DCMS members serve hospital in Tanzania
Wednesday, October 10, 2018
Posted by: DCMS
DCMS members Dr. Todd Sack and Dr. Barbara Sharp spent last month seeing patients at the FAME Medical Hospital and Clinic in Karatu, Tanzania. They have graciously shared their experience and some photos from the trip:
8/28 Tue & 8/29: Jacksonville to Nairobi: We flew from Jacksonville at 1:55pm, changed planes at Dulles, and waited again at Zürich Airport for several hours just after dawn where we sat on a balcony watching jets take with the Alps in the distance. We arrived in Nairobi at 6:40pm, were met by the hotel van from the new, fancy Hilton Garden Inn just 10 min away, checked in, and split in the lobby café what we thought could be our last hamburger. We talked with a smartly dressed business woman who we took for an Kenyan, but who is a Floridian whose business is to export American culture to Africans in the form of the ACT college entrance exam.
8/30 Thu: Nairobi to Karatu: We caught the 8am flight to Arusha. Our driver, Charles, drove us an hour into Arusha, passing the cone-shaped Mt. Meru on our right. We saw small maize fields recently harvested, herds of small goats, fields of tall banana trees, small coffee bushes, carefully tended vegetables, rice fields & mango trees. We used our Visa card to buy necessities-- soap & wine –at a large grocery store in busy Arusha, then headed south across dry Maasai country where we passed many large herds of cows & goats tended by men and boys. These will be our patients at FAME Medical in Karatu! We passed grey termite mounds and a few zebras as well. Thirty kilometers before Karatu, we climbed the steppe and looked over Lake Manyara: the great Rift Valley, plus our first baobabs of the trip.
We reached Karatu in the Mareru Valley at 1:45 and turned right for the red-dusty 2.7 km ascent to FAME Medical, our place of work and home for the next month. We were greeted by the Volunteer Coordinator, Alex Girard, who showed us to our pleasant two-bedroom bungalow, gave us an hour-long tour of the small but impressive FAME Medical complex, and returned us home to unpack. Soon, our evening meal was delivered as it would be each weekday at 4:30. We had dinner on our patio looking across the valley to the low, forested hills of the Ngorongoro Crater World Heritage Site three miles away.
We are asleep at 6pm but near midnight, I was startled by flashlight beams on the ceiling and sounds at the front door. I opened it to find what I perceived to be a remnant of a tradition: the tall Maasai “askari”(guard), in a heavy red cloak shrouding him against the cool night. He carried his club. After I introduced myself, “Jina langu ni Dr. Todd”, he gripped my hand softly with a weathered hand. Then he said to me in perfect English, “You forgot to lock your door.”
8/31 Fri: Karatu Day 2: 1st Clinical Day: A cool, overcast morning. We attended our 1st 8am Morning Report in a small conference room, attended by 12 Tanzanian doctors and nurses, by FAME’s founders Susan Gustafson and her husband, Dr Frank, by two other volunteer physicians, plus the two of us. Some fifteen inpatients were reviewed, and then several of us visited these patients on the daily morning hospital rounds. The first patient we saw was a young Maasai woman with fever and pneumonia, worrisome for TB. We saw two women with who had recent emergency cesarean sections performed for pre-eclampsia (both women doing well), several recent vaginal deliveries (mothers and babies doing well), and a few very premature neonates in neonatal warming beds. One of these died a few days later, the lungs too immature for the child to survive without a ventilator.
I had an energetic day in clinic with Dr. Julius, a friendly, eager man in his early 50’s who has PA-level training. To share with readers the variety of our experience, I recorded some of the twelve Maasai and Iraqw tribe members who we saw together: a small 59 year old Maasai woman, in a deep blue cloak and wonderful silver jewelry hanging from her neck, with right-sided rib pain one month after being gored by a cow with the side of the horn (her x-rays were fine; she received naproxen and reassurance, plus losartan 50mg/HCTZ 12.5mg and counseling for new hypertension); a 1 year old child with one day of mild diarrhea with slight blood (normal physical examination, no treatment needed); a three year old Muslim girl with a small boil on her anterior abdominal wall (the mother was given instructions); a middle-aged Maasai man, a large dagger at his belt, with two months of low back pain and a normal neurological exam (we advised naproxen 500mg); a five year old Maasai girl who was thought to have swallowed a 200-shilling coin seven days ago (Barbara found no coin on x-ray today); an older man with atrial fibrillation & mild congestive heart failure who is improving (we performed an echocardiogram & thyroid blood tests, and added digoxin to slow his heart rate); a mom here for a pregnancy test (“positive”, she was sent for prenatal counseling); a 24 year old woman who delivered her first child here 2 months ago, now with left breast abscess draining pus (she was turned over to Barbara for ultrasound-directed drainage); and a 24 year old Maasai man w fever & cough for 1 week (his chest x-rays were normal; we prescribed doxycycline). I am impressed with the thoroughness and kindness of Dr Julius, the quiet demeanor of his patients, how polite the children are, and how much hypertension is present. We fell asleep at 7pm.
