I have always loved watching sunrise from our safari vehicle, though it was very difficult to get out of bed at 5 am with the sound of rain falling on our tent. It took every ounce of will power to climb out from under the covers of our incredibly comfortable bed at Dancing Duma and freshen up in the bathroom. Thankfully, we had taken showers the night before, so the prospect of getting into the shower and waiting for the hot water wasn’t in the cards. Still, it was a cool morning and required extra layers of clothes which merely meant a very light fleece for me.

Jill and I made it to the main tent for coffee by around 5:30, while everyone else was up and about by 5:45 which was the official meeting time for a 6 am departure. We were packing both our breakfast and our lunch with us for the day so we wouldn’t have to worry about returning to camp and would have the freedom to explore the park wherever that might take us. Today, we were going to hunt for the migration, those massive herds of both wildebeest and zebra that move in a clockwise fashion from the Maasai Mara in Kenya, moving down to the Southern Serengeti, then up through the Central and Western Serengeti before their famous crossing of the Mara River in the north, with many falling prey to the Nile Crocodiles. The Great Migration is the largest movement of land animals in the world by mass with almost 2 million animals being involved, though the wildebeest makes up the largest number of animals in that migration.

With the overnight rain that continued into the early morning, the trails we were navigating were incredibly muddy and required constant vigilance by Vitalis to avoid becoming hopelessly stuck, though, to be honest, the Land Rover once again demonstrated its amazing prowess on these roads, never once coming even close to bogging down in the muck. That isn’t to say that we weren’t slipping and sliding a great amount in the process and, all the while, mud was flying everywhere and especially over the top of the car. Standing, which I do 99% of the time on a game drive, meant that you had an excellent chance of getting hit with mud, and I was very thankful to have been wearing that fleece. The mud is very slimy, and I was also thankful that I had taken a package of wet wipes out of the tent as they came in very handy in cleaning up.

Sunrise was gorgeous and the minute the rays of sunshine hit us you could feel the warmth of the coming day. Though many of the roads began to dry, there were still plenty of flooded sections to maintain a constant level of excitement as we continued our morning slip and slide through the Serengeti. As we approached one of the many smaller kopjes scattered across the landscape, we encountered a huge pride of lions, many of whom were laying the road, while an equal number were sitting atop the kopjes, spotting potential prey far in the distance, for the lion’s eyesight, like all big cats, is far greater than mine or yours. After some time, though, most of this group decided to mosey up the road to another rock outcropping, only to have several other lions come down to join them. As the two groups met up, they greeted each other by rubbing faces and bodies, looking just like a house cat brushing up against your leg as a sign of affection, only these cats were slightly larger.

After watching the lions for some time, it was decided that we needed breakfast and several of our group were also well overdue for a bathroom break. There is a lovely picnic spot that sits atop a hill with 360° views of the surrounding plains. There are legit bathrooms (even with toilet paper) and decent cement tables where we could spread out a shuka. We enjoyed a delightful breakfast from camp along with lots of coffee and tea.

Once ready again for the trail – meaning lots of pre-emptive bathroom visits – we left our breakfast site in search of the Great Migration. We had heard that they were up just north of Seronera (essentially the central Central Serengeti), and, as we head up the road towards Ikoma gate, we found them in massive groups of thousands upon thousands of Wildebeest and Zebra with each having lots of new babies as they were heading up towards the Northern Serengeti and then into the Maasai Mara in Kenya before starting the entire process all over again.

There were not only the massive herds of the animals grazing as far as the eye could see, but there were also long trains of animals traveling in single file or several abreast again stretching for as far as one could see and seeming like it could possibly go on forever, though could clearly have been measured in miles rather than feet. Vitalis explained to us that the migration is so large and spread out over many kilometers that there was a head, a body, and a tail. The herds we were seeing now were the body of the migration and the largest numbers, while there were smaller herds far in advance making up the head. We would see the stragglers, or the animals that were far behind as we were leaving the park tomorrow.

The largest number of animals making up the migration were the wildebeest, though there were many zebras, and they often seemed to be at the front of the smaller herds, as they were leading. The two different animals have a symbiotics relationship, with the zebra protecting against predators due to their much better eyesight while the wildebeest’s better hearing and smell are what provides the herd safety at night from the predators. Either way, we were seeing hundreds of thousands of animals spread out over miles of territory as we came upon them on the drive north.

We spent hours watching all aspects of the migration, often leaving the main road to explore each of the smaller herds that made up this incredible biomass of animals that is the lifeblood of the Serengeti, and so much of the essence of this unique land beyond its fantastic landscape. So many creatures depend on the health of this migration for their survival.

As we continued our drive north, it soon became time for lunch, and the hippo pool, with its services (i.e. bathrooms) was the perfect place for us to stop. Though there are many other hippo pools in the park, this one is set apart by the fact that you can get out of your car and walk up to a crude barrier that sits along the river, and, perhaps just not high enough to make you feel completely safe, you’re able to stand and watch hundreds of hippos as they mingle in their families, or groups, making plenty of noise and, on numerous occasions, decide to make a statement, meaning that they will open their jaws widely, displaying their huge canines in a show of dominance or sometimes for real. There were many smaller babies, who stick very close to their mothers and have the unique feature that they will nurse underwater.

Hippos are responsible for more human fatalities than any other African animal, and I believe than all others put together. Most of these deaths occur alongside the rivers where they are living and are merely a matter of people being to close in contact with them such as women doing their laundry at the waterside. I’ve always found hippos to be incredibly anxious and neurotic, especially when they are out of the water. They will wander miles from their home along narrow paths to graze in the night but must return to the water in the early morning hours as their skin is very sensitive, and they sunburn easily. Standing between a returning hippo and its water as it’s returning home is probably the most dangerous place to be in the Serengeti, though there are certainly many others that could conjure up an equal sense of unease when it comes to being in the wrong place at the wrong time.

The remainder of the afternoon we spent searching for a good leopard, though somewhat unsuccessfully. Leopards are solitary creatures best observed sleeping in the trees, with their long tail hanging down below a tree branch and their most recent prey often sitting beside them in the tree. They are most frequently seen in trees by water sources, though can often be found in the kopjes, as well. You can spot them on the ground, moving from place to place, but given the amount of time they spend in the trees, your best bet is to keep your eye on the lower placed, though high enough to keep their prey protected from other predators like lions, branches of several types of trees. They are gorgeous, powerful animals and an incredible sight to see. Unfortunately, the closest we came today was a questionable spotting in the tree of another vehicle that none of could really verify.

We drove back to camp spotting various animals along the way, though one sad individual we spotted was a lone wildebeest calf that had been separated from its mother and would certainly fall prey to some predator by nightfall. Wildebeest mothers do not protect their young, nor do they pay much attention to them as far as keeping up with the herds. Wildebeest remain populated through a numbers game – each wildebeest has a lesser chance of being eaten the greater their numbers are.

Sunset was incredible from camp once again and distant lightning could be seen all evening all across the horizon. It was African night for dinner with all local dishes, though I will have to admit that none of them tasted like anything I’ve had locally before as they were all incredibly delicious. Chicken, beef, ugali, vegetables, soup, salads. All scrumptious. We had decided to leave camp before sunrise once again, so it was early to bed and early to rise. We would be departing tomorrow so would have to make everything ready before hitting the road.

