Thankfully, the rains of yesterday did not continue and the chance for further excellent weather remained. In keeping with our social plans, later today, we would be heading over to Teddy’s for everyone to decide which clothes, bags, placemats, or other things they would want her to create from the fabric we had purchased on Monday, or fabric that we could choose to buy from her during our visit. More on that later.

There was once again a paucity of patients at the beginning of the day, perhaps a sign that residents of Karatu were still deciding on whether the weather was going to change for good or not. Regardless, it gave everyone plenty of time to get other things done, which usually means that the neuro team will congregate at the Lilac Café to enjoy their coffee, samosas, or whatever else they might have a hankering for in the morning. It would also give the residents a chance to continue working on their Swahili and to brush up on doing their neurologic examination in Swahili, which can be very important here, though patients will often have a hard time following commands given to them in Swahili, so I’m not certain whether speaking their language would make much of a difference in the end, after all.

One thing is for certain, though, brushing up on their Swahili will help prevent them from making the same mistakes that others have made in the past. Most recently, as in the last group here, Jenn spent much of her first day greeting her patients with an enthusiastic, “Jamba!” Unfortunately, “Jamba” does not have the same meaning as the normal greeting here, which is a hearty, “Jambo!,” which means “hello.” The meaning of “Jamba” is “fart,” so I am certain that she had all of her patients quite confused when she initially greeted them. It was not until late in the afternoon, unfortunately for Jenn, that Nuru had the heart to finally correct her faux pas and put her on the straight and narrow.

Meanwhile, a much less embarrassing, but equally funny malapropism was used yesterday in clinic when one of the residents told one of the interpreters, “tutaoana kesho” which apparently means “I’ll marry you tomorrow,” rather than “tutaonana kesho” which means “see you tomorrow.” Quite a different meaning with one extra consonant, but after quite a few chuckles, the problem was all worked out and I didn’t have to worry about having to leave one of my residents here in Tanzania as a married woman.

All vowels are pronounced here, or, as many of my Tanzanian friends have reminded me, you pronounce Swahili as it’s written as opposed to English which is a much more difficult language to learn due to its lack of enforced rules. When I was first here in 2010, everyone told me that I had to meet “Pa-ula,” who I mistakenly thought was a Tanzanian, only to realize that they were referring simply to Paula Gremley, the social worker who first introduced me to the mobile clinic and encouraged me to continue the practice which I have to this day.

Lunch today was the Tanzanian version of pilau, rice cooked with meat and spices so that it becomes a delicious concoction of brown rice with chunks of meat that, depending on whether you’re lucky or not, may be tender. The butchering of meat here, as you might imagine, is not the same as it is at home and very little goes to waste, so it is not uncommon to have chunks of bone included with your portion of meat. The traditional way to eat here is with your hand, so picking up the meat to eat what you can off of the bone is perfectly acceptable and probably the only way to tackle the problem. With the pilau was a lovely, shredded cabbage salad that was delicious as are most of the vegetables here. And, of course, lunch would never be complete without multiple scoops of pili pili, their wonderful chili pepper salsa that is made fresh every day.

Though it wasn’t necessary for us to finish early as we weren’t planning to head over to Teddy’s until a bit later, and, as we needed to bring Annie with us to help out with the language barrier, we would have to wait until she had finished out her day of work. One of last patients was a tough one from both a social and medical standpoint. He was a young man who was accompanied by his mother with reported episodes of loss of consciousness that were concerning for seizures. The other complicating factor is that he was consuming large amounts of alcohol, though had stopped about two weeks ago as he wasn’t feeling well, and the episodes of seizure occurred in the setting of alcohol withdrawal.

As his history and examination were most consistent with alcohol related seizures and possible DTs (delirium tremens) it was decided that we should offer him admission to the hospital to provide him with a benzodiazepine protocol if that was what was required once he was further evaluated (we use the CIWA protocol to determine this) in the hospital. As is often the case, perhaps more here than elsewhere, though, we discovered that there were no available beds in either of the wards, and we have been directly prohibited from boarding patients in the ED for obvious reasons as it would quickly become a third ward.

Not being able to admit the patient was a significant blow as that was the safest thing to do, though his mother was significantly motivated to work with him, so we came up with an alternative plan that would involve providing him a course of tapering benzodiazepines and loading him on phenytoin orally as we were concerned about using levetiracetam with some history of behavioral issues she had described to us. Certainly not our desired approach, but it would have to do in this situation.

Thinking of this case reminded me of a gentleman that Danielle Becker and I went to see in the ward in 2013 when she had come for the very first time. It was another case of alcohol withdrawal and immediately after evaluating the patient and while still writing our note, the patient walked to the bathroom, closed the door, and promptly had a seizure. We ran to the bathroom after hearing the thud, but he was behind the door, and it took some time for us to push our way in to find him post-ictal and having bitten his tongue. As we examined him, he promptly coughed blood in both of our faces, at which point I immediately thought, “welcome to Africa.” Very little phased Danielle, though, and we merely went on to finish the work at hand, caring for the patient. Having the emotional fortitude for this work is essential, and Danielle returned with me to FAME on two subsequent occasions to continue the work that we had started.

We reached home a tad early with time to relax before leaving for the evening. It’s usually best to do things before sunset as it quickly becomes dark here and, given how poorly lit it is around here, it’s tough to make your way around. When we arrived at Annie’s house, she came out with little Denzel who, we were informed, would be coming with us. Though Annie and Teddy are friends, their children hadn’t yet met, so it was exciting to know that we have both toddlers with us while we at Teddy’s.

Unfortunately, as we pulled up in front of Teddy’s shop, we discovered that she had forgotten we were coming and wasn’t prepared for our visit. It wasn’t a big thing, though she had been feeding Allan when we arrived, and she wasn’t able to come out of her shop to greet us with a plate of pipi (candy) as she always does. Allan was fine for a few minutes, but eventually started to cry and she ended up taking him next door to the neighbors so that she could focus on taking orders from everyone for clothes and bags. Meanwhile, Denzel was totally happy to be handed from person to person and never once made a peep of discontent, that is, until the very end of our visit when he was insisting that he be allowed to crawl on the somewhat dirty porch outside, which was something that initially wasn’t going to happen, though eventually did given his persistence.

Everyone worked with Teddy to come up with the items they wanted her to make for them. When we there last, I had asked her to make a runner and napkins for my table at home, which turned out beautifully, so much so that Jill is going to have some similar things made. Others choose pieces of clothing or bags, for all of which she took measurements and wrote them down in her notebook along with names and a snippet of the fabric she would use for each one. She is very meticulous with her notes and her orders, and it has now been at least five years since she has been providing this service to my groups. She had originally been in a much smaller space, and now has her shop at her home, which I’m sure has been much more convenient for her, especially now with Allan.

We had decided to stop at the market after Teddy’s, so I drove into town to Deus Market which I have used since first coming here and being introduced to it. To be totally honest, I’m not entirely certain of why we shop at Deus rather than the other dozen markets that are on the same block in town, but I’m sure that there is some good reason why. The drivers from FAME who do our shopping also shop there unless it’s something they might not happen to have at the time. The vegetable market sits behind Deus, having been recently rebuilt into a completely covered market from the old one that had dirt floors and was only partially covered, though had loads of character.

I had work to do for the evening, though the residents enjoyed watching “Back to the Future” after dinner. Some movies never grow old.

Over the last weeks, we’ve had nightly rains that have always stopped by morning, and it has yet to rain on us walking to work. That is, until today. It rained heavily overnight and continued to rain through the morning as it seemed the clouds had descended upon us here at FAME. All morning long, the rain continued to fall and throughout much of the day making us wonder if the weather had finally changed and the monsoons had arrived. This can happen anytime throughout April and even late March, and when the heavens open up, it can be a deluge. Last year, the rains held off until late April after we had left Karatu and were in Zanzibar. Ten years ago, the heavy rains had come in mid-April and caused us to miss most of our mobile clinics in the Mbulumbulu region as the roads were unpassable with the risk of becoming stranded. The next several days will be a good indicator of whether this is the change of season or just a stray rain shower.

In 2015, we began to keep data on the neurology patients we were seeing at FAME and the various mobile clinics so that we would have some idea of the demographics of these patients, what diagnoses we were making, what medications we were using, and how often patients were returning to be seen. This was internal data that was necessary for us to know in which areas we should be doing more outreach, what medications we should be ordering for clinic, and whether we were helping patients as evidenced by their returning to clinic. We also kept additional data on a very special population of patients, those with a diagnosis of epilepsy given the general lack of recognition of this diagnosis and the number of patients in low resource settings who go untreated.

