu (maybe one or two more items) and would be something of a change. We waited the commensurate amount of time for our dinners to be served, but they were delicious just the same and much appreciated by all. By the time we were finished, it had been an incredibly long day and I was exhausted having been driving for over twelve hours to the crater and back.

I hadn’t mentioned the shida (trouble) that we’d been having with my stretch Land Rover, Turtle, for some time now, but in the end, it turned out that it wasn’t just a matter of replacing the cylinder head gasket as the cylinder head itself was bent and needed to be replace. This meant that we needed to find a used one somewhere as a new one would be too costly and new parts are tremendously difficult to come by here. In the end, we removed the cylinder head from another vehicle in Arusha, but also discovered that the fan and the reservoir cap for the coolant were also malfunctioning which both added to the issue of overheating with the car. One of the fundis (fundi = expert or specialist) from Arusha had been working on things and was shuttling back and forth to Arusha for the last several days.

---

I awakened with a phone call a bit before 6:30 this morning and, upon answering, discovered that it was Victor, the fundi, who had driven from Arusha early that morning to bring Turtle back to Karatu. He had anticipated driving the short Land Rover back to Arusha, but when I told him that we would still need it her here for our mobile clinics next week, it turned out not to be an issue for him. I drove him down to the bus stop and we now had two operational vehicles in Karatu which would make life much easier for us in the end. Despite the early morning awakening, I chose to remain awake for the remainder of time before our clinic was to begin. As there is no morning report on Saturday, it gave everyone extra time to sleep and me extra time to work on my computer. The weather has been amazing so far on the trip with gorgeous mornings and beautiful sunrises.

---

One of our patients this morning was a 26-year-old presenting with their third episode of psychosis that had now lasted nearly a month. The episodes began at age 7 making the diagnosis of schizophrenia very unlikely and we suspected that this was much more likely to represent a depression with psychotic features, they were a bit on the lengthy side as far as the episodes themselves were concerned. Her labs and examination were otherwise unremarkable and in between episodes, she was very functional. She had no abnormal movements either making something like Wilson’s disease quite unlikely. We ended up deciding to treat her with fluoxetine for her depressive symptoms and olanzapine for the psychosis. Beyond that, we would just have to see how she did going forward and hope for the best.

As for our young boy with Tb and who had presented with the focal examination and multiple mass lesions, quite likely tuberculomas, he continued to do remarkably well and was improving every day. He had not had seizures, which was one thing that we grateful for any sudden increase in intracranial pressure as is seen with a convulsive seizure could cause him to herniate given the amount of mass effect that we had seen on his original scan. Meanwhile, his family had decided to take him home given the fact that he was doing better, though unfortunately, that was only on the steroids, hypertonic saline, and acetazolamide he was receiving from us, all of which were completely temporizing, and it would take some time for the Tb meds we had him to provide some clinical response.

We brought his family member to clinic later in the day to explain them him that the boy still had a very serious problem that could easily kill him should anything worsen. At this point, we could try some other things if that happened and asked that his family agree to keep him with use for an additional five days, just to give him some more time for the meds to kick in. Their biggest concern was the money that his hospitalization was costing, and it was agreed that we would split the cost of his care. Thankfully, they agreed which gave us a few more days to watch him improve and, hopefully, continue to do so.

Since it was Saturday, there was school, and Jill had the entire day to relax. She had taken a leisurely breakfast at the Lilac Café, and I had suggested possibly heading up to Gibb’s Farm early since the rest of us would be heading up there after clinic for drinks and dinner. Luckily, the lodges in the area are all gracious to the volunteers who come to FAME as it is a very small community of ex-pats here in Northern Africa, so everybody knows everybody. I checked ahead of time with Gibb’s, and they said they would be happy to host her for the afternoon, so after lunch, we called a taxi that we were familiar with and off she went to spend the afternoon at one of the amazingly relaxing places that I have every visited.

Gibb’s Farm was originally a large coffee plantation that was later turned into a lodge after the Gibb’s family purchased the property, continuing to run the coffee farm, a dairy, vegetable gardens and also a workshop that made all the furniture for the rooms. When I had first come to Karatu in 2009, we were brought to Gibb’s for lunch after traveling back from the Serengeti and, since that time, I have continued to visit the resort every chance I have which is usually several per visit. Shortly after 2009, the resort was purchased by the owners of Thomson Safaris and the main lodge and rooms were all refurbished into what now exists today as a five-star destination resort to match anything that exists elsewhere in the world. To say that Gibb’s Farm is paradise would not be an understatement. It has remained everyone’s favorite lodge to visit here since our program was started.

With Jill safely tucked away in paradise, we proceeded to finish with our afternoon clinic and the plan to head up to Gibb’s as early as possible so that those who wished to possibly swim could do so in their infinity pool overlooking Karatu and the coffee farms that flow down the hillsides. Gibb’s is also high up on the crater rim bordering the Ngorongoro Conservation Area allowing it to offer some activities such as a hike to the elephant caves or clear to the crater rim up high. The elephant caves are actually large depressions where elephants dig up the soil to ingest some of the necessary minerals for their health. I’ve done the hike several times and it is a lovely walk through the woods that take you high up into the Conservation Area and requires you to hike with a NCA ranger who is armed in the event of an animal encounter. Hiking to the crater rim requires an entire day and an NCA guard just the same.

