Our second and third mobile clinics for the week would be to the Rift Valley Children’s Village (RVCV) and the Oldeani Area. The Children’s Village is a magical place in and of itself, though it has also played a significant role in the history of FAME and where it is located. This history of RVCV begins in 2004 when India Howell (Mama India) and Peter Mmassey opened the children’s village to serve as a home, rather than an orphanage, for a handful of vulnerable and orphaned children who would no longer have to worry about who their family was nor whether they would be adopted by a stranger for they already had been taken in by Mama India and Peter. This core group would become the cornerstone of an ever-increasing family that now numbers well over 100 children with the oldest of them having long ago attended college and are now creating families of their own.

After Frank and Susan decided to move to Tanzania with the vision of creating FAME, Frank began working in the Usa River area just outside of Arusha with a general practitioner to begin retooling himself as a primary care doc given all his background had been in cardiac anesthesiology. As the expat community here is rather tight, once India had met Frank and Susan, she began driving her kids to see Frank in Arusha, which was before the highway had been completely paved so it was a four to five hour drive each way at a minimum. It was India who had suggested to them to consider locating in Karatu for several reasons, not to mention that it would be tremendously closer for her to get her children’s care. It was also close to the Ngorongoro Conservation Area and the massive Maasai population living there that was desperately in need of quality health care. Lastly, Karatu was the last outpost of civilization before heading off to the Serengeti and every safari vehicle had to travel through town such that it was likely that FAME could provide care also for the tourists traveling through and that could be a potential for fundraising as well.

FAME first opened its doors in 2008 – there was only an outpatient building at that time with only several doctors, including Frank, and there was a huge emphasis on outreach to the Karatu district so that residents would be aware of FAME. During the early years of RVCV, India had come to realize that it was crucial that she not only provide excellent health care for her own children at the village, but it became increasingly clear that unless the local village children who her kids spent the day in school with were also healthy, it would all unravel and her children would come home sick. The philosophy of providing health care to the residents of the community where her children lived came about and that care was provided by FAME. When I first came to work in 2010, FAME was providing twice monthly medical clinics at RVCV in which several doctors and nurses would travel there to hold a clinic over several days. I participated in those initially, but eventually we piggybacked onto those clinics and held a separate neurology clinic on the same days.

Over time, though, and as FAME continued to grow, it became more difficult to supply the manpower necessary for the medical clinics at RVCV, and it also became clear that patients from the community and the children’s village could be transported to FAME for their care and it was less costly. For neurology, though, we continued to maintain our mobile clinics at the children’s village given the number of neurology cases there that needed our care, and we have continued to maintain those clinics at the same frequency. Today, there is a beautiful health clinic just outside the children’s village that was recently built and is run by Africanus, a wonderful clinical officer who began his career in the Karatu district volunteering with the neurology clinic at FAME as a translator, later hired to work at FAME, and finally hired by the Tanzanian Children’s Fund (TCF), the overarching organization that fund’s the children’s village, to provide health care to the residents of that community and work in partnership with FAME for any patients who required more advanced care.

In addition to the children’s village,  TCF oversees several other initiatives in the community that includes collaborative efforts with education – funding additional teachers for the primary schools, lunch programs for the secondary schools, and now dormitories for the secondary schools – as well as providing microfinance and supporting the Rift Valley Women’s Group in which women are provided training for a number of vocations such as making clothing, jewelry, and other items that are then sold throughout the region to provide income for their families. So, essentially, there are the four arms of the TCF – education, healthcare, microfinance (the Women’s group), and the children’s village.

This now brings us to the African Massage Road, as the road to RVCV once leaving the tarmac is known by. The children’s village sits in the Ngorongoro Highlands and the foothills of Mt. Oldeani, backing up to the conservation area and in the middle of some very huge coffee plantations. Most of the residents of Oldeani community are coffee pickers or farmers as there is very little other industry there. To reach the African Massage Road, you travel about twenty or so minutes on the tarmac from Karatu in the direction of the Loduare Gate that leads into the conservation area. The turn to RVCV off the tarmac is marked by a wooden sign preparing you for what is to come over the next kilometers. Regardless of the warning, though, this is simply one of the most gorgeous drives one could ever imagine. The road travels along a ridgeline for several kilometers with huge farms to the left and a deep valley to the right with numerous thatched roof homes of the farmers dotting the hillside.

The drive for several kilometers along the ridge is fairly mild, unless of course it has been raining, in which case the path is quite slippery, and the vehicles tend to buck and shift with the ruts in the road. At the end of the ridge, there is a sharp right hand turn that leads directly down a steep grade – in the dry season, this is just dusty and bumpy, but in the wet season, and especially if it has just rained, the path is genuinely like a slip and slide, and as long as you have it in low gear and don’t touch your brakes, you’ll be in good shape. We were in good shape today as the road was dry with very little dust and it was just a matter of bouncing down the hill. Once at the bottom and in the valley, you immediately begin a steep incline that requires low gear to make it to the top as it’s incredibly rocky and there is very little in the way of traction. The Land Rover (I’m driving Turtle with our neuro team including translators) has all-time four-wheel drive, so other than shifting into low gear, there is little else to do other than hold on and climb.

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We crest yet another ridge and head back downhill once again towards a gorgeous rushing stream that thankfully has an intact bridge, and then it’s uphill once again. This climb is where I had first driven in East Africa when one of the staff was trying to get our vehicle started uphill and, when repeatedly unsuccessful, I offered to drive and was quickly taken up on my offer. I was a kid in a candy store, never having believed that I’d be driving in such a place – that was in 2011. Having now driven for the here for the last fifteen years, it is no less exciting for me, and I have to pinch myself constantly to make sure I’m not dreaming.  Once up this hill, we’re on a high plateau filled with coffee plants before arriving at the children’s village gate.

Upon entering, there is an immediate sense of serenity that is unmistakable. Though the clinic is now outside of the village gate, I still park in front of the administration building out of a sense of habit as this is where we held our clinics for so many years and walking to the other side, you immediately find yourself in the heart of a home that is like no other. Africanus met us as we entered and brought the team over to the cantina as the mamas had apparently made breakfast for everyone. I headed over to the clinic, though, to leave my bag in the office, only to find that there was a young boy who had been having repeated seizures since earlier. I walked back over to the cantina to make sure everyone knew that we had work to do, though was unaware that everyone had actually been invited to have breakfast – it was a bit confusing, though thankfully, Shannon came over to the clinic to help out with the child, who was by now postictal, and eventually woke up just fine.

It was a hectic start to the day, and we ended up with 30+ patients seen which was a lot with only three residents sharing the burden. Many of these patients are follow up epilepsy patients, though we also had quite a few new patients. The day ran so long for us, that we ended up with patients from the village of Oldeani that missed their rides back to town, which was not necessarily on the way home, but also wasn’t totally out of the way either. After volunteering to take them to Oldeani, Omari, who was driving Myrtle, offered to drive them home instead which was a relief as we were all pretty exhausted. As it was, we were getting home after sunset.