9/1 Sat: 9/1 Sat: Karatu Day 3: Hillview Hotel: We attended 8am hospital rounds, I saw a few clinic patients with Dr Msuya, a young, insightful, intense and compassionate physician. We met a woman with psoriasis who is doing well on methotrexate 10mg weekly (refill written). Barbara read several images and prepared her two obstetrical radiology talks for next week. After the hospital lunch of rice, boiled kidney beans & boiled greens— the entire staff of 150 is offered lunch daily— we took a 30-minute walk up to the simple Hillview Hotel located on a coffee farm, with fine views. We read by the pool, swam, and enjoyed a Kilimanjaro Beer and Hendricks martini (all for $10). We walked the red dusty road home, ate outside our eggplant sauce over spaghetti, and crashed at 8pm. Avoid Dodoma wine (Tanzanian): too sweet! My father tells me that years ago the same winery marketed its product as having “the subtlety of a charging rhino.” Still apt.
9/2 Sun: Karatu Day 4: Walk to Town: Overcast, 65 degrees, slight breeze. We enjoyed scrambled eggs outside on our porch, together with a hospital cat, then we walked the dusty road an hour down into town, saying hello to fellow walkers, past several churches with loud singing. In town, we found wide red-dirt streets lined with small shops, and an interesting covered food market packed with vendors, the passageways barely 2 feet wide. There were sacks of various grains & beans, and piles of potatoes, small pungent red onions, tomatoes, tiny garlics and varieties of eggplants. We ate our lunch on a bench outside a hardware store. After lunch, we bought a bright tablecloth made in Morogoro ($18) and a non-stick pan ($11). We tuk-tuked back home to rest from the afternoon heat and to do email.
9/3 Mon: Karatu Day 5: Ascites: A light day for me due to low back pain from carrying suitcases. On the rounds, I examine a 59 year old man who drinks local spirits (high alcohol “pombe“), who came with ascites, fever, and marked weight loss. His CT scan shows only mild ascites and a few lymph nodes near the stomach. The fever resolved quickly with antibiotics, so we’ll do an endoscopy tomorrow for his weight loss. I spent much of the afternoon with Mr. Daniel Ogechi, the outstanding director of the operating room, who oriented me to their G.I. equipment, serviceable though over 30 years old, bringing nostalgic reminders of my early gastroenterology days using similar equipment.
9/4 Tue: Karatu Day 6: A Talk & An Endoscopy: A cool overcast morning, in low 60s, dark clouds moving north towards us from the Ngorongoro hills. I am certain that it will rain today, but this is the dry season and I am told decidedly that I am mistaken, “mvuo hapana ” (they were correct). Barbara gave two excellent 15-minute talks on obstetrical ultrasound, each well-received and generating good questions. On rounds, she performed a cranial ultrasound on a newborn with meningitis. Dr. Gabriel — who is FAME’s very solid Head Doctor—and I performed an endoscopy on Mr. Chenga with ascites, finding only mild portal hypertensive gastropathy. We will treat him for now for alcoholism. Barbara and I had dinner outside at sunset with fellow volunteers Terry (statistician), Joyce (retired biophysics professor and the lab director), Lauri Costello (family physician), & Kelly Shine (a Yale-trained surgeon). Spectacular stars tonight!
9/5 Wed: Karatu Day 7: Clinic with Dr. Julius: As every morning, we attended today’s 8am Morning Report together with a dozen or so other doctors. The over-night doctor summarized each the 23 in-patients today: people with eclampsia, diabetes, fevers, HIV, TB, elevated liver blood tests, plus several premature & malnourished babies. Today’s discussions were prolonged as we have been joined by a nice, young Canadian couple who are learning FAME’s routines: she a pediatrician and he an ER physician. Next, we walked together through the two wards to examine each patient and formulate today’s care plans. We discharged Mr. Chenga with alcoholic hepatitis and fever. Barbara tells me that when I am out of the room, the team calls me “The Professor!” I worked again in clinic today with Dr. Julius, whose smile is terrific. We saw a 44 year woman with a 3cm hard breast mass (Barbara came in to do an ultrasound & we’ve scheduled a biopsy for tomorrow by Dr. Kelly); a 80 year old Maasai shepherd, dagger at his belt, with one week of cough (x-rays fine, we gave doxycycline plus an inhaler for bronchospasm); a 55 year old woman with several weeks of polyarthritis (we gave her naproxen and a short course of prednisone); a 20 year old obese Muslim student with likely Irritable Bowel Syndrome (we discussed her lifestyle with her and prescribed hyoscine 10mg to take three times a day as needed); a 54 year old with likely mild recurrent diverticulitis (we offered naproxen & Augmentin). After dinner, Barbara prepared for tomorrow’s talk.