Finally, after everyone had been seen in clinic, everyone walked home, and it was time for us to head to Gibb’s for dinner. As we’d be heading into the Crater tomorrow, we did need to pick up some supplies such as bottled water and snacks for the drive as well as needing to fill up the vehicle since we’d be away for the entire day and it’s always best to enter a park with a full tank, water, and snacks as you never know what you might encounter. We picked up Dr. Anne on our way to town and eventually made our way up to Gibb’s Farm, which is a rather long uphill drive once off the tarmac that is typically rather rough, though with recent road improvements, is now a much more reasonably graded road, though still completely uphill.

Arriving to Gibb’s Farm is always an event when it involves guests who have never been there before. The walk from the parking lot to the main lodge is along paths of lovely flowering tropical plants including incredibly large bird-of-paradise plants that have grown far taller than any of us. The pathways wind through trickling ponds, some with lily pads and others with cat tails on which weaver birds have woven their nests. On arriving to the main lodge, the veranda overlooks the entire valley below with coffee plants as far as the eye can see and the distant hills, one in front of the other, completing the most picturesque backdrop. Having drinks on the veranda or at poolside, though, the view and the ambience are spectacular. After meeting up with Jill, we sat around the pool while both Anya and Wells choose to brave the chilly water of the infinity pool with the amazing view and the rest of us just enjoyed the quiet solitude.

We were called into the dining room shortly after 7 pm and led to our beautifully set and heavily outfitted table with more silverware than one can imagine even in the finest of restaurants in the US. Gibb’s is a farm to table restaurant with everything served having been typically grown or raised on site. The menu was a four-course affair with choices for all but the soup course along with freshly baked bread and real butter. Everyone’s dinner was, of course, absolutely amazing. Driving home after dinner, there were flashes of lightening in the distance with booms of thunder all around. The residents worked hard at making our lunches for the crater – peanut butter and jelly or honey along with hard boiled eggs, bananas and cut up watermelon. As we all went to bed, the storm intensified with more winds and nearby crashes of lightening, though we were all safe in volunteer house. It would be interesting to see what the weather would be like in the morning, though it really didn’t matter as everyone was excited for their first game drive of the trip.

Leonard had called me yesterday to let me know that he was traveling with a large group of doctors from the US who were staying at Gibb’s Farm and had been in the Crater for the day. He thought they might be interested in visiting FAME and wanted to see if it was possible to come by in the morning before heading off to the Serengeti. I was thrilled to receive the call from him as this was exactly how my introduction to FAME happened some fourteen years ago while we were here on safari. My kids and I had been with Leonard for tens day on safari and were in Karatu volunteering at a local school for three days. While here, I had asked Leonard to take us to a local health facility and, thinking that he was going to take me to visit a local doctor at their home, he instead brought me to FAME, which at the time was only a single building that was the outpatient clinic.

FAME had only opened a year earlier and was still in its infancy, yet it was somehow clear to me from that brief encounter, going over cases with Frank and Dr. Mshana, that this was to be my home over the coming years. I had spent an hour with the two of them, nearly oblivious to the time or the fact that my children were somehow occupying themselves nearby, but at the end of that chance meeting, Dr. Frank asked if I could return something, and my fate was sealed. Twenty-seven trips later, though we have accomplished so much, I still have more to do both regarding the neurology program that we’ve developed, as well as FAME itself as I now serve on the board and am currently the board chair.

This story has repeated itself time and time again and, for many of the individuals, Leonard has been the common factor. On a number of occasions, I have received phone calls from individuals who have traveled with Leonard, expressing their interest in either volunteering at FAME as a clinician or nurse, or in somehow supporting programs over here that would benefit Tanzanians. At least one of these volunteers became a long-term and very influential volunteer here as she designed most of what the public sees of FAME today through her expertise as both a nurse and an architect.

So, you can never be entirely sure what will come of a chance meeting such as a simple visit while on safari and you should never underestimate the power that such an encounter may have in someone’s life. As we only had our morning report at 8 am, we were in clinic by 8:30 to see patients, though no one would be ready to present to me for some time, so I would be free to give a tour of FAME when Leonard arrived with his group. It was wonderful to see him pull up with his Land Rover and another filled with doctors. He had also mentioned that one of the docs was a pediatric neurosurgeon which was perfect as we would be able to review the images of the young boy with probable Tb that was admitted last night. The boy was actually doing very well after having received his steroids and hypertonic saline as he was up walking (amazingly!) and was talking. Rather than making us feel any better, though, it was merely a testament to how effective steroids could be, at least in the short run as their effects would only be temporizing and we’d eventually have to pay the piper. Regardless, he had survived the night after it became clear that he was not being transferred to Arusha for an EVD.

