Saturday, September 27 – And an even quieter Saturday….

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I will be the first to admit that the pandemic has clearly affected FAME, but not necessarily in the ways one might have expected. When things first hit, FAME went into action mode immediately and was the model of system change in this very rural portion of Northern Tanzania. They set up training sessions regarding safety that were not only attended by our staff, but also by other district health personnel and were likely responsible for the fact that things were handled so well here in this region where supplies and health services are very scarce. In cooperation with the district health authorities, FAME became an integral part of this areas response to coronavirus and, in doing so, served to provide the community with the very same quality healthcare they have become known for over the last dozen years.

And, most importantly, this was an all Tanzanian response to this natural disaster. Though FAME’s model for years has been to have western volunteers here to assist the Tanzanian doctors by teaching them specialties that are not always available here or to help with surgical training, it has always been the goal that this will be a medically self-sufficient healthcare facility completely staffed by Tanzanians who are providing all of the services. In March, when the pandemic hit the world for real and it became clear that we had to return to the US at once for fear of having to “shelter in place” for months (or longer it now turns out), I left FAME with our mission nearly complete and was the last volunteer to leave. It is now September, and there have been no volunteers here at FAME in the interim, yet they have continued to perform in a superlative fashion, on their own and completely self-sufficient, even in the face of the looming pandemic while still continuing to provide all of the necessary “routine” healthcare that they have been delivering since the very beginning of this project. That could not have been done without the amazing Tanzanian talent that exists here and, for that, they are to be commended, though I doubt that any one of them would consider themselves a hero, yet, quite simply, that is what each and every one of them has been.

So, I was the last volunteer to leave in the spring and have been the very first volunteer to return. There was little question for me what the right decision was going to be regarding my return and, barring taking any absolutely unreasonable risks, I felt the need to return for a number of reasons. Top among them were my patients, many of who I have followed every six months for many years and who would expect me to be here for they are not watching the news each night, as we are in the US, to know the exact nature of this worldwide healthcare disaster. There has been a level of trust that I have spent years to develop with the patients here, who know that I return each and every six months and, to have not returned, could have damaged that trust irrevocably, which was something I simply could not fathom. As much as my patients have come to trust me, though, so have the doctors, nurses and staff of FAME and I felt a strong sense of commitment to them, knowing full well that my simple presence would essentially be a moral boaster for them. Seeing me in the corridors of FAME would provide a sense of comfort to those I have come to know as family and would restore their connection to the rest of the world. Any concern of abandonment that anyone here might have had would be quickly allayed by my simple response of “marahaba” to their greeting of honor, “shikamoo,” as we passed in the hallway each time. Simply put, FAME has weathered a tremendous storm in the most successful manner possible and there is little question of them continuing to do so for many more years to come.

The African Galleria

I had hoped for a quiet clinic today as I had been invited to lunch by a good friend at his African art gallery, the African Galleria, that is about 20 minutes out of town in the direction of Lake Manyara. I had been introduced to Nish a number of years ago by one of prior volunteer coordinators and we have stayed in touch since. His gallery is perhaps the largest in Tanzania and relies nearly entirely on the safari company traffic that passes by every day on their way to Ngorongoro Crater and the Serengeti. There are usually hundreds of vehicles that pass, many of who also stop to spend some time shopping. Nish and his brother had just completed a major construction project to develop a wonderful outdoor restaurant as well as major renovations to the inside of their shop so that everything inside and out is now perfect, that is other than the lack of tourists and safari traffic that has occurred since the beginning of the pandemic. There are now signs that some of the visitors are coming back, albeit quite slowly, and no one knows for how long as there are still many concerns about the future of this virus in Africa and elsewhere.

The African Galleria

I sat outside with Nish as my pizza was being prepared and we had the place to ourselves. Sadly, there were no other vehicles or tourists for much of my visit there which was a constant reminder of the current time that we are living in right now and the challenges that remain ahead of us. As we sat at one of the tables of his lovely outdoor restaurant, the impact that all of this has had on every aspect of our daily lives was readily apparent, from FAME, to the African Galleria, to the safari companies that are dependent on the tourist travel to this lovely country. All are trying to make do in these times of hardship and some are more successful than others.