9/6 Thu: Karatu Day 8: Esophageal Stricture: Barbara gave a very solid 7:30am lecture about IV contrast reactions. Rounds were lengthy because the hospital is full. A ten-year old boy suspected of TB pneumonia died in Room 6. I did a bedside paracentesis on a woman with new ascites; my afternoon was dominated by a 39 year old man with profound cachexia from a tight esophageal stricture—a challenging lesion at 28-33cm and even more challenging equipment—but Dr. Gabriel and I were successful at opening it up and obtaining biopsies. These later came back as squamous carcinoma, a certain death sentence and with no options of palliative stenting, gastrostomy, radiation or hospice care.
9/7 Fri: Karatu Day 9: My Big Census: Again, the inpatient beds are full, and I have a big census to manage, big for me who hasn’t recently attended to sick inpatients. Mr. Chenga, with alcoholic hepatitis, was readmitted with fever, having failed my outpatient antibiotics. We debate whether he has TB. Barbara tells us that the peritoneum is thickened on CT, so I did a paracentesis while teaching the technique to Dr. Badyana. In Tanzania, all the testing of specimens for TB is done for free by the Government; we have gone ahead with TB treatment since our other treatments are failing and we do not have confidence in the Government’s test. Mr. Felice, the 39 year old with profound cachexia and suspected esophageal malignancy, was kept overnight after being slow to wake after yesterday’s successful endoscopy; I discharged him home on a soft diet, omeprazole, and instructions to return to in a month to discuss his biopsies. I discharged Mrs. Paulo with a diagnosis of unexplained cirrhosis and ascites, to return as an outpatient with stool specimens to test for Schistosomiasis. I had a pleasant afternoon in clinic with Dr. Jackie. Our Volunteer Coordinator, Alex, made a delicious Greek dinner for the volunteers which we enjoyed outside on Joyce and Terry’s patio. Wonderful stars.
9/8 Sat: Karatu Day 10: Hypertension: Morning Report and ward rounds on this cloudy, cool morning are dampened further by patient after patient with hypertension. There are two with fresh strokes; one died during rounds.
I prepared for Karatu over the summer by reading cover-to-cover a recently-published 420-page tropical medicine textbook. Most of the book is devoted to interesting and scary infections: malaria, leprosy, schistosomiasis, onchocerciasis, trachoma and many more, but 50 years of concerted work by health professionals has largely eliminated these scourges in Karatu. They are replaced by what was allowed just seventeen pages in my textbook: hypertension, diabetes, heart disease, and stroke.
Last night, a baby who arrived with traumatic brain injury died in the hospital— the police may become involved. In clinic, I met with a 69 year old coffee and corn farmer with long term depression and now fatigue. Clinics in Arusha have treated him for years with high doses of chlorpromazine and amitriptyline, which may explain his slow gait and fatigue. His routine labs are fine today, so I switched him to paroxetine 20mg daily.
In the early evening, Alex drove us into town for dinner at Eileen’s Garden Inn, with a lovely garden & swimming pool. The restaurant was full, so we walked down to the Happy Day Cafe. We missed the sign and walked an extra hour on the dusty road at dusk, passing little children, goats and small red-brick homes. We eventually had a nice dinner of pumpkin soup, chicken curry, rice, salad and Kilimanjaro beers ($21).
9/9 Sun: Karatu Day 11: A Grand Walk: Barbara read a few x-rays, then at 10:30am, five of us set out on a grand two-hour walk to town on small red-dusty trails and roads. Just below FAME we walked through a small canyon where a half-dozen men were shoveling red clay into forms to dry in the sun to becomes bricks for homes, then we ascended up and through a small village of 2-room brick houses with tin roofs, past small farms, smiling little children wanting to shake our hands, and a small tourist shop where we bought two bright tablecloths ($15 apiece). We stopped in central Karatu for Fantas at the Lilac Cafe, walked through the covered vegetable market, and headed home by tuk-tuk. Later, volunteers Rosie, Andrew, Ta, Barbara and I crowded into a taxi to Gibb’s Farm, an elegant 22-room hotel ($1000/night), for a 4-course dinner of lovely green salad from their garden, pumpkin soup, poached Lake Victoria perch in coconut broth, and a blueberry compote. We had 3 new martinis from a fine gin list. Because we are FAME Medical volunteers, dinner was just $25 apiece! Bumpy taxi home in the dark.