We reviewed the boy’s CT scans with the visiting neurosurgeon who gave us some reassurance given his present clinical course and also suggested that we add some acetazolamide to our drug regimen to further reduce his intracranial pressure by reducing CSF production. Though it was good to have a second eye on the scans, our concern still remained for we all knew that if took a turn for the worse, we had nothing else at all to offer and it would be impossible to get him to Arusha in time for any lifesaving procedure. It wasn’t our call though and even after explaining this to his uncle, the decision was the same that he would remain here at FAME.

Giving a tour of FAME is always a pleasure given the growth we’ve had over the last decade and the success we’ve had in caring the population of the Karatu district. There is little difficulty in conveying the importance of FAME to the local population based on the attitude of their employees who are all dedicated to same mission that has been in place since its conception. Patients come to FAME based on their trust of the institution and the people that work here. The reaction of any physician who comes to visit FAME is always the same. Visiting rural Northern Tanzania, the last thing one expects to see is a medical institution whose sole purpose is to provide access to a level of medical care that is nearly unavailable anywhere else in the country and is being provided by doctors and nurses whose education and background far exceeds other institutions in the region. Essentially, FAME is a Mecca of healthcare that exists in the middle of a healthcare desert, providing patient-centered care to a population where access was previously non-existent.

Back up to its pre-pandemic numbers, FAME now sees approximately 30,000 patients a year and is continuing to grow on a regular basis. Our recently constructed 25-bed maternity ward is constantly filled with pre- and post-partum women who have come to FAME knowing that it is the safest place for them to deliver their babies, though we also work with traditional birth attendants to constantly improve the safety for mothers and babies alike. Having a radiology department offering services such as a CT scanner and a laboratory providing many automated lab tests, FAME has continued to serve the community with the most up to date services possible.

Walking into this setting after driving two hours from Arusha on a two lane tarmac that will end several kilometers west of town, becoming a dirt road that will traverse the entire northwest portion of Tanzania, one does not expect to stumble upon a center such as FAME, but that is what happens time and time again, and, thankfully so, for it is the Tanzanians themselves who have created this unique and one of a kind institution and have allowed us to assist them in supporting it. In the end, though, FAME is staffed by Tanzanians and is for Tanzanians.

Our young patient with what was suspected to be CNS tuberculosis and multiple mass lesions was certainly doing better and was now on anti-Tb medications, but he was not out of the woods by any means. It was now a matter of watchful waiting and hoping beyond hope that we would not receive a call from nursing that he had worsened. Meanwhile, Pendo, our young patients with the paraplegia who had come into the hospital with urosepsis was continually doing better, but her urinary status would remain an issue for family and caretakers alike. Her mother remained very difficult as she continually wanted to bring her home back to their village where there was not only nothing in the way of healthcare, but she mostly sat on a dirt floor in their home and had little to do. Having a wheelchair in that setting would provide little in the way of improving any function for her. After many lengthy discussions with the mother, though, she was finally in agreement that Pendo could eventually return to school. Unfortunately, what was not entirely clear was how long that would last.

For the afternoon, we had finished a bit early, and it had already been arranged that Dr. Anne would be bringing the entire group of residents and Jill to visit Teddy, who for the several years had taken excellent care of us by making clothing from the wonderfully colorful cloth that truly makes both East and West Africa so unique. I had a workshop scheduled that was on Zoom from 5-8 pm and would be staying at home with a hopefully functional internet for the duration of the program, though highly doubted that would be the case. It is not as much the functionality of the internet here (which, by the way, is almost 100% reliant on the cellular service unless someone has unlimited funds for satellite service), but rather the reliability of the power grid which is notoriously bad and tends to blink out multiple times an evening and is nearly immediately restored by our on-campus generator. Unfortunately, it takes the modem an eternity to reset and recycle each time. This occurred multiple times for Mark’s fellowship interview the night before and would soon occur during my workshop as well.

The workshop was being put on by the American Neurological Association (ANA) and was formally titled a Global Neurology Workshop that has been organized to foster relationships and training programs among the various regional centers of excellence in Africa where there are few neurologists. The global committee had already selected the four regional centers of excellence – Zambia, Uganda, Nigeria, and Ghana – and the workshop’s purpose was to further develop several action plans of short-, medium- and long-term goals. One of the most impressive parts of the workshop, though, was the significant participation of members of the African community which is not always the case and is perhaps one of the most important tenants in global health in that the goals should always be set by the hosting nation and not by those who have offered to provide help. Not heeding to this rule will inevitably end in disappointment and most often by those in need. The workshop was a massive success based on the participation and commitment of those who participated.