The African Galleria

I left the gallery to head back up to Karatu on a nearly empty highway that remained such until I was in town where much of life here seems to be at an almost normal pace with the markets full of shoppers and the normal hustle bustle on the streets that is this place I love. You would be very hard pressed to guess that we were in the middle of a worldwide pandemic if you based it solely on the appearance of downtown Karatu, other than perhaps the near complete absence of safari vehicles plying up and down the main street, coming from or going to the Ngorongoro Gate that leads to the Crater and the Serengeti.

The African Galleria

It was rather late in the afternoon when I arrived back home to my house and I had originally thought that I would be having dinner with Daniel Tewa tonight, though we had apparently had our wires crossed, for he was actually out of town and had expected me a different time entirely. Faced with the sudden freedom of an entire evening to myself, I chose to do some reading from the book I had started here, King Leopold’s Ghost, the previously untold story of King Leopold II and his quest to own a colony that eventually became the Congo Free State where horrible atrocities and genocide of monumental proportions occurred around the turn of the century. It’s a hard book to set down once you get it started and I look forward to reading more each day. It was a relaxing evening of quiet in the Raynes House that night, far different from the house full of residents that I have become accustomed to on my normal trips here. Truth be told, there are advantages to each, though in the end, I much prefer the latter for having my full team here with me allows us to do the most good, see the most patients, teach the most, and ultimately provide the greatest benefit for the people of Tanzania while also allowing those residents and medical students who accompany me to experience the world of global health and health equity.

 

 

Friday, September 25 – A quiet day in clinic….

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It typically slows down at the end of the week for us, but today was exceptionally quiet and we mainly saw a few follow up patients from Rift Valley that we had seen earlier in the week. These were patients that needed laboratory testing that we don’t have available there (though we used to run a portable lab, but more for medical issues) making it necessary for them to travel here. Thankfully, transportation for the villagers in the Oldeani area near RVCV is provided by the vehicles that are traveling from the children’s village to Karatu several times a day which is a huge benefit for them as they would otherwise have to walk miles to get to the main road and catch a bus. There are no buses that travel to that area for several reasons, but probably mostly the occasional condition of the road which can at times be nearly impassable. We had these patients get their blood work first and then did what was necessary based on the results. One young boy had an essential tremor who we had been seeing for several years, but had never had thyroid testing done that I just wanted to check to make certain that he wasn’t hyperthyroid. These tests are very expensive here, costing 20,000 TSh for each, which is about $8 and would be a bargain in the US by any definition, but are out often out the reach of patients here. Still, when providing these tests as part of the 5000 TSh cost of a neurology visit, you can imagine what it requires in support to run this program. Then, when you add in the cost of a month’s worth of medication, it can become even more costly. Some of the anticonvulsant medications that we use at the doses necessary for them to be therapeutic can become very costly indeed.

A panorama from my bike

Another patient that we saw in the morning was a gentleman who presented with numerous complaints that had accumulated during the pandemic, though had no clear underlying cause or unifying diagnosis. While telling us his story, or actually while telling the others his story as it was all in Kiswahili, it was quite clear to me, and I later found out to the others as well, that he was very depressed and that the symptoms he was complaining of were related to this rather than to any underlying physical ailment. His story continued for a very long time until I finally took the opportunity to step out with the others and explain that though I’m sure he had much to share, we were not therapists and that we could help the patient most by making a diagnosis and treating it appropriate. There was little question that the patient needed counseling, but he also needed an antidepressant medication in the short term at least. We eventually provided him with a prescription for fluoxetine, or Prozac, and explained that it was also very important for him to consider speaking with someone in the near future as well.

We hung around for much of the afternoon waiting to see if any other patients would show, but it remained quiet and I took the opportunity to catch up on some of my writing and emails. We were all planning to meet later that evening for a dinner of nyamachoma, or barbecued meat, that is served usually with French fries (chips) or fried plantains. The roasted beef, or sometimes goat, is incredibly tasty and is one of my favorite foods here. You order the meat by the kilogram and it is also served with hot sauce (pili pili) and salt to dip it into. I was totally looking forward to taking everyone out for dinner, but wanted to get a bike ride in first. I realized that I had sent Turtle down to the mechanic to take care of a few small repairs earlier in the day and hadn’t heard back from him which would be a problem since I was planning to use Turtle not only to get to dinner, but also to pick up some of the people who were coming to dinner.

