Friday, October 7 – Departing for the Serengeti, and another Big Five record…

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The view of Oldupai Gorge and Professor Masaki with our group

Having been out last night to the African Galleria, everyone was a bit slow this morning, though thankfully, our departure for the Serengeti wasn’t scheduled until 8 am (still a tad early for Ankita, I think). For me, it was my second attempt at Anna’s birthday zoom that was scheduled at 6 am my time (now October 7, but the rest of my family was still enjoying the waning hours of October 6) and it did take just a bit more for me to get out of bed this morning than it had yesterday. At least I wouldn’t be doing the driving to the Serengeti, a task that Vitalis would be handling for the weekend.

We had originally planned to make our own lunches for tomorrow, but Vitalis had suggested that we instead stop at one of the markets in town that has good pastry type things and samosas that would work not only for our lunches, but also for a breakfast snack for those of us eating (recall, I’m still trying to operate on my intermittent fasting and not eating anything until noontime). Everyone picked out a bunch of little things to eat later as did Vitalis and we also stocked up on smaller bottles of water along with a few frozen bottles that would all fit into the cooler he had brought with him from Arusha. Once raiding the market of most of its baked goods and tanking Turtle up with fuel given the distances we would be driving over the weekend, we were ready to depart Karatu for our weekend of game driving in the Serengeti.

A bush about to be consumed by Shifting Sands

Driving up to the Loduare Gate and the entrance to the Ngorongoro Conservation Area, it seemed like everyone had decided to drive to the crater or the Serengeti this weekend – safari vehicles were lined up side by side on the road even before we had arrived to the parking area one normally uses when going in to get your permits processed. After a few minutes slowly moving towards the gate, Vitalis parked Turtle on the side of the road and left to go to the office to get our permit processed. I jumped into the driver’s seat to keep us moving in a forward direction given the large number of vehicles and, at one point, an MP who clearly had things under control, waved us over to a parking spot where we could sit until we were ready to go through the gate. Vitalis came back moments later saying that he had already taken care of everything, clearly related to the fact that we had put everything through the reservations system this time rather than trying to pay with my credit card at the office gate. It also turned out that there was an international meeting in Arusha for travel companies and agents and they had apparently taken this Friday off to take trips to the crater. How lucky for us. Miraculously, though, we were through the gate quite quickly and on our way back up the crater rim once again, one of my favorite drives in the world as I have previously mentioned and, this time, I would enjoy it as a passenger for the weekend.

Our next stop would be to Oldupai Gorge and a visit with Professor Masaki and the museum there. I had met him about five years ago during a visit here with a close friend and he had taken us to the Leakey’s camp, which at the time had been closed to the public and used for fossil storage. I can still recall him taking me through the small warehouse where the original artifacts were and taking a several-million-year-old mammoth tusk off the shelf and letting me hold it. Since that time, I have continued to maintain my contact with Masaki and have tried to visit him every trip here with the residents, all of who have found a visit to this miraculous place well worth the time. When I first visited Oldupai in 2009 with my kids, the museum had been comprised of two small rooms with some makeshift signs and a few fossils that had been put together many years ago by Mary Leakey. Since them, a new museum has been constructed that is incredibly wonderful – it was built in a circular fashion starting with the oldest fossils here of Zinjanthropus and is divided into four sections with each one being closer to the present as you proceed. The last exhibits cover the modern day tribes here.

Since our first visit, the site has been transformed into a true destination, though I am still amazed at the hundreds of vehicles that pass by every day with only a small fraction of them stopping to visit the gorge and its museums. The Leakey camp has recently been opened to the public as the Mary Leakey Living Museum, and though I’ve yet to visit it, I plan to do so soon. For those of you who are not familiar with Oldupai Gorge or the Leakeys, it is essentially ground zero not only for much of what we know about oldest man, but it is also considered to be the cradle of mankind, for the fossils here tell the story of man’s evolution, the parts of our ancestral tree that made it and those not so lucky, and it was the Leakeys, both Louis and Mary, as well as their children, who were the ones that shared this story with the world. Standing at the overlook with Dr. Masaki telling the story of Oldupai, spread out in front of us in all its glory, one can’t help but feel as though a significant part of our history is still being written in our presence.

Vitalis saving the day with his coffee

Leaving the visitor center and museum, we drove into the gorge, passing by some of the most famous archeological sites in existence, then up the other side and out heading west in the direction of Shifting Sands. This is a remarkable geologic feature that is unique to the Ngorongoro Conservation Area and is the result of an eruption of the sacred Maasai mountain, Ol Doinyo Lengai, which means “Mountain of God,” about 1000 years ago and is composed of black volcanic sand that is magnetized and is slowly being blown west across the grasslands at a speed of about 15 meters per year. The sand stays together due to its magnetic nature and the mound is about 8 meters high and about 20 meters across with a crescent leading edge due to its windblown nature. Both during our last visit and again today, there is a small group of Maasai women who shelter close by during the day, coming out when there is a visitor to sell their beaded jewelry and knick-knacks that are actually quite nice. Living out here in the grasslands must be a very harsh existence and we purchased a number of things from them which was just the right thing to do.

Our first lion after entering the Serengeti

Leaving Shifting Stands, we drove along the smallest of roads heading south towards Naabi Hill and the gate into the Serengeti, though you cross the actually border into the park a bit earlier than the gate. It’s a wonderful drive as we’re off the beaten path and instead of the heavily rutted main road with all its loose and flying rocks (remember our shattered windshield last visit) such that we could enjoy the surroundings more thoroughly without constantly having to slide our windows shut to prevent the dust from coming in. We also enjoyed lunch along the way rather than fighting the crowds at the gate as we had planned and Vitalis won Ankita and Sara’s hearts by having brought thermoses of hot water and a French press to make a picnic pot of coffee that I shared in as well.

An eland, the largest of the African antelope

We eventually arrived to Naabi Gate and as soon as Vitalis exited the vehicle, the heavy latch to his front door fell off the jamb such that his driver’s door would no longer remain closed properly and was essentially swinging freely. We were now down to one operational door and this one was a problem as both of the bolts had sheared off, with the inner portion remaining in the two holes and no way to fix it without a drill gun to drill them out and replace them. Thankfully, something similar had happened to us in the past and what’s required is that something, either a cord or a rubber strap, is wrapped around the pillar between the driver’s window and the one behind with the only problem that neither could be closed when driving and it had to be removed each time he needed to enter or exit the car. There was the additional problem of not being able to lock up.

A topi, one of the many medium to large antelopes of East Africa

Thankfully, there was a repair shop at one of the research garages and Vitalis had repairs done there in the past. We later stopped by the shop and then he brought the car back to them before dinner and we were able to fix the door with no problem. Meanwhile, we began our game drive much earlier than we had three weeks ago, broken door and all, and in short order had pretty much bagged everything necessary for the weekend. I had mentioned previously about the Big Five, those five animals, the elephant, rhino, Cape buffalo, leopard and lion, that were the most dangerous to hunt back in the 20s and 30s when the Great White Hunters were coming to this region, some of who were mortally wounded by their intended victims after they had merely maimed them rather than killing them.

Our female rhino and her young calf

Driving into the park, we encountered the Cape Buffalo, elephant and lion readily, but it is always the rhino and leopard that pose the problem in “bagging” this group. The rhino has been pretty much non-existent here in the Central Serengeti, though we had seen the three of them three weeks ago when we were here and I had little hope of doing so again. Miraculously, Vitalis had heard something on the radio and drive us right to the spot where there were several other vehicles viewing something far off in the distance, but could actually be seen with the naked eye and even more definitively with the binoculars. What we saw was actually a mother and very small calf, clearly not the group from several weeks ago as that group had a nearly full grown calf with them. We watched them for quite some time moving about in the low grass and enjoying themselves.

Now that we had seen four of the five, we were in search of a leopard to complete our quest and didn’t have to wait all that long as we ran across a leopard in a tree along one of the rivers. We still had plenty of sunlight to spare and had found the Big Five in probably a record time of less than two hours after having entered the park. I don’t believe I had ever seen the entire group in a single day until three weeks when we did it before noontime and now we had done it in what seemed like an inordinately small amount of time such that we rolled into our camp knowing that we had really accomplished something significant. It was clearly due to Vitalis’s excellent guiding and perhaps a little help from his fellow guides on the radio, though that is not at all an unusual tool that guides use on a regular basis, sharing information with each other. I just wish that I spoke Swahili if for that reason alone.

Our leopard in the tree to complete our spotting of the Big Five the first afternoon

We checked into our camp where I had stayed three weeks ago and had a relaxing evening. Vitalis left momentarily to have Turtle fixed and returned in plenty of time for dinner. It was a gorgeous night out and one could hear the sounds of many animals out in front of camp – zebra and hyenas were the loudest, though I believe some lions joined the chorus sometime during the night.

Thursday, October 6 – Dinner at the African Galleria and a late night consult…

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Having spent on average two months out of every year here in Tanzania for the last twelve years does amount to a considerable amount of time out of the country and away from family and friends, but the months I have spent away also account for both my own birthday as well as a considerable number of my daughter, Anna’s, birthdays. Over the last two years, as the pandemic has caused so many the inability to travel and visit family, Zoom has probably saved our sanity on this account and I am sure that many families have resorted to the regular family Zooms as we have. Well, today, or at least I thought, was to have been one of those days that we were all going to get together for Anna’s birthday and, given the time differences between California, where she is currently attending veterinary school at my alma matter, UC Davis, and East Africa, it meant that I would be jumping on the call at 6 am my time, which would be at 8 pm Pacific time the previous day for her. Daniel and his fiancée, Chloe, who live in Denver would be on at 9 pm the prior day and Kim, their mother and my ex, would be on at 11 pm east coast time.

Ankita, Taha and Sara presenting on stroke management

Somehow, it never occurred to me that at 6 am on October 6 East Africa Time (Anna’s birthday is on October 6), would actually be October 5 for everyone else and not her birthday. I had woken up around 5:45 am to be ready for the call and when no one had yet signed in, I reached out to everyone on WhatsApp, only to discover the mistake I had made and that the actual call had been scheduled for tomorrow at 6 am my time, which would be, quite appropriately, still her birthday in the US. Somehow, I had missed that important fact on the message that had been sent to me, though even if the date hadn’t been included in the message, it should have occurred to me that it wasn’t yet her birthday. I would just have to do it all over again tomorrow.