The group had a wonderful time at Teddy’s and returned home during my workshop though it wasn’t an issue as I eventually switched to my noise cancelling headphones. I wasn’t able to eat dinner until after 8 pm, which is very late for us, and sometime after that, received a phone call from Onaely, who is our radiology tech, that a neighbor of his had been in a boda boda (motorcycle) accident some days ago, suffering a head injury with intracranial bleeds and was now confused and sedated at his home. He had asked if I could come up to the ED to see the patient which was a bit unusual considering the time and the fact that the patient hadn’t yet been assessed by the doctor on call. That would very likely only prolong the process, so Mark and I eventually trudged up to the ED to see the young man in question, though the story turned out to be much different.

He had been involved in the accident a week earlier and had been admitted to Mt. Meru Hospital outside of Arusha for a week, having suffered parenchymal, subarachnoid and subdural bleeding, though all small. He required no surgery and was actually improving somewhat per his family, though we had never examined him. Given the scenario, we recommended a repeat CT scan that would reassure us that his bleeding was perfectly stable, yet when we made this recommendation, his family declined and wanted to take him to Haydom Hospital which was about five hours away. In the end, it was hard for us to argue with their request as he didn’t seem to be any worse and based on the history and examination that we obtained, he was quite likely on the mend. We walked back to the house, and both promptly went to bed.

I have celebrated my birthday in Tanzania nearly every year since 2011 save one. On most occasions, I have done my best to keep on the down low as I was never one much to be at the center of attention. For my thirteenth birthday, I had traveled to Disneyland on a school trip with friends and even though my mom had told me to be at a restaurant on main street with my friends for lunch to meet her, I decided that we were having fun on the other side of the park and that it wasn’t a big deal. She sat with my brother, a few other friends, and my birthday cake wondering where I was. Since then, others have also tried to surprise me for my birthday but being the totally nosy person (or perhaps it’s always wanting to be in control) that I am, I have always managed to mess it up somehow. I didn’t think there was a chance in hell that was going to happen this visit with Jill here. I was pretty certain that she would want to have some type of party and, to be totally honest, I was looking forward to it. I decided not to keep it a secret which turned out to be a good thing as Susan and Frank wished me a happy birthday before I even had a chance to tell anyone or spill the beans.

Mostly what I think about on my birthdays, though, is my parents and having been raised in an incredibly loving family with tons of support for my brother and me despite my parents having divorced when we were both in early adolescence. I won’t bore you with the story that some of you may already know, but there was never anger or hate in our home and, despite the inability to live together, my parents remained closely in touch and friends until their eventual passing a decade ago. Having had this foundation and upbringing has made all the difference in my life and I am forever grateful for the values they helped instill in both my brother and me. It was into this life and that family that I was born some sixty-seven years ago, and I will remember it every March 9^th.

The education session today was being held by Diane Berthal, who had been consulting for FAME on a regular basis over the last several years, spending three months a year here in Karatu. Last year, she helped the FAME staff and administration create our new Five-Year Strategic Plan which lays out our biggest goals over the next five years and what we will base all decisions on as we go into the future. This morning’s session was on resource management as it applies to the physicians and clinical officers here at FAME. As I also mentioned during the session, we are all ambassadors of FAME and the part the community of Karatu will see when they first enter the system here. This was a session that the residents did not need to attend, and all were grateful for the extra 30 minutes of sleep in the morning.

Since it was now public knowledge that it was my birthday, this meant that I now had to endure lots of birthday wishes throughout the day which included having happy birthday sung to me at lunchtime, afterwork and later at our dinner at the African Galleria. Thursday’s lunch of pilau with meat was somehow extra tasty as the meat seemed more tender than normal, though perhaps this was mostly to do with the day and the fact that I was very much looking forward to heading down to Nish’s and the African Galleria for a birthday dinner tonight. I had told Nish that we would leave as early as possible from work and our afternoon schedule seemed to be cooperating, at least until the last patient of the day who turned out to be tremendously more complicated than any of us had expected, but more about that later.

Several of the patients who came in to see us today were well-known to me such as the young man with cerebral palsy who had come in to see us in the last couple of years complaining of new movements. Without having seen him previously, it was tough to tell what was new, but we were persistent, and the family was adamant that he had been perfectly stable for many years (his long-standing CP then at age 17) and that over the month prior to initially seeing us he had developed new movements that were quite different for him. The case was presented to me, and it was tough for me to tell what was going on, but the minute I saw him, the movements were quite familiar as I had diagnosed two other patients here and it was a disorder that we rarely get to see in the US.

He had Sydenham’s chorea, a movement disorder that occurs in the setting of subacute bacterial endocarditis and is due to a Strep infection resulting in the onset of choreaform movements occurring in adolescent females predominantly but can also occur in males. He has now been receiving prophylaxis with monthly penicillin over the last few years but will need to continue this for at least ten years after his diagnosis to prevent heart valve damage. He is doing very well and has had no complications at this point, but it is extremely important for him to continue the penicillin for the necessary amount of time. His movements have resolved, and his family’s question was whether he still needed to follow with us every six months. As much as I want to continue following him to ensure that he remains on his prophylaxis, there really isn’t a need for him to see us otherwise, so with some reluctance, mostly on the part of my wanted to watch him continue to do well, we agreed that he would only see us if he developed a recurrence of the movements which would be quite unlikely at this point.

