(Note to my readers…The internet over here has become as slow as molasses due to a number of factors. It is now taking over an hour to upload photos and is a struggle. Will hopefully improve soon. TIA – This is Africa)

I have probably spent over 75 nights in the Serengeti since first coming to Tanzania in 2009, and, I can honestly say, that it has never gotten old. Each visit brings an entirely unique experience not only for the animals and the landscape that you see, but also for those that you share it with. Bringing the residents and others to the Serengeti for their very first time is an opportunity that few others have and, for that, I’m very lucky, indeed.

As there was a total of ten of us for this weekend (Joe and Sandy, me and Jill, Marissa, Megan, Gina, Leah, Jenn, and Evan) we wouldn’t be able to fit into a single vehicle and Leonard had arranged to have a Land Cruiser for us in addition to Turtle, a Land Rover. Interestingly, there are far more Land Cruisers being used today by safari companies than Land Rovers, but that was not always the case. As Tanzania had been a British Protectorate until its independence in 1961, the classic safari vehicle in East Africa had also been the Land Rover, driven also by Queen Elizabeth. Over the years, though, Tanzania’s economy became more and more aligned with Asia, partially driven by the Chinese building of the railway stretching across Tanzania from the coast to Lake Tanganyika. With that, more and more vehicles began coming from the east, including the Land Cruiser, other Toyota vehicles, and the Chinese motorcycles, which massively dominate the market there now.

Our Land Cruiser would be piloted by Beatus, a seasoned guide, and the Land Rover by Joram, who had taken it to the Crater the prior weekend. Thankfully, I had purchased walkie talkies to use for communication between the two vehicles, something I hadn’t really used in the past, but came in handy when I was driving the second vehicle last weekend as, that way, you wouldn’t have to guess what the intension was of the other vehicle. We left FAME shortly after 8 am and were on our way to the Ngorongoro Conservation Area gate as we would be driving around the crater on our way to the Serengeti. The highway that runs through Karatu and then up to the gate where the tarmac ends, happens to be the main highway across Tanzania to Lake Victoria in the northwest corner of the country. Large trucks and buses ply this route on a regular basis bringing goods and passengers to the other side of the country.

Several years ago, there was a plan to pave the entire highway across the park, but there was a huge environmental uproar (appropriately so) raising concern for how this would very likely affect the great migration of the zebra and wildebeest negatively. Though I am not certain there is a huge reluctance for foreign travelers to drive this route (essentially the only one on the ground), paving the highway could open up this very natural place to more visitors and more revenue, not to mention the savings on fuel and wear on the vehicles if the road was paved. Seronera (Central Serengeti) has a very nice airport, as well as many other airstrips throughout the park, so any guests not wishing to travel the very bumpy and dusty road can always just fly into the park. To me, that would be missing much of the mystique and beauty that makes this place so unique, but to each his own. In the end, nature won out and the government finally backed down on their plans to pave the route and all was good again in the world. Unfortunately, the NCAA (Ngorongoro Conservation Area Administration) still remains embroiled in controversary with the issue of the growing number of Maasai, a topic that I’ve already discussed earlier.

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Once through the Loduare Gate and into the NCA, our trip took us back around the crater on the same road we drove last weekend, until we reached the descent road as we were now heading down onto the part of the Serengeti plain that exists in the NCA and contains Olduvai Gorge, the most important anthropological site in the world, our first stop on the trip. Olduvai Gorge, or, spelled correctly, Oldupai Gorge is where Louis and Mary Leakey began their work looking for early hominid fossils in 1931, and were eventually successful in 1959. At that time, Mary Leakey discovered Zinjanthropus, later classified as Australopithecus bosei, and finally Paranthropus bosei. It had a very robust jaw and huge attachments for its temporalis muscles, so it was nicknamed “Nutcracker Man.” Zinj was the first huge discovery of many more to follow at Oldupai and the site where she made that first discovery has a memorial where you can visit (and we did) down in the gorge itself.

On one of my earlier visits to the gorge (I have made this pilgrimage many times), I met Professor Masaki, one of the directors who has now been there for many years. Masaki has given each of my groups a wonderful introduction to the history of the gorge, as well as the fact that it was misspelled by the first European to have discovered the vast number of animal fossils here. Oldupai is the Maasai name for the sisal plant that is found in abundance here and is what gave the name to the gorge, but unfortunately, after the first publication of the incorrect name, it has been known by this since its 1913 discovery despite the effort by many to correct the mistake.

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Sitting in the amphitheater, looking out over the immensity of the gorge, it is difficult to imagine how the Leakey’s chose which sites to excavate first, though it did take them 28 years to finally discover Zinj, so it must not have been easy. Oldupai Gorge was the home for the Leakeys until Louis’s death in 1971, though Mary stayed on until 1984, eventually passing away in Nairobi in 1986. Their camp, which still exists is now a living museum and can be visited by the public. I had been fortunate enough to have visited their camp with Prof. Masaki, long before it was open to the public, and it was clearly a spiritual moment. In one of the buildings that housed the non-hominid fossils, Masaki pulled out a mammoth tusk to show me that was several million years old and perfectly intact. Having studied physical anthropology while in college in the mid 70s, it had never entered my mind that I would visit such a place, let alone see things that were not open to the public.

Leaving Oldupai after a wonderful visit to the museum there, we drove into the gorge, first visiting the Zinj site, and then heading up the other side and across the plains to Shifting Sands. Shifting Sands is sacred site for the Maasai as it was formed from volcanic sand spewed during an eruption of Ol’ Doinyo Lengai, or Mountain of God. Thousands of years ago, during an eruption of Ol’ Doinyo Lengai, enough black sand was thrown out onto the plains and, due to its high iron content and being heavily magnetized, it has stuck together as it being blown in one direct across the landscape, moving 3-5 meters a year. The natural geometric shape of the sand is a large pile with crescent shaped leading edge, engulfing any vegetation that is in its way.

Once finished admiring this natural phenomenon, Jill and I hiked the short distance around the front side to look at the markers designating its location during prior years, and then loaded into our vehicle as we began our drive on a trail that parallels the main road for some distance until they finally intersect just before crossing into the Serengeti Park. The trail is essentially two tire tracks that make their way across the dusty landscape with frequent herds of both domestic and wild animals. Once on the main road, we were to Naabi Gate, the true entrance to the park, in no time and quickly found a table for our lunch. Entrance to the Serengeti is per 24-hour period, so it is best to eat you lunch before passing through the gate, while the NCA considers their entrance fee per 24 hours from midnight to midnight. Coordinating these timing differences is a bit of an art, but second nature once you’ve done it a few times, or, better yet, once you don’t pay attention and get stuck paying an additional fee.

From high on Naabi Hill, you have a tremendous view looking north over the Serengeti plain and get your first glimpse of the meaning of the Maasai word, “Serenget,” meaning “Endless Plain.” In actuality, were you to hike the short distance to the top of Naabi Hill, you would quickly have an even better perspective as you would have a 360° view of the flat plains stretching endlessly in all directions. Even this, though, does not give one the full impact of the Serengeti’s vastness. That can only be truly appreciated by driving though the park, where, after even hours upon hours, you hardly scratch the surface and, after you reach each new horizon, you realize there are an endless number of them beyond.

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The camp we were going to stay at for the next two days was in the northern part of the Central Serengeti, and only a short distance off the main road heading north towards the Mara River. On our drive, there were huge herds of wildebeest moving back and forth across the plain in search of better grasses. There were large numbers of calves, all running close to their mothers, and a light brown in color. The calves are easy prey for the cheetah and other predators as the wildebeest, despite their horns, does not defend itself in any manner, quite unlike the Cape Buffalo, which can easily kill a lion by goring it. The grasses are best here in the southern reaches of the Serengeti where they are found in their greatest concentrations in March and April. The classic images of the large herds crossing the Mara River in the north occur during the dry months of August into September as they are moving north to the Masa Mara in Kenya, where they will spend the new year, once again calving and then traveling back south to complete the greatest land migration on earth that has gone on for thousands of years.

We finally reached our camp, Serengeti Acacia Bliss, well before sunset, which is an anomaly as we are normally feeling our way through the darkness trying to find our camp due to poor time management. Game drives at night are strictly forbidden in the Serengeti, and driving at night is only allowed for those who are traveling with a purpose such as getting back to your camp. Not only is it dangerous to drive at night, but it is also disturbing for the animals. Our camp was lovely and one of the nicest that I’ve stayed in over the 15 years of coming to the Serengeti on a regular basis. Their tents were luxurious with solid wood floors, a wonderful shower with hot water, an incredibly comfortable bed and linens, and, best of all, electricity and WiFi in every room that worked well. We were the only ones in camp that night, so had the entire place to ourselves. They started a bonfire before sunset, and we all sat around having drinks and relaxing from the long journey of the day. Having restorative hot showers before sitting down to enjoy the evening made everything quite tolerable.