A fuller view of a packed room for lecture

This morning was again an early day for educational lecture and the residents were to give a talk on stroke using a few cases as examples from which to begin their discussion. Dr. Ken has asked that we use cases from which to teach as it seems to work best for them and also allows the talks to be a bit more interactive, though sometimes it’s a bit like pulling teeth to get the team to offer answers and we have to call on them to do so. A stroke talk here is very much different here than it is at home for a number of reasons that mostly have to do with the therapies that are available for the acute treatment of stroke as well as the testing that can done. All of the efforts in the United States and in the west have been to deal with having the public recognize warning signs of stroke so that patients are brought into the emergency room as quickly as possible where, if appropriate, they can receive the miracle drugs such as tPA, or the newer TNK, which are clot busters (thrombolytics) that will break down the offending blood clot to hopefully restore blood flow to parts of the brain. The big limitation with this therapy, though, is that one, it requires a CT scan prior to administering, and two, is required to be administered within hours after the onset of the stroke for reasons of safety. If given “outside the window,” the risk for a hemorrhage outweighs the benefits of the medication.

Barbecued chicken on the skewer and nyama choma (barbecued short rib)

The availability of CT scanners, and particularly ones that are working as they are frequently down at many sites that have them given the cost to keep one operational, is very poor and it is incredibly unlikely that a patient will be brought to a center with a CT scanner in the short time necessary to do any acute therapy safely. There is also the cost of the CT scan that is involved, and, even if this was possible, the cost of the therapies are very expensive and pretty much unavailable anywhere in the country for stroke. Even if these two technologies (CT and thrombolytics) were readily available and affordable, which they are not, the other matter is the time. Given the difficulty with transportation in the country and the amount of time it takes to get anywhere due to both roads and vehicles (there are no public ambulances or rescue squads here), it would be nearly impossible that anyone would get to a center capable of administering these agents within the several hours from the onset of the stroke necessary to give them safely. And this is not just for places like FAME, but also for centers such as their national hospital in Dar es Salaam. The fact is that patients coming in with stroke, typically arrive to the hospital days after the onset of their symptoms and the stroke has already been completed.

Chicken curry, curried mutton and fried ugali sticks

At home, a huge effort is made in the emergency room to determine what is referred to as “LKN,” or last known normal, which is considered the time of onset of the stroke, unless, of course, their LKN was just prior to bedtime in which case the time is onset would technically be unknown. During their talk, the residents mentioned this term several times and I was tempted to say something as it is really not something that is used here for these reasons, but decided not to interrupt their talk as it was otherwise going very well. This is just to say that working here is very, very different than at home where the focus of our efforts is often directed towards providing therapies that are not even conceivable here without first having Herculean changes in their infrastructure both for their healthcare system and for their economy. And my discussion of acute care of stroke didn’t even touch the newer therapy of mechanical thrombectomy, where a catheter is placed in the artery to retrieve the clot and restore blood flow which can be done much later than the thrombolytics, but requires not only the technology of catheter labs, but also those highly trained individuals who provide the therapy, none of which exist in this country outside of heart institute.

Ol’ Mesara’s amazing cheese samosas

So, as you can see, the problem is quite complex. This does not mean, though, that all is lost as we can still do much in regard to not only providing care that can lessen the functional impact of a stroke in the hours or days after it has occurred, but also there is much to be done in the prevention of stroke, or what we call risk reduction. Recognizing the medical conditions that increase the risk of stroke, such as hypertension, diabetes, smoking, lipid management and cardiac arrhythmias, are incredibly important in populations where these conditions often go unrecognized and untreated. Things as simple as taking an aspirin a day can lessen the risk of stroke in the appropriate patient or even given in the aftermath of a stoke can lessen the severity of a stroke. Improving the understanding of the clinicians here at FAME for the general pathophysiology of strokes and their treatment can go a long way and will allow them to be more effective in both treating their patients who have suffered a stroke and those who are at risk to suffer one due to comorbid medical conditions.

Grilled paneer and roasted beet on a skewer

As we were leaving for the Serengeti tomorrow morning, Turtle was in need of some necessary repairs, as the locking mechanisms in two of the doors were again acting up and there were only two that worked (which thankfully included the driver’s door) so Vitalis was going to come to Karatu early in the day, or so I thought, to get them fixed while we were working. In the end, he didn’t get in town until 2 pm, which did pose a bit of a problem as we had plans to visit Nish’s place, the African Galleria, for dinner tonight which would require transportation. We had also wanted to get there on the earlier side as the others wanted to do some shopping for gifts. Our clinic was going along smoothly and though this didn’t end up keeping us late as the car and Vitalis hadn’t yet arrived, we were delayed by a last minute tourist who had somehow lost their medications and one of them, which was not available in this country, could be replaced by a similar medication we did have, but would require some dosage conversion. Since the medication was one that we do use, we were enlisted to figure this out which did take a bit of time looking things up on the internet and making some assumptions. I the end, we had come up with what I felt was a good solution and we were able to head back to the house.

Intracranial hematoma in a patient involved in a motor vehicle accident with skull fracture

Vitalis finally arrived, though a bit later than we had hoped, and we all drove down to the Galleria for shopping and dinner. Thankfully, it was crowded at the shop so they stayed open later than normal giving everyone plenty of time to shop. Dinner at the Ol’ Mesara restaurant was again fantastic and Nish ordered plenty of food for everyone. We had brought Vitalis with us, who had never eaten there, and Amos also came along. We did enjoy some of their fancy cocktails before dinner, as well as during and after dinner, and the night was rather long, or at least it seemed so, but in the end, it was only around 8:30 pm when we finally left. I think we tried all of the meat dishes they had, but to be honest, the pumpkin ginger soup and at cheese samosas remain my favorite. The grilled paneer that I had tried for the first time a few weeks ago is also now one of my new favorites. The food seemed to keep coming and never stopped and, for the first time there, we weren’t able to finish everything.

A good demonstration of his skull fracture on bone window

Just before we left, I received a call from Onaely, our radiology tech, that there was a young patient there with a small bleed who had been in a motor vehicle accident earlier in the day and that the ward was requesting a consult from us. Not that any of us was looking forward to seeing a patient that night for obvious reasons, though Sara, who really hadn’t had much too drink, became the one that would do the consult along with Amos who was also feeling fine. We returned home and all went straight to radiology to look at the scans first. Even though the patient had skull fracture with some pneumocephaly (air in the head), the bleed, which looked somewhere between an epidural and subdural hematoma, was quite small and required no immediate treatment which we confirmed with Dr. Grady back at Penn just for reassurance, and the patient was fully intact neurologically when Sara went to evaluate him. In fact, the patient didn’t want to remain in the hospital and it took some convincing by Amos to keep him in the hospital overnight. The eventual recommendations were to repeat a scan in 24 hours and, if there was no change, he would not require any intervention. We were all quite relieved that the patient’s situation didn’t require anything more complex in nature such as an overnight transfer, though I believe that Dr. Thomas would have been willing to provide a burr hole if it had been necessary.

I would be getting up ultra-early tomorrow morning for my redo on the Zoom birthday call with my family for Anna’s “real” birthday and then, we would depart for a weekend in the Serengeti. Everyone was filled with excitement, including me, as it is always a thrill for me to bring the residents there for their very first visit to this truly magical place. No matter how many times I’ve been, and it is many, I always manage to see and experience new things.

Another view of his skull fracture

Wednesday, October 5 – A visit with Athumani, Mbuga and Phillipo after work…

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Having spent both of the two previous days on the road, I’m not certain that any of us realized just how exhausted we were after all the travel. I’m sure the drives were just as tiring for the others as it was for me, though having driven over an hour each way to Mang’ola both days, and in the dark coming home on Monday, I was more than ready to stay at FAME for the day as I’m sure everyone else was as well. Mang’ola is by far the toughest drive of the mobile clinics for the drives to Kambi ya Simba and Rift Valley Children’s Village, though challenging in a different way, don’t have that draining, high speed pace on bumpy gravel that always seems like you’re just a bit on the edge the entire time. For certain, the roads to the other villages are bumpy, but they just don’t involve the same nerve wracking challenge, unless, of course, it’s raining in which case they are like a slip and slide and that’s an entirely different story. Leave it say that even though the mobile clinics can be a welcome change, it’s always nice to be home.

Angel had started her annual leave, which is why she wasn’t available for us on Monday or Tuesday in Kitashu’s absence, but thankfully he was back with us today so our team was once again fully intact. There was no educational lecture this morning , so it was just morning report at 8:00 am and then our regular neurology clinic. Mary Ann was leaving today, so it was time for everyone at FAME to give her the standard three claps of appreciation always preceded by “pasha, pasha, pasha, choma,” neither of which the translation or custom I am quite certain of. I do like the three claps, though, as it never leaves anyone questioning just how long they should have clapped or feeling as though they may have ended early. I also said something about what a powerhouse Mary Ann is when it comes to fundraising for FAME, something that is absolutely essential and, without the donations that we receive from individuals, FAME would no longer have the ability to provide the life affirming services that it does to the residents of the Karatu District here in Tanzania.

A visit with Mbuga, the woodcarver

One thing that I was really looking forward to today, of course, was our return to my favorite all time lunch – rice, beans and mchicha. The last two days, we had eaten box lunches that were from the Golden Sparrow and are typically intended for those guests going to the parks and to be eaten on the road. The lunches contained roasted chicken (typically a small piece consisting of a thigh and wing unless you’re lucky enough to score part of a breast), a bun and hot dog, a butter and carrot sandwich, a piece of chocolate, a mango juice box and a hard-boiled egg. Not that there’s anything at all wrong with the box lunch as it was very filling, but I would be willing to take the five day a week FAME lunch of rice, beans and mchicha over just about anything that someone could off to me. Last Saturday, when we had taken the day off, the residents went to the Lilac Café for lunch which I had originally planned to do as well, but just really could pass up the FAME lunch and ended up going with that instead. Somehow, learning how to make the meal at home just doesn’t seem like it would be the same, so I will just have to enjoy it here and know that I’ll have it again when I return.

Our day in clinic was slow but steady and we had actually planned to make a trip in the late afternoon to visit our friend, Phillipo, the coffee grower as everyone wanted to buy coffee to bring home for gifts and we had also wanted to visit another old friend of mine, Athumani Katongo, who is a wonderful artist that I had first met at Gibb’s Farm years ago. His artwork hangs in my office at Penn and over the years, numerous residents have also purchased his works. I had lost touch with him during the pandemic as he had moved from Gibb’s Farm, but I recently learned that he now had his work next door to Phillipo’s at a shop merely known as the “woodcarver’s shop” – also an old acquaintance of mine, Mbuga, who is Makonde from Southern Tanzania famous for their wonderful and very distinctive ebony wood carvings.