A view over the handlebars

I arrived home from clinic and got everything ready for an evening bike ride and took off down the FAME road hoping to fine some nice new route to travel through the back streets without swallowing too much dust from the passing cars. The dry season here can be absolute murder for anyone with respiratory problems around here, and even for those without any issues. The red clay dust coats just about anything within several yards of the road so that all the roadside plants have a reddish orange hue which is usually the tint as my beard by the time I leave. Though I had brought most everything I needed to ride here, I hadn’t brought any bandanas to wear and though I had spoken with Phoebe who was pretty sure she knew where to find some, they wouldn’t arrive until the weekend, so I would have to suffer for yet one more ride with more enough gritty dust in my mouth.

Our nyamachoma dinner group

Looking at the map of where to ride, I did notice that there was a small lake or pond that was on the southeast outskirts of town, or directly cattycorner to where FAME sat on the map. I traveled through the backstreets and then across the highway and into the backstreets on opposite side of town. I eventually found the lake and sat admiring the scenery when my phone rang and it was Soja, our mechanic, telling me that Turtle was just about finished with all of the work that consisted of more than I planned which is usually the case considering the wear and tear these vehicles take here. I hustled back across town to the FAME road and pedaled continuously, eating dust all the way, to make it home before Soja did with Turtle. I beat him with lots of time to spare, though would have to leave very shortly to pick the others up and meet at the restaurant at 7PM with everyone else.

Joel, Selina and Me

By this time, I was starving and quite ready for my nyamachoma, though knew that it would be at least another 30 minutes before everything was cooked. That gave time for everyone to arrive, which in the end was about 9 people. The meat was delicious as expected and we had a second round of meat, taking at least another 30 minutes after ordering, to finish things off. I had decided that this would be my treat considering everyone there had something to do with the neuro clinic and the final bill that included all the beef, chips, and several rounds of drinks was 120,000 TSh including a generous tip that was much appreciated by the waitress. That turned out to be a bit over $52 USD for nine people! It was a great evening that was enjoyed by all.

Me and Abdulhamid

Thursday, September 24 – A day of mixed emotions….

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Participating in a Zoom neurology lecture hosted by Mike Baer in Philadelphia

As is often the case in medicine, there can be massive swings in your emotions on any given day. Today was one of those days where we were able to make such a difference with some patients, yet with others, we had little to offer other than empathy and the hope that we had at least allayed some of their fears for the unknown. It is perhaps no different than in the US, that when you give a diagnosis of a disorder that has no treatment or, at best, is symptomatic and not curative, that patients may seek care elsewhere looking for more answers. In a country with a far disproportionate number of specialists, it is easy enough to find another physician to provide this second opinion, or perhaps even many, but here in Tanzania, that is impossible. There are only a handful of neurologists in the country and those that are here are all generalists, like me, though they do not have the ability to send their patients to subspecialists and experts in a specific field as I do back home. Patients that we see here have often been to several health centers or dispensaries before us with the hope that one of them may have some answers for them. They are often misdiagnosed and given medications or therapies that will be ineffective in helping them whatsoever and, at times, may actually be harmful. We have seen this all too often here and it is very sad when it occurs.

Participating in a Zoom neurology lecture hosted by Mike Baer in Philadelphia

Participating in a Zoom neurology lecture hosted by Mike Baer in Philadelphia

So, on this backdrop, our first patient of the day was a young girl from the Ngorongoro Conservation Area who came to us with a history of recent onset seizures that had begun only days before coming to see us. The most disconcerting thing, though, was that her seizures all consisted of a very focal onset with right arm shaking. When this situation occurs, the new onset and significant focality, we become immediately concerned about some sort of mass lesion serving as a seizure focus, despite the fact that her examination was completely normal. At home, she would have been scheduled for a special seizure protocol MRI even before she walked out the door along with an EEG, neither of which are readily, if at all, available here. The family was Maasai being from the NCA and her mother did not speak Kiswahili, though the young girl did, so we had a three way translation ongoing during much of her visit.

A Maasai mother and daughter

We discussed the need for a contrasted CT scan, but unfortunately, they had no way of covering the cost of the study which is often the situation here. Though the cost of such a procedure is far less than it would be in the US (200,000 TSh or approximately $90 USD), it is often still far out of the reach of individuals here and it is common practice for a patient or family to go back to their village to raise the necessary funds. That is more successful than you might imagine as it is culturally unacceptable here to have money in your pocket with a member of your clan in need. Doing so would be an act that you would immediately be shunned for by the village. As I have often explained before, it is also not possible for FAME to offer free medical services for a number of reasons. A not insignificant portion of FAME’s operating expenses comes from patient fees, but even more importantly, in doing so FAME would immediately alienate all the other caregivers in Karatu who actually make a living practicing medicine and in one fell swoop, we would suddenly be caring for nearly 60 million Tanzanians who would flock here to receive their free medical care. That would become an untenable situation almost immediately.