Ninety- percent of epilepsy exists in low to middle income countries where there are no neurologists and only 10% of patients with epilepsy in the world are receiving treatment. The number of patients with epilepsy in LMIC is staggering and the general lack of knowledge of epilepsy by general practitioners who are caring for these patients of overwhelming leading to a massive treatment gap.

The number of patients visits and unique patients in our FAME Neurology Database has not reached many thousands of patients and several years ago, it became clear that the information contained in the database was very valuable especially to those decision makers for specialty healthcare in the rural areas of Tanzania. In 2020, we applied for a Tanzanian IRB that was granted, though the project ground to a halt due to the pandemic and the difficulties surrounding travel during that time.

The data was first analyzed by Whitley Aamodt several years ago when she wrote up a piece on the differences of neurology diagnoses by tribe. In the fall of 2019, Leah Zuroff performed a wonderful analysis of the demographics of our neurology patients and a cost analysis of treatment by diagnosis. Utilizing a similar format, Megan Shen, who has been entering all of our patient data during this trip, performed another incredibly impressive analysis similar to Leah’s, but using date from 2020 through 2023 and comparing trends in diagnoses and care during that timeframe.  When she shared her presentation with me, it was so meaningful that I asked her to present it to Susan last week, who agreed with me that it was important to share it with the clinical staff at one of the 7:30 am sessions which just happened to be this morning.

The talk was well attended, and though there were not as many questions as I had hoped for by the Tanzanian staff present, those that were asked demonstrated that Megan had clearly gotten her point across regarding the importance of our work here over the years. As soon as we’re home, I plan to have her present this information to the Center for Global Health at Penn as well as to those who have been involved in this project to date. In addition, I plan to reactivate our IRB now that we are back on track after the pandemic.

As exciting as the data was during Megan’s presentation, it unfortunately did not stimulate patients to show up this morning for clinic which was not surprising considering the rain that was continuing through the morning. Our outdoor clinic is well protected from the elements by an overhang on the roof, though the noise of the rain on the fiberglass does make a pretty good racket at times that can be pretty deafening. Thankfully, the rain let up by around noontime, though the clouds hung around for most of the day.

One of the children that had come in to see us for a question of febrile seizures vs. epilepsy who had been seen previously, had a fairly conspicuous rash that was later confirmed by Elissa to be measles as that has been prevalent in Arusha with a confirmed outbreak. Though unlikely to be playing a role in the child’s seizures, other than that it was a concurrent illness contributing her fevers. The history was such that neither Maya nor I felt that it was clear whether she had epilepsy or not, but given the fact that she had numerous seizures, and that she was likely to continue being febrile with her illness, we took the middle road and decided to reload her on levetiracetam and to wait another month or so to decide whether to taper it or not depending on how she was doing. Obviously, if she declared herself and had seizures in the absence of fever, then she would continue on medication. If she was doing well with no further seizures, we would consider tapering her medication.

Another patient who we were seeing in follow up was a child who had been started on carbamazepine for focal status, but was now reportedly having increased seizures on medication, or at the very least, they were no better, so that we decided to load them on levetiracetam with the hope of controlling the episodes and having them return in two weeks while we’re still here. Thankfully, many patients are from nearby and can easily return.

We were still in the midst of an internet problem here and, thankfully, Ke Zhang arrived this afternoon just in the nick of time. Ke has been coming to FAME since 2008 when he was still an undergraduate at MIT, and even though he’s now completed an MD/Ph.D. at Yale and has nearly completed his interventional radiology residency at the Brigham in Boston, he is still the technology guru here and the person who can fix anything that involves software, wires, and electricity. Ke is also on FAME’s Board of Directors with me and arrived just in time for a board update call this afternoon, that is, if he could fix our internet in time.

Unfortunately, that didn’t quite happen, and our board meeting was a bit comical with people coming in and out at the most inopportune times, though everyone persisted long enough for us to complete the call. The funniest moment occurred when William, our director of operations here in Tanzania, commented on how necessary our new ED was as, moments before the board call, a grandmother and granddaughter had presented following a leopard attack that had occurred nearby FAME. Now, it is not an everyday occurrence that we have such an attack, let alone nearby, so this was something quite unusual. More concerning though, was the fact that just before I got on the board call, the residents had all been out in the living room preparing for a run!

I immediately jumped up and went out into the living room, only to find it empty as they had all left running. I sent a message to our WhatsApp group letting them know to be careful, though later discovered that none of them had their phone with them so it didn’t do any good. I got back on the call hoping for the best as there was very little that I could do at that point, though when I heard the front door open, I ran back out and was thrilled to see them all back in one piece. In Philadelphia, we certainly worry about violence, but a leopard attack is not something that we usually think about. Apparently, there had been another attack last week near Tloma Village and, given these events, I advised everyone to change their behavior a bit, though, to be honest, my advice wasn’t at all necessary as each of them had already decided to be more careful without any prompting.

Later that evening, we all watched the new film American Fiction that had been up for best picture. It was an amazing movie that everyone loved, but equally entertaining was the gecko on the wall who had figured out that the light being projected on the wall was attracting lots of flying insects. Throughout the movie, he would dart down the wall into the light to snag a few bugs and then retreat back into the shadows, only to appear again when the next flock of victims were in sight. Not something you’d experience every day back home.

Having gotten a half-way decent night of sleep, the new residents seemed bright-eyed and bushy-tailed, ready to begin their three-week rotation here at FAME. It was time for their orientation that always begins at morning report when they’re introduced. Thankfully, they had all gotten seats inside the conference room as that’s not always the case on Mondays when the entire clinical staff – doctors, nurses, lab technicians, radiology – come so that everyone is included in the clinical discussions. We are definitely in need of a larger conference room just in case anyone is looking to have a plaque with their name on it here at FAME.

I had asked the residents to all go to morning report so they could be introduced to the staff and, as I had driven Jill to the Black Rhino again and would not be back until 8:30, I had asked Megan to do the honors of introducing them since I would not be there. As it turned out, though, I arrived by the end of report, in time to hear about the deaths that had occurred over the weekend and was then able to introduce the residents so everyone would know who these new faces were. With our neurology clinic and the program with have, we are always the largest contingent of wazungu (white people or strangers) during our time at FAME.

There are usually a number of volunteers working here with the Tanzanian clinical staff, so it is not unusual to see other white faces, but the mission of FAME is to have volunteers here that leave something behind, not just to see patients. Over the years, I have met a great many volunteers, virtually all who return, if not on a regular basis, every one or two years. I have been the most frequently returning volunteer based on the fact that I have come every six months faithfully since 2010, establishing the sustainability of our neurology clinic. Another long-term volunteer has been Joyce Cuff, who single handedly developed the laboratory here at FAME and has brought it to a state-of-the-art level from early on. Over the years, Joyce has spent lengthy periods of time at FAME, sometimes spending 9 months of the year, though since the pandemic, her time here has decreased somewhat.

After their introduction at morning report, it was time for the residents to go on a tour of the FAME campus that would be given by Saidi, our volunteer coordinator. When I first came here in 2009, all that existed was the OPD, or outpatient department, building , and the intervening years, the campus has grown exponentially, now containing countless buildings that include apartments and two houses for the staff, four volunteer homes, a duplex for long term volunteers, a laboratory building, two hospital wards, two operating theaters, radiology, a 25-bed maternity wing that also houses a neonatal step-down unit, a reproductive and child health building, an administration building, and a brand new 10-bed, fully functional emergency room that is certainly unique in Northern Tanzania. Needless to say, FAME has grown from an outpatient dispensary to a large hospital complex for which it has obtained the designation of hospital in Tanzania, a big accomplishment.

After Saidi’s orientation session for the residents, it was now time for them to learn to use the electronic medical record, or EMR, utilized here at FAME. The EMR is a local intranet capable system, so is not accessible elsewhere and you must be logged into one of the local FAME networks. The EMR, which is web based, was developed in Tanzania, and is supported by a local company. It is very different than the incredibly robust EMR, Epic, that is used at home and by most institutions in the United States. My relationship with EMRs, in general, has been a love hate relationship. Though I had originally wished that I would be long retired from medicine by the time EMRs became a thing, I have now made my peace with them and have learned to live in harmony, having to use them nearly every day. That’s not to say, though, that I use the EMR here at FAME, for it is the residents seeing he patients who need to be most familiar with it. I had learned it in September 2020, when it was first introduced, and I was here by myself, but have not had to use it since, other than to run reports for our data collection.