I’ve referred to my stint with the second group as ground hog day as I’ve tried to make the experience for all the residents as much the same as possible. We travel to Ngorongoro Crater with each group, visit Daniel Tewa, Phillipo’s coffee farm, Gibb’s Farm, mobile clinics (though they are to different sites), and now the Serengeti for three days and two nights. We had been out at Gibb’s Farm for dinner last night and arrived home a bit late as we had gotten there late, so the residents would be making our lunch in the morning. We wouldn’t have to leave at the crack of dawn since we’d be traveling to Oldupai Gorge first and not arriving to the Serengeti until later in the day.

It had been raining overnight and continued into the morning as we departed for the Loduare Gate once again, but this time, we’d be traveling around the crater rim and descending onto the part of the Serengeti plain that lies in the conservation area before crossing over into the park proper. But first, we would visit Oldupai Gorge, the cradle of humanity, and the single most famous archeological site in the world. The gorge was first identified by a westerner when a German neurologist, who had been researching trypanosomiasis, or sleeping sickness, stumbled upon it in 1913, though unfortunately misspelled the name as “Olduvai” rather than the correct “Oldupai,” the Maasai name for the common sissle plant that exists everywhere in this region.

Luis Leakey arrived in 1931 after learning about the fossils that existed here, and his wife, Mary, joined him just several years after that. They continued to search for human fossils until in 1959, Mary Leakey finally found Zinjanthropus (Nutcracker Man named after his huge molars) which is now considered to represent Paranthropus boisei. What is unique about Oldupai, though, is the fact that multiple ancestors of Homo sapiens were found here at the same levels indicating that they coexisted. This was true of Paranthropus and Homo habilis, though later fossils of Homo erectus and early Homo sapiens were also found in nearby layers.

Oldupai Gorge has always had a special meaning for me since childhood as I followed the exploits of Luis Leakey prior to early death in 1971, and then Mary, as she continued their work at the gorge and the surrounding region. As an undergraduate, I took as many courses as I could in both physical anthropology and classical archeology and was fortunate enough to have participated in a professional seminar in 1977 that was led by Luis’s son, Richard, David Pilbeam, and Donald Johanson, who had just discovered Lucy (3.6 million years old) only several years earlier. It was in 1976 that Mary Leakey discovered her famous footprints in Laetoli that were dated at 3.7 million years and were formed by a group of bipedal australopithecines traveling together as a group. It was upon that background, that in 2009, I insisted that we visit Oldupai Gorge on my very first safari, and I have returned every year since as if it were a pilgrimage to Mecca.

It was in 2017, though, after the completion of the new museum, that I first met Professor Masaki, and we have been friends ever since. He brought me to the Leakey camp well before it was open to the public, and we rummaged through the buildings that contained original animal fossils (the hominin fossils had been long removed). He pulled a several million-year-old mammoth tusk off the shelf to show to me as I nearly fainted out of concern that he would drop it. Masaki has continued to meet me with my groups of residents as we visit this site and gives a short lecture each time on the history and the importance of the gorge in our understanding of human evolution.

After spending time in the museum, we descended into the gorge and across the river at the bottom, now with water from the recent rains in the Endulen highlands around the crater rim. We traveled to Shifting Sands, a large mound of magnetized black sand that was ejected from Ol Doinyo Lengai, the only remaining active volcano in this highly volcanic region, some 3000 years ago. Ol Doinyo Lengai, which means “Mountain of God” in Maa (the language of the Maasai) is sacred to them, as is Shifting Sands. The sand remains together because of its magnetic nature and is constantly being blown in one direction across the plains about 15-20 meters a year.

After leaving Shifting Sands, we drove across the plain on a very small road (really just two tire tracks through the sand), bypassing the heavily trafficked main road, until crossing over into Serengeti National Park. It was another 20 minutes or so to reach Naabi Hill where the entrance gate is into the park and where we would finally eat our lunch, just a bit later than expected.

Once in the park, we began our game drive, looking for whatever wildlife we could spot. It was not long before we found lions, but the massive wildebeest herds that were here just three weeks ago had moved on further north and we would search for them tomorrow. There were small groups of wildebeest, but nothing coming close to the body of the migration that would number in the hundreds of thousands. It had been raining in the Serengeti, and the roads, though passable, were very wet in places, and especially once we veered off of the main road in the direction of our camp. As we reached the woodlands on our way, the road became very muddy, so much so that there were large muddy areas that had to be bypassed by following prior tracks into the grass at times. It is times such as this that you’re grateful that you’re in a Land Rover for they are built for these occasions and will see you safely through any conditions.

We finally arrive to camp as the skies were darkening and, just after all of our bags and camera equipment was safely under the canvas of the tents, the skies opened up and a torrential downpour began. We had hoped to get to our tents and shower before dinner, but the rain delayed us by about thirty minutes or so. It finally let up, allowing us to get to our tents which were beautiful, and we were all able to clean up before finally sitting down to dinner. Tomorrow, we were getting up before dawn and meeting for coffee as we would have our breakfast and lunch packed for us to eat on the trail. There was an air of excitement as tomorrow we would be looking for cats and the migration.

We had been asked to provide one of the educational lectures this week and Holly had volunteered to provide a talk on dementia which is her area of interest and what she will be doing in the future. I was initially worried that the lecture was a bit too in depth, but between her comfort with the material and her delivery, it was very well received. There were some very good questions following the lecture and, most importantly, she didn’t receive the hook for having gone overtime. Always a good sign.

Though we supposed to have left for our mobile clinic around 8 am, given Holly’s talk and the necessary repairs on Turtle, we didn’t get out of FAME until probably 8:30. The new clinic we’d be visiting today was much closer than the others and close to a clinic we’d worked with in the past, though not for several years. We would be heading south down the road towards Endabash to a village by the name of Basodawish. This community has been receiving support from another NGO by the name of Food for His Children, an organization that works to supply dairy goats to families in the region, allowing them to begin providing for themselves. Kitashu had visited the dispensary during his outreach and, having worked with Food for His Children in the past, they were very interested in having us visit with our team. In addition to the crew that had come earlier in the week, we also had Ke who had wanted to come, Faith, our new social media manager, and Saidi, our volunteer coordinator. This would be an issue for space in the vehicles and for the number of lunches that we had, but in the end, it all worked out.

As we arrived at the dispensary, though, it was readily apparent that they weren’t expecting us, and it turned out that the medical officer in charge had been away for a family emergency and hadn’t prepared for our visit. The main issue that we had was that the dispensary was very under resourced, meaning that finding even the bare minimum of furniture that we required to begin seeing patients was going to be an issue. Not only that, but they were having their regular clinic at the dispensary that day which meant that we couldn’t use any of the offices that would have been ready for us. Instead, we began searching the premises looking for suitable space. This was really no fault of theirs, but it meant that we would have to begin scrounging for chairs, anything that resembled a table and could be used to write on, and at least one table to examine to use for examining babies and children.  

Kitashu began looking for chairs and tables, but also needed to begin registering patients, so it was a joint effort. The rooms we were to use needed sweeping and cleaning to be able to be used and we found anything with a flat surface to write on. Joel began to set up his pharmacy outside where I would be staffing the residents and, after a short delay, we were prepared to begin seeing patients. We found benches for the waiting patients to sit on and Kitashu began triaging patients. Unfortunately, there were many MSK (musculoskeletal) patients, though given how muddy it was outside and how determined the patients were too come see us, I didn’t think it fair to turn them away today as long as it didn’t mean being unable to see neurology patients. Towards the end of the day, though, it was clear that we were not going to be able to see everyone, so Kitashu began selecting only epilepsy patients for us to see and asking the remaining patients to come see us at FAME next week. There are buses and vehicles heading to and from Karatu all day long so that it would not have a been a major hardship for them to have come to FAME.