A Maasai mother and daughter

Thankfully, this family was either related to Kitashu or from a nearby boma and he immediately authorized the CT scan to be done while we would work out payment at a later date. I will also add that it is very unusual in situations involving children, that we are not able to find some way to cover the cost of their medical care in some fashion. This is the normal role of Kitashu and Angel as they will sit down with a family and figure something out when it comes to children. We were all relieved to see that her CT scan with contrast was entirely and there was no mass lesion or other abnormality that could be seen as the cause for her seizures. Had we found anything that required treatment, that would have been an entirely different matter in regard to how the cost of future medical care would be handled. There is a government pediatric cancer hospital in Dar es Salaam that does treat children free of charge, but it’s a matter of the family getting to Dar and then their housing while they’re there that must be worked out. It’s not an easy task to figure out healthcare in a country where access is so very limited and fee for service in advance is the rule.

I placed the young girl on carbamazepine given the fact that the seizures were so focal, but noted that we would consider tapering her in a few years to make sure that she still needs the medication and at that time would consider transitioning her to lamotrigine which is safer in pregnancy, but also quite a bit more expensive. It always seems to be a juggling act here in some form or fashion.

Mother and child

My next patient happened to be a 13-month-old little boy who was having significant developmental problems, but more importantly, he was having brief episodes of posturing his arms that was pretty classic for flexor spams during which his eyes would widen in a look of startle. His mother said that these had been going on since he was about 4 months of age and, during the visit, I also witnessed the child to have a number of brief episodes in which he would suddenly extend both of his arms in what I recognized as being fairly classic for infantile spasms. He was completely unable to hold his head upright and his mother also noted that he seemed to unable to see. When I examined him, his head circumference was normal and he was hypotonic, but most importantly, was indeed unable to hold his head up whatsoever. The baby may have responded to the flashlight, but it was difficult to tell and he clearly did not track faces or the flashlight. He did attempt to grasp objects in any manner.

My concern for this baby was that he most likely has infantile spasms which are part of a very significantly disabling epileptic disorder seen in infancy and called West syndrome. In addition to the infantile spasms, children are typically developmentally delayed  and have a typical EEG pattern, though we don’t have EEG readily available here at FAME and I didn’t feel that it would likely change my impression had we sent the child to KCMC for this procedure. There are a number of causes for the disorder, but we have little in the way of capability to test for them here and the child appeared physically normal other than his vision which was clearly impaired. The first line treatment is to use steroids, though after discussing the case with Dr. Dan, it’s very likely that they won’t help given the amount of time that he has been seizing. Still, I placed him on high dose prednisolone and asked them to return in 10 days prior to my departure. There is an antiepileptic agent available in the US that’s helpful for this disorder, but it is far from available here, so we try using a second line agent such as topiramate. The prognosis for this child given his developmental delays, his visual impairment and the seizures is very poor and these children will often develop another severe epilepsy syndrome as they age called Lennox-Gastaut syndrome. Overall, not a generally encouraging outlook for this child, but we’ll see what he looks like when he returns.

Abdulhamid examining one of our patients

And then, adding insult to injury, as if we weren’t already depressed enough, in walks a gentleman sent over to us from Dr. Lisso in the OPD with the complaint of weakness. Abdulhamid was taking his history and after a bit of sorting things out, it quickly became apparent to me that this man was having progressive, painless weakness of his left arm and despite some other complaints that he had, it really boiled down this symptom being the most profound. I had immediate concerns for what we were dealing with the moment this piece of information became clear and mentioned this to the others as they began their examination. Unfortunately, his examination only confirmed my earlier suspicions and he indeed had the constellation of findings that includes both upper and lower motor neuron involvement that define this dreaded disorder. He also had diffuse muscle fasciculations in multiple limbs that pretty much clinched the diagnosis of amyotrophic lateral sclerosis, or Lou Gehrig’s disease.