Once the EMR training was complete, which was conducted by Valence, our IT specialist, and the translators who have worked at FAME before, it was time for us to meet with Susan and Elissa, our long-term pediatric ID specialist, who is now in her second year at FAME. I have spoken numerous times about the transition that one must make when practicing medicine here, not that it is practiced in any way different than it is at home as medicine is the same, but rather it is the environment in which you are practicing that is different. The cultural differences are immense, and even though we often encounter similar cultural differences at home, it is once again the different environment in which you are working and what the accepted norms of treatment are.

Having the perspective from Elissa, a westerner, who has now worked here for several years was essential for the residents to hear and though I have often discussed these differences in conferences at home that I am sure they have all heard, it is not until you are here in person, with the patient sitting in front of you, that you must grapple with these issues. Though taking a history here is far different than at home, not only for the language barrier, but also for the fact that East Africans do not readily divulge the complete story to you on the first go around and what may seem at home to be quite obvious, is not so obvious here. With all that being said, the medicine we practice here is how medicine was meant to be practiced. Simple expectations and limited resources very often require greater skill in eliciting the outcomes that one wishes to achieve.

Having been literally slammed with patients on our first day three weeks ago (I believe that we may have seen thirty patients), today was the total opposite. Though FAME was still overwhelmed with the typical Monday onslaught of patients, we had far fewer coming to the neurology clinic. This has happened before and, in an attempt to compensate for this, we have our mobile clinics structured so that the mobile clinic week for this group will hopefully have a greater number of patients. We will be going to Mang’ola which is next to Lake Eyasi and typically have no issue attracting patients in those areas. Kitashu will travel there this week to make announcements to ensure that we see as many patients as possible.

One child we saw today was a tiny premature baby whose parents noticed that their head had been enlarging. The baby was so very tiny, that when I glanced at them wrapped in their mother’s lap, the first thing I thought was just how microcephalic the baby was, but I hadn’t had the benefit of seeing their body. It is truly a miracle just how many premature babies we have here and how well they will often do which is a testament to the care that they are receiving, both from their family as well as from FAME. We were able to do an ultrasound of the baby’s head and the ventricles did not appear to be overly enlarged so, for the time being, we continue to observe the child and monitor their head circumference.

I have mentioned the issue of treating hydrocephalus here before in regard to having to perform VP shunts that require monitoring and can, at times, have catastrophic failures with the inability to intervene in most of Africa, often leading to death. Though the process of performing an endoscopic third ventriculostomy (ETV) had been introduced by a number of neurosurgeons during the 20^th century, it was not until the procedure was coupled with a choroid plexus cauterization (CPC) to reduce the production of CSF that a true benefit over a VP shunt and its inherent risks was shown. Dr. Benjamin Warf, now of Boston Children’s, performed and studied this combined procedure in East Africa in the early 2000’s, and validated the benefit of the procedure, especially in low resource regions.

After clinic, everyone was excited about going into town to buy fabric at one of the shops to use later at Teddy’s, and it was also market day, so they wanted to see the Maasai Market. We stopped briefly at the change bureau for everyone to get shillings and then headed to the center of town where most of the fabric shops are. Thankfully, we had Annie with us who could help negotiate prices for having six wazungu walk into any shop in town is a recipe for disaster is one is hoping to even pay the regular price, let alone a discounted price. Sure enough, the initial prices given to the residents were way too high, though with some assistance from Annie, they immediately became more reasonable. I never have an issue paying the regular price for something, just not an inflated mzungu price.

Once the fabrics had been purchased, it was off to the Maasai Market, and Annie was excited to come with us as she wanted to look for clothes for young Denzel. I have not walked into a Maasai Market in several years, but, since Annie was there, I felt a bit more adventurous, and we followed her to an area where there were plenty of clothes. Vendors put out large tarps on the ground, perhaps 8 feet square, on which they place clothes for sale, some very orderly, and others completely disorderly. The vast majority of these clothes have come from the US and are shipped in huge bales that are tightly bound and are eventually purchased by a vendor at the docks and then transported to the market. Some are new, others not, and they are in every condition one could imagine. T-shirts from every university in the US and those from the losing super bowl team can be found here.

We left Annie at one of the clothes vendors while we went off as a group to an area of the market that had more kitchen ware. We ran into Isabella, Daniel Tewa’s eldest daughter, who was selling wares from her shop in town here and, having wanted to buy some coffee mugs for the house, we used her to help us with a price, as I didn’t want to offend anyone by making an insultingly low offer. Isabella told us that the six very nice new coffee mugs we had selected would be 20,000 shillings, or just over a dollar a mug. I thought that was very fair.

I not only have a habit of being too trustworthy, but also of carrying my cellphone in an unsecured back pocket all the time. In Barcelona, the pickpocket capital of the world, Jill had repeatedly reminded me to keep my phone in my front pocket, but each and every time I took it out to photograph something, I reflexively placed it back in my back pocket. The market was an ideal place to lose your phone, so I had placed it in a front zippered pocket in my pants, only to discover that moments later, the zipper was wide open, and my phone was gone! I had an immediate sense of panic at the thought of having lost my phone in the midst of this mass of humanity where it would be gone forever. It was what seemed like an eternity before I realized that I had done the same thing as I had in Barcelona – my phone was sitting in my unprotected back pocket, right where I had put it after having taken a photo earlier.

We walked back to the vehicle having left Annie at the clothes vendor and I immediately texted her to tell her we were back in the vehicle. When I went to text her again, Megan, who had stayed back to watch the car, reminded us that Annie had left her phone so it wouldn’t be stolen. Smart thinking.

This is usually an incredibly tiring weekend for me as I drive the entire group back to Arusha for their departing flight home, then stay overnight only to get up before sunrise and drive to the airport to pick up the incoming group when they arrive a 7:40 am. After that, we have breakfast with Pendo, then leave for Karatu and FAME. It’s a lot of driving – remember, we’re traveling at 80 kph (approx. 50 mph) at best and having to frequently slow down to 50 kph (31 mph) through any towns or population areas.

Thankfully, for me, the entire group of residents were traveling within Tanzania before returning home and, better yet, they were all going to spend several nights close by at Gibbs’ Farm. Rather than driving them all to the international airport, three hours away, I was able to drive them up to Gibbs’ which is 20 minutes away. A much better deal for me. As for the group that was arriving on Sunday morning, I had made arrangements to have them picked up when they arrived, and then to have some breakfast in Arusha before making the journey to FAME, arriving here sometime after lunch quite sleep deprived and having slept for most of the journey across the Great Rift Valley.

As I joked to Jill, having now dropped everyone off at Gibb’s Farm, we were now free of the “children.” I say that only half-jokingly, though, as the preparation and logistics for this program can seem overwhelming at times and, once here, the coordination of not only our clinics and mobile clinics, but also the many activities that we do here outside of clinic hours when we are visiting local friends, going on game drives, and eating several dinners out during their three weeks. As I have shared in these blogs, we stay very, very busy here, and though there are certainly moments of down time to relax, I try to make sure that everyone has the fullest of experiences during their stay and that I instill in them the same sense of accomplishment that I have had each and every time I return.

Jill and I had arranged to have lunch at Gibbs’ with some friends from Arusha since we wouldn’t be traveling there for the weekend. During the pandemic, the wonderful buffet lunch that they were known for by all the FAME volunteers was discontinued and it was back to table service which, though still scrumptious, did not have the same panache as that towering buffet that everyone dreamed about. Thankfully, the buffet has returned, at least for the appetizers, soup, and dessert, while the entrée was served by plate. I recall past lunches in the pre-pandemic days where we all competed to see how many plates of food we could eat, and though I won’t disclose who usually won, I can say that his first name starts with “K,” ends with “e,” and has no other letters in between.

Lunch was delicious as expected, and we sat at the same lovely outdoor table under a canopy of dangling lady slippers where we had our earlier dinners, relaxing and chatting with good friends. After lunch, we had hoped to spend some time in the pool as the afternoon had turned out to be a FAME and RVCV volunteer day with all of my residents, Marissa and Kevin, Elissa, and the entire RVCV having a day out there. The pool was once again a bit brisk as far as temperature, but it was so refreshing that it mattered not. With Jenn’s fear of anything creepy, crawly, she didn’t appreciate my rescuing a good-sized African whip scorpion from the pool and then releasing it in the bushes alongside the pool. They are non-venomous and harmless, but I don’t think that necessarily mattered to her as she just wanted it to be gone.