Some of the patients were frustrating as they had never been seen by doctors or had never received a thorough work up and their problems had been there for years. One was a 33-year-old woman with a long history of seizures and a static encephalopathy who the family swore had a normal developmental history until she was in her late teens or early 20s. Trying to sort out what the underlying etiology of her condition was would be an exercise in frustration as we have none of the necessary testing here such as advanced imaging or genetic testing which was what was needed. Even if we had this technology here, it would have been highly unlikely to have found something treatable that would have made a difference for this patient. We adjusted her antiseizure medications to make sure that she was safe and that was all that we had to offer.

One of Holly’s patients, though, was perhaps the most depressing of the bunch as it was an older woman who reported a six-year history of progressive lower extremity weakness and difficulty using her hands who clearly had a cervical myelopathy from a degenerative standpoint. Worse yet, she had lost her bowel and bladder function over the last months, and now had to be carried everywhere as she was completely non ambulatory. Her examination was classic with a spastic paraplegia and wasting in her upper extremities. There was little that could be done for her at this point, though I do believe we gave her some baclofen to help with her lower extremity spasticity. Performing costly imaging studies on her now, even if she could afford it, would not prove helpful for her as she was not longer a surgical candidate. These cases are so unfortunate, though at least we can feel somewhat helpful in telling the families what is going on and that no matter how many other doctors they see in the future, nothing will change.

Another interesting patient that came today was a gentleman who had been treated at FAME for a stroke well over a year ago, but we had no records, nor did we have the results of the CT scan. As it was important to know whether the stroke had been hemorrhagic or not as it would have some determination on the medications we would prescribe, we were about to call FAME when we suddenly realized that we could access the radiology server on the iPhone (FAME uses the AMBRA service), and possible look at the patients CT that way. Sure enough, it was a matter of only a minute or so to search our database for the patients name and open his images. His stroke had been a basal ganglia hemorrhage most likely from his history of hypertension. That was all that we needed to make the necessary recommendations for treatment.

Around the clinic were numerous cultivated plants used for making chai (such as hibiscus and lemongrass) as well as other trees and shrubs that are used her for medicinal purposes. The birds that were flying around through the day included the Fischer’s Love Birds that are so gorgeous to watch, and the fastidious weavers that were taking grasses from the back nearby and building nests in the trees out front.

As I mentioned, the clinic became quite busy at the very end, which is often the case with these mobile clinics. Despite Kitashu’s incredible efforts to spread the word throughout the community that we’re coming, much of the recruiting of patients is done by word or mouth. People call their family and neighbors to let them know we’re in town so that after lunch, we often see an uptick in the patients coming to register. The patients kept coming and it was necessary for us to cut off the waiting list otherwise we would be spending the night seeing patients which was not something any of wished to do. Besides, it was not at all unreasonable to ask some of the patients to come to Karatu and see us at FAME. There was no benefit for the patients to see us in Basodawish rather than FAME as we were providing the same offer for them – a doctor visit, meds for at least a month, and labs, all for 5000 TSh, or $2. As were unable to do labs there, we were actually directing those patients needing them to come to FAME next week where they would get the labs as part of their visit either way.

We had plans for dinner at Gibb’s Farm as Ke would be leaving tomorrow and he wanted to join us for one dinner. We were running late, though, and, by the time we arrived at Gibb’s, it was after dark so that the residents missed seeing this amazing place in the daylight. It had also started raining, so we went inside for drinks and asked if we could begin dinner a bit late to give us some time to unwind. Thankfully, that seemed to work out for the kitchen. We would be eating in their brand-new private dining room tonight which is behind the pool in the old barn, though once we walked in, other than the old wooden beams and rafters, there was very little about the dining room that would have made you think you were in a barn.

We had a large table that had been wonderfully set for the eight of us that were dining that night and the waiters, all of whom we know quite well as I’ve been coming here for 15 years, had to bring all the dishes from the kitchen to our table which was no small task. Dinner at Gibb’s is always an experience, and it was even more so tonight given the surroundings. With the rain continuing to come down, there was little chance of eating outside, so what more could we have asked for than a private dining experience.

Given the distance to Barazani and Mbuga Nyekundu over the last two days (over an hour’s drive), our planned departure times were 7 am each morning which is just a bit early for everyone, especially considering the weather change we’ve been seeing with stiff rains through the night. For today and tomorrow, though, the drives would be much shorter, allowing a more civilized 8 am departure time for which everyone was quite thankful. We typically meet at the junction of the FAME road and the tarmac which is where we pick up all those who live in town.

The junction happens to be a very busy intersection just for this reason. There are also many shops there to pick up supplies, vegetable stands, and a few restaurants where you can pick up snacks for the road, something that Dr. Anne makes sure to do for us each and every morning. Samosas, chapati, mandazi, little chickpea flour bites with veggies – all the delicious breakfast items that come with us in the vehicle and are eaten on the way or when we arrive to our destination.

Driving Turtle down the FAME road to the junction this morning, I felt an extra “clunk” going over one of the larger berms that are used to divert water from running down the road. Despite going very slow over the large bump, I felt the vehicle, which is quite large and like driving a tank, lean slightly to the left after that, and I was sure I had broken one of our rear shocks. Thankfully, the extended Land Rovers have two shocks mounted at each of the rear tires just for this occasion, so I wasn’t worried about the drivability of the vehicle, but definitely needed to have this looked at when I got to town. Sure enough, when I got out of the car to check, one of the shocks had essentially snapped in half and, not only was it not helping to dampen the ride, it was pulling the car down slightly causing a lean that was clearly noticeable.  I let Kitashu know immediately as we couldn’t continue with the vehicle as it was, and he immediately took it to a shop, with everyone other than me still inside, to have the shock removed. We would go on for the day with just a single shock at that wheel, as this was totally acceptable, but would have to replace the shock later tonight. As I have said before, Land Rovers are incredibly dependable, but also very finicky. Thankfully, it is also very easy and inexpensive to fix them. Removing the shock at shop cost 10,000 TSh, or just $4.00.

Once we had Turtle back in fighting shape, we left town and turned off the tarmac once again on the Mang’ola road, though would not be driving nearly as far today as we had over the last two days which I was quite thankful for given the single shock in the back on one of the rear wheels. We passed the coffee farm and eventually came to a small road departing to the right that headed very quickly up into the foothills of Ngorongoro Mountain. With the recent rains, the road was heavily rutted, and with each creak of the rear suspension, I could imagine that single shock deciding to give way, but despite the rough road, it held throughout the day. The road was very similar to the road we take to Rift Valley Children’s Village, winding through ravines, and continually rising upward.

The name of the community, Mang’ola Juu, means “Mang’ola top,” and it was clear from the drive that we were quite high up on the mountainside. We eventually came up a fork in the road and, turning left, came upon a few homes and then the dispensary which was a single large building with a high peak almost resembling a church. Thankfully, the building had several rooms, or offices, where the residents could set up shop once we located the appropriate number of chairs. The dispensary clinical officer and nurse were very happy to see us (always thanks to Kitashu’s advance outreach that he does at each location), and we were quite quickly in good shape to start seeing the many patients who had come for neuro clinic. This area is strictly Iraqw as it is a farming community.