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It was also a night for celebration as Megan had logged in to receive her match results, and she had matched at her number one choice – Mass General Child Neurology! She had wanted to go to Boston and will start there in June as a pediatric intern prior to pursuing her neurology training. Child neurology is essentially a five-year program with two years of pediatrics and three years of pediatric neurology. Dinner was delicious and the stars were fantastic, but it wasn’t long before everyone took to their tents and allowed the darkness to bring them to a quick slumber. There is nothing like sleeping in the Serengeti in a tented camp – it is cold here at night, but the comforter keeps you warm and the sounds of the animals makes you thankful that you’re protected in camp and not easy prey sleeping in the open.

Having traveled to Oldeani and the Rift Valley Children’s Village for the last two days, it was not time to focus once again on FAME. Today, we would be expecting a group of patients from the Tarangire region, an area that is well outside of the Karatu district but have been coming to see us now for several years. Exactly how this relationship began, I can’t exactly remember, but from a standpoint of having longitudinal care, which is really what our impact has been here, this group has been very good about continuing to come back to see us. The linchpin, though, has been Chief Lobulu, a lovely Maasai chief who has continued to seek out patients with neurologic illnesses among his villages for several years now, and has helped arrange for their transport to FAME as well. Though we have never fully worked out the logistics for this arrangement, as FAME is not in the practice of paying for patient’s transportation to Karatu, we have tried to work with Lobulu as closely as possibly to ensure that this very needy group is able to get to see us.

For perspective, the Tarangire region, which includes a fairly large game park, is about 1 ½ hours away from Karatu and is on the road to Dodoma after the turnoff that we make to head towards Lake Manyara, Karatu, and, eventually, Ngorongoro Crater and the Serengeti. The area is fairly dry and dusty and, though there is some farming, the land is mostly good for grazing animals, which is good for the Maasai. Chief Lobulu lives not far from the entrance to the game park, and we have visited him on several occasions as we used to go to Tarangire on one of the Sundays when the rotation was still four weeks. The area is a mix of traditional Maasai bomas and classic Bantu houses. Lobulu, with his boda boda, or motorcycle, will ride around to the various villages in his area looking for patients for us to see, and, when he comes, I will typically reimburse him for the cost of the fuel necessary for his roaming around the countryside in search of patients for us.

The patients he brings are all incredibly appropriate and have included lots of different epilepsies as well as other basic neurologic illnesses. Several years ago, he brought two older adolescent boys with Down syndrome to see us, neither of whom really suffered from any specific neurologic issue but was hoping that we had something to offer them. After we saw them, I discussed the issue more with Kitashu as I thought there might actually be something we could do to help. In 2019, when Marissa Anto first came to FAME with me as a resident, she wrote a short story about one of the children she had seen with Down syndrome (https://fameafrica.org/journal/2019/10/4/theres-no-word-for-downs-syndrome-in-my-language?rq=marissa) and the fact that it was difficult for the patient’s mother as Down syndrome was not something that was discussed here. It is a lovely piece, and I would encourage everyone to read it.

In the US, though there are no simple answers, and families with Down syndrome children still lack the type of support that is appropriate, the one area that we do already have support for is their education and the fact that these children remain in school until they are 21 years old, being taught life skills and other things that interest them. Unfortunately, in Tanzania, education is not guaranteed until the age of 18, as it is in the US. If you don’t pass the national exams after primary school here, then you do not continue with your education. Very short and simple. Finishing your education at age 13 is far different than at age 18 (or 21 in some situations) in regard to your level of maturity and the ability to go off on your own such that the likelihood of failure is far greater given that fact. What I was hoping to do for these two boys was to find some type of vocational rehab for them that would give them the hope of some sort of self-sufficiency in the future where they wouldn’t be a total burden on their family. Kitashu, who is relentless when it comes to searching out this type of information for anyone, but especially if they are Maasai and, even more so, if they are in need of help.

Kitashu was able to locate a rehabilitation center that was not far from the children’s home and, after a visit by the children, their families, and Chief Lobulu, was acceptable to everyone. All I had to do now was to raise enough money to send them to school for necessary 2-3 years to complete their vocational training. After setting up a GoFundMe page for the project, I was able to raise enough money for their tuition and living expenses. Amazingly, both the children were able to complete training, one as a tailor, and the other a welder, and are now back in their villages. Though I have been unable to visit with them since they’ve been back, and I’m unsure of whether or not they have been able to be employed, I do know that they do now have the skills that will ultimately help them. During his visit today, I did ask Chief Lobulu how the boys were doing, and it did seem they were well. With Kitashu’s help, I’m hopeful that I’ll soon learn more and even be able to visit with them soon.

We spent the day seeing the approximately 15 patients who had come together from Tarangire, many of whom were returns, though some who were here for the first time. The biggest problem we have with the group is how to supply them with the necessary medications given their distance from FAME. For most patients, they must return to FAME for their refills, but that has not been possible for this group of patients, and it was not uncommon for them to return reporting that they were well for several months after seeing us and until they ran out of their medication. Kitashu does his very best to send the medications to them when he is aware of what they need, and though this has made a difference, there are still occasions where it has not happened as we would have wished. We continue to subsidize some of the cost associated with the medications, but even that is often not enough. There is still room for much improvement, and we will continue working with Chief Lobulu to help with these patients he continues to bring to us who are in need of neurologic care.

One the things I haven’t mentioned in some time, if ever, is the logistics of seeing our outpatients here. When patients come in to be seen, their history is taken, they are examined, and then we discuss what our differential is and what testing, if any, is necessary before developing a treatment plan. This will often involve basic laboratory tests, some of which we don’t really consider in the US. Checking a sputum for AFB staining (i.e. tuberculosis), is a special circumstance and something we don’t do often in the outpatient neurology setting. On the other hand, testing for malaria and brucellosis are things that are common here and can often present with neurologic manifestations. The point is, though, that patients are sent to the lab for blood and urine studies and then wait until the results have returned, usually within an hour or two, to be seen again to review the results and before any medication prescriptions are given. This is obviously something that would never happen at home unless you were in the emergency room. Because of this, patient visits often last several hours or the better part of a day. One of the patients whose labs we had checked today was from Tarangire, and she unfortunately left for home prior to us being able to review her results with her so Kitashu will need to call her next week to let her know. At times, if labs are checked very late in the day, a patient may leave and return in the morning for the results, though that wasn’t possible for someone from Tarangire.

We were all heading to Gibb’s Farm tonight for dinner which would be two nights in row for Jill and me. Our safari guide, Joram, had come to pick up Turtle, as we were planning to take it tomorrow to the Serengeti, so we were down to Myrtle for our trip up the mountain to Gibb’s, and there were eight of us going to meet Joe and Sandy, and, with Annie, who was also coming, that made nine. Everyone was dressed up for a nice dinner and Myrtle will see five comfortable but does have two benches facing each other in the back storage area. Referring to them as comfortable would not be accurate, though they are certainly more comfortable than crouching in the back. So once everyone was packed into Myrtle, with the four in the very back (Jenn, Leah, Gina, and Megan – the “youngin’s”), we were on our way back to paradise.

After parking and beginning our walk up to the main building, we ran into the Iraqw choir who had just finished their poolside singing that happens for guests several times a week and were walking back to home. When they saw Annie, who knows most of them, they stopped immediately, lined up, and began an impromptu performance for all of us, all standing across from each other on the little path to reception. Though I’m sure it was mostly because Annie was there, I do believe they were also aware of who we were and were honoring us with their lovely serenade for the work we’re doing at FAME. Everyone was touched by the moment.

I had wanted more than anything at the moment to once again jump in the pool to get the day’s grime off of me. I dropped everyone on the veranda and promptly walked to the pool to drop my things, and then to the bathroom to change into my suit. Though I could hear the rumbles of thunder in the distance, there was nothing overhead to worry about, so I sat floating in the cool water with that magnificent landscape of Karatu in the foreground and the remainder of the vista looking out towards the rolling hills of the Lake Eyasi region in the distance. In that moment, the troubles of the world and our country seemed so very distant to me. All I could feel was serenity.

We were seated at the same table as last night, though extended now to seat 11 of us with Joe and Sandy. Dinner started outside, but as it began to rain, they moved us inside without missing a beat. The heavens opened up, though we hardly had a worry, sitting comfortably and sharing stories about the group. When it was time to head out, we borrowed umbrellas for the walk down to the parking lot, then loaded back into Myrtle, and began our drive home. That most often dry and dusty red clay of Karatu turns to slime with the slightest of moisture and when it rains hard, it becomes so incredibly slippery. Driving downhill, even with the all-time four-wheel drive of the Land Rover, the rear end still loves to slide around without notice so you must take your time and proceed cautiously. Once on the tarmac, everyone began to breathe again, and life was good.

We had planned to spend a second day at RVCV and were once again looking forward to the African Massage Road, though we certainly would not be taking the scenic route home this afternoon. Early on, FAME had provided a full medical clinic at RVCV every two weeks for one or two days to prevent having to bring the patients over to FAME, though perhaps four or five years ago, that was discontinued. It had turned out that patients from outside the Oldeani village were traveling to attend the clinic which was not at all the intention, and it would be less expensive and more able to be controlled if the patients were first seen at the RVCV clinic and then, if needed, were referred to FAME for further care. In this manner, they were better able to provide care for people from Oldeani, and that their community was healthier.