Phillipo demonstrating how they remove the chaff from the coffee beans

I had just recently learned that Amos, the clinical officer who has been working with us over the last weeks, was a very close friend of Athumani’s and also wanted to go to visit him when we did. As the drive to get to the woodcarver’s shop and Phillipo’s would take about 25 minutes, we had hoped to leave clinic a bit early, but as is usually the case, Taha’s last patient was a bit complicated as she was a 40ish year old patient with a complaint of left facial weakness, but also had other cranial nerve involvement in the same vicinity and a headache, all of which was new and made us very concerned for the possibility of a mass lesion causing her problems. She absolutely needed a CT scan of the brain with and without contrast, so both Taha and Dr. Anne proceeded to discuss this with her and the fact that she and her family would have to pay at least part of the cost for the study.

This is always such a difficult situation as FAME does not offer care for free, and even though there is a single charge for the neurology clinic that covers the visit, labs and medicines for at least a month, it does not cover radiology and certainly not CT scans. From the very beginning, it was very clear that FAME would not be able to provide care for no charge from the standpoint of funding and that patients would be charged reasonable and appropriate fees consistent with what was being charged by other healthcare institutions in the country. The benefit of FAME is not that the cost of care is any different, but rather that the quality of care which FAME provides exceeds what is available elsewhere in the country. FAME has succeeded in doing that, but must still charge for the care that patients receive.

Sara taking her turn at pounding the coffee beans. The entire process here is by hand

Often, though, when patients are unable to afford a procedure or test, they must go back to their family or their village where they will speak with the elders who may then raise the money from the community to provide the necessary care. Unfortunately, when dealing with these situation, you quickly realize that there are always unintended consequences when dealing with these situations – reaching in your pocket to pay for the CT scan may work in the short term, but what if you find the patient has a problem? The expectation at that point is that you are responsible for the patient’s continued care and that is not a viable option. Unintended consequences are often the result of over zealousness and a failure to think things through to their most likely or possible conclusions.

Our patient needing the CT scan initially disappeared for around 15 minutes, but eventually returned and explained that she would be back the following day to obtain the study which, unfortunately, did not happen. In the coming days, we will have to reach out to her to follow up on this and make certain that everyone is on the same page. Somehow, we will try to do what’s best for the patient going forward.

Stingless bee soldiers protecting the entrance to their hive

We were eventually able to get away and, even though it was a few minutes later than we had wished, we were able to get there in the daylight so we could spend an adequate amount of time with Athumani’s artwork, which worked well for Sara, who found a wonderful painting of four Tanzanian women carrying fresh fish to the market in baskets that they were carrying on their heads. I loved the painting and, if Sara had not purchased it, I would have in a heartbeat as there was something about it that really characterized the people of Tanzania. He does a lot of very cool stuff with his art work using handmade papers and lots of the colorful cloth here to create a fantastic background on the canvas and then paints on top of that. The painting I have is one of an abstract elephant with an incredibly colorful trunk, but I’ve included one that he did for one my residents, Lindsay Raab, that she ordered specially from him.

We spent some time with Mbuga, the woodcarver, as well, though I’m not certain that we bought to much from him. The real highlight was once again visiting Phillipo and his family. They are such a job and the coffee he produces is the best, much of which is also related to the fact that he processes everything by hand right there on his farm and right in front of us. As we arrived, his father was roasting a fresh batch of coffee beans by hand and, one finished, put onto the cooling rack. We were there for enough time that the beans cooled and we were able to package and purchase that batch which made it all the better. We also spent time watching the stingless bees that pollinate his coffee plants going in and out of their hives. The larger “stinging” bees also try to steal their wax, but the smaller stingless bees have soldiers defending the hives. He also brought out some of the honey for everyone to try as it is equally delicious, but he didn’t have any to sell this visit which was unfortunate as I believe Ankita would have purchased his entire stock had he had any.

Athumani with Lindsay Raab in his studio at Gibb’s Farm in 2018 and the painting she purchased

All in all, it was another lovely visit with his family. I can’t remember his wife’s name for the life of me, but his children, Elia and Elizabeth, are just fantastic and I’ve watched them grow over the last several years. I always love playing with them while Phillipo is giving his talk on the coffee process to the others. We drove home that evening incredibly satisfied with a boatload of coffee in hand and good sense that we had helped his family specifically by buying his coffee and it couldn’t have been more “direct from the source.”

Tuesday, October 4 – Back to Mang’ola for another day and clinic in Mbuga Nyekundu…

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After the exhausting adventure we had yesterday, it was up early for our educational lecture today and then back on the road to Mang’ola and the village of Mbuga Nyekundu. This morning lecture was given by Mary Ann and had to do with abnormalities you visually note in babies at birth and what they may or may not indicate as far as an underlying defect. Though most are totally benign, others are significant enough observations to suggest obtaining a CT scan of the brain (for example, excessive or multiple hair whorls may indicate abnormal brain development).

Map of the Mang’ola region

Our drive for the day was essentially the same as yesterday, though we would turn off earlier before cresting over into Barazani and, instead, travel more inland from the lake towards the hills. We had actually driven this same route when returning last night from Pendo’s home, Majiyamoto, though given the darkness that had quickly enveloped us, none of my passengers would have known that we already driven this road. Once again, a long and terribly dusty drive on the heavily rutted, or “washboarded,” road that makes you feel as though all of your fillings will soon fall out if it persists. Thankfully, everyone’s dental work remained completely intact as the road continued on an on until we finally reached the village of Mbuga Nyekundu that sits in the foothills far above Barazani in the distance.

Announcement for our clinic

We had started visiting this clinic at a similar time as we had Barazani, though the number of patients here have always seemed to lag behind a bit, most likely a factor of the size of the village and the population. They have been enlarging the clinic, though, over the time we’ve come and though we were still in the same building we had used six months ago, which was new for us at the time, they already have another large clinic building under construction. The area itself is incredibly windy and throughout the day, it continued to howl excessively.

Starting to register patients

Patients were here early waiting for us and continued to accumulate throughout the day, but we were never swamped. There was one child who had traveled from Barazani as they had showed up late for yesterday’s clinic and there was some debate over what had been promised to them. Kitashu, who had been able to attend only the last part of yesterday’s clinic had spoken with the mom of this child, but there was a difference of opinion regarding what had been said between them. Mom was adamant that Kitashu had promised round trip transportation, but the driver of our other vehicle recalled only that we were responsible for trip to the clinic and not the return. I really wasn’t certain what the issue really was considering the other vehicle and driver were essentially leased for the day to bring us there and back and in between was pretty much down time. In the end, we were able to resolve the issue and the child was transported home with his mother and the crisis was averted.

Anne triaging patients

Most often the one to resolve these issues, Kitashu was not with us today, nor was Angel, our other social worker, so those duties were left to Dr. Anne who handled them seamlessly, though not without some friction as happened with the child’s mom above. Kitashu was enlisted to help with the group that was going out to find the family of the young boy who had died of rabies as the other family members were desperately in need of getting vaccinated as quickly as possible given their exposure to the boy prior to his coming to FAME. There was also the report that a sibling of the boy had also been bitten by the same rapid dog and now showing symptoms. Finally, when the family was found, the sibling was evaluated and, thankfully, not felt to be symptomatic so they received the vaccine in the same fashion as the rest of the family. Had they been symptomatic, there would have been little purpose in supplying the vaccine or immunoglobulin as neither would have provided any benefit. The entire family and anyone else who had come in contact with the child who had died was vaccinated. Though this will end the issue with this incident, there is little question that the problem will persist and there will be further exposures in the future.

Taha and Amos finally behind bars

Encountering a case of rabies in the US would be exceedingly rare for any of us given the rarity of the condition back at home, though they do occur from time to time. There was a case in the ICU at Penn within the last few years, though again, this is something that most physicians will never see in their career. Unfortunately, for Africa and other regions that are similarly depressed economically, rabies is far more common than it need be and is a significant public health problem. Dogs account for 99% of all human exposures to rabies worldwide and, therefore, aggressive campaigns for dog vaccination will ultimately reduce the risk of exposure for humans. Unfortunately, the same countries where these campaigns are most needed are those who are the least able to enact them due their economic issues.

Hussein speaking with a patient

The region of Tanzania where we had spent yesterday as well as today seeing patients, and especially last evening visiting Pendo in her home, is a very culturally interesting area for the diversity of tribes that inhabit it. This is the Lake Eyasi region that is very remote and definitely feels like you’re traveling back in time. The most unique of the tribes that live in this region is the Hadza, or the Hadzabe, who are the last hunter gatherers in Tanzania and also speak one of the click languages known mainly in South and East Africa as well as Asia. I had spent a significant amount of time with the Hadza during our larger mobile clinics in 2010 and 2011 and, during that time, found their language to be truly intriguing. On one occasion, I had accompanied Amir Bakari, a wonderful colleague who was working for another NGO, to visit a distant village during the rainy season to let them know the FAME bus could not make it to them due to the flooding of the roads. Two Hadza men had asked us for a ride to the other village which wasn’t at a problem other than the fact that they were both a bit intoxicated and, when they spotted a small flock of guinea fowl, decided both to shoot their bows and arrows out the open side windows of the vehicle. Given their state, they both missed the birds badly and then had to run outside to retrieve their arrows. What I remember most, though, was their laughing and cackling in the back of the Land Rover, all the time speaking click. I have videos of the drive focusing on the horrible roads we were driving, but the sound track is primarily these two Hadza in the back seat conversing.

Joel dispensing medications

What’s truly sad about the Hadza, though, is the fact that there are probably only 1000 of their tribe still living in the area and remaining true to their culture such that they are marrying within their own tribe and raising Hadza families. Their numbers have been reduced over time by the typical pressures that are placed on such small groups of people, but in this case, it is also the fact that their homesteads have been encroached upon by surrounding tribes, and mostly the Datoga who grave their animals through the Hadza region, running off the typical game the Hadza hunt. What has been left for them to hunt are small birds, dik dik and baboons as all the larger prey have been reduced by this encroachment. I recall hunting early in the morning with a group of teenage boys a number of years ago and being amazed by their accuracy in hunting small birds in the trees, but, in the end, coming home with a string of small birds to feed a small family isn’t something that is sustainable. I came away with an entirely greater appreciation not only for what it takes to “eat what you kill,” but also for the fact that the Hadza are a dying tribe and that both their language and their incredible uniqueness will soon be gone to this world. There are a number of groups working to save the Hadza, but it is unclear if these efforts will be successful or not.