The views from the clinic were spectacular as we had a 180° view of the valley, with Karatu on one end and Lake Eyasi on the other, that we had driven through both of the last two days. It felt as though you could see forever. The overnight rains had contributed to a bit of muddiness, though it was quickly drying up with the heat of the day and the partly cloudy skies. Our facilities for the day would be a small outhouse that had an incredible view from in front of it, but alas, there was no Western Toilet here, much to everyone’s dismay, requiring everyone to use one the squatty potties behind each of the three doors.

Though there were lots and lots of patients, there were also many family members who had come as well as townspeople mostly interested in what was going on at the dispensary though had no need to see us. Kitashu had done his job, and then some, with his outreach announcements getting people to come, though we soon discovered that some of the patients came to the clinic complaining of “gonzi” (meaning numbness) when they went through triage, though when questioned about their symptoms, clearly did not have this and, instead, were complaining of MSK pain, something that we do not treat if we can help it. The dispensaries we visit all have clinical officers who run the centers and provide medical care for these patients, so it is not our mission to be seeing “medical” issues, but rather neurologic disorders. Not only do we not treat medical problems intentionally as it is not what we do, but we also don’t want to step on any toes by treating conditions for which the patients already have adequate care.

After the extra-long drives to Barazani and Mbuga Nyekundu that we had, it was nice to have finished at a decent time of the day. We had plans to visit Daniel Tewa tonight and it was important to get there with some daylight left so the residents would have a chance to see his property as well as his underground Iraqw home that he had built a number of years ago. I had met Daniel in 2009, when visiting Karatu for the very first time and having no idea how that visit would change my life forever. Daniel is not only a self-taught local historian of the Iraqw tribe and culture (he is obviously Iraqw himself) but is also an incredibly well-read man who can discuss virtually any political or historical situation from a totally informed perspective. Daniel had worked alongside my children and me when we were painting the Ayalabe primary school in his village and we have been close friends (or family as Daniel repeatedly points out) since we first met.

I returned to work at FAME the following year, 2010, and phoned Daniel to tell him that I was returning. He invited me to his home to share a meal on that visit, and I have gone to his home every six months since, to spend time with his him and his family. When I began bringing residents to FAME in 2013, I have brought them to meet him each and every time. For each of these visits until the pandemic, he would have the entire group over for dinner and has never once allowed me to contribute anything to these meals as he has always reminded me that it is an honor for his family to provide a meal for us and he would be insulted to consider otherwise. With the pandemic, we stopped doing dinners, but have continued to visit his home, sitting outside on chairs, as I had with my children in 2009, sharing his African coffee (coffee boiled with fresh mild from his cows) as he pours never ending cups unless one absolutely refuses, which I never seem to do.

To say that Daniel is a special person would be an understatement. Over the years, he has continued to provide informational talks to visiting tourists and scholars with many safari companies bringing their groups to his home to hear him talk. Though there is little question that Daniel is the main attraction, the underground Iraqw home that he built in 1991, similar to one that he had spent the first 20 years of his life in when this country was still a British protectorate, has also garnered much attention from academics locally and abroad. The house, which has a low dome roof covered in dirt and grass, is mostly underground and the roof is supported by hand hewn hardwood forming a pattern that separates the rooms, each of which has a separate use. This house, which he built to demonstrate to his children that he was not making up his past, is a smaller version to what he had grown up in and would be the size for a small family or newly married couple.

One of the reasons, or perhaps the main reason, that the houses are underground, is that their animals were kept inside at night to protect them from being taken by the Maasai. The Maasai believe that all cattle are God’s gift to them and that by taking the cattle, they are not stealing them, but rather returning them to their rightful owners. The purpose of the domed roof was that you could hear someone walking over the house and would know that it was a thief at which point, they could protect themselves. The Maasai and the Iraqw remained at odds until 1986, when a formal treaty was finally signed. Meanwhile, as their first president and founder of the country, Julius Nyerere, worked to unite a country of over 120 tribes following their independence in 1961 (and union with Zanzibar in 1964, thus creating Tanzania), it became evident that building an infrastructure the separate villages for each tribe wasn’t going to work and communities were forced to integrate, necessitating the ban of these Iraqw houses and other similar unique tribal homes. Most everyone was forced to begin living in classic Bantu structures (except for the Maasai), and the traditional Iraqw houses have never returned. Daniel’s remains as one of the only still in existence and researchers from all over travel to see it.

Though Daniel remains active and vibrant, we are both 15 years older now than we were when we first met, and he is ten years older than me. I truly worry about what will happen to these incredible stories of the Iraqw after he’s gone and who will carry on with these amazing stories and traditions.

It was once again another long drive on the road to Mang’ola – I would again be driving Turtle with the neurology contingent, and Myrtle would be carrying our support staff. We had an early departure time of 7:00 am, and though we were still in town gathering everyone at that time, it wasn’t long before we were hurtling down the road. The traffic officer remembered us from yesterday, so it was merely a wave, and we were on our way. It was a gorgeous day with the sun shining bright and the road was in excellent condition for our traverse that travels around Ngorongoro Mountain on the way towards Lake Eyasi.

The route we take has such varied terrain as we leave the highlands of Karatu and gradually descend along a terraced valley with numerous drops through ravines that in the rainy season are likely impassable. There is a coffee farm we travel through not long after leaving the tarmac and we end with large green fields of onions and maize closer to Mang’ola. There are scattered villages along the way where most of the workers for the fields live and each gathering of houses has its detachment of boda bodas parked along the road and ready for action should they be hailed by a traveler looking for a ride. There are few safari vehicles we encounter as this is not much of a touristy area, at least in comparison to the crowded game parks of the Northern Safari Circuit. Most of the vehicles we encounter are Land Rovers owned by the locals, packed to the brim with bodies and supplies, plying to and from the Lake Eyasi region on a daily basis or multiple times a day, as the case may be.

We travel almost the same route as yesterday, veering to the left just before descending the shores of the lake, and travel into the nearby mountains only briefly, though long enough to cross high over a deep wash on a short bridge that looks just dependable enough not to worry. Coming over a rise, we descend into the small enclave of houses that form the village of Mbuga Nyekundu (“Red Park”), turning left to reach their dispensary. There are several new buildings that have been constructed since first coming here, and the one that we’ll be working in is a perfect facility for us that has multiple consult rooms, each with windows opening to the outside and on the inside opening to a lovely courtyard.

We’re immediately introduced to John Marwa, an anesthetist working at the dispensary, who was incredibly helpful in getting us started, and subsequently volunteered to help out by taking vitals on all our patients with their portable vital sign machine on wheels that’s identical to those we use in our hospital back in Philadelphia. I’m sure that it was donated by another health organization that has come here in the recent past, though considering that John is an anesthetist, it’s a device that will come in handy when they begin doing procedures here as I’m sure they have planned given his presence at the facility. Given his interest in the work we were doing throughout the day, I asked if he would like to sit in on some of the cases and he took us up on the offer.

The facility is really one of the nicest we’ve had the opportunity to work in here and, similar to the welcoming feeling in Barazani, it was clear that they were very interested in having us here to help with their neurology patients given the fact that so few of the doctors and clinical officers here have had any training in neurology. Being welcomed by a community is such a big part of the impact we can make here with the work that we’re doing. It begins long before we arrive, though, as Kitashu travels to these communities well in advance of our arrival and spreads the word of the neurologic conditions that we are treating. Though there are certainly some issues with triage as evidenced by those patients with MSK (musculoskeletal) pain that we end up seeing, it is still a miracle that we are able to see the number of frank neurologic patients that we do end up seeing. If it were not for Kitashu constantly seeking out these new communities for us to see new patients in, this project would not be as successful as it has become.