9/10 Mon: Karatu Day 12: Tourists : The morning lecture by surgeon Kelly was about the proper observation of patients after surgery. On rounds, we saw a 28 year old British tourist with severe acute diarrhea who we treated with fluids, loperamide, ciprofloxacin, & seconidazole (for Giardia). FAME is situated within an hour of three world-renowned national parks, and four hours from a fourth. Hundreds of tourists pass by Karatu every day; some groups come up the hill for a planned tour of this small, impressive facility (a few leave donations behind), and most days we see one or two tour guides, drivers or travelers as patients. The clinic is very busy and now I see patients on my own. My young translator and one of FAME’s social workers is Kitashu Ngangna from the Ngorongoro village of Oloirobi. He is from the Maasai tribe of herders; his name in his language means “one who owns many cattle”. Kitashu speaks Kiswahili & Kimaasai which is very useful since many of the Maasai herdsmen and women I see, with their elaborate jewelry and daggers, speak Swahili no better than I. Even today, most of the Maasai girl do not attend school so they have no opportunity to learn Swahili or have a modern life. I saw a safari camp chef with gout this afternoon, a woman with rash, a Maasai with chronic cough, and several people with the aches and pains of farming and hard labor.
9/11 Tue: Karatu Day 13: TB & Brucellosis: My 7:30am talk was well-received: I explained liver tests and bilirubin metabolism to the clinicians. I discharged my patient with TB peritonitis. In clinic, I saw a 95 year old Maasai woman, blind for 3 years from cataracts, with eye pain; and a 25 year old Maasai with night sweats, weight loss, edema, ascites & splenomegaly who I diagnosed as having Brucellosis, a bacterial infection contracted from drinking raw milk & blood from his infected herd. Brucella can only be eliminated by culling the entire herd, something that no Maasai could or would accept; I prescribed him gentamycin & doxycycline. I saw a young man with a dog bite on his face; a woman with new asthma made worse by her kitchen’s charcoal stove; a 65 year old Maasai man with new hypertension; & on & on. Long day!
9/12 Wed: Karatu Day 14: Reputations & Second Opinions: When we talk with local people in Karatu, we usually mention that we work at FAME Medical and almost always are told spontaneously how wonderful is the health care. Every day, I see a patient here for a second opinion. Today, I saw a healthy woman with mild forearm pain who just yesterday had extensive tests at a local clinic. There she was told she had typhoid fever, was prescribed two antibiotics (that wisely she did not buy) and was told that she needed vaginal surgery for a tumor. We found no evidence of typhoid or of any infection, Barbara found a 1.5cm vaginal wall cyst using ultrasound, and Dr. Badyana drained the cyst in clinic with a needle, curing her.
9/13 Thu: Karatu Day 15: Dinner Party: Rosie, our pediatrician, gave a terrific talk on resuscitating neonates. I did an endoscopy on a woman with swallowing problems who I diagnosed as “globus phenomenon”, a manifestation of anxiety (wasiwasi) that is common also in the U.S., and I cared for a school administrator with an early miscarriage. At 5, we prepared a small dinner party at our house for two of the Tanzanian doctors, Dr. Gabriel and Dr. Jackie.
9/14 Fri: Karatu Day 16: Difficult Inpatients: The inpatient wards are not full today, but beds are occupied by difficult patients: a 30 year old man with 2 wives and 4 children who was treated elsewhere in town for three months as having TB but came to us unable to swallow; our CT scan demonstrates end-stage oropharyngeal cancer. It is routine in Africa to take a guess and to treat complex problems for TB, knowing that TB is both common and treatable, plus that to miss an advanced cancer rarely is detrimental since treatment is largely unavailable. We sent this patient home today and there is no hospice service. We have a 44 year old man with a severe left-side stroke who we are treating for neurosyphilis based upon the VDRL blood test, again looking for something treatable. He is improving. A premature 2-pound baby died at 1am. As we continued rounds, there are lots of smiles in the room of three young women who just delivered healthy babies.
In clinic, I saw a 15 year old uneducated Maasai girl, married at age 12 and now pregnant; a chef with chronic heartburn; and a 30 year old Maasai woman with unexplained tachycardia and left ventricular hypertrophy who was given propranolol and we instructed to return for an echocardiogram. Barbara and I watched from our porch the sun set behind the rim of Ngorongoro Crater.
9/15 Sat: Karatu Day 17: Eileen’s Tree Inn: Lovely sunny morning, 70 degrees & dry. Morning rounds were interrupted by a healthy baby being born in the delivery room and Barbara leaving to do a testicular ultrasound on another person. After lunch, we walked an hour into town, looked at pretty printed kitenga cloth in the town shops, and walked twenty minutes to Eileen’s Tree Inn, a lovely small hotel ($75pp/night, including meals). We admired the garden, bought colorful woven hot plates, swam in the pool, read emails and had a nice Tanzanian buffet dinner with Drs. Rosie and Andrew from Toronto.