Taha, Amos, Veronica and Nuruana at the end of clinic

One of the other unusual features of this area of the Karatu District and, perhaps, Northern Tanzania, is that there is an amazing amount of agriculture that goes on here, but they specifically grow huge crops of onions primarily and, for this reason, many of FAME employees who accompany us here will plan to stop on their way home to buy large amounts of onions. Dr. Anne and several of the others quite early announced their intention to stop on our return trip to get a 20 kg bag of onions for something like $3 USD if I remember correctly. No matter how you cut it, that’s a ridiculously small amount of money for a very large amount of onions.

Traitors eating lunch in the other vehicle

We left in advance of the other vehicle which was carrying all of the Tanzanians except for Nuruana and Amos as they had elected to travel home with us. It was a much better drive for me than the one the night before that had been done in darkness and when we returned home, it was decided that we would take it easy for the evening considering the busy days we had over the last two.

Always attracting a crowd of children. Finishing clinic with a fist bump

Monday, October 3 – To Barazani and the bush, then back in one piece…

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Sara and Ankita in the “pharmacy” chatting

In our previous configuration of having a single team of residents with me for four weeks, it had been convenient for us to schedule our mobile clinics in a single week, though now, with the two groups each for three weeks and trying my best to make the experience similar, we’ve split the mobile clinics up so that each group could participate. I have been doing mobile clinics, in which we bring a team from FAME to a number of the more remote villages within the Karatu district to provide the same neurologic evaluation that we do here on campus, since 2011, the year after I began our neurology program here. We have now provided these services every six months to a number of villages where we will follow patients and see new ones as needed.


This began in Kambi ya Simba in the Mbulumbulu region and we have continued to provide these services there in addition to the Rift Valley Children’s Village. Other villages, such as Upper Kitete and Qaru became less necessary over time for various reasons of either low volume or perhaps patient’s ability to be seen at other clinics. Several years ago, we began attending two clinics in the Mang’ola region on Lake Eyasi which is a fairly remote group of villages inhabited by the Iraqw, Datoga and Hadza, the latter being the last hunter gatherers in Tanzania still hunting with bows and arrows and speaking click language. Barazani, where we will be today, is the largest of the villages in this region, and Mbuga Nyekundu is another village somewhat smaller and further inland from the lake. Medical services are very minimal here and, therefore, our clinics are typically very busy.

Given the time it takes to get to Mang’ola, that being typically over an hour, as well as the size of the clinic, we typically try to leave a bit earlier than we do for the other mobile clinics. We had decided to leave at 8 am which meant missing out on morning report and learning about any new patients that needed to be seen or follow up on patients already in the ward. Heading up to the outpatient looking for the doctor on call to speak with, I discovered that our young rabies patient had passed away around 4:30 am and was, thankfully, comfortable at the end. Ankita and Taha had gone up the night before and were pretty certain that the end was near as he had very agonal respirations despite still being awake and somewhat responsive.


It was an incredibly tragic case for such a young boy to have died of a disease that was potentially preventable on so many levels, the first of which is vaccinating the dogs, while the second is the public awareness campaign to get vaccinated immediately after any exposure to a potentially rabid animal. There was still a need to confirm the boy’s diagnosis, though, and this would require a limited autopsy, something that is not easy to obtain anywhere, but even more so in a country with a tremendous diversity of cultural beliefs. Thankfully, after everything was fully explained to his family, they consented to the procedure such that we would very likely have that information after several days.

Luckily, I have known the road to the Mang’ola region since my very first visits here as this is the area where the larger monthly FAME mobile clinics took place, though a bit further down Lake Eyasi and more into the Hadza, or Hadzabe, community. These were week-long clinics that involved a large number of caregivers and support staff traveling in an all-wheel drive bus outfitted with a lab and solar power along with several Land Rovers as support, one of which would be driven by me. The road to Barazani in those days was a bit treacherous, but nothing like the drive from Barazani to Gitamilanda, the village we were working out of, which was essentially off road for most of way and what roads existed were very often washed away by the rains or impassable due to mud. Needless to say, it was very exciting.

Taha’s little patient

Today, the road to Barazani has been widened and graded, but still presents driving challenge as it is loose rock for the entire way, passing through numerous washes or ravines that become raging rivers in the rainy season. And then there is the dust. Every vehicle puts up a massive cloud of red dust that stays in the air forever and creates an essential smoke screen making it difficult to see for some moments as you pass. To prevent the dust from getting into our vehicle, we are constantly rolling the windows up and down in the front doors and those in the back are sliding their windows closed for the same reason. For the driver, this is all done while driving 60-80 kph, staying hyper focused on the road to look for larger rocks and/or potholes, meanwhile shifting through the gears on the frequent uphill and downhill portions of the road. Needless to say, the drive is not only a challenge for the driver, but also for the passengers.

We arrived at the Health Center in Barazani, a location that I know well from having been there over the last several years and were greeted by their clinical officer and nurses who had most of the rooms already set up for us and our patients were already waiting to be registered and seen. Dr. Anne did her pre-clinic triage speech about what types of disorders and symptoms we see as it is not our interest to provide medical care for things other than neurology. The clinical officer there is fully capable of doing this and it has never been our intention to alienate any other health care provider as that is not the best way to develop and good relationship and be invited back each time. Six months ago, I had also assisted in providing some necessary furniture for the health center and they were very grateful for that – desks, chairs and benches that would allow our clinic to run more smoothly and would be something they would benefit from in between our visits.

Ankita and Anne evaluating a patient

The residents worked at a quick pace evaluating patients with the full spectrum of neurologic and psychiatric diseases, both return patients and follow up, but no matter how quickly they were seeing patient, they continued to accumulate. At some point after lunch, I recall going out front to see where things stood as far as patient numbers and remember that we had 28 patients in the register with an additional four patients who had yet to be registered. 32 patients for the day with three residents seemed like a pretty full day to me and I went back to my staffing duties in the back hallway. Sometime thereafter, it became apparent that we had exceeded that total number of patient and were already at 39 with several patients still wishing to be seen. It was now approaching 5 pm when we should have been on the road at least an hour prior to that. There were just that many patients who needed to be seen and we could do very little about. Thankfully, we were able to have the additional several patients come to the clinic the following day that would be in another village, but we would arrange their transport.

First meeting Pendo

One of the significant issues we had today was that we had agreed to go out into the bush to visit a young patient, Pendo (which means “love” in Swahili), that Dan Licht and Marin Jacobwitz had seen back in June while here and were working on sponsoring her in school as she had been disabled for over a year with bilateral lower extremity paralysis and had been unable to attend school. She lived somewhere far beyond Barazani in an area that I had driven through years ago on our other mobile clinics, but the landscape is every changing due to the rains. Kitashu knew where she lived apparently and had it not been for him directing us, there would have been no way whatsoever that we would have found her home.

We drove along minor roads and/or trails, through tiny villages and in between homes with the residents wondering what a Land Rover filled with mostly mzungu, and, even more so, a mzungu driving, was doing way out in the middle of nowhere. There were massive river beds that were dry, thankfully, and needed to be crossed at just the right place so as not to high center Turtle, which has a very long wheelbase and can be prone to this. For me, it was incredibly exciting and there could be nothing more than I would rather be doing than this, but I suspect for the others in the vehicle, it was all a bit questionable to them. One of the funniest things, though, and I kick myself for not getting a photo of this, was the fact that there were street signs out in the middle of nowhere indicating the names of what appeared to be livestock trails. The country just decided to put up street signs in over the last six months as they were not here during my last trip. I did like in the past when people asked me what street someone lived on here and I would say I have absolutely no idea since there are no street signs. I can’t say that any longer.

Pendo’s home

We were essentially driving through perhaps the most remote landscape one could imagine, with home which were very small structures of one or two rooms made out of clay and branches and surrounded by brush fences to form enclosures for their livestock. These were the Datoga, who are pastoralists similar to the Maasai, and had no fields or agriculture to speak of. The homes were in small groups that formed more of an enclave than a village as there no structures other than these living units. We stopped at several and asked people we would come across where the family of this young girl were located and, thankfully, were able to finally find her home. Pendo lived in the village of Majiyamoto (which means “hot water” and named for the hot springs nearby), though calling it a village is really a misnomer as the distance between homes was incredibly vast.

Once we found the correct home, Pendo’s brother, who was home at the time as her mother was not, directed us to the front door where we found young Pendo sitting on the ground on a cloth, with her legs folded underneath here. After speaking with Marin, who had evaluated Pendo at the last clinic in Barazani, she had lost the use of her legs about a year earlier and on examination had a T12 spinal level. There had been no x-rays taken or any other tests as it was unclear how that would have changed her management, though at some point, I suspect we will try to obtain more information so as to know exactly was caused her condition. Her legs are severely contracted and unable to be extended in any fashion and the only means for her to move around at present is to scoot along the ground using her arms and to carry her body forward with her legs remaining folded beneath her. She briefly demonstrated this to us and it was very tragic to see.

Pendo in her home

The reason for our visit was that Marin found Pendo to a bright young child with absolutely no future unless she could get to school and then some type of vocation rehabilitation. Unfortunately, she is too young to go to the vocational rehab center we had sent the two Maasai Down syndrome boys to a year or so ago, but Kitashu miraculously found a school for children with disabilities that she could go to until she is old enough to go to the vocational rehab center. Marin is in the process of raising money for this to occur and Pendo will be going to the school in Moshi shortly for a visit to see if it is the right fit for her. We can only hope that this will work out as it would be life changing for her to get to school and later, vocational rehab.

Meanwhile, it was now sunset and we were in the middle of essentially nowhere with the light quickly fading. Kitashu felt that it would be best for us to take a different route, or really just a different direction, to get back to main road that would take us home, but the problem was there were really no roads to speak of and we would have to cross several deep river beds along the way. We made several tries to find a route to cross the dry rivers with no success as they were rather steep banks that were completely unpassable to us. We eventually made it across one, but were still somewhat lost in regard to finding anything that resembled a road or even a viable trail. We spotted a Datoga man walking some distance in front of us and eventually caught up with him to ask for directions. He spoke with Kitashu for some time and, the next thing I knew, the man was climbing into our vehicle to show us the way himself which I was glad he did as it was not an easy path, either to find or to drive. We eventually came upon a major graded road that was clearly our way home and the man hoped out of the car with a tremendous debt of gratitude from us and countless thank yous in Swahili.