Our patient volume remained steady throughout the day, and we ended up seeing thirty patients which is our usual target for a day on mobile clinic. As we are unable to provide the same services when we are out in the bush and not at FAME, such as labs or other tests like echocardiograms or CT scans, some of the patients we see in the villages may be asked to come to FAME next week when are back there. These villages are not so remote that patients can’t travel to FAME if needed, though the major impact of our seeing patients in these clinics is that they often don’t realize that they may have a condition that is very treatable, such as epilepsy, and may end up living for a number of years before they come to see us. With epilepsy as a specific example, very often the patient may have seen someone in the past and was put on a subtherapeutic dose of a medication or one that wasn’t going to work to begin with, and they discontinued it without every going back for follow up. This is quite often the story that we hear both on mobile clinics as well as back at FAME.

Our day finished at a much more reasonable time than yesterday, and we were able to hit the road back to Karatu well before the darkness fell. There were no herds of livestock running out in front of us, though I was probably more attentive after yesterday’s near miss. The subtle lighting of the waning day cast lovely shadows across the road and on all that passed by as we once again rounded the circumference of Ngorongoro Mountain. I have driven this road now for nearly 15 years and little has changed in that time, though I am doubtful that it will remain as remote and pristine forever. Karatu has changed dramatically in that time – there are now solar powered streetlights on the main road as well as more than one paved road. When I first came, there were no buildings higher than two stories and now there are several that reach higher. I suppose that is progress, though I wish it would remain the same, quaint place it was when I first came. I can only imagine how it must seem to others who have been here for a lifetime. I have always been resistant to change.

We drove back up the road towards FAME after dropping off our interpreters and Dr. Annie, happy to be coming back to our home away from home. We had a dinner of rice, beans, and mchicha waiting for us which was comforting as we had missed it at lunch. Tomorrow we would be heading to a brand-new community that Kitashu had found – Mang’ola Juu (meaning Mang’ola up). Though I am resistant to change, I love exploring new places.

We had a full day of mobile clinic this week that would begin in a region called Mang’ola and our first stop would be the village of Barazani. This region has a special significance to FAME as it is where the first mobile clinics were held just as FAME began their operations as a clinic. These mobile clinics, though, were far different than what we provide today, mainly in the fact that we would travel there as a huge group, and spend the week in the region, typically camping out in government buildings with a mattress and a blanket. They were huge affairs that required a ton of logistics given the number of personnel that were traveling together and the support services that were required.

Though not of the same magnitude, we have carried on the FAME tradition of the mobile clinic with our neurology team’s trips to the Mbulumbulu region, Rift Valley Children’s Village, and now to the Mang’ola region for this visit. We had our two vehicles (Turtle and Myrtle) all packed with supplies and the necessary staff to spend the day at the Barazani dispensary seeing neurology patients or anything else that needed our expertise such as the psychiatry patients whom we treat here as well. The drive to Mang’ola is along what is now a good road, but that can always change in a moment with the weather. I recall driving through Barazani years ago with the big mobile bus that we used as a mobile lab when we encountered a washed-out ravine that was nearly impassible at the time and required extensive repairs before proceeding.

Lake Eyasi is a very remote region and historically very old. It is the largest of the Rift Valley lakes (Natron and Manyara being two others) and the home of the Hadza (or Hadzabe) who are the last bushman of Tanzania, still hunting with bows and arrows for their food. The other unique feature of the Hadza is that they are one of the several tribes in the world who speak click language, using clicks as additional consonants in their alphabet. They live several hours away from Barazani on the shore of Eyasi, though we continue to see members of their tribe both at FAME and at mobile clinics on occasion. Several years ago, Mike Baer, one of my residents who had traveled here in 2019, wrote a wonderful story about a member of their tribe who had suffered a stroke and the fact that there are so few of them remaining in the world (https://fameafrica.org/journal/2019/10/3/one-of-only-1500).

Our journey began quite early in the morning as it would take over an hour for the drive to Barazani, and that was if everything went well, and they were no unexpected events along the way. The junction of the tarmac and the road to Mang’ola is just west of town on the way to the Ngorongoro gate. The tarmac, though, is heavily trafficked by safari vehicles on their way to the Crater and beyond, so there is now a traffic control station to register all those commercial safari vehicles travelling to parts beyond. I had no intention in stopping to check in since we we’re to a mobile clinic rather than a game drive, though, as I approached, I was flagged down by the traffic officer to stop. I will usually have one of the Tanzanians explain our circumstances to the police since, ashamedly, my Swahili remains extremely poor beyond saying hello despite the 15 years that I’ve been coming here. As soon as I heard Annie begin laughing, though, I knew we were in good shape as it turned out that the female office was one of her patients at FAME. After a brief chit chat in Swahili which, of course, I couldn’t understand, we were once again on our way.

The drive along the Mang’ola road is gorgeous and travels through very rich farmlands and villages for the farmers and other workers who still toil the soil by hand rather than technology. In the mornings and the evenings, the workers walk along the road with their hoes slung over their shoulders in a fashion that would be reminiscent of another century back at home. There are many vehicles including larger trucks that ply this road all day long and into the dusk bringing produce and people to and from the Lake Eyasi region.

I’ve been coming to this clinic in Barazani for over five years now and it has never disappointed in the excellent turn-out we receive, both in the volume of patients seen as well as the widely varied pathologies represented. The clinical officer in charge, Dr. Damien, has been the same for the last several years, and has also been gracious and hospitable in a manner that has always been so helpful to us. As soon as we arrive, he scrambles around to help us find the necessary furniture for us to get started and to determine just which rooms we could be using. One thing that was added just within the last year and was incredibly appreciated perhaps as much and anything else at the clinic, was their new Western Toilet. African toilets, like most of the rest of the world, are “squatty potties” and, though are just fine for those of us of the masculine gender going “number one,” require a bit more balance and finesse for anyone else.

I was thankful to see the furniture I had previously donated to the clinic was still present and being used as that is perhaps one of the scarcest pieces of equipment that is needed for our mobile clinics. Having no tables or chairs in the exam rooms and no benches for the patients to sit on makes it very difficult for us to see patients, let alone examine them and write the histories that we need to keep as part of the patient’s file. Because of the way that the FAME EMR has been structured, it can only be used on site while on a FAME network. Though it would be very nice for those times in the US that I’m consulted on patients, it would certainly not be considered a priority for FAME

Barazani itself is a very dry and dusty place and has the feel of the last outpost of civilization at times. The dispensary, which is on the far side of town for us, requires that we drive the length of the mostly washed-out road, passing by places of business that are typically bustling with activity, loading, and unloading supplies onto large trucks that are coming and going. Onions are the primary produce that is grown here, though after our visit to the lake later in the day, it became very clear that truckloads of tiny, dried perch were being shipped out from the area after having been netted in the lake.