Yesterday’s foray to Ngorongoro Crater had been a success from the standpoint that not only the weather, but also our vehicle, had fully cooperated with our plans. Several weeks ago, it had been raining most of the days, and quite intensely at that, but somehow, we lucked out as the skies cleared out and we had bright blue sunshine for the entire day in the crater. As for Turtle, the vehicle had been in the shop much of the prior week for little repairs of this and that, including the winch and brakes, and I had received it back from the fundi (expert) the day before we were leaving. All went as planned, thankfully, which was very unusual as the likelihood of my having a significant mechanical breakdown at least once on an outing is extremely high and a very good bet if one were placing odds.

The history of our neurology outreach clinics, or mobile clinics, is something that I’ve covered before, but for those new to our project, I’ll give a recap. When I first came to FAME to work in 2010, they were providing week-long monthly mobile clinics to the Lake Eyasi region that were being funded through a three-year grant from the Dutch non-profit, Malaria No More. These clinics involved a huge, expedition-style contingent of perhaps 25 individuals including clinicians, nurses, lab techs, social workers and support staff that would provide daily clinics in very remote regions far down Lake Eyasi where the Hadza and the Datoga tribes predominate, and there is very little in the way of medical care. I was fortunate to have gone on several of these trips when I started working at FAME, and was able to provide neurology support, though the majority of patients were being seen for general medical issues. Much of the logistical support was being provided by Paula Gremely, who was a social worker who had been here for many years and also had her own non-profit that did social work mostly for orthopedic patients with her business partner, Amiri.

Upon returning from one of these mobile clinics to Eyasi in 2011, Paula asked me if I would be interested in going to a few villages in the Karatu district where she knew there were neurology patients that we could see and thus began the neuro mobile clinics. Our original clinics were to the villages of Kambi ya Simba and Upper Kitete in the Mbulumbulu area, which was about an hour away, and involved taking Paula’s Land Cruiser with me, a clinical officer, a nurse, and Paula, with Amiri driving along with all the medications and supplies we might need. The visits were a huge success in regard to the number of neurology patients we were assessing that included the entire spectrum of neurologic disease with a significant portion of those having epilepsy, many of whom had never seen a doctor for their condition.

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It was through the successes of these early mobile clinics with Paula and Amiri that the idea for a more robust neurology mobile clinic program came about and now involves six days of clinic to more remote villages in the Karatu district with a much larger group that includes two Land Rovers, up to four resident neurologists to see patients, an interpreter for each resident, an additional driver besides myself, a nurse, a social worker, and an outreach coordinator. Over the years, we have selected villages that would benefit most from our presence, and villages have come and gone from our list depending on their need and collaborative efforts. One important fact to recognize is that all the villages we attend are in the Karatu district and do have accessible transportation (typically by bus) to FAME, so that if patients were aware that they have a treatable disorder, they could conceivably come to FAME for their care. The purpose of the mobile clinics is as much to educate the patients in these regions that they likely have treatable neurologic conditions for which they can come to FAME for treatment, if needed. We are still happy, though, to bring our services to villages where we can see many patients at one site and also see follow up patients on our return.

The villages we attended with the prior group of residents included Barazani and Mbuga Nyekundu, both relatively adjacent to Lake Eyasi and in the Mang’ola region, while the third village was Mang’ola Juu (Juu means “up”), which is much closer to Karatu, but off of the Mang’ola road high up on the slopes of Mt. Oldeani. For our mobile clinics this session, we would be traveling to Basodawish, a dispensary with little in the way of infrastructure or facilities, but in an area with lots of patients who are extremely poor farmers. We had previously attended the nearby village of Qaru (where the cobra bite I had mentioned earlier occurred), though for various reasons discontinued working in that location and found need in Basodawish instead. To reach Basodawish, we simply cross the main tarmac directly opposite the FAME road and continue south on the Mbulu road in the direction of Qaru, Endabash, and eventually Mbulu. Continue in this direction, and you would eventually reach the shared capital of Dodoma (both Dar es Salaam and Dodoma share the government offices).

The dispensary here in Basodawish sits adjacent to a very large church that is reached by a tiny road that runs through the center of town, though I use that word quite liberally as most of these villages are made up of a few ramshackle shops (dukas) on either side of the main road constituting “town” with primarily foot paths leading to homes or fields that are nearby. The turnoff to the dispensary is quite easy to miss even if you’re looking for it, though thankfully I’ve been here enough to recognize it and the church behind was certainly some help in being certain I was turning at the correct time. I pulled onto the grass in front of the building where we could wait for the other vehicle to arrive – they had gone to pick up our lunchboxes and had all the supplies necessary for us to get set up. There were a few patients sitting out front, though from past experience, I knew that these were unlikely to be ours as we used an open room in the back for our “pharmacy” and waiting room.

Whenever we show up at a village clinic, it’s important to remember that we’re their guests and to tread very lightly. It’s never assumed we can just take over and occupy their space, so we always wait for their clinician or staff to greet us and invite us in to begin setting up for clinic. We’ve had already made arrangements for our visit long before our arrival, though you can never be sure of who was aware we’d be coming, so just to be safe, we enter as if we’re again asking for their permission. That will usually go a long way towards ensuring that we’ll be welcomed into their community.

Once the rest of the team arrived, we began setting up rooms to use which is often a difficult exercise as many of the rooms are being used for other purposes or may have locks on them whose keys are nowhere to be found. Once we located the three rooms to use, the next step is finding enough furniture for each room. At a minimum, we need a desk and two chairs, though preferably more of the latter so everyone can sit. We typically do not have exam tables at most of the clinics, and it’s usually a struggle just to find the number of chairs we need. Basodawish is one of the dispensaries to which I have donated furniture in the past (benches, chairs, and desks), though even with that, it’s often a struggle to find the necessary pieces, and a few plastic chairs had to be brought out of storage. Once our exam rooms were in place, patients were registered, and vital signs were taken, it was time to get started seeing patients for the day.

The patients in Basodawish ran the entire gamut of neurologic disorders with a number of children and perhaps a disproportionate amount of epilepsy. The community here is very poor which, in a country that ranks in the bottom 15% internationally, means that these patients will always have an issue affording healthcare and medications. It becomes even more important in communities such as these that we pay particular attention to this aspect and the necessity of our social workers to assess patient’s or family’s ability to afford medications becomes paramount to the care we’re providing for making a great diagnosis and placing a patient on the correct therapy is meaningless if they are unable to continue the treatment after we leave due to the costs.

Overall, the clinic was a great success as we saw a reasonable number of patients, many of whom were seeing us for follow up, though some of whom were also new. Shannon had her share of kids which always makes a pediatrician happy. We finished at a decent time and were heading back to Karatu with the sun still shining which is always a positive thing and much appreciated by everyone.