Neurology had originally traveled with the mobile clinics to RVCV, though, when they were discontinued, it merely meant that we would go over there on our own and that has been the model ever since. Every six months, we spend two days at RVCV seeing not only India’s children, but also those children and adults from Oldeani who are in need of neurological care. RVCV had always employed a nurse or nurse practitioner from the US to provide care through their local clinic that was very small and had only a few rooms. Patient charts were kept there, and they would contact patients in need of follow up in advance of our arriving to see patients.

Africanus was the first Tanzanian clinician (he is a clinical officer) to be hired for the job at RVCV, and this trend of hiring Tanzanians was also something occurring at FAME. Though we have always had a full Tanzanian staff at FAME in regard to the clinical staff, our volunteer coordinator and social media director positions had always been held by westerners, though several years ago with the hiring of Prosper as the volunteer coordinator and Sue as our social media director, FAME had also moved in the direction of hiring Tanzanians and we haven’t looked back.

Africanus has really done an amazing job with the health center at Rift Valley as it is now a beautiful facility that really leaves nothing to be desired from our standpoint. At most of our mobile clinics, we are scrounging for tables and chairs and places to put them, and not finding them. Here, we had four lovely consultation rooms with enough tables and chairs for everyone, including Marissa and myself in the back where we were staffing patients. Last year and the year prior, I donated tables, chairs, and even benches for the patients, to the clinics at Barazani and Mbuga Nyekundu as trying to find these items always seemed like it took half a day, and we were often unsuccessful. Having furniture to see patients is not an absolute necessity but does make things a bit easier. In the village of Upper Kitete, where we no longer go, we would see patients in the nurse’s office sitting on a stool with the patient on a bed, while in the labor and delivery room, we would just use the two available beds.

In the early days of our mobile clinic, around 2011, Paula and Amir had taken me to make house calls to some patients who were unable to make it to the villages. In those situations, we would see patients wherever it was practical, and it always seemed to work out somehow. Being creative in these situations, or to be honest, in Africa, is a necessity if one is to ever get things done or be successful in ay way. I believe this falls under the heading of “TIA” – This is Africa – which Frank taught me to use on a daily basis when encountering any of these situations.

On arrival to the clinic, following our drive on the African Massage Road, there were already patients waiting for us on the shaded benches out front, though everyone needed to caffeinate a bit first and headed for the kitchen. We had gotten there a few minutes earlier than we had yesterday, so there was no concern about the time. With everyone back at clinic, though, it was time to get down to business and to begin seeing patients. Joe had decided to spend another day relaxing at Gibb’s, and you could certainly not blame him for wanting to do so. We had worked hard last week with many patients and, given that he and his wife, Sandy, were staying at Gibb’s as there was no room at FAME (how sad for them), it was not surprising that he wanted to take advantage of the activities there. Gibb’s Farm is one of, if not the oldest, lodges here in Northern Tanzania and is truly an amazing place.

I don’t think there was anything surprising in clinic for us today, though one of the residents had a patient who had suffered from Pott disease a number of years ago, with significant vertebral collapse, but, thankfully, was not paraplegic as most patients with this condition are. Specifically, Pott disease is tuberculosis of the spine, or tuberculous spondylitis, and causes collapse of the vertebrae and spinal cord compression. The thoracic spine is most commonly involved with the lumbar and cervical levels following. This extrapulmonary manifestation of TB does not present acutely but takes time to develop such that patients will usually present with back pain, often without neurologic manifestations initially. Patients presenting with the complaint of back pain and a history of TB, therefore, must be more fully evaluated out of concern for vertebral osteomyelitis.

Several years ago, just after I had left FAME for the Serengeti, a young patient presented with back pain and lower extremity weakness that had just begun and on examination, was myelopathic. With a few WhatsApp messages, I diagnosed Pott disease and told them to obtain a CT of her thoracic spine based on a lack of upper extremity signs and, indeed, she had erosion of her T5 vertebrae and compression of her spinal cord. She was referred immediately to KCMC for orthopedic surgery due to her compression, though I don’t believe she ended up doing well in the end which was very unfortunate.

For those that know me, it’s not very surprising that I’m going to once again mention the meals at RVCV, but today’s lunch was once again delicious – homemade bread, chicken salad, tuna salad, fruit salad, and a green salad with some incredible cookies for dessert. Once again, our Tanzanian support staff, except for Dr. Anne, had decided to eat something more palatable for them.

Once finished with our clinic, the residents went over to the small duka (store) next door to the clinic to look at handiwork from the Rift Valley Women’s Group to look for things that might interest them. I have purchased lovely items from the shop over the many years that I’ve been coming to RVCV and have given many of the items away as gifts, though some of the original pieces I purchased have remained in my home and remind me of this very special place every time I see them on my shelves.

We were eventually on our way home and there wasn’t any question whatsoever that I would NOT be taking my shortcut through the fields again, which came not only from me, though had I even thought of going there again I think there would have been a mutiny by the rest of the team. Yesterday’s drive was one of the more hairier drives I’ve taken anywhere, and, considering how long I’ve been driving here in East Africa, along with the fact that I used to drive a Forest Service fire truck off road in the High Sierra, that’s saying just a bit.

For the evening, the residents had very much wanted to go to the new Lilac Oasis on the outskirts of town as, even though it wasn’t yet fully open, they had told us they would be happy to have us for dinner some evening. It’s a beautiful new facility that, when it is fully completed, will have a spa and swimming pool, as well as a bar and restaurant. When I first came to Karatu in 2010, Nicky was working as the manager of the Happy Days restaurant, but soon after opened the Lilac Café at FAME, and now has numerous hospitality businesses throughout Karatu including being a partner in the Black Rhino International Academy where Jill is working.

Jill and I had decided to skip the Oasis and let the residents have an evening off from being supervised by me and, instead, since Jill was already visiting with Joe and Sandy at Gibb’s, we decided to have dinner there. After dropping everyone off at the Oasis, I decided to take advantage of the amazing pool at Gibb’s Farm – the water had a chill, but it was perfect for the warm day and incredibly refreshing. The view from the pool is the same as from the veranda and looks out to the west in the direction of FAME. Looking out over the edge of an infinity pool with the mountains and the sky in the distance and the sun beginning to set, it’s just magnificent and there is very little that can match that combination.

Dinner at Gibb’s is also a total experience, and even though we had planned to come back tomorrow night with everyone, it was a lovely affair. Having been working in Karatu for the last 14 years, I have come to know many of the staff at Gibb’s Farm and it is always a reunion returning there. Jill and I arrived home around 9 pm to an otherwise mostly quiet house thinking for sure that the residents were still out at the Oasis. We were up for a bit listening for their return, though never heard it, but figured that they were grown up adults and could care for themselves. As Joe had a 7:30 am lecture in the morning, we were up early, and I was surprised to find Megan up and preparing her breakfast as I had assumed she had come home late and was even further surprised to learn that had all arrive home before us last night and had all gone to bed. Some things never cease to amaze you.

The Rift Valley Children’s Village (RVCV) is an institution in the Karatu district and Northern Tanzania and is one of the main reasons that FAME is located where it is. After Frank and Susan came back to Tanzania with the intention of creating a health center, it was through Mama India’s, suggestions that FAME be located in a place of great need, close to her Children’s Village, and, even better, on the safari circuit so that any visitors to the area could be cared for by the center. Karatu fit the bill perfectly as it sits immediately adjacent to the Ngorongoro Conservation Area, the home of over 100,000 Maasai in great need of medical care and is only 45 minutes from the Children’s Village that India had founded near Oldeani that was also in need of medical care for its children and the residents of the nearby village. The fact that it was also on the “northern safari circuit” was very important not only to provide care to tourists traveling to the Serengeti, but also for exposure to many tourists who come to visit FAME and are interested in assisting with support. Many of the current volunteers, including myself, first visited FAME while on vacation just to see the facility.

India Howell had come to Tanzania originally with the tourist industry over twenty years ago, but quickly realized the incredible need for support of young children who were either homeless or were unable to be cared for by their families due to poverty. After taking in several children, it became apparent to her that creating a children’s village, rather than an orphanage, was what she would do, such that the children would have their own home rather than waiting for, or fearing, adoption. The Rift Valley Children’s Village has become a true home for these children, numbering greater than 100, all of whom have been adopted by India and her business partner, Peter. The children are raised and go to school either in the village or next door at the primary school, eventually going to secondary school in the nearby village of Oldeani, and then finally to college all over the country. Regardless of where they go, though, Rift Valley Children’s Village will be there home forever, and they can always return here during school breaks.

In addition to the Children’s Village, The Tanzanian Children’s Fund (TCF), which is the overseeing non-profit, also funds several other initiatives that are more than amazing. They have been working for several years with the women in the area creating microfinance opportunities and cooperative groups to empower women to generate income for their family through various crafts such as sewing and beadwork. They have also worked in cooperation with the local village in providing lunches for the schools to prevent children from having to walk long distances home at lunch with the risk of not returning for the afternoon session. More recently, they have also joined forces to help finance dorms at the secondary schools, initially for women to prevent predatory attacks while walking to and from school, but also now for boys. Lastly, the TCF has funded healthcare not only for the children residing in the Children’s Village, but also for the entire community as it was recognized very early that for India’s children to remain health, the community and the other children in school needed to be healthier as well. Today, we will be working in the new health center that was built by the TCF for this very reason. And Africanus, the clinical officer who had originally worked with our neuro clinic and then with FAME, now overseas all the healthcare for the broad swath of the community.