The clinic building itself is very basic but had all of the necessities for us to run four clinic rooms and a steady flow of patients along the way. Much to Christina’s dismay, there were plenty of wasp’s nests just outside the doors and there were also small bats hanging under the eaves just outside on the large porch where we were staffing. If you walked over to them, they were scurry across the wall, but none flew away. As is everywhere in Africa, there were tons of birds singing away throughout the day and the plants, all of which Dr. Damien had planted, were lovely. At lunchtime, we had a new treat that was on a trial basis. We had previously brought box lunches, similar to what you take with you on safari, from one of the Karatu establishments that were priced very fairly, but unfortunately were not as appetizing as we had hoped. I had contact Gibb’s Farm to see if they could make us lunches for the week at perhaps a discounted price and, thankfully, they were gracious enough to be willing to do that as they were not overburdened with making lunch boxes for safari guests during the low season. The lunches were awesome and a real hit with the residents and staff alike. After the dust of the drive and the busy morning, it was a nice break to be able to eat a good lunch before seeing patients again in the afternoon.

The afternoon was going well which gave us the option of driving down to the shores of Lake Eyasi for a visit with the fisherman that we’ve met there before. Little did we know, though, that there had been a population explosion not only of the fish in the lake, but also the many fishermen who had come from all parts of Tanzania, some with their families, to reap the benefits of this event. They had created a small city of hundreds of tents along the beach at Barazani, and elsewhere along the lake I would imagine, with huge mounds of dead fish rising well over six feet scattered across the beach. They would bring their nets far out into the lake using small dories and then haul them back towards the shore manually with the result being an incredible amount of these tiny perch-like fish caught in their nets. They would then scoop them out with buckets into large wheelbarrows to bring in further on shore to lay them out to dry.

It was a huge operation that I had not seen before, despite having visited the lake several times in the past. It’s clear that this massive explosion of the population of fish in the lake only occurs at a specific time of the year and we had simply missed it in the past. The smell of hundreds of piles of dead and drying fish was immense and pungent and remained in our noses for a long time following. We were told that the fish would be ground into meal to use for chicken feed.

We left the lake a bit later than expected for the long drive home in waning light of the evening. The road, which is dirt and gravel for the most part with some fairly rocky stretches is driven at 60-80 kph – not a speed for the faint of heart. At one point, a herd of goats and sheep shot out from some bushes to run across the road directly in front of Turtle traveling at a fair speed. I slammed on the brakes, but trying to stop a vehicle the size of Turtle on a dirt road isn’t an easy task. We were sure that we killed at least one of the animals and I was already preparing in my mind how to negotiate with the owner when we discovered that all the animals had escaped alive. Driving home in the late evening is always a risk as that is when all the herds of livestock are being driven home by their owners, undoubtedly having to cross the roads.

We made it home just a bit worse for the wear, but safe and sound. Tomorrow morning, we would be returning back to Mang’ola on the same road, but to a different village, Mbuga Nyekundu.

Throughout the early morning hours, a very fierce thunderstorm raged with constant lightning and thunder that felt as though it was centered right on top of us. The sound of heavy rain on the tin roof and the bright flashes followed by the loud booms kept us intermittently awake, though it was also somehow settling to be sleeping comfortably in our little home that we have here. I have always slept with my screened windows open, as do most others in the house, as the nights are usually brisk, but not cold, and the overhang of the roof is more than enough to prevent most any downpour from coming in the house. I have even been here in the monsoon season and have yet to see anything close to reaching the inside of these structures.

The morning was slow as we didn’t have to be to clinic until 8:30 am as it was not only Saturday, but also still Easter weekend and we suspected a low patient volume given that. I decided to eat my granola outside as the rain had stopped and the views with the low clouds were wonderful. Looking out over the overgrown landscape, I suddenly spotted a reedbuck, which is a small to medium sized antelope that are usually alone or in very small groups in the marshes (hence their name) or brush around small bodies of water. It’s color is a reddish brown, close to auburn, and they are very shy. How this animal got into the FAME compound wasn’t clear, though I suppose it might have squeezed through the fence somewhere. It sat there perhaps 25 yards away from me and wasn’t aware that I was watching. I was able to wave to the others inside to come out and see it and everyone made it out in time before it disappeared into the brush. It was very cool to see such a beautiful creature just outside our back door and was a real treat.

We had a slow but steady stream of patients come in which was fine as we had planned to go to the African Galleria for dinner tonight and hoped to leave early enough to do a little shopping there as well. As is usually the case, though, a more complex patient seems to come in at the end of the day requiring our attention and throwing us off schedule. The child that Marissa had seen initially several weeks ago in focal status and has been seen back on several occasions with adjustments in their antiseizure medication returned once again even though they were not supposed to come back for at least another week to allow our plan to work.

When we had originally seen the child, we had recommended that they have a CT scan given the focality of the seizures and the fact that they had started only a month ago in this 7-month-old child, but unfortunately, the family was not in the position to obtain one. Given the difficulty we were having in controlling the child’s seizures, though, we felt that it was very important to have an imaging study as it would very likely affect the recommendations that we were making. It was a holiday Saturday and late in the day, so Angel gave us permission to obtain the scan and the particulars would be worked out later with the family as far as payment was concerned. Without a clear history telling us what was going on, we would also need to contrast the scan and that would require a creatinine, further delaying the scan.

When the scan was eventually done, we all went to radiology to look at it and when the scan was brought up on the monitor, it was quite clear, even from across the room, why the child was continuing to seize despite our best efforts at treating them. There were no normal areas in either hemisphere of the brain with both cortical and subcortical destruction that, given the lack of history, was most suggestive of some devastating encephalitis, probably viral. The brainstem and cerebellum were perfectly intact.

Maya and Michael went back to speak with the family regarding the incredibly poor prognosis and the fact that it would be unlikely that we would be able to completely control their seizures going forward. The rest of us went back to the house to get ready to head down to the African Galleria. When the two returned, Maya frustratingly told us that after further discussion with the family, the child had not been developing normally and, furthermore, their birth history was entirely consistent with hypoxic ischemic encephalopathy, or HIE. How this had eluded everyone who had seen this patient previously was puzzling, though as I have pointed out repeatedly, getting an accurate history here can be like pulling teeth at times.

With this history, it was clear that there was very little we could do for this child from a functional standpoint, though we could certainly continue to adjust their antiseizure medications with the hope of lessening their seizures, but that was certainly not a given. Had we had the history of HIE from the very beginning, it may have changed our recommendation for the CT scan, though possibly not. It was just another example of the difficulties there are in when seeing patients in other cultures and trying to obtain the necessary information to provide the appropriate care.

Thankfully, Maya and Michael returned in time for us to depart for the Galleria with the possibility of shopping and we were off. Ke had been at the house since 3 pm as I had told him that was the departure time, though things usually don’t go perfectly as planned, especially here. We arrived around 4:30 pm with the shop closing at 5 as it was slow season. Everyone seemed to have a sufficient amount of time to shop, and we sat down for dinner shortly after 5 pm. Dinner was delicious, as expected, and there was no trouble for Holly to find enough vegan-safe things to eat there. Though one of the things they are known for is their barbecue, they had a wide variety of vegetarian options that were cooked without animal products. Nish ordered a vegetarian curry with rice and vegetarian samosas specifically for Holly, both of which were scrumptious per her report. We couldn’t finish everything and brought some of the meat home with us.

We had needed supplies for our game drive to the Crater tomorrow and, luckily, all the shops were open when we got back to town on our way home. We hoped out of the vehicle, and all went on our separate missions with Jill and me going to the vegetable market where we found not only things for the crater, but also for dinner tomorrow night. We had gotten a big pot of rice from the kitchen on Friday that in the fridge and we were planning to make fried rice, both vegan and regular.