One of the other patients who came today was a gentleman I’ve been treating since the first year that I arrived. He is a truly lovely patient who came to see me with predominantly psychiatric issues, but as I came learn back then, there are no psychiatrists here and, therefore, we’re the closest thing to a psychiatrist that they have in this region. After spending some time with him, it was clear to me that he had bipolar disorder, or manic-depressive disorder, and that his life was falling apart around him. Thankfully, several of the medications we have here and which we use commonly as both are also anti-seizure medications could also be used effectively for bipolar disorder. Between valproic acid and lamotrigine, I decided to use the latter for its better side effect profile and when he returned six months later to see me, he had a complete turnaround in his symptoms and was rebuilding his life. He has continued to follow with us ever since and other than a few little tweaks here and there, has remained incredibly stable and functional.

The last of the long-term follow up patients who came back today is a young woman who had also initially seen back in 2011. She came to see us with a seizure disorder that was secondary to a neonatal stroke that had resulted in a hemiparesis and, because her seizures were not well controlled, she was unable to attend school, which is so often the case here. Though clearly if a child is having daily frequent seizures, it may be difficult for them to remain in the classroom, but having an occasional seizure is another matter. More importantly, though, is the fact that the majority of these children have not been maximized on their anti-seizure therapies as they have often not had the opportunity to see a doctor, let alone a neurologist. This patient responded very quickly to adjusting her medications and has been seizure-free for many years. More importantly, she was able to go back to school and has now completed her secondary education. It is so rewarding to see what the effects that your care can have not only regarding the underlying neurologic disorder that you’re treating, but also in the functional status of the patient as well as their life in general. This is such an important part of what we do here.

Meanwhile, as I had mentioned earlier, it was our intention to finish as early as possible so that we could all travel down to the African Galleria for my birthday dinner and to possibly do some shopping as well. Things were looking quite well for us until a 15-year-old patient was seen in clinic who looked absolutely terrible and was complaining of new onset headache, weight-loss, and lethargy and who I had seen vomit while he was waiting to be seen. His examination also demonstrated a left hyperreflexia. Most of the symptoms had been present for the last 1-2 months and there was absolutely no question that this patient was in dire need of a CT scan as we were very concerned about the presence of a mass lesion. It was not until late in the afternoon, though, that he was actually able to get into the CT scanner as he need to have his creatinine checked for the contrast he would need to receive.

The non-contrast scan was incredibly ominous and even though it didn’t give us the entire picture, it demonstrated what appeared to be at least several mass lesions and a significant amount of vasogenic edema and mass effect. The contrasted images told the rest of the story in that there was a large right frontal ring enhancing lesion along with another large midline ring enhancing lesion that was obstructing CSF flow near the front of the third ventricle. The vasogenic edema was also massive and there was some subfalcine herniation with midline shift. We immediately called the only neurosurgeon in Arusha as the child would need an EVD, or extraventricular drain, immediately to relieve intracranial pressure and impending hydrocephalus, a procedure that we did not do here at FAME.

While we were making these arrangements to possibly transfer him to Arusha, the situation was being explained to his uncle, along with sharing the scans with him, who was communicating the story to the patient’s family who live in the Ngorongoro Conservation Area. What came of all this communication, though, was not encouraging to us as the family did not wish the boy to be transferred to Arusha even though we explained to them that his risk of dying from the intracranial pressure was very great and that there was absolutely nothing we could do for him at FAME other than to give him medications that would hopefully reduce the pressure, but that this may only be temporizing.

We braced for a rough night and placed the boy on IV steroids and hypertonic saline to do whatever we could at reducing his intracranial pressure, but we had nothing else to offer him other than supportive measures such as keeping the head of his bed elevated. Doing a lumbar puncture for diagnosis was not an option given his increased intracranial pressure and we were relying on the radiologic appearance and the likelihood of other diseases here which put tuberculosis at the top of our list as these very likely represented meningoencephalitis and multiple tuberculomas.

After getting him admitted to the ward and all his medications ordered, the team was finally ready to depart for dinner as everything was pretty much on autopilot and there was nothing else for us to try if things went south overnight. Mark was unable to accompany us as he had a fellowship interview schedule tonight but was able to partake in the birthday cake and ceremony that was held for me prior to heading down to the Galleria. The cake was beautiful, and everyone sang happy birthday – Prosper, Rose, and Annie were all here to share in the festivities, though somewhat brief as we needed to get on the road for dinner as soon as was humanly possible. The cake was delicious and, even though it was a bit odd having dessert before dinner, Jill reassured me that there was absolutely no rule about this in life.