By now it was dark and time for headlights which is never a thrilling idea as the headlights on vehicles here are not well leveled and driving in the dark is treacherous. Any oncoming vehicle is blinding and then there is the dust cloud that follows. With my bright lights on, I could just about see my way, but with all of the oncoming motorcycles, whose headlights were worse than the cars, along with the cars and trucks, I was constantly turning my bright lights on and off throughout the drive. Maintaining one’s focus on these roads is essential in the daylight and, in the dark, is a matter of making it home safely or not. Thankfully, we arrived home in one piece, though all a bit frazzled. It had been an epic adventure and, coming from me, that’s saying a lot considering some of the crazy travel incidents I’ve had in the past here in Africa. After arriving home, I made my special gin and tonics with mango juice for everyone and they were more than well deserved. Not only had it been an epic adventure, but it was day that none of us will soon forget.

Sunset in Majiyamoto

Sunday, October 2 – Another wonderful day in the crater…

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Ankita, Sara, Taha and Amos en route to Ngorongoro Crater

Awakening in the predawn darkness here in Africa is far different than back home for so many reasons, but the obvious one can best be summed up by a question. Just how dark is dark? Both because we are so close to the equator, where the sun both rises and sets very quickly and completely, and there is far less ambient light here in Northern Tanzania by magnitudes of difference from most anywhere on the East Coast of the US. We were scheduled today to once again travel back in time to a place that has changed little in the several million years since it was first formed.

Wildebeest making their morning trek

Ngorongoro Crater, which is actually a caldera, or the remnant of a collapsed volcano, is actually the largest dry caldera in the world and is a remarkable geographic landmark that is considered one of the eight natural wonders of the world and is a UNESCO World Heritage Site. It is unique among most parks in Tanzania as the animals are resident and do not migrate with the other herds that are so famous for their other wonder of the world, the Great Migration of the wildebeest and zebra. The crater contains all the animals of the other nearby parks except for the giraffe, as it is too steep for them to descend from the crater rim, and the Nile crocodile, as there are no flowing rivers within the crater itself. The one animal that is best known here within the crater are the black rhinos that now number somewhere around 30 and are heavily protected as they had been hunted to near extinction. There are also black rhinos in the Serengeti in such places as the Moru Kopjes, the Western Corridor and the Northern region near the Mara river and Kenya.

Resting hippo

We had planned to leave the house at around 5:50 am so we would arrive to the gate shortly after it opened at 6 am. We had also invited Amos, a clinical officer student who has been volunteering and working with us for the last month. He is a terrific translator and is going to make a great clinician and has never been on a game drive in the past to any of the parks which is quite common for most of the Tanzanians here. Though the entrance into the parks is negligible for East Africans, the cost of a vehicle and driver, the limiting factor, is not. He was waiting for us at the junction of the FAME road and the tarmac and was there early as I suspected he would be given the incredibly prompt and respectful person he is. The residents had made lunch for him as well, so we were all set for what would hopefully be a wonderful day in the crater.

The Loduare Gate, the entrance to begin the drive up to the rim, is also the only way to get into the Ngorongoro Conservation Area and on to the Serengeti and then to the west side of Tanzania, so not only is it the only way for every safari vehicle to get in, it is also the only way for the trucks plying this route to get in and travel to Mwanza and other cities to the west. Two weeks ago, there had been over fifty safari vehicles here, but that was later in the morning and, thankfully, most tourists like to have their breakfasts before traveling. We had beaten nearly every safari vehicle to the gate, but I still had to wait in line for the truck drivers that were at the registration window waiting to do their paperwork and pay their fees for entrance and transit. I finally reached the window and again found the process to work perfectly smoothly like it had when I was here three weeks ago – we had our paperwork in hand and were ready to begin one of my favorite drives in the world.

A selfie at the lunchspot

Driving up the crater rim is an experience like no other. You ascend about 2000 feet in a very short distance up a very windy dirt road with hairpin turn after turn and a sharp drop off to the one side. Primordial trees and vines line the road on both sides and at the exposed cliffs on the uphill side, the elephants have left their marks where, using their tusks, they mine for minerals in the soil that they then eat for their nutritional value. Occasionally, you may run into elephants or some stray Cape buffalos crossing the road in front of you on their morning constitutional. On a rare occasions, you can come across a leopard using the road for transit as we have several times. I’ll never forget when Jess Weinstein, one of my former residents, slept through a leopard sighting on the road, though then again, she slept through much of our safari that weekend.

A male ostrich

It was a pretty overcast morning so I was suspecting that we would be in the clouds on the rim, and, sure enough, we were in the incredibly dense cloud cover even before reaching the rim road such that the overlook for the crater looked like you were standing on the edge of an ocean. Worse yet, we were driving through pea soup thick fog or clouds once we started our way around and it was very difficult to see anything through both the moisture and the dust that was being kicked up by the vehicles. There was a safari vehicle in front of me that was helpful as I could see his brake lights in the distance, but there was a sweet spot for the distance behind him between the clouds and the dust that I had to manage in addition to not being able to see much of the road with its ruts and bumps, not to mention that there were vehicles also heading in the other direction. Thankfully, we encountered some blue sky peeking through on the far side of the crater and, by the time we were overlooking the road heading off to the Serengeti and the lovely valley that exists there, there was open sky above us. The one-way descent road was just in front of us with its gate to check in to the crater for there is a separate fee that is paid to visit it, which we had taken care of at the main gate, and after a bathroom break and popping the tops, we were ready to descend to the floor far below.

Our rhino from a distance

As I had mentioned before, the herds of animals here are resident animals, meaning that they do not migrate in or out of the crater, but will remain here their entire lives. As we had seen previously, there were huge herds of zebra, wildebeest and Cape buffalo all throughout the crater floor and, given that it was morning, most were slowly heading out of the surrounding hills and towards the sources of water at the center of the crater. Lake Magadi is the large lake at the center, but there are also large sources of water in many other areas making it impossible to drive in many places due to the swamps that are created by the water sources there. The other common animals that are seen on the floor include Thompson gazelles, Grant gazelles, hyenas, jackals, elephants, eland, hippos, and, of course, the many cats that include lions, cheetahs, serval, caracal and leopards. The cheetahs have been difficult to see here for the last several years and I have never seen a leopard on the crater floor, only the rim. I apologize in advance to the hundreds of bird species here that are truly spectacular, but are far too many to name. The elusive rhino (it took until my third visit here to see one) is what most people are here to see, do not like to come out on windy days as they rely tremendously on their hearing for defense as they have incredibly poor eyesight.

By lunch time, we had seen all of the more common animals, but we hadn’t seen a lion or rhino yet. We were using our short wave radio to listen for any spottings by the other drivers which is all in Swahili, but, as Taha reminded me, we had Amos in the car who could listen and translate for me. After a nice lunch that included ice cream from the snack truck that sits there every day, we took off in search of the things we hadn’t seen so far. I had spoken with a guide when we were at lunch, and he had not yet seen a rhino or lion either, so it didn’t look hopeful. Suddenly on the radio, there was mention of both animals and in a location that was not too distant as nothing really is in the crater.d

Resident zebra at the South Village main building
Sara and Amos overlooking the crater from the Tree Village main building

The lion turned out to be a solitary cat sleeping under a bush in some distance, but at least they could see it through their binoculars. The rhino was even more distant, though that is not at all unusual given their elusiveness, and the line of vehicles was entirely commensurate with the sighting. With binoculars, the shape of the rhino was easily evident and, as it moved through the high grass and brush, one could make out its distinctive horns, the unfortunate feature that led to its near extinction over the last century. Thanks to the conservation efforts of the Tanzanian government, though, with near militaristic enforcement and protection of the animals, they are once again thriving despite their rather slow reproductive rate. They are an incredibly awkward looking animal that is beyond shy and, despite this, they still manage to strike fear for their sometimes aggressive behavior when forced to protect themselves or when there is a calf somewhere around. When hunted, though, these large and unwieldy animals can use their large horns quite effectively when defending themselves and there are plenty of stories of hunters who have succumbed to their attacks. This is why they are one of the Big Five animals along with the lion, elephant, leopard and Cape buffalo, all of who are equally dangerous when being hunted. Thankfully, they are not threatened by our long camera lenses.

The view from the South Village main house deck

Now that we had seen the lion and the rhino, and with no further radio traffic regarding other sightings, it was time to drive by the hippo pool and then the Lerai Forest on our way out of the crater. I had spoken with my friend, Ladislaus, at the Ngorongoro Crater Lodge about having us stop by for a tour and some coffee or drinks before departing the crater and the NCA. He is always so gracious and was happy to have us come by which is always such a treat for everyone, given the fact that it is one of the most luxurious lodges not only in Tanzania, but probably in all of Africa.

Ankita visiting the wine cellar and hoping to make her husband jealous

Arriving to the lodge in Turtle, so incredibly dusty adlong with the rest of us, I always seem to feel a bit self-conscious walking into a main house for one of the three villages there as everything is so very clean and immaculate. It’s easy to forget that we’re in Africa, though considering the views of the crater from every single window, the sight quickly reminds you of where you are. Ladislaus has great stories that he tells us of the history of the lodge and his journey to get there and become one of the village managers for the camp. There are also some resident animals at the lodge and, as we arrived, zebra were wondering around the lodge in small groups. There was also an older Cape buffalo, normally a very feared animal, snacking on some of the bushes outside of one of the rooms that didn’t seem to mind our presence, even though Taha seemed to get just a little closer than Ladislaus wanted when trying to get his own photo with the beast. Thankfully, he survived the encounter. After using the restroom, Ankita came running out to tell us that there was an elephant outside. Sure enough, an elephant was crossing the grounds directly in front and was the closest view of these great animals that we had all day.

A view of the South Village main house from below
The dinner menu at the Tree Village

They took us to a few rooms to check them out, one in the Tree Village that was a bit smaller and let luxurious, and the other at South Village that was much larger and far more luxurious. All of the rooms have incredible views of the crater not only from their deck, but also from their toilets, bathtubs and bedroom. Once finished with our tours, it was time for us to depart as I had to be back to FAME by 6 pm for a meeting with two members of a company that aligns philanthropic clients with non-profits looking for funding. We rushed around the rim and then back down the main road descending to the Loduare Gate and then on to Karatu for my meeting at FAME. We arrived at 6 on the nose, and I had to run in, jump in the shower to clean all the filth and dust off of me from the day and then run next door to Joyce’s house where we were having our meeting.