Though it was Good Friday and a holiday schedule for the FAME staff, we were holding our regular neurology clinic, and it was the first week for this group of residents meaning that we would be seeing patients all week as well as Saturday. Since Easter was falling earlier this year than it normally does, the holiday would be occurring smack in the middle of the second group’s rotation, clearly affecting the volume of patients. With next week being in the Mang’ola region, though, I was pretty certain we’d make it up as the volume is pretty high when we’re there.

Even though there is a significant tendency for tribes here to continue following some of their traditional beliefs, many of them have more of a dualistic religious tendency, observing both Christianity and their own belief systems. The actual percentages for the country are about 2/3 Christianity, 1/3 Muslim, and perhaps only 5% with a single traditional belief system. The majority of the Muslim population lives on the coast given the history of the Arab trading in years past (Zanzibar was the capital of the sultanate of Oman at one time), but there is still a substantial population of Muslims within Karatu as can be evidenced by the call to prayer that can be heard throughout town given the number of mosques that are here.

I have mentioned the number of tribes that are here in Tanzania previously, but just to reiterate this important fact, there are over 120 unique tribes who all have their own traditional belief system and their own language. The largest tribe in the country is the Sukuma, who live in the Mwanza region east of Lake Victoria, and make up about 16% of the entire population of Tanzania. The next largest tribes do not even come close to the Sukuma when combined. Though Swahili is the national language of Tanzania, it is not spoken by everyone and mostly depends on the level of education and how much a particular individual travels outside of their local village needing to communicate with others. A great many Maasai women who never leave their boma, or their nearby community, speak only Maa, and require a three-way translation when they come to clinic. Most of the Iraqw we see do speak Swahili, though a great number of the very elderly members of the tribe speak only their native tongue, KiIraqw.

Today would be Megan’s last full day of work ending her month here at FAME. I had mentioned previously the incredible job she did analyzing the patient data from our database of neurology patients we’ve seen since 2015, specifically looking at the 2020 to 2023 patients and looking for trends in patient return, adherence to medications, top diagnoses, and the cost of caring for these patients during our clinics here. Though our plans to begin a prospective analysis of data with specific questions relevant to the Tanzania Ministry of Health was derailed by the pandemic, we have continued to accumulate data that remains extremely valuable in regard to insight for not only neurology, but other specialty care. Though Megan will be leaving Penn for her residency in pediatric neurology at Mass General Hospital, I remain hopeful that she will continue to be involved in our project. We will miss having her here and I’m sure the Lilac Café staff will miss having her spend her mornings there while doing her data entry.

As it was a holiday schedule, there was no morning report meaning that we all got an extra half hour of sleep. On arriving to clinic, there were no neurology patients waiting to see us, so all the residents took the liberty of going to the Lilac Café to enjoy coffees and some snacks, while I remained in clinic, as is usually the case, to work on my blog and keep track of things just in case patients showed up. Despite the holiday, or perhaps as a result, some patients began to show by mid-morning meaning that I had to let the residents know so that at least the sufficient number could return to begin seeing patients. Either way, though, the day remained quite slow and there was lots of opportunity for the residents and translators to do some bidirectional teaching, neurology on one side and Swahili on the other.

At lunchtime, I was happy to see that it was favorite lunch being served, rice, beans, mchicha, and lots of pili pili on top. The normal Friday lunch would have been ugali and nyama (beef), which, although is very much a local lunch, it’s not my favorite and Charlie is usually the main benefactor on my end, much to the detriment of his ever-enlarging figure. We have tried in the past to cut him off from table scraps, but it has always been for naught as he just seems to wind his way into everyone’s heart and, if that doesn’t do it, he is a relentless beggar.

Patient-wise, it was the standard fare of epilepsy and headaches along with a smattering of MSK (musculoskeletal) patients that always seem to sneak by our triage, but appropriately so as it’s not always the purpose of triage to weed these patients out. Back home, I am more than happy to evaluate patients who may not have a neurologic etiology for their symptoms, for how else would know without a neurologist seeing them. Here, it is somewhat the same, though considering we are subsidizing the neurology clinic, it becomes a bit counterproductive for us to see too many MSK or non-neurologic patients. Psychiatry actually falls under our purview here as there no psychiatrists and we do receive some education in that area during our training, so these patients are followed by us normally.

One of the patients we saw today was a young boy with infrequent generalized tonic-clonic seizures who we have followed for some time and have increased his antiseizure medication to valproic acid 1000 mg twice daily that was a decent dose given his body weight, but still had not completely controlled his seizures, and there did not seem to be an issue with compliance. In the end, we made the decision to switch him to levetiracetam rather than going up another notch on the valproate. Levetiracetam is a medication that has become widely used back at home, though I often fear that is because it is so simple and safe to use rather than it always being the best medication for the patient. For this patient, though, it would allow us to start the new medication and get it to a therapeutic level rather quickly, whereas lamotrigine would have to be titrated very slowly due to its interaction with valproate and the risk of a Stevens-Johnson syndrome that can occur with the combination and can become life-threatening.

Everything was wrapped up early enough in clinic for us to make it home in time for the residents to have a nice walk, though I did caution them about sticking together and absolutely no stragglers given the recent leopard attacks that had occurred nearby. Leopards are very shy animals who would be frightened by a group of chattering humans walking together in the open despite how tasty they might appear. They are stealth hunters who sneak up and attack their prey before they are even aware that something is happening. It is very rare to ever see a leopard chasing an animal as they are so lethal and efficient in their hunt. A human sitting by a stream doing the wash would be legitimate prey, but not a group of walking and talking residents.

Jill and I had been invited to an early dinner tonight with Ke, Frank, Susan, Caroline, and Nickson – all either Board members or executive committee members – at the Lilac Oasis, the newest addition to the Lilac enterprise in Karatu which has been developed by Nickson over the last ten years. The Lilac Oasis, which sits just beyond the grade descending from Rhotia and heading towards Karatu, is an incredible compound that includes a bar/lounge, a restaurant, an executive meeting center, and an outdoor music venue where he had his “Dungu,” or mobile party bar build into a safari supply vehicle. The Dungu sits at the outdoor concert venue but can be driven virtually anywhere it is needed – we used it for our Board party last year having it park behind Frank and Susan’s house and it was a real hit.

The food at the Oasis was delicious and consisted of four different types of salad for the table, soup, and then amazing, barbecued meats – chicken, short rib, pork, and skewers of beef and chicken. The skewered beef was perhaps the most tender beef I’ve had in Tanzania. Their chef did an incredible job with every dish and, even though everyone was stuffed, we somehow managed to fit in the dessert of ice cream and fruit. After dinner, Jill, Ke, Caroline, and I sat down at the music venue for another hour listening to a live band playing wonderful Tanzanian music and then head home thinking what an enjoyable evening it had been.

The residents, who remained home despite the fact they could have gone out by calling a taxi, decided to watch a movie. Jill and I had strongly recommended CODA, which none of them had seen, and were thankful that they all enjoyed it. Though the story was a bit predictable, the incredible acting by an amazing cast made up for the lack of a creative story line. It was a feel-good movie with Oscar winning acting.

The first week for the new residents was winding down and, though the patients have been a bit sparce, there were still interesting things for us to see, and one of our patients today was perhaps one of the strangest to come along for a number of reasons. The month was also coming to an end for Megan, our medical student, who I believe has had an amazing time and, equally important, has been an incredible help keeping our database up to date. I will plan to keep her involved in one way or another even though she will be leaving Philadelphia shortly to begin her child neurology residency in Boston.