We remained at Gibbs’ until nearly 5 pm, when we were scheduled to head over to India Howell’s home for “sundowners,” the term here in Africa for drinks at sundown, which I’m sure has some colonial origin, but has survived despite our best efforts to rid ourselves of that nasty history. Regardless, India’s home was lovely, and we relaxed and told stories well into the evening along with Frank and Susan and many of India’s older children who now live in Karatu rather than back at Rift Valley Children’s Village.

Megan had spent the day relaxing and working at the Raynes House, something that I have gotten to do only once which was my first trip back to FAME after the start of the pandemic and before residents or medical students were given permission to travel by the University. I spent my evenings at the house reading and working, and had lots of downtime on the weekends, though did take a number of the FAME staff on their very first game drive to Tarangire National Park and to the NCA.

Rather than being at the airport at the crack of dawn on Sunday morning to pick up the arriving residents, I was enjoying myself and having a relaxing breakfast at the Raynes House. Was it not for my being constantly “on service” when the residents are here, I might have felt guilty, but thankfully, I did not. Megan, Jill, and I sat around the breakfast table enjoying the conversation with not a care in the world – though I did repeatedly check to make sure that the residents had arrived and were picked up safely at the airport. We did not expect them until well after noontime, so we had he entire morning to ourselves.

The new group eventually arrived around 2 pm, having made the trek from Arusha following their marathon flights from Philly, expect for Michael, who had been in South Africa with his partner for vacation before traveling here. They were exhausted and needed some time to regroup before we would head downtown for dinner. The new group consists of Michael Perez, Christina Boada, and Holly Elser, each of whom are adult neurology residents at Penn, and Maya Silver, our pediatric neurology resident from CHOP. Megan will still be for another week prior to heading home.

We drove downtown around 5 pm to grab some dinner at the Lilac Café downtown and all sat outside chatting under the darkening sky as sunset neared. Jill and I walked to the market in town to grab some supplies, making sure we dodged the boda bodas the entire way. Walking back to the Lilac, a local wedding procession of perhaps five vehicles passed us by, the last vehicle being a truck with a brass band in the back playing tunes that sounded like a cross between a Dixieland jazz band from New Orleans and a Mexican brass band playing Banda. It was gorgeous evening and I think everyone knew just how lucky we all were to be here.

The last day of clinic for the current group of residents would start a little early as we had the M&M report that I had mentioned yesterday to attend at 7:30 am. The M&M is run very tightly with specific time constraints and a discussion that follows each case to be presented noting things that were done correctly and things that can be improved. The entire process took close to an hour so that our morning report was running late and the presentations of the patients on the various ward services were abbreviated to allow everyone to begin work only a few minutes late.

We had planned to have a half day of clinic to allow everyone time to pack tonight for their departure tomorrow. Marissa would be leaving this afternoon to head up to Gibbs’ Farm to meet her boyfriend there who was arriving today at Kilimanjaro. Unfortunately, he had missed his original flight out of NYC that would have had him to Kilimanjaro early this morning, and, instead, had to fly a circuitous route to Washington, D.C., then to Addis Ababa, and finally into Kilimanjaro, arriving not until 1 pm. The most important part, though, was that he was on the final leg of his flights and would soon be on the same continent.

With Kevin’s arrival today, Marissa would be departing FAME, and I would once again be on my own as the only faculty here to supervise the residents. Having another faculty member here with me, which has happened on only limited occasions over the years, has always been a real treat as it allows for some downtime during the day in which I can get other things done, like this blog. Over the last several years, having all four residents constantly seeing patients throughout the day, normally keeps me completely occupied in that capacity, and can be very exhausting by the end of a big day seeing more than thirty patients. With Joe having been here for the first two weeks, and then Marissa for the second and third weeks, I’ve had some breathing room. Well, that would all end today.

The little six-month old child who had presented several days ago with focal status back hadn’t returned to clinic yet, so we asked Kitashu to give them a call and get them back in before we finished the day. Thankfully, they made it in, and it appeared that the carbamazepine we had started was helping, though it was still a bit early to make that determination as we were still up titrating the dose (carbamazepine cannot be loaded) and it would be another several weeks before they were on a full therapeutic dose. The family was also describing some abnormal movements that sounded like myoclonus, or possibly spasms, and, if this continued, we would consider switching them to topiramate when they return.

We also saw a 9-year-old boy who had a long standing non-specific static encephalopathy, though the child was dysmorphic appearing and very likely had an underlying syndrome, as well as many years of untreated epilepsy. As with many of the patients we see here, he may have had a history of a brief and unsuccessful trial of phenobarbital when he was young but hadn’t see anyone in many years for his seizures. He was placed on one of “broad spectrum” antiseizure medications, such as valproic acid or levetiracetam, though I cannot recall which it was. Equally important, though, he had never been referred in the past for any rehabilitation which, in the long run, would be helpful with the possibility of improving his functional status.

Monduli is a rehab center that is just this side of Arusha, that is government run and free to patients with disabilities that could benefit from inpatient physical, occupational, and speech therapy. We will often send our patients with cerebral palsy or similar syndromes when they around three years of age as the benefit is less significant if they are younger than that. The good news is that services for the patient are covered, but to go there, the family must accompany the patient, essentially live there for several weeks’ minimum, and those expenses, which are often much more than families can handle, are not covered, making the situation very difficult at times. The philosophy of having the family accompany the patient in rehab and learn the techniques that are used by the therapists is a totally valid one, but unfortunately, with very limited healthcare funding, the advantage of this wonderful opportunity is often lost.

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The clinic was coming to an end for this group of residents, all of whom had an excellent experience (at least that’s what they’ve told, though I do believe them), and, over the three weeks they have been here, they have had the opportunity to develop close relationships with the translators and other staff they’ve been working with on a daily basis. Traveling to a clinic such as FAME, and in a country such as Tanzania, leaves little to the imagination of what you are doing or what the purpose of being here really is. We always have a lunch at the Lilac Café here on campus with everyone involved with the clinic our last day, or when each group leaves. That means all the interpreters along Kitashu and Angel. As food usually takes about an hour, we had sent some up to order the food early, though in the end, we all ended up at the Lilac waiting for our food but were not disappointed when it arrived.

While at Manor Lodge on Wednesday evening, Jenn had spoken to me about the possible collaboration between Wharton (Penn’s business school) and FAME not only for fundraising, but also for help with global health systems management from a business and infrastructure standpoint. I had wanted to have Susan hear it directly from Jenn, so had set up a meeting time for us to meet with her and hopefully with our onsite director hear, William. Well, nothing necessarily goes according to plan here as you’ve probably noticed. Our late morning meeting soon became a noontime meeting and then slowly morphed into an early afternoon meeting that we had at the end our lunch. It was an interesting discussion that will certainly be worth exploring in the future.

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We were home quite early and after a bit of rest, we all decided to take a walk. Though the fields behind FAME are absolutely gorgeous and the best for a power walk in the morning or evening, my favorite walk from FAME is still down into the brick quarry that sits next door at the bottom of a ravine. Bricks here are made in quarries, which are essentially places were the dark red clay is easily mined and then formed into bricks. From there, the bricks are stacked into large blocks nearly ten feet high that usually have two, though sometimes one, firebox in the bottom in which piles of wood are placed for firing the bricks. The huge stack of bricks is then completely covered in mud and the bricks are ready for firing. This will make the bricks essentially impervious to water, so a house build from them doesn’t just melt with the first rain.

There are quarries all over Karatu, but the one nearby is one of the bigger around. Walking down the steep hillside into the quarry, you follow a cow path to the bottom passing a few smaller digging sites. At the bottom of the ravine is a creek that is normally easy to cross, though unfortunately, it was not crossable today without all of us having to take off our shoes which we didn’t think was smart. Had we crossed and gone up the other side through the larger part of the quarry, we would have ended up on the Tloma village road and ended up at the junction with the Gibbs’ Farm road where the woodcarver shop and Phillipo’s home sit.

In the end, we walked back up the hill and took the road in the direction of the fields. It was a beautiful evening and perfect timing for a walk. We eventually walked down to the fields and then back up to FAME where we all settled in for the night. Leah, Jenn, Evan, and Gina would be heading to Gibbs’ Farm in the morning, and I would be driving them. Though they originally wanted to leave here at the crack of dawn, I convinced them that leaving at 8:00 am was far more reasonable.