It was the first Sunday for the second group which is always the day I take them to Ngorongoro Crater. As I have mentioned previously, these days are ones that I am looking forward to from the moment we arrive, though there is always some anxiety that is associated with the drive. To begin, I’m driving a nearly twenty-year-old Land Rover that has been modified as a safari vehicle and has driven almost exclusively over the roughest roads one can imagine – and Land Rovers are finicky, requiring constant repairs that are very often makeshift and imaginative (think chewing gum and duct tape). Mechanical breakdowns are commonplace and there are no service stations where we’re going, let alone two trucks or mechanics. Essentially, every safari guide is capable of doing essential repairs on their vehicle to get it back on the road, though some are better than others, and I’m not included in either of those categories. The other anxiety provoking part of the whole process is the fact that I am typically questioned, sometimes extensively, Conservation Area rangers when checking in at Loduare Gate, the entrance to the crater and to the Serengeti, as there are almost no non-Tanzanian drivers entering among the hundreds of vehicles going into the crater on any given day. Amazingly, I showed them the permit that Pendo had created for our game drive, which was on my phone, they put the number into the computer, then gave me my paperwork, and we were off on our way in no time at all.

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Since there was one less resident, and Jill had returned home, there were going to be only four of us in the vehicle including me, which left us plenty of room to bring others along. We had invited our three Tanzanian translators – Novati, Saida, and Glory – to come along for the day. The cost for Tanzanians to get into the Crater is only 10,000 Tsh (less than $5) each compared to our $70, and the vehicle cost of $250 would be regardless of whether there were four or seven of us. Though residents here have the ability to go into the crater for little cost, they rarely have the opportunity to do so as the cost for a safari vehicle, driver, and fuel would cost at least $300 for the day, well out of the reach for nearly all Tanzanians. Whenever we have open seats in our vehicle, I always try to fill them with those Tanzanians who are working with us or other FAME workers. During the beginning of the pandemic, when I came alone as the residents were not allowed to travel, I filled the Land Rover with Tanzanians from FAME and took them to Tarangire National Park for the day and, on another occasion, to the Conservation Area to share in a goat roast nearly all the way to Oldupai Gorge. We stopped at the Ngorongoro Crater Lodge for coffee and cookies on our way back, a place none of them would have had the opportunity to visit on any other occasion. I had never seen so many selfies taken before.

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I have written about the crater on so many occasions before, but save it to say that it is one of the most magnificent natural wonders in the world – it is the largest complete dry caldera (collapsed volcano) in the world measuring 10 miles in diameter and 2000 feet deep that contains near all the same animals that one would fine in the Serengeti other than the giraffe (it’s too steep for them to descend the walls), and the Nile crocodile as there are no running rivers to support them. All the cats – lions, leopards, cheetahs (though their numbers have diminished due to competition from a growing hyena population), caracols, servals, and more. None of these resident animals has any need to migrate as there is year-round food available in the crater, whether it be the grasses for the herbivores or the herbivores for the carnivores – either way, life is good.

There is little question, though, that beyond its sheer beauty, Ngorongoro Crater is about the black rhino. Heavily hunted in the days of the Great White Hunter to the extent that they became seriously endangered, then heavily poached in the country until they were almost extinct, they are now making a significant comeback through the protection of the Tanzanian government and the rangers of the Ngorongoro Conservation Area  and the Serengeti National Park where the whereabouts of each and every rhino are heavily monitored night and day.

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Hemingway’s The Green Hills of Africa, one of his few non-fiction novels, takes place in Tanganyika, and mostly at Lake Manyara, from 1933 to 1934, when he and his wife traveled through the area hunting black rhinos, which are now essentially non-existent in those areas unless one were to wander there from the crater in which case it would be quickly relocated back to safety. Rhinos are one of the big five of Africa with the others being the elephant, Cape buffalo, leopard, and, of course, the king of the jungle, the lion. What do each of these five animals have in common? They were each an animal, who when hunted, could turn easily into the hunter if you were unlucky enough to have missed your first shot, and were each known to have killed many of those who sought them as trophies.

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Once through the Loduare Gate, we were on our way to the crater rim on my absolute favorite drive in the world, a dirt road that through a series of switchbacks, takes one up 2000 feet alongside a deepening canyon with trees reaching for the sky above the dense forest canopy. The trees and vines appear primordial and there is clearly the sense that you are traveling back in time to the prehistoric days of the dinosaurs, and that a tyrannosaurus rex may pop out of the undergrowth at any time. These are the Ngorongoro Highlands that I love, and the East Africa that I dreamed about as a child. Once atop the rim, you reach the crater overlook to get your first full view of what you are about to descend into and explore, though there is another 40 minutes of travel to the opposite side of the crater, where the paved descent road with probably a 12% grade drops you down to the crater floor in no time. The use of low gear on your transfer case is highly recommended to keep your brakes from overheating. Once on the floor, you’re free to pop the top and enjoy the rest of the day exploring the immense crater floor.

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Within minutes of driving, we came across a group of several Land Cruisers with one that was stuck in the mud along a trail that was leading them to a group of lions. I used our tow rope that had gotten us out of trouble in the Serengeti, but the weight of the vehicle and force required to pull it free was too much for the strap and it unfortunately broke on one end on the first try. Next, I pulled out the winch cable that I had just repaired with the new controller that the fundi had found for us and, sure enough, was able to tug out the vehicle with little trouble. Unfortunately, though, the driver, while still trying to reach the lions in the same direction, immediately became stuck once again. I had to drive to his other side through some deep mud to pull him free this time, though all went well and this time, he made sure not to get stuck once again. We drove to the lions and enjoyed watching them for a few minutes before heading on again.

We came upon our first rhino spotting in a similar location as where we had seen the only one we found three weeks ago, and even though it was quite a distance away, it was clearly distinguishable as a rhino. Over the course of the next several hours while on the crater floor, we made an additional seven rhino spottings, though two were repeats, but even so, we had seen six individual rhinos that included one very close (for a rhino, that is, as they are very shy), and a pair of mothers with two babies. They are spectacular animals that, no matter how hard you try, are difficult to imagine how they came to be from an evolutionary standpoint, though here they are right in front of you. Their eyesight is incredibly poor, and they rely primarily on hearing for defense, so do not come out on windy days in which they would have a hard time locating their enemies, even though for the life of me I can’t imagine what enemies a full-grown rhino would have. Recently, eighteen white rhinos from South Africa were brought into the crater with the cooperation of the NCAA (Ngorongoro Conservation Area Authority) to eventually release in the crater and establish a viable breeding population but haven’t done so yet and they are still penned in the Lerai Forest. White rhinos (an original misinterpretation of the Dutch word “wide,” referring to their mouth as opposed to the black rhino which is more beak-like) are nearly twice the size of a black rhino which is simply hard to imagine, though I’m sure I’ll be able to see it someday soon after they’re released.

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After taking the ascent road out of the crater, we were at the gate in plenty of time (remember, it closes at 6 pm, and if you’re late, you could end up spending the night in the Conservation Area), and back home before sunset. Our plan for dinner was fried rice, and we had gotten a container of cooked white rice to put in the refrigerator several days ago since stale rice makes the best fried rice. This seems to be our post safari meal these days, and we have a steady supply of white rice from the FAME cantina. Tomorrow, we would begin our mobile clinics for the second group. Bisodawish on Monday, then Rift Valley Children’s Village on Tuesday and Wednesday. The weather over the weekend was great and we’re hoping it remains that way for our Serengeti adventure in a week.