At home, I would have referred him for an EMG for further confirmation of the diagnosis and could have certainly sent him to Dar es Salaam to have had this study performed, but given his findings on examination and his history, it would really have been superfluous and very costly for him with no chance that it would have changed his management. Though a medication does exist in the US to “treat” this disorder, it merely extends a patient’s life by months at best and is extremely costly so that it is most likely not available in any country with socialized medicine, let alone a here. This disorder is hard enough to explain to patients in the US, where most everyone has heard of Lou Gehrig’s disease, and it was particularly difficult to explain to our patient, though it was imperative to do so and prevent him from going to other health centers for other opinions where he may be misdiagnosed and mistreated. Certainly, we can never be totally sure that won’t happen, but we do our best to prevent it if we can. As I have mentioned before, it is not uncommon for patients here to seek opinions from multiple health centers when they don’t fully understand what is going on or may not be comfortable with what they’ve been told. It is as important for us to make patients feel that they have been fully evaluated as it is to provide them a treatment, and more so if no treatment is available.

Revo speaking with one of our patients

Fully deserving a break from the cases we had seen, a long term patient of mine came in that I have been treating successfully for bipolar disorder that I had diagnosed a number of years ago and had placed on lamotrigine. He continues to do well and just came in for refills which he continues to do religiously every six months. I was so grateful to see him today of all days. At the very end of the day, a trauma case was brought into the ED and it was so impressive to see the doctors and nurses in action where only several years ago there had been no ED. The patient had been involved in a traffic accident and had suffered a head injury, so I did stick around to look at the CT scan for them, which was thankfully normal. Having no neurosurgeon here, we would have to send any patient with a subdural hematoma to Arusha to be treated. We’re hoping at some point to train the doctors here, most of who also do surgery, to provide burr holes for these patients when needed.

I took the evening off in regard to my bike riding and was looking forward to signing into our neurology faculty meeting back at Penn as it was going to be a town hall format dealing with all of the current ongoing stresses trying to manage work and home life in the age of COVID. It was a great meeting and I am so happy to be part of a department that is continually discussing this issue as well as the racial injustice we are dealing with at home. Though I am for the moment somewhat insulated here in Tanzania, these are very distressing matters that we will need to deal with as a society and as a department and keeping this conversation in the forefront is the best way for us to overcome these serious issues together.

 

 

 

Wednesday, September 23 – A second day at Rift Valley Children’s Village

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Patients waiting for clinic

It was another early morning for me, not only due to the fact that we had planned to leave for RVCV by 8 am, but also because there was a patient in the ward that Dr. Gabriel had asked me to see prior to our departure. This was a woman in her 50s who had been brought to FAME after developing rather rapid onset of right sided weakness by history and who had undergone a CT scan of the brain that demonstrated an enhancing mass lesion in the left frontoparietal region with a significant amount of mass effect and edema. The radiology techs were not yet in so I was not able to view the study myself but based on the report from Dr. Alex, our radiologist in the US reading our studies here, it seemed pretty apparent that we were either dealing with a metastasis or primary brain tumor like a glioblastoma multiforme. She was also HIV positive and without knowing her CD4 count it was difficult to tell whether she was immunocompromised or not as that would certainly impact our differential with things such as toxoplasmosis if indeed her CD4 count was low.

Registering for clinic

Robert, Revo and Kitashu

Revo prepared to see patients

Based on the description of the CT scan, I was pleasantly surprised to find her awake, though she had significant left hemispheric deficits indicating that most of her hemisphere was not functional. She had a left gaze preference, complete right visual field loss, was globally aphasic, had a dense right hemiplegia and, finally, complete loss of any response to painful stimuli on the rights. The fact that she was still awake given her examination with such extensive involvement of the left hemisphere was quite remarkable. I wrote up my consult making the recommendation to place her on steroids given the extensive amount of edema that was seen on the CT scan and we packed up for our departure to RVCV. Later in the morning, I was able to speak with Gabriel about the patient and learned that they were transferring her to Dar es Salaam at the family’s request, but that he would be certain to give her the steroids before she left. The following day, I finally had a free moment to review her scan for myself and was again very impressed that her level of consciousness had been as good as it was prior to her transfer. That is typically an indication that the process has been more of a chronic one as the patient is able to “tolerate” the edema without significant change until one day it just becomes too much and is the straw that finally breaks the camel’s back, resulting in a sudden neurological change in status that appears to be more acute even though the process had been going on for a longer period of time.