9/16 Sun: Karatu Day 18: Ngorongoro Crater: Five of us from FAME Medical departed at 8am with guide Norman for a day at the world’s loveliest national park, Ngorongoro Crater. It’s actually a conservation area, not a national park, since now as for 300 years the Maasai graze their zebu cattle and goats close to the wildlife. We drove over low volcanic hills created when the mountain exploded 1-2 million years ago creating Ngorongoro Crater, past large wheat fields, & paused briefly to listen to the Swahili Sunday service at a small church. At 8:30, we entered the Park, only 14 miles from Karatu. We drove up through the rainforest to the rim for a breathtaking view of the 12 x 10km crater. Then we drove further past a Maasai village and herds of cattle and goats. For the rest of the day, Norman drove us around the crater floor watching animals: giraffes, elephants, hundreds of buffaloes, Grants & Thompson gazelles, wildebeests, wild dogs, flamingoes, Crested cranes, zebras, lions (with fresh wildebeest kill in the lake),
jackals, warthogs, hippos, ostriches, Egyptian geese, and a Black rhino. On our way back, we drove a dusty road for 30 minutes along the crater rim watching the crater from above. At a viewing station we saw an elephant and two more rhinos. As we left the Park, eight elephants and a troop of baboons crossed the road. Back at FAME Medical, we had dinner at the Lilac Cafe.
9/17 Mon: Karatu Day 19: Visiting Specialists: On rounds, we saw a woman with small bowel obstruction likely due to adhesions who went on to successful surgery; and a woman who was attacked with a machete by her husband’s 1st wife, producing deep cuts to scalp, arms & legs. I saw seven people in clinic, among them a laborer with testicular pain (sonogram by Barbara was ok), a college student with vaginitis, a farmer with uncontrolled hypertension that led to a severe stroke two months ago, and a retired honey merchant in a wheelchair with athetoid movements and leg weakness.
FAME has a team of six academic neurologists visiting next month who will see these two men as well as hundreds of other neurology patients who will come to Karatu or will be visited in nearby villages by our mobile van. Epilepsy is common in Africa, the result of childhood febrile illnesses, trauma, and strokes. Anti-seizure medicines are inexpensive and available but tricky to prescribe safely. The visiting team will work closely with FAME’s Tanzanian doctors to formulate a long term management plan for each patient. Outside specialists enhance the enjoyment of practice by FAME’s Tanzanian professionals and contribute to FAME’s reputation. For example, when Barbara is here, the patients learn that their x-ray or ultrasound will be reviewed in the next few minutes by a highly experienced American radiologist, or often by a doctor in New York after we leave. Each visiting volunteer helps to improve patient care by giving one or more lectures and participating in hospital rounds.
9/18 Tue: Two Talks & A Hedgehog: At 7:30am, I lectured to the medical staff on Clostridium difficile, an dangerous iatrogenic infection that plagues U.S. hospitals. It has not been diagnosed yet at FAME Medical in Karatu but shall be within a few years as the hospital grows; I presented a 2016 paper describing the disease in Mwanza, just 300 miles away.
Rounds included a safari driver who came in coma and was found on CT scan to have a devastating intracranial hemorrhage caused by hypertension; he died that night. A severely malnourished 3-year old Maasai girl came to us last week in coma with terrible lesions reported by Barbara on the head CT; on therapy for TB, she is now awake and eating.
At 4:30, I gave a very basic talk to the laboratory staff about liver physiology and blood tests.
We took out to dinner at the Lilac Cafe in central Karatu Barbara’s young and competent radiology technicians, Japhar and Onaely. When they are together there is always laughter! We had a large plate of roasted goat (mbuzi choma), flavorful but tough, a fresh salad, a creditable pizza, and a hamburger. A six-inch hedgehog waddled in off the street during dinner— we picked it up for a few minutes and then let it waddle back to the street. No one seemed surprised but us!
9/19 Wed: Karatu Day 21: Stress: Tanzanian society bears a lot of emotional stress. These are hard-working people, whether as farmers, herders, tradespeople or professionals. Many of our patients and colleagues are doubly burdened by poverty that is always close at hand, and by the struggle to get ahead in an emerging economy. Our fellow physicians seem pleased to be able to work in a highly-effective hospital like FAME, with skilled co-workers, adequate equipment, a good laboratory, and a well-stocked pharmacy, all at low prices (a CT scan is $10 for locals, a bit higher for tourists). But about half the doctors live here alone for many years, 3-5 hours from their families in Arusha, Moshi or further off. We can sense the stress that this causes.