The route to RVCV is a gorgeous one that travels out of Karatu on the tarmac in the direction of the crater, but then leaves the hardtop in favor of the traditional dirt road that is interrupted frequently by large humps that are used to divert water from the road when there are intense downpours and to prevent the road from washing away. As you make the turn from a tarmac, there is a sign (somewhat blocked now from the high brush) that foretells what everyone is about to experience. “The African Massage Road” is a fairly accurate representation of the remainder of the trip to RVCV. What the road lacks in comfort, though, it makes up for in sheer beauty. Turtle is packed full of the neuro group plus Dr. Anne and one of our interpreters, all of whom tolerated the ride, though I must admit that it was eerily silent in the car for most the journey. What they didn’t know at the time, though, was that this drive was to be tremendously less bumpy than our return home.

Driving up to the RVCV, one would think they have arrived at Shangri-La, as that is pretty much what this place is to those who live here and those who visit. There is an immediate sense of wellness and safety as you drive through the gate and even more so getting out of your vehicle and walking through administration. The old health clinic occupied one hallway of the open administration building, but there is now a brand-new health center that is just outside the children’s village and on the grounds next door. The health center is one of the nicest we’ll work in and was designed to provide room for clinics such as ours as there are four offices for the residents to work in, another office for registration, and another to set up our pharmacy. In the back, there is a small room with a desk that Marissa and I can sit at while staffing the residents for their patients. It is the perfect clinical space for us.

Patients have come from the surrounding community of Oldeani and have been mostly triaged by Africanus, so there are few patients here with non-neurologic disorders, though, not surprisingly, a few patients with back pain and joint pain will always make it into clinic as it often very difficult to sort that out until you’re taking their history.  There were a number of children, which makes Marissa and Gina very happy, as well as Megan, who is planning to go into child neurology. As expected, headache and epilepsy make up most patients, though numbness and tingling seem to make up a close third. None of the patients are as sick as those we saw yesterday in Kambi ya Simba.

Before we know it, it’s lunchtime, which is one of the highlights of coming to RVCV. There is a large volunteer staff there and they are well taken care of in a much different fashion as at FAME where everyone, volunteers, and employees alike, eat lunch together and have the same menu. Here, volunteers eat meals that are as close to what we eat at home as possible – we had pizza, salad, and fruit salad today – all were equally delicious. I haven’t had salad in sometime, so that was a real treat. Most of our Tanzanian staff, other than Dr. Anne, have chosen to eat a more traditional African lunch that is served elsewhere. I remember the first time I visited with other volunteers and was somewhat uncomfortable with the Tanzanian staff eating elsewhere, but then came to realize that it was their choice and not in any way discriminatory as they preferred to eat food that was more familiar to them.

After lunch, it was time to continue working with our patients and making it through the charts that had been stacked in piles of pediatrics and adults. Though our residents, whether adult or pediatric neurology, are trained and willing to evaluate both children and adults during their residency, they are far more comfortable sticking within their specialties, and it is no different here. I will say, though, that dealing with hypoxic-ischemic neonates is not something any adult neurologist would feel comfortable with, and for this reason, I am so glad that we have had child neurology residents with every group since last fall, and hopefully, that will continue to be the case. When it comes to evaluating neonates or very young infants, they are invaluable.

We finished a little bit later than anticipated (which is often the case, so I don’t know why we don’t anticipate it more) and headed back in the direction of Karatu. There is a lovely road that I usually take going home as it is different than the one, we came in on and has fantastic views of the crater wall beyond near endless field of crops. I have taken this road countless times and have never had any difficulty on it, though today was not to be the same. Between the recent rains (prior to our arrival) and the fields having been recently plowed and, along with it, some of the road (basically two tire tracks), the driving was completely treacherous and not for the feint of heart. There were huge holes in the road, water diversion trenches that had been cut, and between the two tire tracks of a road, the grass was super high as there had been little traffic through there in some time. Meanwhile, the width of the trail, as far as the brush lining both sides, was much narrower than my vehicle for most of the drive adding to the excitement.

Then there was the steep descent into a deep valley and an ascent up the other side. I will often shift in low range for the descent, though didn’t need to do so this time, though on the other side, while ascending, it became a must as the road was heavily rutted and having to slow down for the bumps to avoid a mutiny by those sitting in the back seat, losing my momentum on the climb necessitated having it in low range for the climb. Even with that, I could feel the tires losing grip on several occasions, though, thankfully, Turtle performed marvelously, and we successfully made it up the hill. There were still some difficult rutted portions of the remaining drive, though the end was in sight as we could see vehicles zooming past on the tarmac. Once I reached the main road, there was a resounding round of applause by all the passengers, though little did they know that I was breathing a huge sigh of relief myself that we did not get stuck along the way as the other vehicle had taken the normal route home and we would have been entirely stranded.

We had rescheduled our visit with Teddy for tonight, so after arriving home, everyone cleaned up and we loaded back into Turtle again to head across town to her shop. Visiting Teddy has become a highlight of our trips to Tanzania as having clothing made from the wonderfully colorful cloth here is a real treat for nearly all the residents. Normally, I will take a chair and sit on Teddy’s porch with my computer, working on my blog, but tonight, the residents were incredibly efficient, and they were finished before I knew it.

The very neurology mobile clinic that we held was in April 2011, my second trip to FAME. I had gone on the larger FAME mobile clinic to the Lake Eyasi region that was a huge affair as we spent the entire week in the bush, and it was not a specialty clinic, but rather it was general medicine. We would take the FAME all-wheel drive bus that carried our supplies, a few passengers, and on-site it would double as a lab if there was no space else at the facility we were using at the various locations. Patients would travel for days to get to us, and they would form long lines to be registered and given a number. Paula Gremley and her partner Amir were two individuals that were integral to the operation as they would do a lot of the outreach prior to our traveling, and they would also help with all the necessary food arrangements as it was a huge group with all the doctors, nurses, and support staff.

Paula and Amir also ran their own non-profit and it was on this second trip that Paula approached me about going to a few villages in the Mbulumbulu region to see and evaluate patients with neurologic illnesses that she thought was very important. Our team was very small back then and was comprised only of Amir and Paula, me, one clinical officer, and a nurse/pharmacist. The very first location we traveled to was Kambi ya Simba (Lion’s Camp), a village in the Mbulumbulu region of the Karatu District where there was no health center at the time and our clinic was held outdoors out of necessity. Patients sat on a long log in the order they were to be seen and I had a small desk set up in an open area where I would evaluate the patients. Our nurse had a table set up a short distance away and patients would take the scripts I had written up to her so that she could dispense the medications and answer any questions they might have.

Over the years with the development of our neurology global health program, these mobile clinics have become much larger and involved, as we now bring multiple teams of neurologists and travel to multiple sites throughout the Karatu district to deliver neurologic care to those patients unaware of treatments that might benefit them or are unable to get to FAME unless they were sure it was for something worthwhile that they would benefit from. Paula had selected the Mbulumbulu region to begin our mobile clinics based on the need in this region and its proximity to FAME as patients would need to travel to FAME at times for lab work and refills.

That very first clinic was incredibly memorable for many reasons, and I have continued to Travel to Kambi ya Simba every six months for the last 14 years. Probably six or so years ago, the government decided to build a very large health center there, expanding the services available on location, and we now see patients in one of the several buildings on campus, though we still have lots of trouble finding adequate chairs and tables for the room, though this is an issue at every clinic site that we travel to. In addition to Kambi ya Simba in the Mbulumbulu region, we had previously traveled even further out along the escarpment to the village of Upper Kitete, which had been extremely busy at times, though when streamlining our clinic schedule, the village was dropped, and patients were recommended to travel to the nearby Kambi ya Simba clinic instead.

Departing Karatu this morning took a bit of doing given all the logistics. We had the flat on Turtle in Ngorongoro and that tire needed to be replaced, though we would have to travel without the spare for today as we couldn’t get the new tire until tomorrow. That was actually OK since we had a good spare on Myrtle and having flats on both vehicles would be pretty unlikely, and very bad luck if it did occur. For the mobile clinics, we bring all the necessary medications with us along with all the translators, social worker, nurse, and driver for the other vehicle. We finally made it downtown to drop off the flat and get our box lunches and we were off. The road to Kambi ya Simba, which can be very gnarly at times, was nice and smooth (at least for Tanzania) as it had been recently graded. The drive is gorgeous as we travel through lush and fertile valleys with lots of different crops growing along with those tending the fields. The sky was bright and clear.