Revo evaluating a patient

Revo evaluating a patient

The drive to RVCV is, of course, one of my favorites and some of the most stunning landscape one can find everywhere. The region is populated primarily by the Iraqw, one of the two most common tribes that we treat here in the Karatu district, with the other being the Maasai who are most populous in the Ngorongoro Conservation Area where they graze their large herds of cattle, goats and sheep. This morning, the clouds have burned off my earlier than yesterday and the warmth of the sun was a welcome addition and harbinger of another wonderful ahead of us. We arrive quite early, so much so that Katie, the nurse at RVCV, had just prepared her breakfast and coffee thinking that we must still be in transit. There was absolutely no rush for us to get started, of course, and we had the entire day in which to see our patients at a very comfortable pace. Though we had planned to see a greater number of patients today, we were under no deadlines such as the board update call I had from the day prior and we could stay until we were finished.

Robert enjoying himself with a helper

Revo evaluating a patient

We again decided to use the two rooms and two teams that we had done the day before and which had worked out incredibly well. For the day, we had about an equal split of epilepsy and headache patients, though we also saw a Parkinson’s patient who had quite significant impairment and was off his medications as they had run out. I was devastated when I learned that somehow our carbidopa/levodopa (Sinemet) supply had been left out of the box of medications that we had brought, but realized that it wouldn’t be difficult to send the medications to him on the following day. This morning, we had actually met one of our patients from yesterday along the road to give her a supply of fluoxetine (Prozac) that hadn’t been available to pack, but had arrived while we were gone. The handoff went without a hitch and is often how things are done here on mobile clinics as no matter how hard we try, there is always the chance that something might be left behind or still on order as we set out for clinic that might only be an hour away by vehicle, but often many more hours by public transport or on foot.

One of our patients at RVCV

Kitashu, Revo and Robert relaxing at the end of the day

We once again took our break for a delicious lunch made by the house mamas and one of the volunteers had even baked some delicious chocolate cookies that were the perfect dessert for such a day. After we had made it through our day of patients and before leaving, we had decided to visit the duka (shop) where the Rift Valley Women’s Group sell most of their merchandise through. This program is one that has been around for some time in connection with the RVCV and has been a mechanism for training and marketing of items that are made by the women of Oldeani for sale in many of the lodges throughout the Northern Tanzania. Arturo has been helping to manage and grow the group for the last three years and has done a remarkable job, though will be leaving in the near future. I always bring the residents here to buy gifts for home given the excellent cause that the money is going towards and the fact that all of the items are remarkably well made and very affordable for what they are. We had visited the duka yesterday and done a fair amount of shopping, though it was a unanimous consensus that we all visit the shop again today for there were still a few items calling our names. It is such a wonderful project that it is almost impossible not to want to find something there.

Lunch at RVCV

A view of RVCV

Driving home, we all stopped to take a few photos at a spot that not only overlooked the beautiful fields that seemed to go on endlessly into the distance, but also that mountains that formed the eastern rim of the crater and Mt. Ngorongoro, the tallest of them that also lays to the east of the crater. It was a really glorious afternoon with the sun shining strong and a stiff breeze afoot. It was the kind of afternoon that reminds one of all the reasons for coming to East Africa in the first place, and, for me, Tanzania specifically. I was driving a vehicle full of Tanzanians and we were all here for the very same reason, which was to help the residents of Northern Tanzania with their neurological issues while also leaving behind a legacy that would continue to provide this care in my absence. With the group of doctors, nurses and social workers I was transporting this day, there was little question in my mind as to the security of that dream.

A view of RVCV

Another view of the wonderful countryside heading home.

Scenery on our return trip

Having arrived home at a decent hour with plenty of daylight remaining, I decided to head out for another of my mountain bike rides exploring the environs of Karatu. I have been trying to take a different route each trip just to learn the various areas, many of which I have never been to previously during my many trips here. There is a short cut that I always take to get to Gibb’s Farm and also to Daniel Tewa’s home, so I had set my mind to taking this short cut, but knew that there would be one steep downhill section that might pose a bit of an issue. As I approached the section, I slowed to a snail’s pace and thought that I would just cruise down it slowly, but apparently that was not the tact I should have taken. Shortly after starting the descent, my front tire promptly slipped in some loose soil and down into a rut that crossed up my handlebars and threw me over the front. Thankfully, I was traveling extremely slowly and found that my greatest injury was too my pride, though I did get a rather nasty road rash (though I was not on tarmac) on my right thigh and right forearm. Surely it was a badge of honor for having taken my first spill in my incredibly short mountain bike career, but I was no worse for the wear and got back in the saddle to finish my ride.

A selfie of Abdulhamid and me in front of Turtle

Road rash from my mountain bike spill

 

Tuesday, September 22 – It’s off to Rift Valley Children’s Village….