About half of my patients in clinic today were here for what turned out to be largely emotional problems. I saw a 20 year old shop assistant who claimed to be unable to swallow his saliva but swallows liquids and solids well. He had a normal oral and neck exam; we discussed that he has thick saliva from inadequate fluid intake, plus he has lots of anxiety. I saw a 22 year old woman with chest pain that turned out to be panic attacks; and a hardworking safari guide who has been bothered by fears of driving his safari vehicle over a cliff. I discovered that his intrusive thoughts likely are the result of having two demanding jobs and responsibility for a large extended family, all keeping him from grieving the death of his twin daughter four years ago. We are referring him to a counselor near his home in Arusha.
The word for “anxiety” in Swahili is “wasiwasi”; there isn’t exactly a translation for “clinical depression”. My Maasai translator was quick to tell me that “wasiwasi” belittles the complexity what we see: true grieving by people with no time to grieve, the stress of needing two jobs for a family’s bare survival, the discomfort of long distance displacement, and sometimes true psychosis.
9/20 Thu: Karatu Day 22: Empiric Care: Barbara began the day at 7:30am with an excellent talk on using ultrasound to evaluate scrotal emergencies. At morning report, we debated whether to do another head CT on a semi-comatose small child whose encephalitis has deteriorated despite twelve days of acyclovir for suspected viral encephalitis; again, it was proposed to start TB therapy as a last effort. This approach has seemed to me to be futile most of the time that I have seen it tried here, yet in another room, a small Maasai child with lesions in the brain seen by Barbara on head CT scan, that the FAME doctors treated for possible TB, is now much better: awake, looking around and eating. We met another patient with hypertension and severe stroke. I worked in the Outpatient Department during the afternoon; in the evening, I prepared for an upcoming talk and we packed for our safari
9/21 Fri: Serengeti Day 1: Bern Erasto, our guide from African Traits, picked us up in his Toyota Land Cruiser at 9am, for the day-long drive to the central part of Serengeti National Park. “Safari” is the Swahili word for “a long trip”, and there is also a verb: “kusafiri”, to take a big trip.
We drove from Karatu again up along the rim of Ngorongoro Crater— one of the world’s best views— and down the other side through dry Maasai country. We stopped at the village of our Maasai FAME translator, Kitashu Ngangna, where met his wife, saw his small Catholic church (services are conducted in Kimaasai only), met the lead church elder, and chatted with a mob of small, dusty children who ran away when we tried to take their pictures. We saw a herdsman with his 60 cattle, a few zebra and gazelles just a hundred yards away. The wildlife like to linger near the cattle because the fierce Maasai ward off predators. Driving on, we passed large Vernonia bushes covered with purple flowers, past a large seasonal lake with flamingoes grazing for blue-green algae, a family of five giraffe in front of a herd of cattle, and forests of stunted flat-top acacias. A Noon, still in the Ngorongoro Conservation area, we descended onto a vast dry plain with in a very dusty washboard road. There were occasional herds of sheep, cattle & goats tended Maasai, and more wildlife. We passed the turn-off to the Oldevai Archaeological Museum that was created by the Leakey family.
At 12:30pm, we entered Serengeti National Park. The Maasai word is “Siringetti”, meaning “endless place”. Indeed, the huge flat plain seems endless, dotted here and there with small rock outcroppings where lions like to perch, and a few volcanic hills. We drove another four hours to our hotel, seeing animals along the way. We parked twenty feet from two male lions resting under an acacia. We stopped to see a male lion on a ten foot mound, with two females & two cubs hiding in the grass at the base. Near a water hole was a pride of six lions resting together under a small acacia, the mother tagged with a tracking collar. Two Redbuck were seen near a creek. We saw as well Toppi, many Hartebeest, a dozen blue-green iridescent Crested Guinea Fowl, a family elephants eating tall grass near a pool, an eagle, baboons, hippos, near dusk a leopard sleeping in a sausage tree, and 5 more a lions under a different tree. A family of fifty elephants crossed the road within 30 feet of us; we found six Malibu storks and a small herd of Cape buffalo.
At 6:30pm, we drove up a hill to the luxurious 20-room Kubu-Kubu Tented Lodge in Seronera area of central Serengeti. Ours was a huge room with large balcony and outdoor shower viewing the Plain below. We regretted not bringing our swimsuits for the disappearing edge pool. We had a nice Tanzanian barbecue dinner with local lamb.
9/22 Sat: Serengeti Day 2: More Than 200 Elephants: Bright sunny morning, started cool and warmed to the mid-70s. I had a British-style breakfast of fried eggs, baked beans, bangers, papaya & hot coffee on the hotel balcony, watching about 100 Cape buffalo on the Plain below us. We left with our guide, Bern, just before 8am, the roof up so we drove standing and able to see 360-degrees. I was happy to have my warm leather coat to start. Within twenty minutes, we encountered a field Waterbuck (they look like American Elk), Cape buffalo, gazelles of several types; a dozen small mongoose, a herd of forty female impalas herded by a single, antlered male, two dozen Helmeted Guinea fowl, and a half-dozen warthogs.