At the Galleria, dinner was relaxing and as amazing as it always is. Nish ordered our food – the cheese samosas are to die for, the grilled halloumi skewers were just incredible, and the pumpkin ginger soup (my favorite) was scrumptious. And, as always, the drinks felt as they were well deserved given the day we’d had in clinic. The Dawa, which has been the standard, is a modification of a Kenyan drink, Nish’s home country, and is gin, tonic water, honey, and lime with a muddler to mix and crush the chunks of lime and mint that are also added. They are very effective. At the end of dinner, of course, they brought out a birthday cake for me – Babu Mike – that actually had olive and grape tomato halves for decoration.  All the restaurant help came out singing the traditional “Jambo Bwana” and carrying my birthday cake with them. I also received a lovely gift from Nish and the Galleria that is a lovely Songye power figure statue from the Democratic Repulic of the Congo.

On returning home, Mark was still on his Zoom interview. He later shared with us that the internet had gone out three or four times during his interviews and that he had to wait for the router to recycle each time and reconnect. My only comment to him was, “TIA,” this is Africa.

We were pretty certain that today would be busier given the fact that Kitashu had gone to the market yesterday to announce our clinic once again to the town. Though our recurring neurology clinic has now become very well established over the last 13 years that I have been returning, we have realized that it is still very important for us to inform the general public of our clinics as the population here is in constant flux. Karatu has grown tremendously during the short time that I have been coming and I am constantly amazed each time that I arrive with the amount of vertical building that has gone on and the number of new hotels and lodges where there were none when I had first come. Also, what used to be a total frontier town where the only paved road was the main drag through town en route to the Crater gate. Now, many of the backstreets off from the main road have been graveled, if not paved, and are nearly civilized. In the past, rains would completely take out a road with nary a thought of doing so. I guess this is the price of progress and little can be done to hold it back, unfortunately.

Kitashu is our main outreach coordinator and spends a good amount of time during the month or so prior to our arrival visiting the villages where will hold our mobile clinics as well as letting everyone now the dates that we will be at FAME. In addition to being our outreach coordinator, Kitashu, along with Angel, are also the two social workers here at FAME who assist with any of our issues that involve patient’s difficulty with payment for services or medications as well as communicating with patients and families to explain why they may require treatment or admission to the hospital and especially when they choose to decline it as can often happen and, when it does, can be very disheartening.

As very few patients have the national health insurance and, even if they do, FAME does not participate with it due to the difficulties with what it covers and the difficulty in payments. It is most often the concern about how patients and their families will pay for treatment and services that is the roadblock to providing what is needed and what is necessary. If an elderly patient comes in the hospital with a stroke, the first question by the family is often about when they can take their loved one home, rather than which rehab center or nursing home will their family member go to. On the infrequent recommendation to family for admission to the hospital as the patient’s problem either needs inpatient therapy or further evaluation to tell exactly what is going on.

During today’s clinic, a young girl named Pendo was brought to us from home for she had been having intermittent fevers and difficulty urinating. I had first met Pendo during my last visit here in the fall when we had been asked to visit her in her home which was about 30 minutes outside of Barazani and the crazy adventure had been well described in my fall blog. Pendo had unfortunately become paraplegic in the last year or so, presumedly from Tb of the spine (Pott’s disease), though we have no records of prior evaluations, nor do we have any imaging studies as it was felt that this would not change her management. Through the help of individuals at CHOP, funds were raised to not only send Pendo to a good school in Moshi, but also to obtain some health insurance for her, though neither of these at the moment were very helpful as she had been sent home from school due to GI issues (she is chronically constipated due to her spinal cord issue and has no bladder function).

She had been brought to us today as she had been having recurring fevers, difficulty urinating and had foul smelling urine, all pretty convincing signs that she, at the very least, had a urinary tract infection that needed to be dealt with and, could even be something requiring more than just oral antibiotics. She was sent off for labs and, despite the fact that she actually did not look that bad, was found to have a WBC today of 63 thousand, extremely high and far higher than any of us had anticipated, and raised concerns that she might indeed have urosepsis, which would require inpatient treatment for at least several days of IV antibiotic. Her mother, as it turns out, was very much against considering any type of admission and merely wanted to bring her daughter home. No matter how much we tried to convince her otherwise, she resisted our every argument, but eventually relented and at least allowed us to admit her overnight. She had other children to consider, and, in her eyes, Pendo was no more deserving than her other children who would have to go without if she had to pay even the smallest of additional medical expenses for Pendo’s care. With some last-minute negotiations, we were finally able to convince her mom to at least allow us to admit her overnight and, thankfully, she received the necessary treatment for now.

Of the other patients we saw today, Mark had a patient who was extremely hypertensive and didn’t seem to want to drop to something reasonable and seemed to be a bit confused raising our concern for a hypertensive encephalopathy and further risk of stroke. Rechecking the BP even after treatment with medication didn’t seem to matter, though at the last minute, the BP seemed to begin drifting downward, avoiding the need to be admitted to the hospital for BP control. That was good, because earlier in the day, we had been summoned to the ED to see a patient with continuous seizures, or status epilepticus (a potentially life-threatening condition), who needed our assistance. Wells went to see the patient, who was indeed having very frequent generalized seizures and a suppressed mental status with an otherwise non-focal neurologic examination. She also had a history of having developed a paraplegia the prior year, again raising concern for Tb of the spine, or Pott disease, but these details were unclear from her family.