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Our neurology mobile clinics have become a fixture at FAME over the years as I have been doing them since 2011 when I come for my second trip. Unfortunately, due to both the pandemic and the elections here this year, it had been decided long before my arrival that we would not be holding these clinics as usual, the former reason being obvious while the latter reason is a bit subtler and has to do with the fact that FAME must remain as politically neutral as possible in anything that it does and any appearance otherwise could easily be misconstrued by someone. The loss of the mobile clinics would be a blow to the normal work we do here, but then again, I had no residents to share the work with me and the number of patients that could be seen would have been particularly limited compared to the amount of resources required to for the clinics. I was quite thrilled, then, when I found out that we would at least be make the trip to Rift Valley Children’s Village while we were here, one of my absolute favorite places on this planet.

My crew..Revo, Adam, Christopher, Abdulhamid, and Kitashu from left to right

I have long ago lost count of the number of times that I’ve visited RVCV for clinics over the years, but it easily dozens. I’ve told the story of the Children’s Village a number of times on my website, but suffice it to say that it’s a magical place founded by India Howell and is one of the reasons that FAME is here today for it was India that suggested to Frank and Susan that they build their clinic in Karatu and, as they say, the rest is history. The Children’s Village is not an orphanage, but rather a home to about 100 children at any one time, all of who have been adopted by India and her business partner, Peter. The children are her children and they live in the village until they are old enough to go away to college after having received an excellent education at the school next door where India has partnered with the community to create a better learning environment with more teachers. The children have a phenomenal record of passing the national exams and advancing in the educational system here.

Revo taking a good history

FAME has been providing regular medical clinics at RVCV until only the last couple of years and I have been providing neurology care to children there as well as residents of the nearby village. Over the last two or so years, with limited manpower at FAME, it has made more sense to transport patients here than to hold the general medical clinics at the village, but I have continued the neurology clinics as part of our mobile clinic program and it has been very successful. RVCV has always had a nurse to run a small infirmary there and in the recent years, the clinics have been incredibly well organized and efficient such that it has been a pleasure for us to visit and see patients. One other huge perk is that we’re fed a delicious lunch whenever we’re there as they have a number of volunteers of their own who are fed every day.

The village is in the middle of some very large coffee plantations and the drive there is beautiful. We travel in Turtle with all of supplies and head in the direction of the Ngorongoro gate, leaving the tarmac just before beginning the climb up to the entrance to the park. We travel along a ridge top with Iraqw thatched roof houses scatter along the hills heading down into the valleys. As we take a sharp turn, we begin to make our first descent and then up the other side of the valley only to descent again in the direction of a small creek that is crossed before rising sharply up to the coffee plantations that surround the children’s village and school. The village that we used to pass just before entering RVCV has been abandoned as the government is apparently going to build new buildings, but the brick skeletons of the old homes remain and it remains a question of how soon them is going to occur. As we drive through the gates, our patients are all sitting on benches in from of the dispensary portion of the main building, patiently waiting for us even though we have arrived much ahead of schedule.

Revo taking a good history

Not knowing the total volume of patients and being seriously under manned for this visit, I decided to have Dr. Adam and Abdulhamid work together, as I felt that they would most easily complement each other, and then Revo and I would work together so that we would have two rooms working for several key reasons, one of which was that I had a FAME Board phone call that I wanted to participate in at 4 pm. On most of our visits here, we will break into at least three rooms given the number of patients that show up and we typically will have a pediatric neurologist with us to see the younger children that might show up. Today, I gave Dr. Adam and Abdulhamid the task of seeing the young children, after I which I would staff every patient, of course, and Revo and I would tackle most of the adults.

Adam and Abdulhamid evaluating a patient

Only just having graduated from medical school and ready to start his internship, Abdulhamid has become incredibly proficient in neurology with his decision to pursue this as a career and I would stack him up against anyone at the same level of training in the US with similar interests. I had no doubt in his ability to teach Dr. Adam the necessary skills of obtaining a thorough neurologic history and performing a detailed neurologic examination, and as they would be presenting every case to me, we would work on the differential diagnosis part of the equation together as a team. While they were seeing their patients together, I chose to allow Revo to essentially evaluate his patients with me sitting in the room while he took his history and then also observed his examinations. Though Revo had decided on a career in ophthalmology, his abilities in the world of neurology have also become amazingly sharp and it was clear to me by the many comments he made that he was finding neurology equally fascinating and rewarding in regard to the ability to use only the history and examination to develop a detailed differential. Watching his reaction when everything suddenly clicked while evaluating a patient would have filled any educator’s heart with joy. I have no doubt that wherever his career leads him, he will always remember these lessons in neurology fondly and they will serve as a great foundation for him in the art of medicine and the differential diagnosis.