Arriving to the health center at Kambi ya Simba, there were few patients to be seen initially, but as the day went on, the number of patients continued to build so that by the end we had seen 30 patients which is a good number given we only had three residents to see them. The problem we ran into, though, was that the patients who came later and to be seen later, were the sickest of the bunch, requiring more extensive care. The morning went quickly and before long it was lunchtime, which is always eaten in our vehicle as it would be rude for us to eat in front of our patients given the fact most of them probably did not have enough food at home. That’s a practice I learned very early in my time here and have continued to practice religiously as I believe it to be very true. During our first visit to Kambi ya Simba, though, we were given lunch by the villagers, and I remember fondly sitting down with the villagers for a local meal of chicken stew. It was quite an honor. With the size of our contingent these days, feeding us is no longer a viable proposition for the villagers.

Many of the early patients were those with headaches (kichwa) or the “numb and tinglies” (gonji). Headache is our number one diagnosis that we see here in our neuro clinics, and I suspect with a similar frequency as what we see at home. We treat it virtually the same as we do at home, albeit with far fewer imaging studies as it seems there is less anxiety here about something being really wrong. Tricyclic antidepressants have been the mainstay of headache preventive therapy for many years at home, and it is equally so here in Tanzania.

After lunch, more and more patients began to appear and the small grassy slope across from where I was sitting suddenly filled up with several children that were clearly dealing with static encephalopathies of varying severity as their parents (mostly mothers) were caring for them while they waited. At one point, an elderly gentleman sitting across from Joe, and I began to vomit, and it was quite obvious that he was having a seizure. His family was dealing with him, and though we wanted to get him in a room sooner than later, the rooms were already filled with patients so he would have to wait until we had a free room. He woke up after his seizure, which was good thing, but then proceeded to have another shortly after Leah began to evaluate him.

His wife informed us that he had a heavy alcohol history of at least 5 years but had stopped drinking about a week prior as he hadn’t felt well. Seizures seen in the setting of alcohol withdrawal typically occur within 48 hours of discontinuation of drinking, so this was a bit far out and, though not impossible, raised concern for some other process. Also, his seizures were clearly focal and alcohol withdrawal seizures are most often generalized, though again, focal seizures are possible. When there are several atypical features (the time course and focality of the seizures for this patient), it always makes us worry that we’re dealing with something else. Our recommendation to his family was that we bring him back to FAME with us to admit him for his alcohol withdrawal and to prevent further seizures. One problem was that we had run out of levetiracetam as we hadn’t brought enough with us today, so we didn’t have anything that we could load quickly. His family was not prepared for us to bring him to FAME, so instead, we gave him some carbamazepine (we were worried about using valproate without first having labs to check for alcoholic hepatitis) and hoped for the best. The family agreed to come to FAME on Thursday, so hopefully we will see him again.

Meanwhile, the children with the static encephalopathies and seizures were the last to be seen, and one of them was very likely in non-convulsive status epilepticus when we saw as the family said that he had been sick and less responsive for the last several days. Marissa and Jenn had evaluated him, and it was clear that he was not doing well and needed more aggressive care. Again, being out of levetiracetam was a real problem as we had nothing else that would act quickly enough, so Marissa crushed 3 mg of lorazepam tablets (a benzodiazepine), mixed in a bottle cap with water and delivered it to him orally with a syringe. It did seem to help somewhat, but the child definitely needed to come back with us to FAME to be admitted and further evaluated. We finished up with clinic and loaded he and his mother into the back of Myrtle.

Given the number of patients, clinic lasted much longer than we had anticipated, and it was almost 6 pm before we departed. The sun sets around 6:30 pm here and our drive is directly west heading home meaning that we would have the sun directly into our eyes for most of the drive home which a real problem navigating the narrow, windy, and dusty roads that we travel on here. Though all of us are more than happy to stay late working seeing amazing neurology cases, that is not particularly true for all the FAME staff that we’re working with, and I feel bad for them as they have families at home waiting for them. Joe was sitting in the front passenger seat as I was driving and there were times that the visibility from the dust was nearly zero. Between oncoming traffic and pedestrians walking on both sides of the road, there were one or two times that I had to come to a nearly complete stop as I couldn’t see a thing with the dust and the sun.

We arrived back to FAME and the young boy in status was taken to the ED where he spent the night as there were no beds in the ward for him that night. Marissa and Gina spent some time with the ED attending as we felt the boy needed antibiotics and antiviral agents (he was now febrile) as well as a lumbar puncture with concern for a CNS infectious process. He was also loaded on levetiracetam by nasogastric tube. I had to drive Joe up to Gibb’s Farm as he and Sandy were now bunking there (rough life, I know), and, by the time I returned, everyone was already back at the house eating dinner. Marissa was still unsettled with the boy’s presentation and treatment, so the two of us went up to the ED after dinner to check on him. There was a tourist there as well who had unfortunately fractured her femur while on vacation, so there was a bit going on at the time, but we were eventually able to help direct some of the child’s care with the help of Gina, who had also come up as we needed an ophthalmoscope in preparation for a lumbar puncture.

Also, Evan Rosenberg, our fourth resident, had arrived in Kilimanjaro this morning and to FAME shortly after noon. We would be incorporating him into our clinics beginning tomorrow and he would have an on-the-job orientation. It has been an incredibly long day, and it was not until late that our work was done. Everyone was a bit exhausted, and we had our mobile clinics beginning tomorrow at Rift Valley Children’s Village.

(Note: Many of the wildlife photos were taken by Gina Chang and Megan Shen)

I have been to Ngorongoro Crater over two dozen times, and it has never gotten old as each visit has been unique, whether it be the animals or the guests who I accompany. Ngorongoro Crater is a World Heritage Site and one of the jewels of the Tanzanian park system (the Serengeti and Kilimanjaro being the other two). It sits within the Ngorongoro Conservation Area, a dual use land that is occupied by the Maasai, who graze their cattle there, and the wild animals who share it with the Maasai and their cattle. There is currently a major political/environmental conflict in Tanzania that involves the NCA and the Maasai due to overcrowding and was very likely an inevitability. When the Serengeti became a national park in the early 1950s, it was necessary to relocate all the Maasai living there and by the end of the 1950s, the Ngorongoro Conservation Area was created with the intention that the Maasai and their cattle could exist there in harmony with the wildlife.

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When the NCA was created, there were 8000 Maasai living there. Currently, there are more than 110,000 Maasai living in the NCA with well over one million cattle and the government has proposed moving the majority of them to a new location in NE Tanzania in the Tanga district. This has come with much opposition from the Maasai and others, and the entire plan is currently in limbo so it is unclear what the next steps will be.

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For now, the NCA remains one of the most beautiful regions on earth and the crater is at the heart of the NCA. Together, they comprise some of the most ruggedly natural land I have ever seen and having explored a good portion of it, there is still much more to be seen. Ngorongoro Crater is actually a caldera, having been formed from a collapsed giant volcano several million years ago, leaving a 10 mile in diameter and 2000-foot-deep hole in the ground that is home to thousands of animals with no need to migrate as they have everything they need inside. Everything is there other than giraffes and Nile crocodiles and it is home to one of the densest concentrations of lions in all of Africa. What more could one hope for? Better yet, it is perfectly easy to navigate for a novice game driver such as myself as it is impossible to get lost in a giant hole in the ground.

Normally, I take our entire group on safari to the crater on the first Sunday (Safari Sunday), but given the number of people we have currently, it was necessary to have another guide travel from Arusha to drive the stretch Land Rover (Turtle), while Jill and I would take the short Land Rover (Myrtle) and tag along behind them. Though I have done this dozens of times, I thought it would be best, since we were hiring a guide, to have them with those who had not been on safari much so that they could hear things from a professional. Besides, I love driving Myrtle and it would give Jill and I some alone time among the animals.

The Crater and the Conservation Area have their own administration and their own rangers to protect the wildlife and to prevent any indiscretions from occurring that might damage the environment. Travel in and out of the NCA and the Crater is heavily restricted and the only way to the Serengeti by vehicle is through the NCA, so you can imagine the amount of travel through the Loduare Gate that leads to the NCA, the Crater, and on to the Serengeti.

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Driving up to the rim of the crater, over 2000 feet up, is a wonderful excursion as you feel as though you are traveling back to some primordial time, fully expecting a T-rex to come out from behind a tree at any moment. You travel up and up as the trees grow taller and taller trying to reach the sky from the bottom of the deep ravines rising to the rim. Finally reaching the rim, it’s a gorgeous day and, from the lookout overlooking the crater, everything sits before you like an illustrated map – Lake Magadi, the lunch area, the hippo pool, Lerai Forest – it feels as though you could reach out and touch them. It’s another 20 minutes or so driving around the rim road before you begin your descent to the bottom of the crater along a newly paved one-way descent road. From above, we could see a group of safari vehicles located just as the road reaches the bottom. The universal sign for a big cat, or a rhino, but there are no rhinos typically in this region of the crater, so it much be lions.

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Sure enough, reaching the bottom, a male and female lion, a mating pair, come walking along the road in our direction so there’s no need to maneuver our vehicles as they came to us. A mating pair of lions will usually leave the pride for 48-72 hours, mating every 30 minutes continuously during that time to best ensure that the female becomes pregnant. Minutes later, as we began to drive away, we ran across the male’s brother heading in their direction, but he stopped short and settled in the shade of some large dump trucks that had been left at the junction. He won’t interfere with his brother’s mating and will leave them alone for the time being.