View from the South Village main house
An elephant walking across the grounds. He had been much closer moments ago

Afterwards, Susan invited me to accompany the two advisors who I had met with earlier, she and Mary Ann for dinner at the Lilac Café in town. With everyone pretty hungry and me exhausted from an entire day of driving in the crater, it took well over an hour to get our food, but, then again, this is Africa! Too my incredible pleasure, though, while waiting for our dinners, in strolled, or, more accurately, waddled, one of the cutest animals in all of Africa right at our feet – a hedgehog, who had come in from the street probably looking for warmth. He seemed to be heading towards the kitchen, though there would be no food for it there considering their diet consists mainly of insects and occasional small reptiles. I followed him in and one of the kitchen workers picked him up and handed him to me. He squealed and twitched about a bit, but was as cute as advertised. I set him back down on the floor at which point he promptly waddled away seemingly quite happy and in search of some juicy bugs. Thus, I happily added yet another animal to my list for day and my long list of animals seen over the last thirteen years. Life is good….

An African hedgehog

Saturday, October 1 – A roller coaster of emotions and a birthday dinner at Gibb’s Farm

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It had been an interesting day and evening yesterday as they had been so very different for us – the tremendous diversity of the clinical problems we had seen, some neurologic and some not, that had really run the full gamut of emotions, though unfortunately more that were incredibly trying rather than hopeful unless you count the gentleman with the brainstem hemorrhage who could have looked much worse than he did. The little baby who everyone had worked so hard to keep alive and even beat the odds, eventually did not, but more from cultural issues than medical. The young boy with what we believed to be rabies and, if so, the only thing to offer would be comfort care. Of the bunch, our real hope for a good outcome would have to rely on the mother who was 25 weeks pregnant and was transferred to ALMC – there was still a reasonable chance that either her pregnancy could be extended or, if she delivered, that the baby would survive against all odds as they often do here given the resilience of the patients and people living here in this often harsh environment.

Our unfortunate young boy with rabies

Meanwhile, I had spent the night at Rift Valley Children’s Village in some luxury given the lovely dinner and lodging we had there as guests and board members of FAME. I had a tiny bit of angst over having left the residents on their own for the night, but in the end, they had enjoyed themselves at the Highview Lodge and despite several messages that I sent this morning, they went unanswered as the entire group had slept in quite late and hadn’t seen them. I wasn’t really worried, though, as I knew if anything seriously wrong had occurred, I’m certain that I would have heard about it.

It was another group affair at India’s for breakfast with the large group of older kids home from school sitting at her very long dining table having cereal and friend and Kahawa, or coffee. I broke down and had a bowl of granola, corn flakes, blue berries and yoghurt, even though I’ve been amazingly firm about sticking to my intermittent fasting that I started several months ago. I don’t eat until noon and finish by 8 pm and I’ve felt great with this regimen that fits perfectly with my schedule both here and at home. We left RVCV by around 11 am and were home before noon, back to FAME and a quiet schedule for a rare day off for us. The clinic had slowed up during the week and Anne, who is a Seventh Day Adventist and whose sabbath falls on Saturday meaning that she will typically take these days off when we’re not around, but will graciously work them during the time that we’re here. Given that we expected very low numbers of patients for the day, both for us and the OPD, and the fact that Anne has been working most Saturdays, we decided not to schedule clinic for the day, but to remain available should there be any inpatients for us to see or should a straggler happen to wonder into clinic needing to be seen by us.

We had also planned to have dinner at Gibb’s Farm tonight which we would have done for no good reason, though we could also celebrate both Ankita and Taha’s birthdays at the same time. With the plans for dinner and an early arrival at Gibb’s, we could try to finish up any business at the clinic early and be on our way at a reasonable time. Depending on the weather, we would also plan for a possible swim in their pool.

The young boy with presumed rabies was still in the ward and, even though there was really nothing to offer in regard to treatment of his underlying condition, we were providing him with comfort care measures, meaning any sedation or muscle relaxation that would make him more comfortable. Taha and I made our way over to the ward to discover that he had been moved to the isolation ward that had been created with the pandemic, and now was to be turned into a surgical ward for post op patients as FAME was working on beefing up their surgical program as part of our new five-year strategic plan.

Enjoying the Gibb’s Farm pool

The boy had been on standard isolation precautions previously, meaning only gloves, masks and eye protection, though the main issue was really to avoid any secretions, but primarily his saliva. I had mentioned previously that there has never been a case of human to human transmission of the virus, other than through organ or cataract donation, but given the consequences of contracting the virus and becoming symptomatic, meaning certain death, doing everything possible to prevent its transmission seems pretty reasonable. The boys older brother remained at his bedside and the boy was certainly quieter than he had been the previous day, likely the effect of the standing haloperidol and as needed lorazepam that he was now receiving. We had his brother conversing with him while we stood mostly in the doorway so as not to risk exposure and it was clear that the boy remained severely encephalopathic and, by the way he was handling his secretions, it was also obvious that he was unable to swallow. He was refusing to drink any water per his brother and, very shortly upon our watching him, began to launch streams of his saliva across the room in a spitting action that was very impressive and very dangerous for those of us in his vicinity. He wasn’t screaming any longer, but was babbling on and on about which I had no idea, nor do I believe did his brother. It was very, very sad to see this young man in his current condition, but there was absolutely nothing to do for him other than provide compassion.

Tloma Village Choir

We walked over to the OPD to find the doctor who was covering the ward for the day just to discuss this case as well as the gentleman with the brainstem hemorrhage. The timing was good as they were just about to order rabies immunoglobulin for the boy, but this had been discussed the night before with folks from a Tanzanian NGO team as well as an ID consultant back home and it was very clear that once a patient is symptomatic, neither the immunoglobulin nor the vaccine will provide any benefit. It would be a waste of a very precious resources and, thankfully, our timing was perfect as we were able to intervene and prevent the immunoglobulin from being administered. At the same time, we were also able to pass on the news that they could discharge the man with the brainstem hemorrhage as he continued to do well and was surprisingly ambulatory.

Enjoying the Tloma Village Choir and the view around the poolside at Gibb’s Farm

With our work at the clinic complete and any cloud cover having broken up, it was time to consider heading to Gibb’s Farm. The others had decided that they would like to check out the pool, though neither Mary Ann nor I were up for that. We made it there by late afternoon and the weather was spectacular with bright equatorial sun and plenty of necessary shade throughout provided by their magnificent trees and landscaping. Sally, their general manager, just happened to meet us at the front entrance of the property and invited us to join them at the poolside at 5:30 pm for the local Tloma Village Choir which I had seen several weeks ago, but ended up equally entertaining as they had been the first time. She also invited the residents to enjoy the pool as much as they wished which was a real treat for them.

Taha and Ankita’s birthdays

It was a lovely late afternoon and evening with the residents swimming and Mary Ann and I sitting in the shade and just enjoying the peace and quiet that is Gibb’s. At around 5:45, the choir came marching in and gave a very nice performance of song and dance and then it was time for dinner. They did have drinks at the poolside during the choir performance that I believe we all took advantage of, and then it was time for dinner, which, of course, was amazing as usual. I had told them of Taha and Ankita’s birthdays, so, come dessert time, the waiters and kitchen staff came out with two plates, each containing a personal chocolate cake, candle and decoration with their names. They all same “Jambo Bwana” first followed by “Happy Birthday” twice, once for Ankita and another for Taha. It was tremendous fun.

Ankita enjoying multiple desserts

We drove home at a reasonable time given the fact that we were leaving for Ngorongoro Crater quite early the following morning and still had to prepare our lunches, which the residents were going to do, and I would gather up all the additional supplies necessary for the trip that included most camera equipment and binoculars. I have two cameras, one for me and one for the residents to use, both with longer telephoto lenses and perfect for shooting photos of the animals. They were all incredibly excited to be going tomorrow.

Preparing lunch for the Ngorongoro Crater drive

Friday, September 30 – A very challenging clinical day…

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A crowded morning report with Mary Ann teaching about child development

Today, we were very busy on numerous fronts and it all seem too start with morning report. But first, Mary Ann had wanted to cover a topic that was very dear to her heart, and ours as well – child development – in about 10 minutes at the beginning of report. She had some very tables and graphs that were simple and easy to remember and would help to identify whether a child was meeting their developmental milestones or not. There is certainly a wide range on when a baby reaches of these milestones, but at least this gives one a ballpark for reassuring parents. Not every child is spot on with their dates, and reassuring families is often the most important thing. The charts Mary Ann presented to help with these determinations were very simple to understand and would also be very easy to put in one’s iPhone for future use, especially by those adult neurologists of us seeing these children when we don’t have a pediatrician or pediatric neurology around. It was also Ankita’s birthday today, so everyone sang Happy Birthday to her at Morning report, but then we had another surprise for her that she would receive at lunchtime along with Taha, whose birthday was coming on Sunday.

Our patient with the brainstem hemorrhage

There were two patients in the ward that were both concerning from a neurologic standpoint and would each need our attention sooner or later. The first, was a gentleman in his 50s who came to FAME after drinking and then developed nausea, unsteadiness, right sided weakness and diplopia. We were clearly worried that he had a brainstem event and, since Ankita is planning to go into stroke, she was more than happy to go see this patient and to check out the situation. The patient looked much better than anticipated given the story we had heard, though he continued to have excessively high blood pressures, probably a manifestation his chronic hypertension which had unfortunately not been adequately controlled previously. The patient went for a CT scan of the brain at some point that morning that demonstrated a very significant brainstem hemorrhage that should have caused far greater deficits than he had, which was certainly good for him considering that there was very little we had to offer him other than restricting him from any antiplatelet agents and managing his hypertension going forward.

Hypertension and stroke occur with a much greater incidence in Sub-Saharan than what we see at home and much has been written about in the countless journals on the subject and numerous studies concerning this matter have also confirmed this additional burden of disease here. Hemorrhagic stroke also occurs at a higher incidence in Sub-Saharan Africa and this is very felt to be due to the excessive amount of undiagnosed and untreated hypertension here where it is always an issue trying to treat chronic disease in culture that still hasn’t fully recognized this entity or the need for chronic medications. Treating an infection with an antibiotic or a case of worms with albendazole requires only a short course of treatment and you’re done. Taking medications for any length of time is something that requires an entire readjustment of the thinking here.

The other case that we had to see in the ward was a 13-year-old Maasai boy who had come in last night and was reported to be confused and was also complaining of pain in his legs. Dr. Jacob, also a Maasai, had conversed with the boy and noted that he wasn’t entirely confused and had mostly been complaining about his leg. Taha had offered to go the ward to see the boy before our clinic, but the true extent of his condition and all its ramifications would not unfold until much later in the day.