A young patient and his mother

We saw a mix of patients from the children’s village and the surrounding community today as well as a mix of new and return patients. So often we see patients with new diagnoses such as epilepsy and are able to begin treatment that will allow them to lead a productive life or finally be able to go to school. Occasionally, though, we make diagnoses that have no treatment and must tell a patient and family that their condition will only get worse over time. This morning, Revo and I evaluated a young boy with Duchenne’s muscular dystrophy who we have seen in the past and have done what we can to make his life a bit easier, but with full knowledge that he will become progressively weaker and eventually succumb to the illness long before he will have had the chance to experience some of life’s pleasures that we all wish for our children.

A young patient of ours

Despite his illness, he is a normal sized young boy who can no longer walk on his own and is unable to sit unless he is propped up in a chair and, even with that, has a difficult time mustering the necessary body control to stay upright. When doing so, his arms are so weak that he is mostly unable to raise them for any length of time though his mother has assured us that he is able to eat on his own. As is most often the case with these degenerative disorders, patient succumb to medical complications that occur as a result of the progressive weakness such as aspiration pneumonias or infected bed sores from sitting in a wheelchair for long periods of time. The latter is not a problem for this young man, though, as a wheelchair would be very difficult to use here as there are no streets or paths that would provide accessibility, so instead his mother carries him on her back and he thankfully has enough strength to clasp his arms around her neck. Given that he is almost the same size as his mother at 12 years of age, it quite obviously not a tenable situation for much longer. It is very unlikely that he will reach the age of 20. Amazingly, neither he nor his mother really have any complaints to voice to us at this time and we did what we could for them to answer whatever questions they had regarding the present and the future. There was little consolation in the fact that they had clearly accepted this young boy’s fate, which was certainly not as bright as his mother would have wished for him, and if there had been anything that any of us could have offered to change the course of history, I have no doubt that each of us would have done so, but it was not to be.

A severe burn injury as a result of an epileptic seizure and an open fire

Many years ago, on one of my solo trips here if I recall, or at least I had seen the young boy by myself before anyone else had arrived, I made the same diagnosis in a young Maasai. I had just arrived into Kilimanjaro when I received a message from FAME that a patient had arrived with a neurologic problem and that they had put him in the ward for me to see whenever I arrived. They told me that he couldn’t walk and had lower extremity weakness making me worry about Pott’s disease, or TB of the spine. What he had was something completely different, though equally devastating. He was a tall and gangly Maasai boy of about 11 years of age and his mother, who was the only family member accompanying him, was incredibly young. I remember taking a detailed history using a Maasai translator and once I went to examine him, realizing that it was not only his legs that were weak, but his arms as well. With his examination being consistent with a muscle disease and given his age and progression, there was little question as to the diagnosis of this young boy.

Revo doing an exam

Later in the day, I sat in another room with his mother and tried my best to explain the genetic disorder that I felt her son had and from which he would continue to worsen and eventually die. Despite everything we have now have in medicine, there was no treatment to provide to him that would alter the course of history. In the Maasai culture, young boys grow up to be warriors, and what I explained to her that morning was that her son would not grow up to become that warrior she may have dreamed he would be. She sat, incredibly stoic on the bed across from me, never once allowing her emotions to get the better of her, though I knew full well that she had understood every word I had given her. I knew that this had to be tearing her up inside more than it was me and that eventually she would need the benefit of someone to talk with, but clearly that was not me. I sent in one of social workers after I had spoken to her and it was a short while later that I had heard the muffled sobbing that I knew would eventually come and I was grateful not only that I had the opportunity to assist in the care of this young boy, but also that his mother had the chance to grieve on her own terms.

Robert and a fan

Our return drive from RVCV was quite uneventful, other than the fact that we were again traveling through some of the most gorgeous terrain in this already spectacularly amazing country that never ceases to amaze me in it diversity. I made it home in plenty of time for my 4pm Board update call and after that, took off on another bike ride to end my day. I spent the evening reading and doing busy work, preparing for another day tomorrow as we would be heading back to RVCV for a second and busier day.

Arturo, who works with the Rift Valley Women’s Group, and some children