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The crater floor was very, very green and there was plenty of water everywhere such that the grasses were very tall, and it was hard to see many of the smaller animals. Over the next several hours, we proceeded to see just about everything including one of the thirty black rhinos in the crater, though from afar. Black rhinos were, at one time, nearly extinct, but have been heavily protected from poaching and have a made a very successful comeback over the last years. They are spread throughout the Serengeti and Ngorongoro including a sanctuary just for them in the Serengeti. They are a spectacular animal and equally strange animal with a shy personality and terrible eyesight, relying almost exclusively on their hearing for protection, causing them to remain hidden when the wind is high. I’ve seen them close on several occasions, and they are a joy to watch.

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There were plenty of lions for us, though none seemed to be hunting, something that is seen more commonly at dawn, but that didn’t stop us from hoping. No cheetahs or leopards were seen and only a few hyenas, but there were plenty of Thompson and Grants gazelle, wildebeest, zebra, Cape buffalo, and eland. More than enough to make everyone happy. We did have one incident that involved cutting a tire on the Turtle, our stretch Land Rover, that Jarom changed quickly, and we were back on the road again. Though flat tires are not uncommon here, this one was unfortunate as it was a reasonably new tire and did not suffer a puncture, but rather the sidewall was sliced by a sharp rock meaning that it cannot be repaired and used again safely but will require a whole new tire. This would not be Africa if it were not for these challenges that seem to occur on every trip.

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It is not uncommon in the crater to have very localized heavy rain and we managed to find that later after lunch. We were on top of Table Mountain, a flat rise that has a wonderful panoramic view of the crater, watching the rain begin to fall and slowly move in our direction. We actually ended up driving into it on our way out of the crater and it was pretty intense, enough so that I discovered a very brisk leak where the roof met the body just at the front of the driver’s door. The water pretty poured in and despite holding a towel up to it, it became more than a nuisance until the rain finally stopped and we were back into the sunshine. Our plan, as it has been for the last 5+ years, was to stop at the Ngorongoro Crater Lodge to visit with my friend, Ladislaus, who is one of the camp managers there. For each group, he has graciously offered to host us for coffee or drinks at is one of the top lodges in all of Africa and is a real treat for the residents.

The Ngorongoro Crater Lodge began as a hunting lodge years ago before there was any projection in the Crater. It was later developed into a five-star lodge with cottages that are beyond description, all with views into the crater. There are three camps – two with twelve cottages each (North and South Camp) and one with six cottages (Tree camp further down the slope into the crater). Each camp has its own lodge where meals are served, and one can lounge. For as long as I’ve known him, Ladislaus has been offering for me to stay at the lodge, but I hadn’t taken him up on the offer until a year ago, when Jill and I were lucky enough to spend two nights there in total luxury. They operate on the British system of lodges, and each has its own butler who takes care of all the needs of their guests. When Jill and I had gone out walking one day, we returned to a drawn bubble bath and rose petals in the shape of a heart on the floor. That was only one of the unique things we experienced while staying there. The chef was amazing, and the food was unbelievable. Ladislaus is also their sommelier, so having his input on the wines we were drinking was extra special.

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Our group enjoyed a visit with Ladislaus as he told the story of his journey with the Crater Lodge and now to become their sommelier. We had coffee, tea, and cookies before they eventually took the group to see one of the cottages. It was a wonderful ending to our day in the Crater and we all loaded into the Land Rovers for the journey home. Normally, we’re rushing to make it through the gate by 6 pm when it closes, but today we were actually well ahead of schedule. We drove Joe and Sandy Berger up to Gibb’s Farm as they will be bunking there for the next week, and the rest of enjoyed a dinner at Lilac, which, as can be imagined, took the prerequisite hour after it was ordered. Thank goodness we’re in paradise, where time doesn’t exist.

We had finished a strong week of neurology at FAME, and it was time for our only Saturday clinic of this three-week block as we will be in the Serengeti next Saturday and the following one will be our changeover weekend with this group departing and the following group arriving. That’s good, as Saturdays tend to be slower on the whole. There is also no morning report on Saturday, or Sunday, for that matter, so we had an extra 30 minutes in the morning with clinic not starting until 8:30 – that gave plenty of time for Jenn and Leah to get to the Lilac for their morning coffee and for Gina to complete her run. I don’t recall for certain if Megan had gone with her or not, but regardless, it was an extra few minutes in which to get things done. With an invitation from Amanda, Jill had amazingly found a yoga class for the morning, instructed by the Black Rhino headmaster’s wife. So, everyone had someplace to be for the day and something very much to look forward to in the evening.

With our normal complement of residents and translators, but now with Marissa to also assist with the pediatric patients, and Joe was still here for the adult patients, there seemed to less for me to deal with throughout the day. It had also rained a bit throughout the night, which makes it more difficult for patients to travel to FAME on the muddy roads until they dry, often delaying everyone’s arrival. The red clay that is so ubiquitous here quickly turns to a sticky mud and coats virtually everything in sight, turning your shoes into 5 lbs. weights on your feet. Driving can be equally tenuous in the big rains of April into May where the red clay becomes more a slip and slide, though there was not enough rain last night as that situation takes at least several days of constant rainfall, and we haven’t had that yet. How the workers at FAME keep their shoes and clothes so clean as they show for work each day remains a mystery to me for it has not been my experience. I will routinely wear my mud boots from the house each morning when it’s raining, and bring a second pair of shoes to switch to once I am there.

Though the morning started slow, it was soon enough that we had patients showing up to be seen. With Marissa now here and her strong interest in headaches, she was very interested in gathering some data on those patients who might benefit from an occipital, or other types, of nerve block or trigger point injections. We have traditionally used bilateral greater and lesser occipital nerve blocks in patient who are felt to have occipital neuralgia, but it has become clear over the recent years that the occipital nerve blocks are often very effective for other types of headache such as chronic intractable migraine, especially when they are interspersed with Botox, as they definitely “cool” things off and provide at least some short term benefit. For several years now, I have brought along the necessary supplies for us to provide these injections and I have a suspicion that they may be perhaps even more effective here given how often women carry things on their head and how heavy the loads are. In building our maternity ward at FAME, I watched the workers carrying 5-gallon buckets of concrete on their heads.

It wasn’t long at all for Marissa to begin assisting with this procedure for patients to be evaluated for headache. As in the US, we frequently use tricyclic antidepressants for chronic headaches, whether migrainous or not, and have very good success with these older and very inexpensive medications such as amitriptyline and nortriptyline. When we’re seeing patients in the US for headache, in addition to deciding what our treatment options are, we are always trying to decide what “red flag” symptoms or signs the patient may have as a way of determining whether or not the patient needs to have an imaging study of their brain, either an MRI or a CT of the brain. The threshold, though, must be much higher here for several reasons, not the least of which is that virtually all our patients do not have insurance and are paying out of pocket for their care. Additionally, practicing in a low resource setting means that access to imaging for most patients is very limited. The closest MRI scanner is two hours away and is also very expensive for most. Though we have a CT scanner at FAME, providing these services not only has a cost associated, but must also be priced similarly to other facilities in the local region to prevent patients not under our care from traveling to FAME just to obtain their CT scan.

So, deciding whether to recommend a CT scan to a patient can have significant ramifications. Labs and medications are bundled into their neurology visit, along with the cost of the visit itself, though they are subsidized by FAME, so there is a cost to someone. Radiology studies, including CT scans, are not covered, and are therefore borne by the patient and family. In the same fashion as my earlier discussion about unintended consequences, if we feel strongly that a patient requires a scan and they are unable to afford it even after a discussion with our social worked, then, and only then, will we have a more lengthy internal discussion regarding what type of resources we have that might be used to help with the cost of the scan. Never once will the patient be told that their mzungu doctor is helping with the cost of the scan.

This situation arises on a regular basis and though it certainly places greater pressure on the clinician regarding determining what studies to obtain or not, it is appropriate and something that has long been called for in the United States, where the cost of healthcare at its present state is unsustainable. Though I am certainly not in support of patients being unable to obtain studies due their cost to them privately, having some form of a nationalized base health insurance for all those in the US is an absolute must going forward, coupled with the option for those with the ability to pay additionally to have further benefits (a two-tiered system). IMHO.

I had hoped we’d get home very early from clinic so we could leave for shopping at the African Galleria as we had planned, but unfortunately, we had several more complicated patients show up at the end, so we were pushing our window to leave. I arrived back to the house with the others and went into my room to change. On stepping out the door, it turned out that they had planned to wish me a happy birthday (it was my 68^th today) and present me not only with a very nice cake, but also, Mary Ann had made some banana bread that was delicious. As we were heading to the Galleria for dinner, we decided to forgo eating the cake, but did sample the banana bread (one of my favorites, though I have many). I was finally able to corral everyone into our vehicle and we began our short journey to the Galleria.