(Note: there are no photos of Kafika House out of respect for the children and for security reasons)

The education lecture for the morning had been cancelled this morning as we would be having a monthly morbidity and mortality (M&M for those in the medical field) conference tomorrow morning. These conferences are typically large affairs with the entire staff participating and are meant to be a learning experience for everyone involved. Back home, M&M conferences are held by every department and are considered protected in a legal sense in that any and all information pertaining to the conference is not discoverable during a legal proceeding. This allows for an open and impartial discussion by all parties involved without fear of repercussions, legal or otherwise. Though at home, M&M conferences are closed to anyone from outside the departments involved (as an example, we would never invite interviewing residents to an M&M), all the volunteers were invited to attend the conference here.

It was our last full day of neurology clinic for the current group of residents and our morning was going particularly slow as it had rained overnight into the morning which always portends a slow start given the difficulty of travel until the roads dry. Jill and I had arranged to visit the Kafika House at 2 pm with Pete, our visiting pediatrician from Australia, whose sister just happens to be the founder of the non-profit that runs the program. Jill would typically take the school bus home after lunchtime, but that can often be a lengthy ride, so I had decided to drive over to the black rhino to bring her back to FAME for lunch prior to us leaving with Pete. Given the fact that there were few patients showing up to clinic, this didn’t seem like it would be an issue at all, and Marissa was totally fine with holding down the fort in my absence.

There are three routes that one can take to reach the Black Rhino International Academy from FAME. The shortest and most direct route takes you alongside the fields behind FAME where we have often taken walks over the years, but in the best of circumstances, this route is heavily rutted and, after a rain, can become nearly impassable. The safest route to take for a number of reasons, but it is also the longest by both distance and time, is to drive all the way out to the tarmac, head out of town, and then turn onto the Shangri-La Road which takes you to the Black Rhino. I chose the middle route that takes you up behind the Highview Hotel and then down a fairly steep and rutted road, but one that is easily passable. Unfortunately for me, it wasn’t completely passable to everyone. Three quarters of the way down a long and muddy road that is a single lane, there was a large dump truck that had become stuck while trying to back into a property.

Initially, I was quite patient and more than willing to wait a few minutes while they figured things out, but when they broke out the shovels and began digging, I figured it was time for me to bail. Unfortunately, that meant that I would have to reverse Turtle (Saidi had borrowed Myrtle to go into town to pay for my medical license) up a very steep, muddy, and rutted one lane, at best, road in a vehicle that was the size of a small tank. You’ve heard me sing the praises of the Land Rover before, but I’m telling you, they can drive anywhere on any type of terrain (that is as long as they are running). I put the transfer case into low range and began backing up the hill using my mirrors, and Turtle didn’t miss a beat. I had to drive down to the tarmac to get to the school and had gotten out of a mess, but was now running late, and Jill was wondering where I was as I didn’t have a signal where I had been so couldn’t tell her why I was running late.

When we finally got back to FAME, it seemed that someone had opened the flood gates as there were numerous patients now being seen, plus a young boy in the ED who was in focal status but had been like that for at least a month. Marissa had everything well under control, though I did feel a bit guilty as I’m sure it was more stressful than what she had signed on for. In fact, by the time we had arrived, I’m pretty sure that she had taken care of staffing everyone along with dealing with the focal status boy.

The 13-year-old boy in the ED had apparently had epilepsy since he was very young, and other than a brief trial of phenobarb when younger that either knocked him out or didn’t help his seizures, he had been on no other medications and continued having infrequent focal seizures while on no treatment for most of his life. Something had changed over the last month, though, and he began having multiple seizures per day that were, thankfully, still focal. He was initially given lorazepam in the ED which stopped his seizures and was then loaded on levetiracetam to prevent his seizures from returning. Though carbamazepine is a fine antiseizure medication for focal epilepsies, and is quite inexpensive, it can’t be loaded quickly and takes days to get a decent level in someone. Levetiracetam, a much newer medication, can loaded more quickly, either orally or intravenously (though we have no IV formulation here), making it a much more viable option in this situation.

With everything in good order in the clinic, thanks to Marissa, Jill and I went to grab a quick lunch before heading to Kafika House with Pete. Today’s lunch was pilau, most everyone’s favorite (mine is still the rice and beans) including Charlie, who knows the days of the week by whether there is choma (meat) included in the meal that day as he benefits greatly from the gristlier bits that can be inedible. Unfortunately, this has been an extremely bad habit for Charlie, and despite trying to break him of this habit on numerous occasions, it has gone for naught, and Charlie can safely be described as a “big boy.”

Pete had offered to drive us to Kafika House, which is very near Gibb’s Farm, and I rode in the back seat with his two children, Ollie and Astrid, in their car seats. Coletta, their nanny sat in the third row for the ride up. Astrid, who has to be one of the happiest children any of us have ever seen (though Pete corrects us noting that she is until she’s not), kept me entertained for the entire ride with both of us blowing raspberries at each other in succession or playing peek-a-boo.

Kafika House, (https://kafikahouse.org/) which began as Plaster House, but changed its name last year due to the types of patients they were seeing, was started in 2008 by Pete’s sister, Sarah, as a rehabilitation center for children who were undergoing surgical correction for orthopedic conditions and would require prolonged rehab after their surgery. Their model, which is to locate children in need of these surgeries in the communities as well as those who arrive at their doorstep, provide presurgical evaluations, then surgery that will take place at the hospital, and then back to Kafika House where they will remain for the entirety of their rehab, which may be several months.

They had originally partnered with Arusha Lutheran Medical Center (ALMC) in Arusha as far as a location for their surgery but have since branched out as the conditions which they treat have expanded. In addition to the orthopedic issues some children have, they are also now providing both plastics (cleft lip and palate, burns) and neurosurgical (spina bifida and hydrocephalus) procedures using surgeons that will often come from the US just for the surgical days or some surgeons who are in country. They are currently doing around 1000 surgeries per year in total.

The significance of all this, in addition to the simply amazing organization that Kafika House has become, is that they have partnered with FAME for their site in Karatu and where their surgeries will occur. Once or twice a month, we will have a small group of 6-10 young children show up at FAME for their preoperative evaluations and they will march down the hallway in between their various testing stations. They will typically come back in the following days for their surgery, spend one night here in the surgical ward postoperatively, and then will be transported up to Kafika House where they have a full complement of nurses to manage anything including IV antibiotics for those patients requiring them.

Kafika, which I am told loosely translates to “have arrived,” is the perfect name for this organization for when pulling through the gates, you absolutely feel as though you have arrived, and there is little question as to the healing power of this loving and tranquil place. Kafika House is located in the previous residence and grounds of Margaret Gibbs, the matriarch of Gibbs’ Farm and longtime resident of Karatu. As we took our tour of the property and visited the different rooms full of laughing and children, many with their mothers if they were young, the loving and healing nature of this place could not help but emanate from every corner of the house and elsewhere. On the porch, looking out over the magnificent landscape that slowly blends into that of the conservation area beyond, children with casts on one or both lower limbs sit pleasantly in chairs or on mats and are clearly in the place they were meant to be. There is little question that they have arrived.

We had a quiet evening at home, though there was a definite groundswell from the residents that involved an evening at the Golden Sparrow, Karatu’s long-standing disco/night club for dancing and consumption of Konyagi, Tanzania’s local gin that is referred to as “The Spirit of the Nation.” We have always said, “what happens at the sparrow, stays at the sparrow,” but there have been multiple postings by me of photos and videos, so I can honestly say that is not entirely true. Neither Jill nor I were up to an evening out due to stomach issues, but even more so, the two of us had taken secnidazole earlier in the day that necessitated neither of us drink alcohol for at least 48 hours. It was a legit excuse, so I drove all the residents (Marissa had bowed out as well) down to town with the promise that they would get home safely by cab. Annie and Hussein had also joined them later in the evening so I was happy to know there would be someone looking out for them. Surprisingly, they were all up, bright eyed and bushy tailed, for our 7:30 am M&M conference the following morning.

As morning report on Monday, Wednesday, and Friday, here has become a much more involved affair with the entire clinical staff of FAME showing up and there not being enough room for everyone in the large conference room, we have been sending only one or two residents for each session to avoid all of us standing outside and being unable to hear. Tanzanians are often very soft spoken when speaking English, which is what is spoken at morning report, and it’s hard enough to hear them if you’re inside the room, let alone standing outside with your ear to the open window. The nurses are now presenting the cases which has served its purpose well, which is to involve them more in the treatment plans, while the doctors still contribute during the discussion if there are more technical issues to discuss.

Our role at morning report, in addition to gaining some insight into how treatment decisions are made by the staff on patients in general, is to also listen for anything that sounds halfway neurologic, meaning that we could potentially contribute to a case. If that occurs, we will either have one of the residents round with the team and see the patient at that time, or they will come back to clinic and then return to the ward later with one of our translators to provide a full consult on the patient.