We drove today about thirty kilometers over the vast Serengeti Plain— just the Tanzanian part is approximately 200km long and 70 wide. We rode over immense dry, flat grassy plains, by small river banks with lush high grass, next to stony outcrops where we looked for lions , and through acacia forests. We saw hundreds of zebras, wildebeest, and various antelope; an African Fish Eagle with its white collar & head; five huge hippos out grazing who walked quickly to the water as a big male lion approached; three dik-dik nibbling, four female lions hidden in tall grass near a creek; an old male lion under a log near the road, and a herd of more than three hundred Thompson’s gazelles. For eighty minutes around Noon, we watched a cheetah stare at a herd of tasty gazelles slowly moving past from right to left, but no chase occurred. We passed then dozens of elephants, and saw two large crocodiles in a slow, small creek. We saw three warthogs and found a pride of six lions with full bellies sleeping eight feet from us under a tree. At 3:30pm, forty other cars gathered with us to watch two cheetahs as they crossed the road in front of our car and try to stalk a family of hartbeast on the left side of us, while eighteen elephants walked by munching away on dry grass 20-30’ from us on the right. We gave up on these cheetahs after an hour.
I was surprised and a bit concerned by how close we came to elephants and other animals. During each of my past safaris, 22 and 52 years ago, there were very threatening postures and bellows when passed within even fifty yards of a male elephant. Bern explained that Tanzania has long-controlled the poaching within most its parks and have trained the guides well so that none of today’s animals have ever been threatened by a human or heard a gunshot. A German wildlife biologist told me over dinner one night that there is recent concern that the comfort that Serengeti cheetahs have around cars is making it more difficult for cheetahs to hunt—both time we watched cheetahs, a bevy of safari vehicles pulled up and made the potential prey wary.
A few minutes further along the track were at least 140 elephants scattered over a quarter mile of the Plain and a few minutes further were thirty more. Our elephant tally is at least 220 today! We reached the lodge at 5:15 to have chardonnay on our balcony overlooking the Serengeti as the sunset, had dinner, and were abed. Tired!
9/23 Sun: Serengeti Day 3: More Than 250 Hippos: Bright sunny day in the 70s with a light breeze. We checked out of the lovely Kubu-Kubu Lodge at 9am and drove north towards a hippo pool. On the way, we passed hundreds of zebra walking single-file to the water. We saw a few impala and dik-dik as we drove through a low acacia forest. We encountered our first big tsetse flies but had no bites today.
At the hippo pool, we walked to a river bank observation post above a pool perhaps 200 feet wide containing at least 250 hippos. Hippos come out to graze on grass at night but lounge together in water most of their days. We saw huge mothers sleeping with tiny floating babies; groups of adolescents in play fighting, and adults splashing themselves with their tails to keep cool or bobbing up every few minutes for air.
Leaving the Park, we drove more than an hour due south over the vast dry plain of yellow-brown grass. We stopped to see a female cheetah scouting for game under a tree aside the road.
We had a brief tour of Ngorongoro Crater Lodge where we stayed in 1966 & 1996. The view remains spectacular, but the buildings are now painted and decorated to look like rich English manor houses inside & out. We preferred the simpler Maasai-white bungalows that we enjoyed with my parents. We were happy to get home to FAME at 5:30 for a light dinner at Lilac Cafe.
9/24 Mon: Mild Flu: I stayed home today with the same mild flu that went through the clinic staff two weeks ago: fatigue, cough but no fever. This bug was tolerable while sitting in the vehicle all day on safari, but I wouldn’t make it through even a morning at FAME Medical where we are busy moving between the hospital wards on rounds, the Outpatient Department for clinic, Radiology to review images with Barbara, and the Lab to ask questions about results. I finished a fourth talk that I will give on Wednesday, worked on my travel notes, and studied Swahili. Barbara brought lunch for both of us from the canteen, the same surprisingly tasty meal that is offered on most days: boiled kidney beans, steamed rice and a vegetable dish of well-cooked collards and onions. Barbara diagnosed by CT scan her second case of TB in the brain of a child.
9/25 Tue: Karatu Day 27: Tribes: Overcast morning, no wind, 65 degrees. Rosie gave an excellent talk on the complex topic of how to feed premature infants. Rounds were busy: a woman with eclampsia (a life-threatening complication of late pregnancy) needs to have her delivery induced this morning; a child with TB meningitis is improving but Barbara explains must be moved to Arusha three hours away for brain surgery because pressure has built up in the brain. We visit a man with the puzzling combination of urinary obstruction, mental confusion and elevated liver tests elevations, a French tourist with acute appendicitis whose life we saved over the weekend, and a young Tanzanian man with acute intestinal volvulus who we also saved with surgery. There were new healthy deliveries overnight.