We had planned to have dinner at the African Galleria tonight as we are on our own for dinners on the weekend nights and, besides, it was my birthday today! The African Galleria is difficult to describe as a souvenir shop as it also has lots of artwork, antiques, and gems in addition to the items one would normally pick up on a trip to another country. It is a pretty amazing place that I’ve seen grow from very little since I’ve been coming to Tanzania and, several years ago (4 to be entirely accurate as it was just at the beginning of the pandemic), they built an incredible open-air restaurant that serves some of the most delicious food here in Tanzania. The founders, Nish Dodhia and his brother, Punit, were raised in Mombasa, Kenya, but have lived in Tanzania for a number of years, so the food at Ol’ Mesera restaurant is a blend of East African Cuisine.

The menu for the Ol’ Mesera also includes several very yummy drinks, though my favorite is the Dawa, which means medicine in Swahili, and they make it with local gin, honey, tonic water, lime, and diced cucumber, served with a muddling stick. One of my favorite foods is the Zanzibar Mboga Mboga soup, which is an amazing pumpkin, coconut, ginger soup that I just love. Two other favorites are the cheese samosas and the grilled paneer and beetroot skewers. Putting this together with their chicken mishkaki (grilled skewers), nyama choma (barbecued short rib), mchicha (spinach), pilau, grilled corn, and many, many other amazing dishes, it is always a wonderful culinary adventure going there.

We traveled home early enough for the residents to make our lunches for our safari in the Ngorongoro Crater tomorrow while I took care of getting our camera equipment together. We had picked up our safari guide, Joram, in town so he could drive us home and then take the stretch Land Rover back into town to fix an ignition problem we were having with it. It was starting only intermittently and, when it didn’t, it required a push to pop the clutch which, thankfully, worked quite well.

Being as isolated as we are here in Tanzania, that is, no television, and even more importantly, no MSNBC, can be a bit disorienting at times. It’s so easy to come over here and completely forget all the troubles of the world, focusing only on what is right in front of you. The rest of the world can seem so very distant when you wake up to the sounds of the morning dove and other local birds and realize that your local commute to work will be a five-minute walk to our outdoor covered clinic. Sure, the economic situation here is not rosy by any means, and it’s often difficult for patients to afford their medications here as it is at home, but people are happy and lead their lives as they have done for many years before we were here. There is a completely different pace to life and there are certainly benefits that come with that. People are happy and pleasant and that is worth embracing.

At the end of morning report, we learned from Pete that it was International Women’s Day, a day to thank all those women who have made a difference in your life as well as in the lives of others. Here at FAME, there are women who work every day in every capacity to improve the lives of those we see who have come to FAME to seek help. The necessities of life that we all take for granted at home, such as food, healthcare, safety, or numerous other things, are not so readily available to everyone here in East Africa, and mothers here will often travel days by foot to bring their children to a health clinic where they may receive care. FAME’s catchment area of 2.9 million occupies much of Northern Tanzania and it is not uncommon for patients to travel large distances to reach us to receive much needed care.

For myself, I could not help but think of my mother on this International Women’s Day, for it is because of her that I am here in the first place. I’ve previously written an homage to her on this site, but on this day, I cannot help but write again about the significance she held in forming those things that were most important to me. She was an adventurous woman who, from my earliest memories, sought to take the path less traveled so as to explore what was less familiar, and at times, less comfortable. Along with my younger brother, the three of us traveled to remote places throughout, Southern California to camp and explore those natural areas that others knew little about – Death Valley, the Anza Borrego Desert, Vasquez Rocks, Julian, Mammoth Lakes, the Owen’s Valley, and others. With sleeping bags, a camp stove, cans of beans, and our Plymouth station wagon, we would ply the back roads in search of campgrounds or tiny hotels in which to spend the night.

From that sense of adventure, it was not surprising that my heroes growing up were not sports figures or movie stars, but rather explorers and anthropologists who traveled the world in search of the unknown. I had always had a keen interest in Africa and animals, again having stemmed from her interests, and the fact that we had a menagerie at home which eventually turned into a pet shop that we ran for several years of my adolescence. The dream of traveling to these remote lands, something clearly instilled by my mother, was all that existed for many years, though my brother and I did get to travel to Greece during college one summer while backpacking through Europe on our Eurail passes. Of course, my mother was also responsible for that as it was her gift to us from the sale of our childhood home.

The decision to travel to Tanzania on safari with my children in 2009, though most immediately was the result of Anna’s interest in wildlife, was really the outcome of what my mother had instilled in me and had then been transferred to Anna.  Coming back to Africa after that first trip in 2009, though, was my mother’s influence and I very much recall the moment that I realized just how much she had been responsible for that trajectory. I was staying in Gitamilanda in the Lake Eyasi region during one of our mobile clinics. It had been an incredibly hot and sticky night and, after waking long before sunrise, I had decided to take a walk into the bush on my own (there are few predators in that region).

Standing there, alone, with the entire expanse of the Great Rift Valley looming before me and the realization that early man had also walked this ground in the distant past, my thoughts were immediately drawn to my mother and the role she had played in my having arrived at that point in time. I immediately phoned her to tell her how much I loved her and how much she meant to me. Though I am not entirely sure how much she understood of my phone call as she was already in the early stages of dementia, I am certain that she knew it was me and that I was in Africa. In less than a year, she would be gone, and it occurred while I was here at FAME doing what I continue to do to this day. Knowing that we shared so much in life, this work I do is as much her legacy as it is mine. She is greatly missed.  

Otherwise, our day was a bit less hectic with fewer patients than days earlier in the week. Of the patients seen, there was a young woman who we had been treating for seizures for the last few years with incomplete response despite several medications whose brother brought in a video of her typical episodes today for the first time. With the video and a more detailed description of her episodes, we were very comfortable now with a diagnosis of PNEE, or psychogenic non-epileptic events. These are episodes, that used to be called pseudoseizures, actually fall under the heading of conversion disorder, or somatic symptom disorder, and are treated not with anti-seizure medications, but rather with psychotherapy and selective-serotonin reuptake inhibitors.

Though patients with PNEE can also have co-existing epilepsy, meaning the diagnoses are not mutually exclusive, but that situation is not as common as it was once believed. We see PNEE very often in the US, and I suspect that it is seen with an equal frequency here in Tanzania based on my clinical observation over the last 14 years. Not having access to EEG here certainly makes the evaluation and diagnosis a bit more challenging, but ultimately it is a clinical diagnosis. As for the patient we were seeing today, they received the explanation that is normally given to patients which is that what they are having is very real to them, but is treated with different medications, and that the episodes will eventually resolve on their own. The patient was started on fluoxetine (Prozac) and asked to return in six months to see us again.

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Another interesting patient we saw today, and were thankful that Marissa Anto, our pediatric neurology attending, arrived today when she did, was a complicated two-year-old child who had suffered what sounded like an encephalitis previously, from which they had recovered, but had never regained any of their developmental milestones and, overall, seemed to be regressing somewhat. There was very little to go on, unfortunately, but on the laboratory screen, the child’s ESR, or sed rate, was elevated, raising the concern that there could possibly be some type of an inflammatory or auto-immune process going on. With nothing else to offer the child, it was decided to give them pulse dose steroids. We had brought Depo-Medrol to use for our headache nerve blocks and this worked perfectly well for an IM injection of medication for this child.

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For the evening, I had made arrangements to visit with Daniel Tewa, a close friend who I was originally introduced to in 2009 when volunteering at a local school with my children. Daniel was a village elder who spent time painting with us and had also invited us to his home to hear about the Iraqw culture. Upon returning in 2010, I had contacted Daniel, having dinner at his home, and meeting the rest of his family. I have continued to visit with Daniel on every trip since 2010, and he has graciously accommodated every group of residents that have come to FAME since 2013. Daniel is a self-taught historian of not only the Iraqw tribe, but also of the entire world, whether it be geography or current events, and every visit to his home is a time to learn something new. I have valued each and every time that I have sat down with Daniel, and his insights into the history of Tanzania, which has been quite colorful, have been priceless.

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Besides having my neurology team come visit, though, Daniel has served to provide the history of the Iraqw culture to safari goers and other visitors as well as academicians with an interest in the history of this country. In 1993, after continually telling his children that he had grown up in a traditional Iraqw underground house and them thinking him crazy, he finally set out to building one. It took several years, though, when completed, he had built a traditional underground home that the Iraqw had lived in for many years as the main purpose was to protect their animals from the Maasai, whose believe was that all livestock were God’s gift to the Maasai, and they were merely taking back what was rightfully theirs rather than stealing. The home served to protect their livestock and themselves from the Maasai, who they were at odds with (in reality, war) until 1986, when a truce was finally signed.

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Sitting with Daniel and drinking his wonderful African coffee (coffee boiled with fresh milk) is a unique experience that is hard to describe. Regardless of the fact that I have visited with him on more than 25 occasions, I have always learned something new about Tanzania and its history. He has twelve children (11 of his own and one adopted after their mother died in childbirth) and I have met most of them over the years. Despite the fact that Daniel only finished primary school and would be the first to remind you of this, nearly all his children have graduated college and are working throughout the country in various professions. From having grown up in an underground house long before there was a Tanzania, Daniel has persevered to become the treasure that he is, and we have been lucky enough to have experienced him many times over.