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The last Friday morning of the month is always reserved for a 7:30 am M&M (morbidity and mortality) conference here at FAME – I usually try to attend these, but today’s topic was DKA, or diabetic ketoacidosis, a topic not very dear to my heart. Weighing whether or not to get an extra half hour of sleep, I chose the former and skipped the conference, though with a smidgen of guild, I must admit. Though it’s doubtful that I would have learned anything I could apply directly to my practice of neurology, I’m sure there would have some process issues brought up for discussion that I could have either contributed to or benefited from hearing. It’s very unusual for me to miss this type of meeting, so I must have been tired and felt that I needed the sleep.

The weather seemed to make a bit of a turnaround today as the sun appeared to shine more than the rain fell which lifted everyone’s spirits and brought more patients into clinic. At the dinner I had gone to last night at the Plantation Lodge, the group was planning to go to Ngorongoro Crater the following day which was good as we were scheduled to go on Sunday, and I was anxious to hear just how wet the crater was and whether the roads were all passable. I had only been to the Plantation Lodge once in the last several years for a FAME Board function, but it reminded me of a very funny situation that had occurred back in the fall of 2018 when we had been invited to have dinner there by one of the managers as one of my residents had treated them for a bad back.

The drive to the Plantation Lodge has never been well marked and is truly off the beaten path, so I had stopped shortly after leaving the tarmac to ask a local walking if I was still heading in the right direction. I was, of course, but immediately upon putting my vehicle back into gear, the entire gear shift, from the below the floorboard, came completely off. I was holding the gear shift knob in my hand with about 18” of the shifter attached and nothing coming out of the floor. Needless to say, I was just a bit shocked but then started laughing as it was one of the funniest things I had ever seen, until I realized that we had better figure something out to keep us on schedule as there was no way that I wanted to pass up a free dinner at a very respected lodge. Peter Schwab, then a medical student, was sitting in the front seat next to me, and the two of us began feeling around just below the floorboard and were somehow miraculously able to wedge the gear selector into third gear, but that was going to be about all we could do, and there was certainly no possibility of getting it into another gear while we were moving.

Thankfully, most large four-wheel drive vehicles, at least serios ones, have a transfer case that allows you to shift the vehicle into four-wheel low gear when it’s necessary to have extra low gearing. You can actually shift into and out of low gear when you’re moving very slowly, and this allowed me to start the vehicle in third gear low and then shift quickly into third gear high before we got moving too fast. I managed to drive us the remainder of the way to the Plantation Lodge for dinner and parked on a slight downhill slope to get rolling when it was time to go home. What I didn’t count on, though, was the uphill exit from the parking lot which proved to be a significant impediment as I wasn’t able to get up enough speed to make it up the hill without bogging down.

I had everyone get out of the car to push (mind you, this vehicle is the size of a tank), while I gunned the engine to take off once I let the clutch out. My good friend and colleague, Steve Gluckman, was with us, and all I remember was hearing him groan as I looked behind me in the side mirror to see him bent over in pain as the rear wheel had spun and shot gravel back at him like buckshot. Thankfully, other than a bruise to his thigh, he was uninjured as I had thought I might have seriously hurt him. Everyone jumped back into the car now that I had reached the top of the hill, and we were back on way to FAME with only two usable gears – third gear low and third gear high – but at least our bellies were full after having a wonderful dinner on the house.

We had a respectable number of patients today – 9 – with mostly epilepsy cases and several HIE babies as well as an older cerebral palsy patient. Shannon, of course, evaluated the children with developmental delay, though one again, there is very little for us to help with other than to treat their epilepsy if they have it, spasticity if that’s present, and then to make recommendations for physical therapy which can be quite beneficial even at very young ages to improve their chances of some functional status. With the status quo to have far less prenatal care as well as the widespread belief by many tribes that restricting calories for the mother during pregnancy with the obvious result of having smaller babies with subsequently lead to fewer birth complications. Unfortunately, the latter if obviously untrue and results rather in malnourishment of the fetus and perinatal insults.

We had no plans for the evening other than relaxing while Shannon had planned to go out for a run. She had changed into her running gear and was just about to head out the door when Saidi called me to tell me that a leopard had been spotted on campus and that everyone should remain inside for the evening. Though Shannon was obviously disappointed that she couldn’t go running, she would have been far more despondent had she taken off a few minutes earlier and bumped into a cat several times larger than Matilda and not nearly as friendly. Shortly after Saidi’s phone call, Susan texted me to let me know that not only had the leopard been spotted on campus, that it had actually been seen around the volunteer houses. This was an incredibly unusual situation for these animals typically do not wander anywhere near occupied structures and even when there is an attack reported, they are most often in more remote areas along paths or trails. For an animal like a leopard to come close to human contact it would surely have lost its way and would be doing anything in its power to remove itself from the situation. Other than the child in the conservation area that was attacked outside his school while using the outhouse, most other attacks have all occurred when people have been walking in the dark in areas where they probably shouldn’t be.

As I have everyone working five days straight to begin their time here, I now schedule our first Saturday as a half day so the residents can pick some activity to do. Today, we were planning to go the African Galleria in the late afternoon so everyone could do some shopping, and then we would stay for dinner as the food at the Ol’ Mesera is as good as any around. The clinic was very slow today with only three patients, though they were interesting cases as far as teaching goes. One was an elderly gentleman who came with a weeklong history of a facial palsy that was clearly peripheral (meaning it involved his facial nerve and not a brain problem) and there were no other specific risk factors other than he had a history of diabetes. In the United States, the first thing we think about when someone presents with a peripheral facial palsy is whether they could have Lyme disease as this is very often the presenting symptom and Lyme disease is endemic in the US, especially in the Northeast. Though Lyme disease exists in Tanzania, it is by no means endemic, and the leading non-idiopathic cause of Bell’s Palsy is HIV infection, which you should reflexively check in a patient like we do Lyme disease in the US. Thankfully, his HIV status was non-reactive, and it is most likely that his facial palsy is idiopathic, though we now know that many of these are actually secondary to Herpes zoster or Herpes simplex.

One of the other patients seen today is a long-term patient of mine who I first saw in 2011 with symptoms that were classic for bipolar disorder (and more specifically bipolar II) and has been stable on medications for the last fifteen years. When he had first come to see me, it wasn’t entirely clear what his problem was, but the more we talked, the more it was clear that he had an underlying psychiatric disorder that had caused him to be dysfunctional, losing his job and family. I placed him on lamotrigine, a medication that has proven very effective for bipolar II and his life turned around. Though he did not recover everything he had lost previously, he has remained extremely functional since starting the medication and has stabilized further over the last several years with the addition of olanzapine to his medication regimen. Every time I see him, he thanks me profusely for having recognized his problem so long ago and placed him on the correct medications so that his life has been more normal and productive over these last years.

I heard from Annie Birch today regarding the weather in the crater for our expedition tomorrow. Annie has been a fixture here in Karatu since long before I was coming and now manages her own safari company, Aurora Africa, which does small custom safaris to Tanzania and elsewhere. She is an amazing authority on anything to do with Tanzania or travel, and much more. She is a great resource. She was in charge of the group I had dinner with on Thursday and even though she hadn’t been able to go to the crater on Friday as she had stayed back with one of the travelers who wasn’t feeling well (and had come to FAME), it was great to hear from her that the crater was as magnificent as ever and there were no problems with the roads there. Taking my own group and guiding there always carries its own portion of anxiety given all the things that can happen – vehicle breakdowns (yes, this happens nearly every trip), no good animal sightings (has never happened, but I worry about it just the same), or problems with our paperwork. I’ve always been up to the task and really look forward to it each and every time, but it is a lot of responsibility just the same. Regardless, it remains a dream come true of mine to be driving a Land Rover through East Africa, and there is absolutely no substitute for that, at least for me.