As we learned last fall, though, the fact that a patient doesn’t sound neurologic in morning report doesn’t mean that they are not. LJ had been rounding with the team when a patient was presented and there was just something that made her worry that the patient may have had a stroke as the reason for his symptoms, which was not the direction the presentation was going in. She briefly examined the patient during rounds but came back later and was more convinced of her hunch and obtained a CT scan confirming her suspicions. The changed the entire plan for the patient and greatly affected his treatment.

This issue, though, is not necessarily the fault of the clinician. As I’ve mentioned before, information in East Africa is on a need-to-know basis and this is equally the case when patients come in to be treated. They, or their families, will not always share with the doctor all of their symptoms, or they may share something that they think may be related or is not. It is absolutely necessary to obtain a complete review of systems and to perform a complete examination on a patient as you will very often find out of the way clues to whatever disease process is affecting the patient. This can often be very frustrating as no matter how hard one tries, it is not at all uncommon for very significant features to slip by and have major implications in the care of a patient.

I recall one patient that Danielle Becker and I were seeing a number of years ago who appeared to have a simple mononeuropathy with a specific differential, but when I asked Dr. Ken what his thoughts were, he told us there was something that just didn’t add up when he was speaking with the patient. They also had a rash on their chest, and, when further questioning the patient regarding their social history, it turned out that he was married, but was living with one of his children. When Ken asked him why that was, it eventually came out that the patient’s wife had kicked him out of the house. Not that it would have made the top three on our differential, but when we checked the patient’s RPR for syphilis, it was positive, and it turned out that the patient both neurologic and dermatologic complications of syphilis that needed to be further treated. Things are not always what they seem to be and there are cultural nuances that may take years, if ever, to appreciate here.

The optic neuritis suspect patient, who we had seen yesterday and had recommended that she have an MRI of the brain, returned today reporting that she was completely unable to do so, which was not surprising given the cost of such a study (about $200) which is nearly the annual income for many families. Our concern, once again, was whether the patient could potentially have MS, which would greatly affect our recommendations for treatment going forward. We were also unable to get any further vision testing as Sehewa, our awesome nurse anesthetist who also doubles as our eye doctor, was out of town until Friday and the patient was unable to travel to KCMC which would be the closest ophthalmologist with the expertise in picking up any abnormalities.

So, the dilemma before us was how suspicious we were with the clinical features of the patient and whether we felt the patient should be treated for optic neuritis, which, at home, would be a course of IV steroids. There is also good evidence that oral steroids are as effective as the intravenous ones, but it was the dose of steroids that was the problem as she would require 1000 mg of either methylprednisolone intravenously, or its equivalent, or 1000 mg of prednisolone orally. The only problem that we had was that our prednisolone was in 5 mg tablets meaning that we would have to give the patient 200 (!) tablets, and the only IV steroid we had was dexamethasone that came in 8 mg vials, and we would need a total of 187.5 mg, or nearly 24 vials, which would be very expensive.

We presented the dilemma to Eric, one of FAME’s two pharmacists and who has been most involved with the day-to-day operations now that our long time pharmacist, Egbert, has taken on the role of a project manager. After pondering the issue for a few minutes, Eric remembered that I had brought several boxes of Depo-Medrol injectable, that we use for nerve blocks for our headache patients, with me last fall that were good through May of this year.

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In addition to there being data for using oral prednisone tablets (1000 mg daily x three days), there is also data for using the intravenous formulation of methylprednisolone mixed in a smoothie or fruit juice and taken orally. This was popularized by Elliot Frohman, an MS specialist who was at the University of Texas for many years and is now at Stanford. In any event, as our Depo-Medrol was a formulation of methylprednisolone that was meant to be injected into tissue, and we had plenty of it, we decided to mix enough of this into bottles of a multivitamin formulation that the patient would drink daily for three days. Each tiny bottle contained only 40 mg of the Depo-Medrol, meaning that we would have to aspirate the contents of a great number of bottles to make enough to mix in with the multivitamin. That being said, it was a plan that would not only work to get the necessary medication into the patient, but we had excess of this medication that would be expiring in several months and was the perfect excuse to utilize it. The cost would all be covered by the patients visit to neurology.

Dr. Anne and Evan sat at a table methodically aspirating enough bottles to mix in with the multivitamin and, once finished, we had three small bottles of liquid continuing the appropriate amount of medication that she would take daily for three days. We would have her come back in several weeks to reassess her, but for now we had a plan that would work.  

We had plans tonight to have dinner at the Manor Lodge, and lovely resort that is high up on top of a ridge that is just shy of the NCA, but does border it and, in fact, requires that you drive through a short easement to get to the main gate. It always seems, though, that when we have these plans with the hope of leaving at a decent time, we have one of the more complex patients of the day show up at the very end. The patient that came today, with tons of records both from within Tanzania, as well as several visits to a neurologic facility in India, was a young man with a very complex seizure history and was accompanied by his stepmother.

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At home, the residents affectionately refer to these patients as “OSH-bombs,” with the anacronym “OSH” referring to “outside hospital.” These are patients who have been admitted to an outside hospital for days, or even weeks, and are then accepted for transfer to one of the University of Pennsylvania hospitals, often arriving with stacks of records (hopefully) concerning their recent care that must then be reviewed, summarized, and ultimately presented to the attending physician. These patients will often arrive after hours as that is when beds become available in the hospital from earlier discharges. These patients can very often be much more ill than was conveyed in the initial transfer communication.

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This patient, who came from several hours away, had stacks of records and films that needed to be reviewed and then discussed in order to come up with our recommendation for treatment. Thankfully, he had not previously tried too many medications, so we were able to recommend a reasonable trial of an anti-seizure medication that was new for him along with a plan B if that did not help. He too, would follow up with FAME in the future to see how he was doing on the new medication regimen that was suggested to them.

We were finally able to head home and get ourselves ready for a nice evening at a very lovely lodge. I hadn’t been up to the Manor Lodge in over a year, to be honest, but had heard through the grapevine that their food was still top notch and, knowing that the grounds of this lodge are some of the most beautiful around, it was the perfect opportunity for all of us to spend an evening together relaxing. Marissa had offered to take everyone to dinner here as it would be much easier than trying to get everyone’s schedule together at home.

The drive up to the Manor Lodge, as I mentioned, is a journey that travels through a small part of the NCA, but, in addition, travels up through the Shangri-La coffee plantation, one of the largest in the area. Coffee is surely king here and is second only to the tourist industry with the game parks. The rich volcanic soil, the altitude, and the amount of rainfall here make the Ngorongoro Highlands the perfect environment for growing the rich Arabica coffee bean that is most popular for this region. Until recently, Tanzanian coffee was unavailable in the United States, though I have seen it slowly enter the specialty market at home over the last several years.

The Manor Lodge is owned by the South African company, Elewana, and is designed after the wine region of their home country. The manor house is a large and very formal building that is absolutely gorgeous inside, but in a completely different style and setting as that of Gibb’s Farm which is elegant and casual. This place is simply elegant. The dining area is very formal, and the settings have more silverware than I’ve seen anywhere in Africa, or even at home, for that matter. Thankfully, the dress is not formal as that would never go over here, at least in this century. The bar is pretty much from a scene in Out of Africa and would not have shocked me had I seen Ernest Hemmingway resting in one of the lounge chairs having just returned from a rhino hunt. How they ever transported the baby grand piano up that hill is beyond me.

Simply put, the Manor Lodge is one of the loveliest properties in all of Northern Tanzania, and I suspect, all of East Africa. I have never stayed there, which isn’t saying much as I have never stayed anywhere here other than the Ngorongoro Crater Lodge for two nights, but the rooms, which I’ve toured, are equally elegant and comfortable. The dinner we had was also amazing and was far beyond all of our expectations. It was a five-course meal, and each course was in itself a work of art. Needless to say, everyone was incredibly thrilled with the meal, and we were all thankful that Marissa had suggested having dinner there as a special treat.

As Pete was giving the morning lecture on neonatal sepsis, I wanted to go as did the pediatrics contingent of our group – Marissa, Gina, and Megan. I had mentioned before that Pete and Amanda have been spending the year here, along with their two children, Oliver, and Astrid, as volunteers in pediatrics and emergency medicine, respectively. They are being funded by an Australian non-profit, though their choice of location wasn’t something that occurred entirely by chance. Pete’s sister is the founder of Plaster House, now known as Kafika House, with is an NGO that had originally been set up to provide treatment for children with surgically correctable orthopedic disabilities but has grown over the last twenty years to include neurosurgical and plastics procedures as well. They have sites in Arusha and Moshi, and now Karatu, partnering with FAME as the facility in which to provide these surgeries.