It was also the last day of school before Easter Break, and that included the Black Rhino where Jill has been working. Though I know she has very much enjoyed the freedom of her retirement back home, I also know she’s enjoyed helping the teachers here with further developing some of their early education skills. I would also have to admit that I’ve enjoyed bringing her to work on those days that she couldn’t bum a ride off of Pete or Amanda, since their son, Ollie, is going to school there as well.

Having grown up with only a passing interest in sports, unlike most other boys my age, I mostly worshiped the explorers of my time and imagined myself setting off on many of their adventures. There were the oceanographers, such Jacques Cousteau and Robert Ballard, that certainly held my interest, but it was really those hearty explorers of Africa and South America that I loved to read about and dream that I would one day follow in their footsteps. Traveling here in 2009 for my original safari felt like that dream had come true, but never in my wildest dreams would I have imagined that I would be spending several months a year for the next 15 years in East Africa and that it would become as much a home to me as Philadelphia had become.

 But driving through the countryside here, whether it be on the tarmac or dirt roads, will always have the feel of exploration for me as it is just so unique and even the simplest route can become a challenge depending on the circumstances. Beyond the exploring, though, I have just become so enamored with Land Rovers and their amazing ability to drive through practically anything anywhere. Turtle, which is what is referred to here as a stretch Land Rover has been fully decked out for game drives with a pop top and seating for 9 people, but in doing so, it drives more like a tank than any other vehicle I can think of. When you are driving through rough terrain, flooded roads, or even rivers, that’s not necessarily a bad thing as it means that you’ll always make it to the other side, no matter what. We often joke that the winch that we installed on the front of Turtle is not for when we get stuck, but rather to pull Land Cruisers out of the mud after they become stuck.

Myrtle, on the other hand is a really sweet ride and simply a joy to drive as she is pretty much a stock 1996 Defender 110 with a 300Tdi powertrain that was purchased and fitted with new seats, new wheels, and a new paint job. Myrtle performs like a tank, meaning that she can drive through anything, when it’s needed, but is comfortable and performs much better than Turtle given the weight differences.

When going out on our mobile clinics, we take both vehicles given the size of the group, and I always end up driving Turtle, mostly because I have the residents in the vehicle with me and, as a vehicle, it is much more finicky. Rather than having to explain everything to the other driver, it’s easier for me to drive myself. It is nice, though, to have our entire group (residents, me, and usually Dr. Anne) in one vehicle and to have the support staff in the other vehicle so that they can chatter in Swahili without having to be limited to English when they’re with us.

And now for the strange patient that I had mentioned in the opening paragraph. A very cute 4-year-old boy was brought in by his parents to see us for an injury he had suffered two months prior but was still having symptoms that had concerned his parents. The history that was given was that he had been running and had fallen on a nail that he stuck in his forehead and was unresponsive for about 30 minutes following. He was taken to a local dispensary or hospital that apparently had X-ray and, after a skull film was done, his parents were told that the nail had not penetrated his skull. What had bothered his parents, though, was that he had been complaining of left frontal headaches (where the injury had occurred) on a daily basis since the event. The child’s neurologic examination was entirely normal.

There were several concerning pieces of information that were concerning to me, the first being that we did not have the skull films that had been done. The other issue I had was the fact that the child was still having headaches two months out as I wasn’t sure that young children typically had the same post-concussive headaches as we see in adults. I recommended that we obtain a CT scan of the young boy to be absolutely certain that we knew what we were dealing with.

At first glance, it was clear that the CT scan was not normal and that there had been a significant injury to the frontal lobes. There were hypodensities indicating that he had suffered, at the very least, a parenchymal injury related to the concussion, but more concerning was the appearance of the brain which suggested that the nail had penetrated through the skull in the left frontal lobe and then across the midline to the right. The bone windows confirmed, as did the 3D reconstruction of the skull, that there had been penetration through the frontal bone.

More puzzling, though, was the hyperdensity that could be seen deep in the frontal lobes, midline at the falx, that didn’t necessarily appear to be a hemorrhage and, on the contrasted scan, did reveal some enhancement. There was no evidence of cerebritis or any infectious etiology. Thankfully, Ke was here to look at it initially with us, and though he is not a neuroradiologist, he was concerned that the abnormality could represent a traumatic aneurysm, something that would need far more expertise than we had available here. I sent to the images to Kerry Vaughn, a pediatric neurosurgeon working at KCMC for the year, and she agreed that this was something that needed further evaluation either with an MRA or an angiogram in Dar es Salaam. The patient’s father was most comfortable with KCMC as he had been treated there before, so we made the referral and are hopeful that they will bring the boy there.

With further questioning, it turned out that the nail had been pulled out of the boy’s head prior to the parents arriving on the scene, but they did confirm that the nail was about 4 inches long, exactly what would be needed to reach the anterior communicating artery and to cause a traumatic aneurysm or pseudoaneurysm. It was another example of how difficult it can be to obtain accurate histories when seeing patients here – things are not always what they seem to be and without having the experience of working here for several years, it can be very frustrating.

We had once again arranged to visit Phillipo and his family this evening as we were in need of more good coffee for the house, and the new residents were excited about going there. Though there was another safari group that had stopped by, they were finishing up their visit, so Phillipo greeted us and took everyone over to see his process of preparing coffee beans. As soon as Eliza had seen me, she ran up wanting me to put her on my shoulders which is inevitably what happens as she loves to tower over everyone. Jill had brought her to books as a gift and, for the rest of the visit, she carried those books around with her. At one point, I asked her to read me some of the Frog and Toad book that she’s been given, and she did incredibly well, telling us that she had learned to read in both Swahili and English in School.

Phillipo’s three children help (Eliza, Elia, and Richard) with all the chores related to processing the coffee beans, though their eldest, Richard, will often be away at school, so we bump into him ls less frequently when we’re here visiting. Phillipo led everyone into the coffee plants most nearby his home so they could all see the actual beans on the plants, and he described to them how long it took for the coffee bushes to become productive. Following their walk through the coffee plants, Phillipo once again demonstrated all the steps it took to process the coffee beans including roasting the beans. Everyone had a chance to participate in pounding the beans to remove their inner shells as the outer shells had already been removed in press previously, after which they were soaked and dried awaiting our arrival.

Once pounded, the beans were winnowed to remove the chaff, and were then put into the roaster, 5 kilograms at a time. The roaster is hand turned for 40 minutes to obtain a desirable medium roast, though I don’t believe that Phillipo ever checked a watch (he didn’t wear one) or his cell phone (I didn’t see him take it out of his pocket). It all had to do with when the beans began to smoke heavily, at which point he knew that it would be another ten minutes. After the coffee is roasted, it’s put on a screened bin to allows any remaining shells to fall off, and then shaken to finish the process. Once cooled, it could be packed as whole beans in 500-gram bags, or ground and then packaged in the same size bag.

In addition to buying his coffee, which everyone did, though I was buying too many bags to get from him that day, everyone gets to taste a small cup of his brew that Fausta (pronounced Fa-usta), his wife, brings to us in a press and a small cup for everyone. Then it was time for him to show us one of his many beehives that are populated by stingless bees, and to taste the honey that’s collected from them. It’s a very floral honey that is very delicious and, in the past, we have purchased his honey from him as well as the coffee. When all was finished up, Fausta came out with a small jar of honey for Jill to thank her for the books that she had brought for Eliza. It was very obvious that they were incredibly touched by Jill’s thoughtful gesture, though she certainly did not expect a gift from them in return.