The residents spent over an hour shopping at the African Galleria while I sat outside in the restaurant for most of the time, having drinks with Nish as well as two local friends, Will and Alex. Will had worked for the RVCV for several years in administration and is now doing consulting work in Karatu. Alex, who is from Liverpool, has been working for the RVCV and the Tanzanian Children’s Fund (TCF), their parent organization for nine years working with the school programs they fund. Dinner was great as usual, and we got home at a decent time as we’d be getting up before sunrise to head to the crater – we’d also be taking our three Tanzanian translators with us as they don’t get to go very frequently, and I figured I could spring for the $5 entrance fees for them.

The rainy weather seemed to be continuing making it either difficult for patients to get to clinic or they were choosing to go to their fields to till – regardless, the number of patients who were showing up continued to be exceedingly small. One might think that perhaps we had stamped out all the neurologic disease in Karatu district, but I know well from past experience that this has never been the case as there has always been more than enough work for us to do as long as we can get the patients to clinic. We’ve definitely seen spells of decreased volume for us before, and it has always been related to other events occurring in the country – whether it be the rain or a presidential election, in which patients tend to remain home, or harvest time, when they are in the fields, either way, they are not here for us to see them. Presidential elections in Tanzania (I have been here for four as the term in five years) have always been heavily contested here with regions either leaning towards the ruling party or towards the opposition, and the recommendations for us has always been to avoid political demonstrations at all costs, though that also seems to hold for the local villagers who tend not to want to travel during this time.

One of the patients seen by Shannon today was an eleven-month-old child who was brought in for concern of developmental delay as well as for frequent infections and appeared to have a diffuse rash consistent with varicella zoster, or chicken pox. The vast majority of children that we see in clinic with developmental delay is the result of birth injuries such as HIE (hypoxic ischemic encephalopathy) or perhaps other genetic disorders that we have no way of diagnosing here as we are far from getting genetic testing for these patients when it wouldn’t be changing their prognosis or treatment. This child, though, had clear dysmorphic features, which hadn’t been brought to the mother’s attention previously, that were consistent with Down syndrome, or trisomy-21.

This was clearly the reason for their delay to date in milestones and, perhaps more importantly, it was necessary to make the diagnosis to provide the necessary medical care such as following thyroid levels annually, as they have a much higher prevalence of hypothyroidism that increases with age, and make plans for rehab. Unfortunately, the government rehab center in Monduli, which is free for the patient therapy, but can be costly as their family must accompany them and find housing, doesn’t see patients until they’re two years of age which is starting late for these children. There is another rehab center in Moshi that we have recently contacted that is not a government hospital and will see younger children, though we just at the beginning of any collaboration. Hopefully, that will work out as these children with developmental delay from HIE, Down syndrome, or any similar condition, would benefit from starting therapy at around four months old.

I’ve mentioned in the past that we have seen Down syndrome patients not uncommonly at FAME, and Marissa Anto, one of our child neurology superstars who visited here as both a resident and attending, wrote a small blurb for the FAME website about her experience with a mother with a Down syndrome baby that was quite touching (There’s no word for Down syndrome in my language). The history of children with severe developmental delay in this country, with its incredibly harsh environment, extreme poverty, and complete lack of any social safety nets, has not been one of extreme compassion or altruism, but rather one of harsh reality. In the not-so-distant past, these children were set aside and not provided adequate sustenance, or perhaps even worse, and would rarely, if ever, survive past infancy as a matter of practicality.

As an example of how things are managed differently here as opposed to at home, Shannon also saw a young two-year-old Maasai boy who had a normal birth history and was developmentally normal but presented with recurrent, prolonged generalized febrile seizures that were consistent with complex febrile seizures based primarily on their duration. Febrile convulsions in children are benign, and we usually don’t treat them unless there are extenuating circumstances that would indicate an increased risk for harm or that the child actually had epilepsy that was being provoked by fevers. This child had been started on levetiracetam 125 mg bid previously based on the fact that they live quite far from any medical facility or hospital should the child have a prolonged convulsive and need medical care. After discussing the situation with his parents, it was clear that they felt more comfortable continuing his medication and the decision was made to continue his antiseizure medication for another six months and then discuss discontinuation when he returns for follow up.

That night, the rain fell as hard and fast as I’ve ever seen it here, and then the lightening with its tremendous thunder began and continued through the late-night hours and into the morning. As many of my friends and family know, I have always had an attraction to thunderstorms that dates all the way back to childhood but was further honed when I began working as a Forest Service firefighter immediately after receiving my undergraduate degree. I spent four seasons working for the Inyo National Forest and was stationed in the Mammoth Lakes Ranger District, which is in the heart of the eastern High Sierra and just below Yosemite, where I began working on the fire line as a grunt, but eventually worked my way up to TTO, or tanker truck operator.

For anyone who has spent time in the High Sierra, you would be familiar with the frequent thunderstorms that roll through the mountains on a regular basis, most often with magnificent lightning strikes and thunderous booms, that would, on occasion, strike a tree and ignite a forest fire. Whenever thunderstorms were forecast, we would be sent out on lightening patrol – which meant sitting in our fire trucks at the top of some peak with our binoculars watching the lightning strikes hit the ground and looking for “smokes,” or the beginning of a wildfire. We would then call the coordinates of the strike into the fire tower, who would locate the potential fire and, if big enough, would dispatch a crew to that location to prevent it from spreading. Now, some would ask whether sitting on the top of a high peak during a thunderstorm was actually a smart thing to do, but as the invincible twenty-somethings we were, we never really questioned that, and just did our jobs and somehow survived.

This morning’s educational lecture had been cancelled as the doctors were having a meeting that didn’t require our attendance, so we rolled up to report at around 8:15 am after they were finished with the doctor’s meeting. There was lots of discussion going on in Swahili, which none of us understood of course, but we were soon aware that there was a significant undertone of sadness in the room only to discover that a young fifteen-year-old boy had died the night before from a cobra bite. The area where he was bitten was in the Qaru region, a place where we had previously gone for one of our mobile clinics, and he had been brought initially to the local government hospital, where he was observed for several hours before being transferred to FAME. The local hospital did not have any antivenom, where FAME had a full complement of the polyvalent antivenom that could have been used. Unfortunately, by the time the boy arrived here, it was far too late for even the antivenom to work, though he was given one vial of it before determining that it would no longer be of benefit to him.

The most common cobra species in Tanzania are the Naja species whose venom is composed primarily of postsynaptic neurotoxins, cytotoxins, and cardiotoxins that cause rapid paralysis, severe tissue necrosis, and respiratory failure. There are both spitting and non-spitting species of cobra that are found in Northern Tanzania, with the former having the ability to accurately project their venom into the eyes of their attackers up to several meters away, immediately incapacitating the victim. The polyvalent antivenom available here has done away with the necessity to identify the exact species of snake or to have the correct antivenom available, though it’s essential they receive treatment as soon as possible after the bite as the toxins delivered immediately begin to cause remote effects that can be irreversible after only few hours, leading to death.