Ankita, Dr. Anne, Amos, Taha and Sara conducting a teaching session during a lull in clinic

When it came time for maternity rounds at morning report, there was very vigorous discuss regarding a woman who was 25-weeks pregnant and had been having significant issues with severe hypertension for several weeks so there was concern over impending pre-eclampsia that would not only risk the life of her child, but hers as well. The problem was that her baby wouldn’t survive being delivered at 25 weeks here in Tanzania and that the closest full neonatal intensive care unit that could deal with a neonate that small was in Arusha at Arusha Lutheran Medical Center, or ALMC.

An amazing birthday cake in Tanzania

Initially, there seemed to be the decision that the woman should be advised to deliver her baby, who would not survive here at FAME or, if they did, they would undoubtedly have a tremendous burden of neurologic deficits. If the woman did not wish to proceed in this fashion, then that bridge would be crossed at that time. At this point, Mary Ann weighed in heavily with the recommendation that we should strongly consider transfer to ALMC immediately as was a very difficult situation and, that in her experience, it was much safer transporting the mother and infant still intact before delivery than it would transporting a 25-week premature infant on their own after delivery. In the end, after discussion with ALMC, the director of the hospital agree not only to take the woman and her unborn child, but also committed to covering the cost of their care if the patient and family were unable to do so. Miracles to happen every so often.

When it came to our lunch that day, I had asked Prosper to have a cake made for both Ankita and Taha that could be presented during lunch and all the staff could sing, “happy birthday.” The cake hadn’t quite shown up in time, though I was able to drag my feet long enough for everything to get set, which meant having the cake brought to the kitchen and placed on the counter where our lunch is traditionally served so they would see it immediately upon entering the cantina. Sure enough, they were both entirely shocked, as was I , and I think they were both quite surprised to see such a gorgeous cake here in the middle of Africa and I was equally so. There had been lots of kidding about what they both could expect and Anne had them convinced that they were going to have cold dirty water poured over their heads when they least expected it, though, of course, this was all a rouse and there was no such thing, or at least not that I’ve ever seen. Typically, though, the birthday cake is to be cut in many bite sized pieces and then everyone lines up to have the one whose birthday it is feed them a piece of cake with a toothpick. I had to do this for my 60th birthday at the Highview Lodge, but for today, it was just a matter of singing “happy birthday” to the two of them while the cake was doled out to everything along with their rice and beans.

Sometime during the afternoon, Mary Ann had brought some sad news to me regarding one of our recent patients, a young 28-week premmie born at FAME earlier in the spring who had actually been discharged home but had been admitted several times in the recent past with complications of her bronchopulmonary dysplasia. She had come back in well over month ago and had been slowly gaining weight and improving, but still required the smallest amount of oxygen otherwise she would desaturate. While the last group was here, Cara had seen this child daily and, on some days, multiple times checking in on her. Apparently, her bebe (grandmother) came in insisting that she be discharged so they could take her to KCMC, though, in the end, that was not their intention. Given her even tiny oxygen requirement, it was not surprising that the child died without it shortly after having been discharged from the hospital. She was a beautiful child who had battled back from incredible odds only to suffer the consequences of a complete lack of understanding despite our best efforts otherwise.

So, now back to our young boy who had been brought in last night with complaints of confusion and leg pain. His vitals were fine and there were no signs of infection or meningitis that we could find, yet he was seeming to worsen with increased confusion and all of his lab work was unremarkable . At some point in the midafternoon, though, it was reported that he was having difficulty swallowing and, upon learning this, Taha because concerned about an infamous disease that is rare at home but not in other parts of the world like Africa and Asia. He quickly asked the boy and his older brother who was also there whether he had been bitten by an animal prior to the current symptoms having started.

Sure enough, the boy related the story that he had been bitten in the heel by a dog that was aggressive and that he and his younger brother had subsequently killed. He also reported that his younger brother had also been bitten by the dog. The boy was encephalopathic and had very rapidly developed severe dysphagia and, shortly thereafter, was documented as having a fear of drinking water, or hydrophobia, when he was offered it. The boy had the hallmark features of rabies and, sadly, now that he was symptomatic, the disease would be 100% fatal with no adequate treatment existing anywhere in the world.

When I arrived later in the evening, the boy was severely agitated and screaming in his bed, confusion and was unable to swallow his own saliva. I will never in my life forget that image of his massively wide eyes and the look of fear or madness in them along with his continued screaming in Maa, the language of the Maasai. At that point, as we had little doubt to the diagnosis, we began treating him with comfort measures to reduce his suffering and first gave him some haloperidol, a strong tranquilizer to calm him down and provide some sedation. I also immediately put into action the network of contacts that had been developed six months ago when another child had presented to FAME and immediately died.

The issue wasn’t in regard to treating a patient currently symptomatic, but rather doing contact tracing for any exposed to the boy who would benefit from receiving rabies vaccination, the current recommendation from the CDC and WHO for the prevention of human to human transmission, though a case of human to human transmission of rabies has never been confirmed outside of organ or corneal transplantation. The matter, though, is one of absolute, 100% safety as there is no room for mistakes when a disease is uniformly fatal and can potentially be prevented by receiving a simple vaccination. Any healthcare worker or family member who had been exposed to the patient’s secretions, a scratch or any other means of possible transmission should receive a vaccination. Taha, who had made the amazing diagnosis to begin with, would be one of those at FAME to receive his vaccinations.

In the midst of all this, a number of us had been invited up to Rift Valley Children’s Village for dinner and to stay the night, Mary Ann and I were to be staying in the Kili House, their accommodations for their own board members when visiting, but given the partnership between Tanzanian Children’s Fund and FAME, the two of us apparently qualified as board members. Frank and Susan stayed at India’s home and Dr. Elissa, a previous volunteer at the RVCV many years ago, found lodging with some of India’s older children. It was a lovely night that followed an incredibly hectic day and it was so good to relax for a moment.

An ad for the Rabies-free Tanzania campaign in the past

Meanwhile, the residents had decided to visit the Highview Hotel which is next door to FAME as they had a spa with massages, manicures, facials and pedicures, all of which they took advantage of prior to having dinner there as well. The hotel even provided them with a ride home that night which was actually very good considering several days later, there had been a killer bee attack nearby and a local woman died as a result. This was obviously a specific situation in which they were near the bees or working with them and not something remotely likely to happen otherwise. Still, I was quite happy to know that the residents had made it home safe and sound after their night out.

Thursday, September 29 – Movie night at the Raynes House…

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Though this morning’s lecture, which was given by Mary Ann, our visiting pediatrician and fellow board member, was on the topic of neonatal hyperbilirubinemia, it had quite a bit of relevance to us as neurologists as the significance of this condition is one, that it results in the neurologic syndrome of kernicterus, which produces a condition akin to cerebral palsy, and two, it is completely preventable and often very predictable in certain populations. The incidence of hyperbilirubinemia, and thus, kernicterus, is much higher in patients with glucose-6-phosphate-dehydrogenase deficiency, or G6PD deficiency, an x-linked genetic disorder that is found in a very high incidence in African-American males in the US as well as other regions of the world including Africa. There is also a relationship between G6PD deficiency and sickle-cell trait, both of which will cause hemolytic anemias that, in neonates, will result in hyperbilirubinemia and, if not treated, eventual kernicterus.

Mary Ann giving her lecture on hyperbilirubinemia

Elevated bilirubin occurs in many babies and is most often not harmful and will be cleared on it’s on, but there are many situations in which a babies bilirubin is elevated beyond normal, such as immunologic incompatibilities between the mother and baby, severe bruising of the baby that may have occurred at birth or certain genetic or ethnic factors that may impair clearance of the bilirubin. When the bilirubin reaches severely high levels, it must be treated as an emergency and the babies should be receiving phototherapy immediately for just as in stroke, time is brain. If babies don’t respond to phototherapy in regard to lowering their bilirubin levels, then it may be necessary to perform an exchange transfusion, but this is a life-saving procedure that carries significant risks and is used only in the most severe of cases and those in who the risk of brain injury is immediate.

Our grocery request for the day

A number of members of the staff were unable to attend the hyperbilirubinemia lecture as there had been a “mzungu” emergency in the OPD prior to the beginning of the teaching session. A young visiting child from one of the nearby lodges had apparently had something to eat that had caused an allergic reaction with diffuse urticaria and some wheezing, but did not have any significant airway obstruction nor did they have any mucosal involvement to indicated that they were having anaphylaxis. Just the same, no one was really interested in proving the point, so the child was given some steroids and antihistamines just to be safe, but it did require the attendance of several of the doctors right at the point that Mary Ann was giving the talk.

Teaching in the clinic – Ankita, Sara, Amos, Annie, and Taha

As is usually the case, there was some great discussion on the topic that followed the talk and also some very good questions. One that was asked by Dr. Ken, related to the use of phenobarbitone (phenobarbital) in the baby to help hasten the decrease in the level of bilirubin, something that I had never heard before, nor had Mary Ann, but sure enough, when I did a quick search on the internet during morning report, I found numerous references to both giving the mother prenatally and the baby postnatally the medication. This is not a practice in the United States, but does sound like it is used in some resource limited settings, similar to here at FAME, as the phenobarbitone will induce the liver enzyme pathways to clear the bilirubin quicker. Very ingenious and something that makes a lot of sense once you hear it.

In the process of getting a CT scan

After report, we checked on our little baby with the seizures who was miraculously doing very well and had been seizure-free since noon the prior day and looked very well. We had made some simple adjustments in the baby’s antiseizure medication regimen and the combination was holding – he was still on four medications, but we were weaning one them so he would be going home in a day or two on three medications as long as he continued doing as well as he was now. Again, his mom was incredibly understanding and, though clearly thrilled that he was doing so well, did understand that he was still developmentally delayed and that this was not going to improve necessarily with his seizure control. If his seizure burden prior to coming in to see us had been so excessive that it was limiting his development, though, he could have some subtle improvement and that would be something to hope for, at least.

Our little seizure baby

Our clinic was again rather slow today and though it was not entirely clear as to why, I have seen this in the past typically in times of harvest or the rains, but neither of those were ongoing at present. The effect of the pandemic could certainly be playing a role, though not in the manner most would expect. Tanzania was hit tremendously harder by COVID-19 from a financial aspect than it ever really was from a medical standpoint for as worldwide travel had essentially shut down over the last two years both in regard to the availability of flights and to its safety, the number one industry here, that being the tourist trade, was decimated.