Pete’s talk was, of course, great, not only for its content, but also for his wonderful humor which is undoubtedly enhanced by his Aussie accent. Though the need for Amanda’s expertise given the new emergency department opened late last year was clear, Pete has provided invaluable assistance in all things pediatric and then some. Having him here to help teach, along with Elissa, has provided a solid team of educators as the two of them really understand the nuances of providing care in resource limited settings, an area that Pete has worked in much of his career and Elissa, having been essentially raised with FAME in her genes. It is always essential to realize, though, that any volunteer here at FAME, whether short term, long term or intermediate, are transient, and that the true strength of FAME and its mission, resides in the Tanzanian staff who are here, day in and day out, to provide the best of care to the residents of Northern Tanzania.

After the talk, I drove Jill to the Black Rhino International Academy, where she has been volunteering during her time here (https://blackrhinoacademy.org/) as she did last year when she visited. Jill’s background as an early education specialist and kindergarten teacher for many years has made her an incredible resource for the school which started with the early grades, or levels, as they are referred to in the British system, but has continued to add years as their children have grown. The Black Rhino is an amazing facility that is the creation of Caroline Epe, a longtime member of FAME’s administration, and Nickson Mariki, a FAME Tanzanian Board member and much, much more for the town of Karatu. Nickson, who I have known since first coming to Karatu when he was managing the Happy Day pub, now also owns and operates numerous Lilac enterprises throughout Karatu that include the Lilac Café here at FAME which, in addition to providing food for all the inpatients here, serves as a place for everyone to get snacks when needed, and also as a home base for our medical student, Megan, to have a cappuccino or a latte in the morning which doing here data entry.

The drive to the Black Rhino, which is really just a stone’s throw from FAME, can vary from mundane to exciting depending on the route you’d like to take. The shortest way to get there is through the fields behind FAME where everyone walks, but the trail is overgrown and very narrow, and there are some major ditches just waiting to knock your vehicle out of alignment. I did that once with Jill a week or so ago and learned my lesson. The intermediate route, which is less exciting, but still carries a modicum of the unknown, is a drive that takes you up behind the High View Lodge. Though the road is heavily rutted, it’s easily passable and much shorter, unless, of course, there is some other vehicle that is stuck, making the route impassable. That has happened to me twice now, one of which required that I reverse up nearly three-quarters of a very steep and muddy path. Thankfully, the Land Rovers are virtually unstoppable in low range, even in reverse, and it took me faithfully up the hill without a whimper.

Much to everyone’s dismay, our internet has been incredibly problematic over the last several days. Apparently, Vodacom (the carrier we use for our router) has had an outage over this last weekend due to undersea cables having been disrupted with major impact on West and Center Africa and some impact here in Tanzania. This is one of the other corollaries of the TIA principle – nearly all internet here is by cell tower, not fiberoptic cables or satellite as those are incredibly expensive – and Mr. Musk has not seen fit to provide StarLink to the country as of yet. When the system is down, it can be incredibly isolating and unsettling as you lose your connection with home and the outside world. Posting a blog becomes impossible given the need to upload photos, in addition to my blog, and spending hours constantly fighting with the internet isn’t very much fun, let alone productive.

Leah had an interesting patient today who was an older gentleman who had been having focal seizures for about eight years that had never been evaluated by us before. He was from the Conservation Area and, though he had spoken Swahili previously, his son felt that he had lost much of this ability as well as some trouble with his ability to speak his native language, Maa (or KiMaa). There was also come complaints of mild right sided weakness that, though on his examination, the only focal findings were an upgoing toe on the right and some difficulty following directions, but it was unclear if that was mainly an issue with the translation (English to Swahili and then Swahili to Maa) or with language. Puzzlingly, though, there was no history of an event that had occurred, such as a stroke, that would have explained his seizures or his examination.

The history was so difficult, we couldn’t tell if there was progression of any of the features or not, which would have raised concern for a mass lesion that was growing, but regardless, there are lots of things here that can cause focal seizures that include brain abscesses, subdural hematoma, stroke, neurocysticercosis (though unlikely in a Maasai as they don’t raise pigs), toxoplasmosis (if he were HIV positive), or lymphoma (again if he were HIV positive, though unlikely for eight years). In the end, we recommended that he have a CT scan to sort things out, but they were unable to do it today as they would need money from home, so it was determined that he would return for the study. Meanwhile, he was placed on an antiseizure medication, which was the easy part of the treatment plan, and we would get his scan done when he returned in several days.

Having patients return to complete their evaluation is always a mixed bag as there are certainly times where they don’t come back, though that is the patient’s prerogative, and, as long as you’ve been completely clear as to the reason for the return, i.e. they are fully informed, then that is patient autonomy. Though we would always love to know what the issue is as soon as possible, it doesn’t always change your immediate management, and can therefore wait until the patient is ready, or, at times, we will manage just the same without the additional information.

One of our last patients to be seen for the day, and a more complex patient as is usually the case, was a young woman coming in with several days of painful eye movements and vision changes that to any neurologist raises the immediate concern for optic neuritis. Her examination was entirely normal other than the findings on her eye exam, that still made us worried about the possibility of optic neuritis. Though optic neuritis can occur in isolation, it is very often the presenting clinical feature of multiple sclerosis, and, in the US, there is little question that a patient presenting with these symptoms would get an MRI of her entire neuroaxis (brain, C-spine, and T-spine) to see if there are any other lesions to make the diagnosis of MS.

We recommended that she have at least an MRI of her brain, partially due to the question of a field cut on her exam, but also as a screen for MS as I’ve mentioned, but, for that, she would need to travel to Arusha to NSK and it would be twice as expensive as an MRI. She wasn’t sure if she would be able to afford getting the study done, so said that she would speak with her husband and come back tomorrow to let us know what her decision was. As I’ve mentioned earlier, though MS is felt to be much less common on the equator for a number of reasons, the incidence isn’t zero and is probably much higher than has been suspected in the past due to lack of testing and lack of neurologists.

We finished our day and all headed home to relax for a few minutes before heading out to town for supplies as well as to pick up everyone’s orders from Teddy as she had sent notice that everything was complete. With Turtle back, it would mean that everyone had a seat since Myrtle’s rear seats left a bit to be desired. We drove down to the change bureau as the residents needed shillings, and then to the liquor store as they also needed wine and other spirits. Once completely stocked up, we made the short drive to Teddy’s shop where was once again waiting for us with her huge smile and a plate full of candy. Allen was awake and it was great to see him again, though initially, he was a bit afraid of me. He eventually warmed up to me and it was so nice to spend some time there. I’m usually sitting out in front of her shop with my computer, but I didn’t bring it this time so was able to enjoy the surroundings a bit more. In addition to the residents picking up their things, for once I ordered some things for me – a runner for my new dining room table along with some matching cloth napkins. I can’t wait to get them home and to try them.

It was back home for dinner, after which I worked in our room while Jill read, and the residents all watched “Devil Wears Prada.” We would be going out for dinner tomorrow night to the Manor Lodge.

Having returned from the Serengeti less one vehicle, as we had been forced to leave Turtle behind at camp with the fundi who was busily working to return it to running order, we were now back at FAME for a week of continuing to see neurology patients, many new, but some follow ups that we had instructed to return. We have been tracking data on our patients now since 2015, well over 5000 of them, so have lots of information on the distribution of new vs. return patients, where our patients are coming from in regard to areas within the Karatu district and beyond, tribes, categories of illness, medications that are use, mostly to help us with planning future clinics, though all of this data is invaluable regarding a free-standing specialty clinic in rural Africa. An IRB has been obtained, but unfortunately, our efforts were thwarted, or at least delay, by the onset of the pandemic and the inability for those involved in the program to travel. Stay tuned, though, as we are in the process of resurrecting our original plan to make this data available to those who could most benefit from it – the Tanzanian health system.

Mondays are always the busiest of days at FAME, as most patients tend not to come on weekends, though for some reason, many patients were showing up on Sundays until we instituted an additional fee for visits on Sunday as everyone here needed a day of rest and that was the only way to achieve it. Unfortunately, the effect has now been to overload Mondays, though since everyone is well aware of the situation, the expectation at the OPD (outpatient department) is that it will be a late day. The other situation that has been occurring, though, has to do with the fact that medical services in the NCA have been reduced with the plans for the Maasai move and, even though is not yet a fait accompli, just the anticipation of changes has made an impact.