As if almost on cue, a good-sized scorpion decided to show up in clinic that morning only a few feet from where we were seeing patients. When someone spotted it and said something, I thought for sure it was one of the harmless whip scorpions that are found here, but, in fact, it was the real deal and looked like it was ready to cause some trouble. It had captured a large cricket that it had attached to its back in some fashion, though I removed it, there was little question that this scorpion was not pleased at all to be played with. I grabbed a teacup that was sitting on my desk and corralled it without causing it any harm to either me or the arachnid. I didn’t have the heart to kill it, so walked it some distance from the clinic and freed it to go about its own devices and hopefully not travel underfoot.

We had only three patients for the day, so it was a good that we had a few diversions to keep us occupied. We finished relatively early and I had been invited for dinner at the Plantation Lodge with Susan as there was a tour group staying there that one of my fellow board members, Barb Dehn, had organized, and she thought it would be nice if we could share information about FAME and answer questions they might have for us. There was great conversation and it was a lovely evening. The Plantation Lodge is pretty far off the beaten path, and I was thrilled that they had offered to have one of their safari guides come pick us up given the state of the roads. Though it would have been fun to have taken on the challenge, it was more important that we made it there safely, as the last thing I would have wanted to have happen would have been to miss such a fine dinner.

In prior years, when residents were here for a full four weeks, travel would be easy as I would bring them to FAME from the airport, and we’d all leave at the same time as well. As the Penn neurology residency program grew and as interest in the rotation increased, though, we began to run short on spots and our program had always been available to any resident in good standing. As a solution, in the fall of 2022, we expanded the number of available slots for residents from Penn and CHOP to a total of sixteen per year – twelve adult neurology and four pediatric neurology – four groups that would each spend three weeks with two groups in the spring and two groups in the fall. My time at FAME would also be expanded to spending six weeks twice a year for a total annual time of twelve weeks or three months. With the travel times to and from the US, this would result in a switchover weekend in which the first group would be departing from FAME on a Saturday, while the new group would have already departed on Friday evening from Philadelphia, and would be arriving to Tanzania early on Sunday morning.

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This meant that I would drive my departing residents to the airport (a three hour journey) for a Saturday evening departure, drive the hour back to Arusha to overnight there, and then get up at the crack of dawn the following morning to drive back to the airport to pick up the residents who would be arriving at 7:35 am, after which I would drive the new crew back to FAME. Needless to say, this was a very exhausting agenda for me, but I had always felt better dropping everyone off and picking them up at the airport myself. Fast forward to the following spring which was Jill’s first to Tanzania with me, and I once again made the grueling Karatu-Kilimanjaro Airport-Arusha-Kilamanjaro Airport-Karatu run, but now with Jill accompanying me. As Jill does not come for the fall trips (she’s busy enjoying the end of the summer at Long Beach Island which, of course, I can’t blame her for), and being the creature of habit that I am, it was back to the airport schlepp for me again when the residents switched over.

When Jill accompanied me for her second visit to Tanzania in the spring of 2024, it quickly became very clear to me that she had an agenda when it came to the switchover weekend and what was going to happen this time. Her reasoning, which is of course always impeccable, was that the residents were adults, or more specifically “grown-ass adults,” and could easily make it to the airport on their own (we actually arrange a shuttle from FAME for them), and that the arriving residents could just as easily make their way to FAME (again with us arranging for them to be picked up at the airport). I’ll have to admit that I was just a little bit anxious about things working smoothly, but with steady Jill’s reassurance, I was able to recognize that my OCD had gotten the better of me, and that the world wouldn’t come to an end by my not bringing the residents to and from the airport as I had always done previously. And perhaps even more importantly, it was tremendously healthier for me not to experience those changeover weekends the way I had been doing. So, rather than that brutal drive to and from the airport overnight, Jill and I made plans to get away overnight at one of the luxurious resorts in Karatu that offer discounts for FAME volunteers for just such an occasion.

On Friday, we had a half day of clinic, and the residents had decided to take out all their translators to lunch at the Lilac Café downtown once we were finished. Working every day for the last three weeks, they had all developed very close friendships and, as all of the translators are also clinical officers, everyone had the opportunity to learn from each other, whether it was medicine, Swahili, or Tanzanian culture. Even though we had called ahead with our orders, there still seemed to be a delay in getting our food, but that was fine since everyone was enjoying the company and we had no real plans for later in the evening other than talking amongst ourselves. It was a quiet evening at home for everyone to relax and pack, and all looked forward to sleeping in the following morning after the schedule they experienced for the last three weeks between work and game drives in the Serengeti. Vitalis would be coming at around 10:00 am to pick them up as he was concerned about traffic in Arusha with an East African Community Conference (Arusha is the “capital” of the East African Community – Tanzania, Uganda, Rwanda, Burundi, and Kenya) ongoing as well as weather related issues with flooding throughout Northern Tanzania due to all the rains that had been occurring.

Jill and I had made plans to visit Manyara’s Secret, a lodge on the far side of Lake Manyara that has wonderful views as it overlooks the lake and the wildlife in addition to having reportedly excellent food and plunge pools in each one of the lakeside cottages. We packed only what we’d each need for the night and were on our way in Myrtle, the short Land Rover. One our way, we stopped at the African Galleria for a quick lunch (this would allow us to have dinner, breakfast, and lunch at the resort as it was full board) of our favorite pumpkin soup, cheese samosas, and Thai chicken curry that was utterly scrumptious. After leaving the Galleria, we descended down the rift into Mto wa Mbu, which lies at the north end of Lake Manyara and is always the first area to flood when the rains begin. Two years ago, water was covering the entire road for several miles through town which is always a bit treacherous considering there are gigantic drainage concrete lined ditches on both sides just for similar occasions – driving into one of these by accident would definitely ruin an otherwise pleasant day.

The flooding today was far less extensive than before, but there was still only a single lane down the middle of the road that was drivable for most vehicles – the little three-wheeled bijajis (tuk tuks) do not have much ground clearance, though, so had water above their floorboards. We were slowed down a bit by the other vehicles trying to ford the flood, though made it through safely and began our search for the turn-off for Manyara’s Secret. I tried using Waze first, which unfortunately gave us the wrong turn, so we ended up pulling into the wrong resort that was less nice than I had expected and was happy to find out we were in the wrong place. After just a tad of redirection, though, we were able to find our way and arrived at the correct location, where we were thrilled as we walked to reception and took in the incredibly lovely view of their infinity pool overlooking the lake.

The weather was perfect, though there were rain clouds in the distance that never quite made it over us, and later that night, we had a wonderful light show in the distance with bursts of lightening in the clouds as well as a few bolts here and there. The food was delicious for each of the meals and the service was equal to any we’ve had elsewhere. We both agreed that we’d come back to stay again sometime soon and perhaps enjoy several nights as opposed to only one. The setting there was really spectacular – fishermen were out on the lake in simple boats or canoes, either standing to through their nets, or paddling vigorously to spread them out. The birdwatching was also excellent with numerous species along the lakeside. We even had black-faced vervet monkeys for a bit, though they were more of a nuisance and clearly unwanted around the pool and eating area, having to be chased away by the staff.