Status epilepticus is normally treated with IV medications to stop the seizures as soon as possible, though unfortunately, the only IV seizure medication we have here is phenobarbital and, due to its respiratory suppression at the necessary dosing to stop seizures, it is something that we don’t rely on in adults given that we have no way of ventilating patients her FAME (outside of our OR, that is), it is not particular comfortable loading patients on this medication. She had already received phenobarbital and valium and we needed to come up with something that would last longer without causing her to stop breathing. Levetiracetam, or Keppra, is a medication that can be loaded quickly, either IV or through an NG tube, and we have used this quite successfully in the past. The trouble is that levetiracetam, though available and registered in Tanzania, is quite expensive. We can use it in these necessary and limited settings, though it is unfortunately difficult to place patients on long-term given its cost.

Her CT scan later that night was normal, and it was very unclear what was producing her seizures, though we were worried about a meningoencephalitis and possibly Tb despite her lack of B symptoms or other constitutional symptoms by history. The plan was to do a spinal tap given the normal CT scan and to go from there once we had some results. Meanwhile, her seizures had slowed down on the levetiracetam, but had not completely stopped, so we added valproate to her drug regimen with some further success. We would have to keep a close eye on her and see how she was in the morning.

It was going to be a quieter time at home this evening as there were no social events that had been planned and it was a gorgeous evening outside. Having loads of work to, I had opted out of any activities, though everyone else, being up for a walk after it was suggested to them, decided to take advantage of the weather and lovely evening. On my very first trip here, in 2010, I had decided to take a long walk at sunset to get some nice photos, but after trekking for nearly an hour up onto a high ridge for the best vantage point of sunset, quickly realized that I had forgotten to bring a flashlight. Darkness falls nearly instantaneously here and there was absolutely no moon that night and, furthermore, this was before we were using iPhones here in Africa. I started my long walk home, in the darkness of night, with only my camera to protect me, thinking that I could perhaps throw it at an attacking animal giving myself an extra moment to escape. I made it back to the volunteer house in one piece, though my two housemates at the time, Carolyn, and Joyce, were not at all amused with my little escapade and proceeded to sternly berate me for scaring the crap out of them.

So, as I sent my team of residents along with Jill out to walk into an unfamiliar rural African countryside with what I thought were some reasonable directions of where to head and what to avoid, I had full confidence that they would all make it back safely. I also told them that with the setting sun, they would find darkness upon them very quickly and to try to be back in an hour so as not to duplicate the wonderful experience I had so long ago. You can imagine my surprise then when Anya arrived back to the house nearly an hour later along with the report that she and Wells had actually broke off from the group to do some running and she had returned on her own while Wells had continued his run. This meant that Jill, Mark, and Usha were off walking on their own and it had now been an hour which is when I had been planning for the entire group to return. Wells did come back after his run, but it was some time for the others to return and quite close to sunset and looming darkness. Needless to say, I was not overly impressed with their attention to detail, nor for their common sense, but they were all back safely and that’s all that counted. Having a chance encounter with a Cape buffalo, an elephant, or a leopard in the waning sunlight is not a particularly comfortable situation and, thankfully, it wasn’t something that had to be dealt this time.

 

We now have phone in each of the volunteer houses which is a double-edged sword. In the old days, if you were needed at night or after hours, someone would come to the house to find you and knock on the door or the window to wake you up. Over the last few years, though, the ward has become increasingly busy and the patients sicker such that the on-call doctor overnight may need assistance in dealing with those patients that are sicker than usual. I had forgotten to tell everyone, and when someone called from the ward about a new stroke patient, they weren’t able to get their point across, and so, the call didn’t register properly and wasn’t passed along.

It wasn’t until a bit later that evening, when I had already gotten into bed, that a friend of this patient’s family texted to let me know they were at FAME and asking if I could go to the ward and evaluate the patient myself. Although, I know that we teach everyone that “time is brain,” the stroke had occurred days ago and there was very little we were going to offer overnight unless he was worsening. I texted back saying that we would hear from the ward if there were any major issues, but that we would see the patient in the morning after morning report.

Tuesdays and Thursdays are educational days here at FAME and the medical staff meets at 7:30 am (or 1:30 Swahili Time) for a lecture that can be given by either one of the volunteers here or by one of the Tanzania staff. We try to do as many of these lectures as possible as it’s a great way to reach all the FAME staff, including those who do not work with us directly during our clinics. We’ve covered many, many topics in neurology over the years and as there are often newer doctors when we arrive, and it certainly never hurts to repeat as much of this information as possible along the way.

