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.
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.
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.
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.
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.
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.
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.
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.
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.
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.