On Sunday morning, I received word from the incoming group of residents that they had all arrived safely and were making their way through immigration – the visa system had been down before they left, so none of them had actually received their visa yet, though they had their application numbers which turned out to be sufficient for them. Vitalis had the group finally and was making his way back to FAME with them which was our only deadline for the day as I had the keys to the house. We left Manyara’s Secret to make our way home before they arrived which worked well for us, though we didn’t have time to swim after lunch which was the only disappointment of the weekend.

We greeted Jonathan Perkins (JP), Shannon Shipley, and Vivian Chioma as they arrived safely with Vitalis, who has been my go-to driver for the last groups. After showers and a few minutes to catch their breath, we all headed down to the Lilac Café for a relaxing dinner after which we all made it back home so they could get a good night’s sleep before orientation in the morning and seeing patients in the afternoon.

It was education day and the last of the four lectures for the residents today – the staff had asked for a talk on mood disorders (depression) as well as associated conditions, so Lydia and Ozi had taken on the challenge. As neurologists, we do receive extra training in psychiatry and, in fact, our board in the US is the American Board of Psychiatry and Neurology from which we obtain our board certification, though it is specifically in neurology and the examinations are completely separate. The fact of the matter, though, is that we end up treating all of the psychiatric disease when we’re here and, as Frank has reminded me many times, we’re the closest thing to a psychiatrist that they have here. Unfortunately, he can also go to extremes with that philosophy like when he wanted me to be the one to place burr holes here for subdural hematomas – “you’re a neurologist and you know where the problem is so you should just drill the hole,” I would often hear from him. I continually fought back as I’m not a surgeon (you would not want me operating on you) and was eventually able to bring Sean Grady, then Penn’s chief of neurosurgery, to FAME to teach the clinicians here, all of whom do surgery, how to place burr holes and save people’s lives. I have always been one who knows my limitations and have never felt obligated to do things that I’m not trained to do nor comfortable doing.

Lydia and Ozi’s talk went over very well, and so much so, that they spent an entire hour presenting the subject with lots of questions at the end, and were never once shoed off the stage or hurried despite the fact that the talk was supposed to only be 45 minutes including questions. The entire staff were incredibly attentive during the entirety of their talk and their questions clearly indicated just how much they were able to absorb on the subject which was quite a bit. We do have reasonable medications here including the SSRIs, SNRIs, atypical neuroleptics and typical neuroleptics, as well as both valproic acid and lamotrigine for bipolar disorder. Gabriel asked me about lithium (commonly used for bipolar disorder), which is available here, and why he’s never seen me use it – my response was because it scares me when you don’t have lithium levels to follow and lithium toxicity can be extremely serious and harmful.

Our clinic for the day was a mix of patients, though the predominance was, once again, epilepsy with a smattering of everything else, including schizophrenia, migraine, post-concussive headache, dementia, catatonia, and stroke, though not to forget the one patient with musculoskeletal pain who that slipped through triage. From very early on, it was clear to us that epilepsy would have a place of its own from a standpoint of need, not only because there were so few neurologists here to treat it, but mainly due the impact that epilepsy has on the patient, the family and society when it is not treated properly. In addition, it was also clear that the burden of epilepsy here was immense. To begin with, 90% of epilepsy in the world occurs in low to middle income countries which is exactly where there are the fewest neurologists to treat it – patients with epilepsy in Tanzania, like much of Africa, have essentially no chance during their lifetime to see a neurologist, let alone an epilepsy specialist, as there are so few of either here. Physicians in Tanzania have very little neurology education during their medical education and training and almost none have ever had the opportunity to work with a neurologist during their training or in their career.

In addition to the social stigma of having epilepsy and seizures, the risk of uncontrolled epilepsy has a huge impact on disability, as patients with epilepsy are extremely likely to suffer serious injuries such as burns (households in Tanzania cook over open fires) and fractures. We have seen so many severe burns here from children or adults with epilepsy who fall into cooking fires or accidentally spill boiling porridge on themselves that it is clearly a major health risk. And none of this even takes into account the much higher risk of SUDEP (sudden unexplained death in epilepsy) in those patients with poorly controlled epilepsy. Lastly, children with poorly controlled epilepsy are not allowed to attend school which places a huge burden on their family given the likelihood that they will never be able to earn a living sufficient to support themselves with no education. With all this in mind, it was clear to us that successfully treating epilepsy patients, and especially children, would make a huge difference.

I had first met Dorothea Dickson in 2011 – she was a 9-year-old child who had a history of a likely neonatal stroke that resulted in her having a spastic right hemiparesis, but more importantly, she was having focal and secondarily generalized seizures that had never been controlled on medications, and, as a result, she had never been allowed to attend school. Over a short period of time, we were able to titrate her onto an appropriate dose of carbamazepine (one of the more common and least expensive antiseizure medications used here which was appropriate for her likely seizure etiology and type, and she became seizure-free after many years of uncontrolled seizures. Equally important, she was able to begin attending school and was eventually able to begin secondary school. Dorothea, who is now 23 years old and who has been seizure-free for many years, was seen today in clinic and continues to do remarkably well as far as her seizures are concerned. Had it not been for our neurology clinic at FAME, and its emphasis on epilepsy, it’s hard to say what would have happened to Dorothea, and quite frankly, whether she’d still be alive today.

Once we had completed our clinic for the day, we had planned to go back to Teddy’s to pick up the clothes the residents had ordered the week prior. It’s always a joy for me to visit her as she has two very young children, Allan and Adrian, who I always enjoy seeing as having clothes made is really not my thing personally, and other than a few shoulder bags that I’ve had made as gifts, I’ve lived vicariously watching everyone else buy their fabrics, communicate what they would like to have made, and then enjoy the fashion show when we go back for their fitting. Also, over the last couple of years, Teddy has also been keeping all of her fabric scraps for Jill to use for her artwork, so that’s been another thing for us to get done when we visit. A giant sack of fabric scraps is excellent to use for padding gifts in your luggage.

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The education aspect of FAME has been an essential factor from its very founding and has continued to be one of the most important parts of FAME that has set it apart from similar organizations that have brought healthcare to underserved areas of Africa and elsewhere. The “E” in FAME has been integral in both providing opportunities for Tanzanian healthcare workers to further their education through provided sponsorships allowing them to return to formal education programs and earn advanced diplomas or certificates that would have been otherwise impossible without funding. Those opportunities have always been one of the cornerstones of what FAME has had to offer the Tanzanian medical community and those that have chosen to work with them.