Sara being a softie at lunch with Charlie – How he loves Thursdays

The impact was devastating as the safari companies, the lodges, hotels and restaurants all felt the brunt of the loss of visiting tourists, but also the jobs at these businesses that supported the towns and villages also became non-existent and it was very difficult for people to get by. How a family who had been paying school fees for their children and paying their bills and were just barely making ends meet were going to make do was not entirely clear. Even though over the last several months, the tourist trade has dramatically rebounded and many of these jobs have returned, the financial stability of the country, that is, if one could ever really consider it stable, has not completely returned and many of the businesses that had previously accounted for the job market are not fully up to speed. I’m sure there is also a fear of what would happen if there is again a ban on travel due to a blip in the pandemic – business owners must have this in the back of their minds and are hoping to protect themselves in some manner should it happen again. I am sure that these effects of the pandemic are still in people’s minds after the trauma of the last two years.

Our garden at sunset

Turtle needed some minor repairs and I had wanted to get them taken care of prior to our upcoming trip to Ngorongoro Crater on Sunday, so I drove down to our mechanic’s place in town, though he was unfortunately not in. The young boy who had helped me with the rear door of the vehicle last week was there, though, and proceeded to fashion a gasket for my oil filler cap that had been leaking and at least took care of that problem. Our doors had begun to act up again and we were back to having only two of the four doors working from the outside – these Land Rover conversions to a full on safari vehicle have still not had all the bugs worked out and I wasn’t able to fix that problem today. At least my door and one of the other back doors work and though it’s a pain to lean over and open the doors from the inside, we can do it.

From the Dr. Joyce’s veranda

We had dinner on the veranda of Dr. Joyce’s house (the Hoffman House) which is next door to ours and has much more space for us and also has a great view similar to ours. We had wanted to join Mary Ann as she’s staying there by herself and besides, I had promised Joyce when we had built our house that we would continue to have dinners on her veranda as much as possible. The two cats were as annoying as ever despite the fact that our meals were completely vegetarian. I’ve never seen cats who are willing to pounce on chapati, but somehow, these two are more than willing to do so.

After dinner, Mary Ann asked if anyone wanted to play Bananagrams and Taha, Ankita and Sara were up for it, so joined her in the house to play. They came back home later reporting that Mary Ann had won every game and they were very impressed with her skill, which certainly didn’t surprise me at all. I’m just not a game player and will typically do my best to sit out, having been quite successful so far on this trip. After they returned, we decided to watch a movie and everyone decided upon the original Top Gun. Though I had planned to work while watching, I’ll have to admit that I didn’t get much done as it was hard not to pay attention to the movie as we had it playing on quite large on the wall with my inexpensive LCD projector and the sound through a USB speaker which made it quite entertaining.

The tiny baby gecko in my room

I did interrupt the movie at one point to share a baby day gecko that I had caught earlier with the others, though I’m not sure how much they appreciated it. They were entirely shocked when I let it go back in the house where I had found it, but given that these little creatures catch the mosquitos, I wasn’t about to put it outside. Later, as everyone was going to bed, I caught another, even smaller, baby gecko and knocked on Taha’s door, though he was again not very appreciative of the gift and wouldn’t let me release it in his room, so it went back to my room in the end. Hopefully, no one had bad Malarone dreams of giant man-eating lizards that night.

Wednesday, September 28 – A visit to Teddy’s after clinic…

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In addition to discussing our patients, morning report is a time for any announcements to be made and today was Alicia’s last morning at FAME after having been here for two months as part of her global health fellowship. She spent the first month as the only volunteer here at FAME which one might imagine could be rather lonely, though it is also a time where one is forced to become a part of the routine here rather than hanging around with the other volunteers as is sometimes easier than making new friends. In the early years for me here at FAME, there always seemed to be other volunteers that were here at the same time, though it was only one or two at a time. Later, when bringing the residents, my role drastically changed as I was in charge of the group and most of my time was spent making sure that everyone and everything was taken care of and in the right place. During my one visit in the fall 2020, during the height of the pandemic and prior to vaccinations, I was here alone, but by that time I had become a fixture at FAME and everyone knew me, a much different situation than if you were here volunteering for your first time.

A crowded conference room for morning report – doctors and nurses

So, after morning report, Alicia spoke to the staff about how amazing her time was here at FAME and how much she had learned in addition to how much she had been able to pass on to the staff regarding maternal care. In my role as a board member of FAME, it had been clear to me that the benefits of her involvement had been tremendous, both in regard to deliveries as well as prenatal care, and that her visit would have a lasting effect on the staff and patients here. Having relationships such as these for global health fellows that come on more of a long term basis is extremely important. Alicia had come through a relationship with Creighton University, that had been established several years ago and had previously brought a surgical fellow, Dr. Kelly, for an entire year, and Dr. Alyssa, another OB/Gyn who had come in 2020 prior to the pandemic. Our hope, of course, is that these fellows with eventually also become long term volunteers who will continue to visit FAME in the future, though even if they don’t, their positive impact on the health of the residents of the Karatu district will be long lasting.

Ankita examining a patient

We started out work for the day with our little baby in the ward who had been seizing overnight and was now in need of making a change. The decision after last night’s discussion with my peds neuro fundis (experts) was that we would put him back on phenobarbital, but not a loading dose given all the other medications he was on. We spoke with mom, who has actually been incredibly patient with us given the difficulty we’ve had in controlling her son’s seizures, and informed her that we were going back to the phenobarbital and our hope was that he would stop seizing or at least that they would slow down significantly. While seeing the baby this morning, he proceeded to have a seizure for us during rounds just to prove the point that something needed to be done. As he had an IV in, we decided to go with IV phenobarb as that would get on board the quickest. Sure enough, his last seizure of the day was around lunchtime and, after that, they reported no seizures at all to us for the remainder of the day. The baby was sedated throughout the day, of course, but was still arousable and, most importantly, still breathing. Finally, we were making some headway with this child.

Ankita and Taha sitting with Amos and Hussein – education time

The clinic day remained rather slow which allowed a good amount of time for the residents to do some neurology teaching with our translators, who also happened to be clinical officers and could greatly benefit from the additional time for education. Going over such topics as management of headache, and migraine specifically, back pain, epilepsy, and the neurologic examination were all areas that were incredibly helpful for them to work on during these downtimes. Unfortunately, we’ve had more of these lulls in patients than we would like, but there’s very little that we can do to change things and there are times that we wonder whether we’ve actually stamped out neurologic disease in the Karatu District. As quite unlikely as that was, it still crossed our minds.

At one point, Kizitu, who is in charge of all nursing services here at FAME, and is also a Maasai, came by to check on how we were doing and ended up answering questions from the residents as they were curious about his tribe and their culture as they make up a significant portion of who we see here, along with the Iraqw, who are the other tribe that we see in significant numbers here at FAME. Interestingly, it has been these two tribes, the Maasai and the Iraqw who have been at odds in the most recent past, not signing a treaty until 1986 to ensure their continued cooperation. The Maasai are pastoralists, acquiring wealth through there large herds of cattle, goats and sheep, though it is traditionally cattle that are their main source of food, eating the meat, drinking their milk and also their blood on special occasions. This practice (the milk and the meat, not the blood) and the fact that everything is unprocessed, actually exposes the Maasai to an infection that is seen here commonly called brucellosis, though on rare occasions it can actually develop into neurobrucellosis which then becomes much more serious and our problem.

Angel speaking with a few other staff

The Maasai are probably the most well-known of the Tanzanian tribes (there 128 culturally distinct tribes in Tanzania) for their colorful dress, their way of life (mud huts grouped into a family unit, or boma) and their warrior reputation, though it is also due to the fact that tourists traveling here have the greatest exposure to them as they live in and around many of the national parks and the game reserves. More recently, there has been tremendous controversy regarding the Maasai living in certain areas and especially the Ngorongoro Conservation Area, where they have become extremely overcrowded over the last thirty years and have greatly encroached on the resident wildlife such that the government has proposed moving them from what they consider are their ancestral lands. This struggle is still ongoing today and a lasting solution is still in the works.

Kitashu in traditional Maasai dress

Regardless, the Maasai, who make up a significant portion of those who work and are seen at FAME and also live in the Karatu District, are an extremely proud and culturally profound group of people who I have become very close with during my work here at FAME and have found them to be a both wonderful and unique people. The Maasai range throughout Northern Tanzania and most of Kenya and though most of them speak Swahili, many who are from the more remote areas speak only Maa, their traditional langue, making translation for these patients often a three-way affair.

Once clinic was finished for the day, it was time for me to bring everyone over to Teddy’s shop for them to select fabrics and then decide what each of them would like to have made with them. I had first met Teddy several years ago when I was introduced to her by our former communications director here a FAME who had used her for having clothes made. Teddy’s original shop was just off the road past Carnivore, a local’s bar and restaurant that served only grilled cuckoo (chicken) and chips and had a tiny dance floor – Carnivore has now been replaced by the Golden Sparrow, which was built by the same owner. From the very first time I had met Teddy, I was sure that she was the one who would best take care of my residents going forward and we have never been disappointed.

Teddy’s shop

Teddy has now moved to her very own shop which is in her home on the far side of town and, even though a bit further for us, it is an outing that everyone enjoys. She has a small duka (shop) that carries lots of general supplies for the neighborhood and then also has her fabrics and sewing machines. In the past, we would typically first go to a fabric store to pick out the patterns that everyone liked, but just recently, Teddy has acquired a great number of these incredibly colorful and distinctive fabrics for sale at her own shop, so it was now only a matter of going there rather than having to make two stops.

A happy group at Teddy’s – Teddy, Taha, Sara, Ankita, and Mary Ann

Everyone found fabrics that they liked and began to give her their patterns for the clothing they wanted made while she diligently began taking everyone’s measurements and putting them down in her notebook with tiny swatches of each fabric she was to use to make the piece of clothing. We had brought Mary Ann with us, and even though she didn’t want anything made as she does all of her own sewing at home, she did find two very nice pieces of cloth that she wanted to bring home and use. For me, I have never really had anything made, and even though I am totally enthralled by the colorful designs of the fabrics, they have just never felt comfortable on me for some reason and having something made that I would never wear just doesn’t seen like a good option. So, I live vicariously, enjoying bringing each group of residents to Teddy’s shop, them thinking it’s an imposition for me, when, in reality, it’s a total joy for me, both watching them go through their process of deciding on fabrics and what to make as well as the joy of bringing someone as deserving as Teddy this steady business for her shop. She takes care of the residents and we take care of her.