It was our third day of clinic, and everyone had hoped for a more reasonable workday, given that we had finished late on both previous days. We were still having plenty of patients show and the reception area for FAME was equally swamped once again. Given the number of staff that show up for Morning report on Monday, Wednesday, and Friday, only Leah and I were planning to go as representatives for the group. Walking up to the main conference room, we quickly found that there was a management meeting happening this morning (first Wednesday of the month) and were redirected to the administrative building where there is yet a smaller conference room, but it utilized when there are multiple meetings taking place. Thankfully, there was a seat for me as my back has been bothering me and I wasn’t looking forward to standing for the meeting.

I had forgot to mention that we have educational lectures every Tuesday and Thursday at 7:30 am that are most often given by visiting volunteers, and that yesterday’s lecture had been given by our visiting urologist, Dr. Levine, and was on male sexual dysfunction. Though certainly a fascinating and important topic, it was fairly far afield from being of use for the neurology residents, so they all excused themselves to get some extra sleep or more time for breakfast. On the other hand, I had decided to show up more from a standpoint of courtesy to the presenter than anything else, though I must admit that I have dealt with this topic among my patients for a number of years and was reassured to learn that very little had changed since the advent of Viagra. Still, Sari has a wonderful way of presenting the topic, and I’m sure much was learned by all those who attended.

I’ve typically had the residents give presentations while they are here, but over the last years, as the volunteer numbers have steadily risen, it has become more and more difficult to secure enough slots for the residents and we have inevitably had them combine their efforts for each lecture. With the TB meningitis patient in the ward, Joe has volunteered to give the talk upcoming on Tuesday on just this subject given his background in HIV and neuroinfectious diseases. I’ve warned him that he will be speaking to general practitioners and not a roomful of neurologists, so will have to be sure to speak more slowly and be certain that everyone is understanding him.

Over the years, our neurology talks have obviously repeated themselves – as amazing and interesting neurology is, there is a limited number of talks that can be given to primary care practitioners in rather rural Africa. We have covered epilepsy, headache, stroke, the neurologic examination, reading CT scans, neuromuscular, tremor, Parkinson’s disease, pediatric neurology, and the neurologic examination, each on multiple occasions for giving several lectures a visit twice annually over the last 14 years adds up to quite a few lectures over that period of time. They have all been well received and though much of the staff here at FAME has been here for multiple years, hearing them several times over has never been an issue both as a reinforcement of the material and having it presented in a different manner each time.

From my very first visit to FAME in 2010, I have also maintained an open line of communications with the staff here to help them with new neurology cases or follow up cases in between my visits. Often, the patients can be quite complex and, in addition to the history, I will be sent videos of the patient’s appearance or examination but trying to make a diagnosis based on someone else’s examination can be difficult, especially if they are a novice. Early on, I may be given a very simple history such as a new patient presenting with weakness, and I would be given nothing else. Weakness in neurology is something that could be related to a great many sources and, because of this, it requires more information to even begin an evaluation. We divide the nervous system into two big buckets – the central and the peripheral nervous system, and weakness from each of these will act very differently and have very different exam findings. So, after a year or two of coming to FAME and teaching everyone how to take a history and examine a patient, I would receive the information necessary to begin investigations and to develop a differential diagnosis for the patient. This was such a major turning point and has only continued to improve so that I will now receive information enabling me to develop a working diagnosis with them and a plan for investigations.

In previous blogs, I have spoken of a patient with multiple sclerosis who we had diagnosed about two years ago and had started on a medication that was unavailable here in Tanzania (in fact, there are no MS drugs available here) and which we have been able to bring from home to provide her with treatment. We had once again brought a supply of the medication for her that would last another six months and I had contacted after arriving to make sure she came during our first week here as I had hoped that she could see Joe and, for that matter, either Leah or Gina as well, both of whom are also MS neurologists. She was able to come today and was already on her way here.

Though the risk of developing multiple sclerosis is multifactorial, one of the more significant factors playing a role in one’s likelihood of developing this autoimmune disorder has to do with the latitude of where you live and, more specifically, where you spent the first 15 years of your life. The incidence of MS is the lowest along the equator (strongly felt to be the result of high vitamin D levels) and essentially increases the further away from the equator you are raised, whether it be the northern or the southern hemisphere. Once you reach the age of 15, though, that risk is essentially fixed and will not change regardless of where you may immigrate. That is why the incidence of MS is very low here in Tanzania, as well as other equatorial African countries, though just how low that is may be very difficult to tell. Having very few neurologists to make the diagnosis and very few MRI scanners to help confirm it when it’s considered, the numbers seem very small, but it’s unclear just how accurate that may be.

Though I believe I have seen one or two patients over the last 14 years who I believe may have MS, it was difficult to make the diagnosis due to the lack of accurate history (as I discussed yesterday), the lack of follow up and the inability to obtain an MRI due to availability and cost. This patient, whose history was suggestive, had already obtained an MRI scan that she brought with her to her first visit and very clearly demonstrated abnormalities that were consistent with the diagnosis. After some doing, we were eventually able to bring her medication and she has been stable since that time without progression of her disease or any MS flares. Having the ability to provide treatment for her was crucial and with continued treatment, the hope is that she will remain symptom and episode free going forward.

The infant who had been in clinic yesterday with her mother, who was the patient, and raised concerns for hydrocephalus, underwent an ultrasound of her head this morning as she had an open fontanelle that allowed for this. Thankfully, she did not have any evidence for hydrocephalus on the study and would not have to be referred for a shunt.

As for the young boy with TB meningitis who has been extremely ill for the last two months and remains unresponsive, he is not being ventilated (no one is ventilated here) and only continues to receive his TB treatment such that his family wants to take him home and continue to treat him there. This is a common theme here (much different than at home) as families are paying directly for their medical care and, even though it is very little from our standpoint, the amount adds up quickly and is often difficult to pay. When patients are here only receiving medication, families very often want to take them home for financial reasons. I remember an 88-year-old woman who had suffered a large hemispheric stroke a number of years ago and, despite the fact that she was hemiplegic, she could swallow, and within three days, her family wanted to know whether they could take her home or not. This would never have occurred at home.

We had decided that since he hadn’t had a CT scan in some time, it would be good to get one given the nature of his meningitis and the risk of hydrocephalus, as well as the fact that his ventricles were rather large when looked at previously. Unfortunately, the CT scan demonstrated that his ventricles were enlarging and that he needed to have a shunt placed to allow the fluid to drain or another procedure that works similarly. Thankfully, Kerry Vaughn, a pediatric neurosurgeon who visited here at FAME for two weeks a few years ago with Sean Grady, both of whom were teaching the staff here to do burr holes for subdural hematomas, is currently doing a one-year global health fellowship at KCMC in Moshi and would be able to weigh in on the case.

Arranging these types of transfer for care is always a difficult situation as it is almost never based on bed availability as it is in the US, but rather on the financial issues that are at play. Very few people here have health insurance, and though there is a national plan, very few people participate in it, meaning that nearly all individuals are paying for care out of pocket. Though it is often a matter of speaking with their family and their community to raise the funds, it is not something that we are used to dealing with at home. Before a patient can be transferred, there must be some type of guarantee of payment, often delaying the process. As for this boy, he has been accepted to KCMC, and though the financial aspects still need to be worked out, it appears very likely that a solution will be found, and he will be transferred.

Interestingly, just yesterday, Joe was speaking with me about a colleague he knows, Ben Warf, who’s a neurosurgeon that spent time in Uganda, and during that time, despite having placed many VP shunts, continually wanted to find a procedure that would provide similar results for children with hydrocephalus without having the risk of subsequent shunt failure that were an emergent event. He went on to develop the endoscopic third ventriculostomy and choroid plexus cauterization (ETV-CPC) that was found to prevent developmental and brain growth delay in a randomized trial that included 100 children. When this boy is transferred to KCMC, it is very likely that he will undergo an ETV-CPC as will the other child that we referred, also with hydrocephalus.

Our day ended much earlier today, allowing us to finally head into town and visit the exchange bureau so that everyone could get some Shillings to use. Several years ago, there were exchange bureaus practically on every street corner here, but when it was found that they were essentially laundering money, they were all shut down overnight, and exchanges could only be done in banks with your passport. Thankfully, that situation has become less strict and, once again, there are exchange bureaus, though they are more closely monitored now and still require your passport. The exchange rate currently is 2650 Shillings to the dollar (I think it was around 1400 to the dollar when I first came in 2010) and their largest bill here is a 10,000 note – less than $4.

Once they had Shillings, the first request I had from the residents was to take them to a liquor store where they could buy more wine. Luckily, the liquor store was right next door, and they were all happy.

Meanwhile, we had been told that we must visit the Lilac Oasis on the other side of town as it was a new place to visit for dinner, drinks, and dancing. The last time that I was there six months ago, it consisted of a food truck, a bonfire, and music, all outside, but it is now a magnificent facility with a lovely restaurant and bar, a swimming pool, a spa, and the loveliest of landscaping. It’s still under construction, but open for some of the activities. We’ll report more once we visit it for real.