The other educational aspect of FAME, though, has been their volunteer program providing an opportunity for physicians and nurses from the United States and Europe to come and work side by side with the Tanzanian caregivers at FAME and to bring new ideas and alternative means of offering healthcare to the local population. This collaboration, though, has always been a bidirectional exchange of information and has offered a platform that allows both the Tanzanian caregivers and the volunteer caregivers to not only work together, but in complete unison, to enhance the level of care provided. The advantage for FAME and the people of Tanzania has clearly been tangible based on the outcomes data as well as the introduction of new services. The ability to provide burr holes for subdural and epidural hematomas, a life-saving procedure that was previously unavailable at FAME until the equipment was brought and personnel trained as a result of Penn neurology and neurosurgery’s collaboration with FAME and the addition of FAME’s head doctor and lead surgeon, Dr. Manjira. These patients were previously transported to Arusha or Moshi, two to three hours away, with many having died en route or even after arrival. Similar services in many other specialties have also been brought to FAME through our robust volunteer program.

These educational programs, providing further education for FAME caregivers and employees through sponsorship, as well as the volunteer program providing bidirectional learning opportunities, are what makes FAME so special and unique in this world of global medicine where so many good intentions fail to come to fruition, and both programs and equipment brought low resource countries so often fail to improve healthcare and are ultimately for naught. This is why I have spent the last sixteen years working to further develop and maintain the partnership that originally began with an unplanned visit hoping to simply see a Tanzanian medical center, but instead, finding this mecca of healthcare and all those individuals who have given their time and energy to make FAME Hospital what it is today.

Clinic today was moderate once again, with eleven patients total, as this was our third week here and we had seemingly done a good job in stamping out neurologic disease in the Karatu district. This was the last week for the current group of residents as they would be departing on Saturday and a new group would be arriving on Sunday, hopefully, given the current world events and specifically the Middle East Crisis. The arriving residents had unfortunately all been scheduled to originally travel with Qatar Airways, though because of the crisis and the closed Qatari airspace, they all had to cancel those reservations and scramble to find flights with an airline that wouldn’t be flying close enough to the Middle East to pose a problem. They had all opted to fly with Ethiopian Air through Addis Ababa, which I had also chosen to rebook my return ticket, while Jill booked with KLM traveling via Amsterdam.

After clinic was over for the day, I had planned to bring everyone to visit with Daniel Tewa. I have written about Daniel so often in the past as I have brought each and every group of residents to visit with him, though it would be helpful to once again give a bit of background for this incredible individual whom I have known for over sixteen years. When I had first come to Tanzania in 2009 with my children, Thomson Safaris, the company I had chosen to take our trip with, had offered to set up a volunteer experience for us which is how we ended up spending three days in Karatu and what set in motion the events that changed my life forever. Our volunteer time was to be spent at the Ayalabee Primary School in Karatu, where we would be helping paint the school, and we had also brought school supplies with us to give to the teachers and children. As one of the village elders who was acting as a liaison, we were introduced to Daniel Tewa, and we very quickly became friends – we visited Daniel’s home where he has built a replica of an underground Iraqw house, similar to what he grew up in for the first twenty years of his life, and learned a bit about the Iraqw culture.

Fast forward an entire year to when I was planning my return to Tanzania to work at FAME, and I contacted Daniel to find out about visiting again with him, and he endeared himself when he recalled our visit the year before and actually remembered both of my kid’s names. He invited me again to his home, and this time, I learned about Tanzanian hospitality and the fact that a guest to your home in the afternoon is never allowed to leave without first being offered dinner, otherwise it would be considered rude. We shared a traditional Iraqw meal in the central room of his typical Bantu house, just the two of us as women would normally only eat after the men had finished, and shared stories of our families and the world. Daniel is a self-taught (he only went through primary school) historian and political scientist who can quickly recall statistics about any of the fifty United States (capital, when it became a state, square miles, etc.) as well as give you a dissertation on any current topic in world politics. In the early years of my coming to FAME alone and not with residents, I would always visit Daniel for dinner at least once during my trip here, and we would always have long discussions about essentially whatever was going on in the world that day, or even deeper subjects such as homosexuality, a very controversial topic here given the fact that it is very illegal and punishable by death. We didn’t always agree on everything, but there was mutual respect between the two of us and our discussions were always heartfelt, lasting well into the evening time.

When the visits began to involve my residents, our dinners moved from his home to his daughter’s, Isabella, who lived close by and could accommodate more people as our group now numbered five or more. Despite my insistence on helping with the cost of these outings, Daniel would never hear of it for he said that we were honoring his family by our presence and for what we were doing for his country of Tanzania by our act of volunteering and working at FAME. On one occasion perhaps ten years ago, as Danielle Becker and I were leaving town, we stopped by to say goodbye, and his youngest son Stanley (who by the way was adopted by Daniel and his wife, Elizabeth, after Stanley’s mother died during childbirth, and he became their 12^th child) was at home. Daniel told me that they had just been to the local hospital as Stanley’s knee had become swollen – Danielle and I were in shock when we looked at his knee and even two neurologists could see that it was infected and in need of intravenous antibiotics, not something that had been given to them by the hospital. I called FAME and arranged for Stanley to be seen immediately and, sure enough, he had a horribly infected knee that without proper treatment would have been a disaster. It was incredibly serendipitous that we had just happened to stop by at the right time and it’s a story that Daniel and I have shared many times over the years.

I had thought our visit this evening would be for the typical African coffee (coffee boiled with fresh milk and strained) and perhaps some sweet cake that Isabella would often pick up in town, but when we arrived, there seemed to be a bit more going on than just that. I had Daniel show everyone his methane gas gathering system that’s still in use even though since my first visit he has plugged into the local electrical grid. When I first arrived, their lighting and cooking were done entirely with methane gas that is produced from the urine and manure of his three cows mixed with water into a large underground tank which then ferments with the methane gas routed out the top and into pipes running into his house. The remnants of the process form a sludge that is then forced out of the tank by the pressure and is used as fertilizer as it runs into the fields after it’s formed. They still use the gas for their cooking but have since plugged into the grid for lighting.

We then went to tour his underground Iraqw house that he built in the early 1990s after he was tired of his children not believing him when he told them stories of growing up underground in such a house. Prior to and for a number of years since independence in the early 1960s, the Iraqw and Maasai were enemies primarily because the Maasai believed that all cattle were God’s gift to them such that when they took the cattle from the Iraqw, they were only taking what was rightfully theirs and it wasn’t stealing. To protect their cattle from the Maasai, the Iraqw would take all their livestock into their underground house to join them for the night and could hear if anyone came walking on the roof of their house which was forbidden at night with anyone doing so was immediately considered to be a thief and attacked. It was not until 1986 that the Maasai and the Iraqw finally signed a treaty.

As we gathered at the table and chairs in front of the house that he is building for his grandchildren to stay in, we were informed that it was his daughter, Bernadeta’s, birthday and that his family (remember, twelve kids in all) always celebrates his children’s birthdays even if they may be elsewhere in the country living at the time. As such, they had prepared a delicious dinner for us of roasted chicken and chips (fries) along with drinks. We absolutely hadn’t expected this, though it was incredibly fortuitous as we hadn’t yet eaten and for whatever reason, the dinner that had been brought to our house which we checked before we left seemed to be somewhat inadequate for us. We sat enjoying first his African coffee, and then our dinner, chatting away about world politics and listening to him recite those challenging facts about each of our states. There was so much food for us that we departed that evening quite full and very satisfied.