There so many patients by mid-morning that the FAME staff had begun to bring additional benches for patients to sit on in an area near us that was exposed to the sun so required that they also tie a net shade over the top to protect the patients. It was all a bit of mayhem as it was even hard to get around with all the patients around reception and slopping over into our area. Somehow, though, everyone managed and, even though, we ended up losing Annie to the OPD at the end of the day so she could help out, the number of patients left at 5 pm were remarkably small and I was quite impressed with the efficiency of the clinical staff to get everyone managed. Given the number of patients that were there after lunch, I would have thought everyone would have been there until midnight.

One of the more interesting patients that was seen during the day was a little six-month infant brought in by their patients as they were having abnormal movements for the last month. On examination, the child was unfortunately in focal status epilepticus, meaning the child had essentially been seizing continuously for a month and, the concern in that situation is the focality of the seizures and the possibility of there being an underlying mass or other lesion causing them. The child was given lorazepam in a similar fashion as we had done at Kambi ya Simba with our last infant in status, just to break the seizure, and they were then loaded onto an antiseizure medication, though I can’t recall whether Marissa had started them on levetiracetam or valproic acid.

We had strongly recommended that the child undergo a CT scan, but as is often the case, the family was unable to afford the cost of the study at the moment, though did agree to come back and have it done in several days. The child’s exam was actually quite good despite the focal status, but that was not nearly reassuring enough for us to forgo the imaging study. Hopefully, when the return, the seizures will have been controlled, and they will be able to obtain the CT scan to help determine if the seizures are symptomatic or idiopathic.

Though our clinic was steady, we did not have near the extra volume that the OPD had and were thankful for that as everyone was a bit tired from the trip home from the Serengeti. I had checked on the whereabouts of Turtle earlier in the day and the news was that she had been fixed and was back in running order on her way to Karatu. They had changed the cylinder head at the camp and the mechanic was driving the vehicle back through the Serengeti and the NCA to Karatu and should be arriving in the evening. At around 6:30 pm or so, the mechanic, who speaks very little English, was at hour door along with an askari (security), as they wouldn’t let him drive into FAME without first checking with me. After reassuring the askari that yes, indeed, I did know the mechanic, we communicated as best we could – at one point, I thought I was playing charades with him as I was acting out windshield wipers to make sure that he fixed them (which he had). I was happy to have Turtle back at FAME and, even though it had been a major hassle having to get the other vehicle, it all worked out in the end as it most often does.

Everyone wanted to watch a movie for the night and Jenn had purchased “Anatomy of a Fall,” which had just been up for an academy award for best picture, so it was decided that we would watch that. Evan had perfected his popcorn making techniques the night before, even using butter to make it just like being in the movie theater…. almost, that is. The movie was an incredibly character portrayal of relationships and expectations wrapped around a mysterious death and a murder trial. It was well worth watching.

There was a talk on neonatal sepsis at 7:30 in the morning that I had wanted to attend even though it’s a fair distance from what I do on a daily basis, so it was to bed after the movie and another day of our clinic tomorrow.

With Turtle still hurting and our hope for another vehicle materializing by morning having vanished, we had decided to have a nice breakfast at a decent hour and then see what our fortunes held for us. Breakfast was amazing and, even though my stomach, which had been in poor order yesterday, hadn’t yet fully recovered, I couldn’t resist the omelette station (there’s something about an omelette station in the middle of the Serengeti that gets me every time) and the crispy bacon. Jill thought it was a bit much for me to have added the Tabasco sauce to the eggs, but there are just times when you must live dangerously, and this was one of those times. Fresh fruits and juices were plentiful as was the pressed coffee.

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Unfortunately, even after enjoying breakfast with a generous amount of time, there were no sounds of another vehicle arriving in the distance, and it was unclear from our communications when that was going to occur. I knew that a new cylinder head was arriving this morning to the Seronera airport, but what unclear to me was whether they were waiting for the part to arrive and then shuttling it here to us with the vehicle we were going to use to get us home, or whether those were independent. To understand this dilemma, one must be familiar with the East African culture as it relates to communication. The simplest way to put it is that everything here is on a need-to-know basis. Information is generally kept “close to the vest” here and I have come to realize that it is not a distrust issue, but rather it is to prevent one from worrying about something. The less that is shared with you, the less you have to worry about if you don’t know enough to be aware of something wrong. I have been caught in these situations numerous times in which I am asked to intervene in a situation without having been given the full story, only to find myself on the wrong end of a discussion for being poorly informed on the details.

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As we sat waiting at camp, it became more and more clear to me that the specifics for the additional vehicle for us to use and to get home were something that was either unknown or it just wasn’t going to be shared with us. At some point in the morning, though, I made the decision to send all the others off once again on safari in the Land Cruiser with Beatus, while Jill and I would hang around camp waiting for the other vehicle with the hope that it would show up in some reasonable amount of time for us to do some game viewing. Despite multiple messages telling us that the vehicle was on its way, along with a few false alarms when we heard other vehicles approaching the camp, the vehicle didn’t arrive until well after noon to pick us up. The big issue we had now was that we had to cross over into the NCA by a certain time, otherwise each of us could potentially be charged for another day in the Serengeti which was a whopping $80 per person. We had originally intended to meet up at the visitor center, but with the long delay we were having, they would meet us instead at Naabi Gate, the entrance to the park and pass through so as not to accrue the additional fee, at least for a part of the group. We found the others, who had already found a table for everyone, shortly after arriving to Naabi, and all had our lunches together.

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We said our goodbyes to the camp staff and hit the road, heading first for the visitor center where we were hoping to pick up some supplies for Kitashu’s boma where we’d be stopping after leaving the Serengeti. The small store in the village where the locals shop at Seronera did not have what we needed, so we make our way towards the gate to meet up with the others there. By the time we reached the gate to have lunch, there was time enough to relax and eat without feeling the pressure of needing to be somewhere on time, though we did need to get rolling to Kitashu’s boma as the main gate for the NCA would close at 6 pm sharp and spending a night around the crater waiting for it to open up again in the morning  was not something any of us would have enjoyed.

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We were still in need of supplies for the village which I had been taught to bring many years ago when visiting the Maasai socially. I usually make a point of having our guide buy them in Karatu before we leave – soap, cooking oil, rice, sugar, tea, and, most importantly, pipi, or candy, for the children – but had forgotten to do so when we left. There is a very small village, Kimba, that contains many shops used by the Maasai that is very close to Kitashu’s boma and would work well for picking up these things, so the decision was to stop there first. The village is only about half the size of what it was just a few years ago as part of the process of moving the Maasai out of the NCA, though there are enough people still residing in the region to keep the businesses open.

Kimba is only a short distance up a small road that is immediately off the rim road, though with recent rains, the road was extremely bumpy and rough. To say the village is quite rustic would be an understatement, but this is essentially a model Maasai village (not boma) that one sees throughout the NCA, and had several shops, a bar, and, surprisingly, a hotel. I had jumped out of the car with Joram to buy supplies while Jill, Joe, and Sandy, had remained in the vehicle. Joe had joked with Sandy about checking out of Gibb’s and coming to stay at the hotel in Kimba, but, appropriately so, she declined his offer considering the surroundings. If that wasn’t enough, Joe then offered up Jill and Sandy to one of the locals to take as his wives, but, thankfully, the offer was declined, and we were able to take the two them home with us. Having to explain to the families why there were left in the NCA would have been a bit difficult.

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Once stocked with supplies for the boma, we left Kimba and drove the short distance to Kitashu’s home, where he spends most weekends taking care of his cattle and any other business needing attention. Kitashu was born and raised here in the NCA and walked to and from school six kilometers ever day. While working at FAME, he has brought his wife and two children to live in Karatu as his oldest son goes to school at Tumaini currently and his younger son will likely go there as well soon. Kitashu has graciously opened his home, as have so many other Tanzanians, to the residents and others traveling with us and it has always been an incredible experience for everyone. His entire extended family turns out to share in the festivities that include dancing, singing, building a fire, and sharing a goat roast. We did everything today other than the goat roast, as he wasn’t sure of our arrival time, though in fact, most of the group weren’t interested in eating goat today.

We departed the boma making a beeline for the gate in both vehicles (including Kitashu catching a ride back to Karatu with us), riding around the rim with the crater in full view to our left, and then heading downhill through the primordial forest. Though this is a once in a lifetime trip, Jill and I will be doing it again in several weeks and looking forward to every minute of it. The Serengeti is a magical place that is beyond comparison and no matter how often you visit, you will always see or experience something new.