The staff had wanted another lecture on the neurological examination, and it was decided that Wells and Anya would deliver the first lecture of the trip. They were able      to get through most of the lecture in the allotted 45 minutes (Dr. Ken watches the time like a hawk and will be sure let us know when we’re over the time limit) and it was decided that they would finish when Usha and Mark would be doing the pediatric neurologic examination. As have pointed out in the past, the fact there are so few neurologists in this country means that patients will rarely have the opportunity to see one, but it also means that almost none of the doctors we work with have ever seen a neurologist do an exam and have been taught only by non-neurologists. To us, the examination is essentially sacred, and it is difficult to express to anyone, other than another neurologist, just how very much we rely on it and the history for our diagnosis and treatment. Testing is most often secondary to us and is used primarily to support our hypotheses.

After Morning report, Mark, who is planning to go into stroke, went to evaluate the patient who had come in last night. He was a 90-year-old gentleman who, on examination, had a complete left middle cerebral artery syndrome meaning that he was globally aphasic (he couldn’t speak, nor could he understand) and couldn’t move his right side at all. He hadn’t yet had his CT scan of the brain, but when he was brought over for this study, it turned out that he actually had a medium sized hemorrhage without significant mass effect. With the bleed, it meant that we had less to do for him than we had thought we had with the original diagnosis of a bland infarct that would have required aspirin and a statin. Though there was some hope that he might improve given his hemorrhage, this was not to be the case, and over the next several days, he remained global aphasic with the dense hemiplegia and was eventually discharged home to his family. He was unable to swallow safely and, in the end, will probably suffer complications of an aspiration pneumonia.

I received news that our shida (trouble) with Turtle persisted and what had seemed like an easy fix was now involving replacing the cylinder head gasket, at the very least, and would quite possibly require replacement of the cylinder head itself which is not a small feat to say the least. They removed the head and brought it back to Arusha, but eventually needed to bring the entire vehicle back to Arusha to work on it, finally getting it to us on Saturday morning with everything fixed, or at least we hope so. In the meantime, Myrtle was more than sufficient for me to drive everyone around Karatu.

Along the way, Usha did see a young child with an examination concerning for hydrocephalus. This condition, which is most often congenital, and certainly so in the absence of some other process such as a mass lesion, would eventually require a ventricular shunt to prevent further accumulation of fluid and increased pressure intracranially. Unfortunately, we do not do these procedures here at FAME, but they do them in Arusha, at one of the hospitals there, or at Kilimanjaro Christian Medical Center in Moshi, where there is a neurosurgeon, though these procedures are also done by the general surgeons in Arusha. So, the baby was referred to Arusha for placement of a VP (ventriculoperitoneal shunt) that will drain fluid from the ventricles of the brain into the abdomen and will be left for life.

Having Myrtle here to drive around was pretty much essential for me as, having grown up in Southern California, I have always had a vehicle of my own and have always been mobile. Life without a car for me is unthinkable and even when I travel to remote places, I will usually rent a car just to be mobile. We have not yet put the back seats into Myrtle, and with the two-bench configuration that are facing each other in the back, a drive into town was a bigger production than expected. Mark and Wells were being subjected to sitting in the back (boot) of the vehicle on cushions that we had borrowed from the couch on our back veranda. The pillows certainly softened the blow on their backsides, but it was more the fact that I missed seeing one of the many well-hidden speed bumps on the way to pick up Dr. Anne that really stuck in their minds, mostly because I think they both struck their heads on the ceiling of the car when they bounced out of their seats. Thankfully, there were no serious head injuries (some might say that I knocked some sense into both) as the neurosurgeons here are few and far between, and both were willing to accept my sincere apologies for having introduced them to the “African massage” in such an unanticipated manner.

After picking up Dr. Anne at her home with plans to head downtown, I had forgotten that it was market day in Karatu. I have described the phenomenon of the Maasai Market on several occasions in the past, though the take home message should be that is shear mayhem on a rather logarithmic scale and not for the faint of heart. My recommendation to anyone considering a real visit (meaning spending at least an hour shopping) would be to have one of the stiffest drinks you can imagine immediately prior to arriving or taking a strong dose of Valium (sorry, diazepam here) to soften your senses enough to tolerate the constant barrage of those peddlers and hawkers doing everything in their power to get you to purchase something from them. I drove them to edge of the market where several chose to get out of the vehicle long enough to confirm what I had told them which was about five minutes maximum.

After stopping by a change bureau (of which there are very few after the government crackdown a few years back finding that the change bureaus were all laundering money) for we had not a shilling to spare among us, it was off to buy fabric as the group would visiting Teddy, our seamstress, later in the week to have clothes made before their return. Mind you, I do not have any clothing made and, so, sat in the vehicle waiting for the group to finish their search for the perfect pattern. I was very surprised to see everyone returning after what seemed like an incredibly short time, but it seems they were all very focused on the task at hand and had all chosen the fabrics they desired, several of them choosing to share fabrics as well. We drove home well before sunset and had the benefit that today was also one of our grocery days, so the cupboards were no longer bare as they had been on arrival. It was a late morning for us tomorrow (by a whole 30 minutes) so we would have a bit more sleep, though considering most everyone was in bed well before 10 pm, having enough sleep was of little concern to anyone in the group.