I recorded the many tribes represented by my clinic patients today: Maasai, Iraqw, Chagga, Nyrramba, & Mbugwe. Every day, I learn about a new tribe. Tanzania has more than 130 tribes, none particularly large, each with its own language. Kimaasai, for example, sounds nothing like Kiswahili. Each tribe has its own native area but there is lots of moving around and intermarriage. This has been a good thing for Tanzania because no tribe has become dominant, or particularly exploitive, avoiding the horrific tribal violence of Rwanda, Nigeria, Kenya, Uganda and others.
9/26 Wed: Liver Management Talk: I compressed 30 years as a hepatologist into a 30-minute talk on how to treat severe liver disease. The challenge was to create useful treatment protocols using only the tests and therapies that we have here at FAME Medical (liver transplantation is NOT on the list). Afterwards, I received three big claps, a Tanzanian tradition for expressing appreciation.
In clinic, I saw a 22 year old school teacher with constipation, a gardener needing stitches for an accidental inch-long machete cut on his left knee, a delightful retired 87 year old missionary nurse — here since 1956—with lots of medical problems, mostly stable. Barbara is very busy, including with a patient with a giant Echinococcal cyst involving half the left lung.
Several of us went to dinner again at Happy Days. I had nice samosas and chicken curry. It ironic that most of the large Indian community of shopkeepers and traders was forced to leave Tanzania in the 1980’s, yet favorite foods available everywhere are curries, chapatis, and samosas.
9/27 Thurs: Karatu Day 29: Overcast day in the mid-70s. It is getting warmer and this will bring next month’s “short rains” to restart the growing season. Andrew Jacques, the Canadian ER doctor, gave a terrific lecturer on reading EKGs. On rounds, we saw a 12 year old Maasai boy with his right hip destroyed by abscess who will be transferred today to an orthopedist at the regional hospital in Arusha three hours away. I did an endoscopy on a 41 year old Maasai woman with dysphagia; her test was normal, including passing a 44Fr Maloney dilator. Clinic is busy— 120 people seen. I saw a 28 year old Ngorongoro Crater Maasai man with left leg pain from walking his 20 cattle & 30 for 12 km on steep terrain every day to find water, a student with constipation, a woman with costochondritis, a safari lodge chef with vague abdominal pain that last year resolved with parasite treatment so I will retreat him with albendazole, a woman with the same upper respiratory virus that I have. As for me, I’ve begun antibiotics for a worsening cough, but today’s chest x-ray is normal. I am going to rest rather than join Barbara and the other volunteers for dinner at Gibb’s Farm.
9/28 Fri: Final Day at FAME Medical: The day began in the mid-60s with a brief rain shower, after which it remained dry, overcast in the 70s.
In clinic, I saw a young woman who presented four months ago with ascites and normal liver tests. As we saw so often over this past month, someone guessed that it might be tuberculosis and treated her without proof. While the World Health Organization frowns on this approach for fear that indiscriminate medication use will lead to drug resistance, the patient now is healthy, smiling, her ascites gone. Still, I hope my lectures this month will prompt the doctors to perform a diagnostic paracentesis the next time a patient presents with ascites. If so, this trip will have been useful.
I saw an 83 year old American plant pathologist who is introducing here a variety of disease-resistant tomatoes; he fell getting out of the shower and has a terrific bruise but no fracture. I met a primary school teacher who told me he has sixty in his classroom and who has chronic refractory dyspepsia, anemia (hemoglobin 7.8), and no blood in his stool. We scheduled him for upper endoscopy. We considered performing an endoscopy on a woman who describes chronic upper abdominal pain and today’s ultrasound by Barbara is normal; it turned out that she is 5 weeks pregnant, so I canceled the procedure and prescribed cimetidine to get her dyspepsia through the next eight months.
After work, Barbara and I walked down the red-dusty road to find the mother of a small boy who Barbara sketched from a photo she took in our first week. We found the family— mother, father, and three small children—sitting on the dirt in their front yard eating dinner. Barbara gave the mother a lovely pencil drawing of her little boy, and to the box a box of Crayolas. They seemed pleased.
At 6, Susan and Frank, who are our hosts at FAME, had we five physician volunteers to their home for wine, samosas, cashews and a month of stories.
There were many farewell conversations and photos today: at Morning Report with the doctors and around the campus with individual ward clerks, nurses, doctors, technicians, social workers, gardeners, and watchmen. We expressed our admiration for their dedication, compassion, effectiveness, and teamwork. We thanked them for welcoming us, for teaching us so much, and for allowing us to be helpful here for four weeks.
In Tanzania, you rarely say “good-bye”, but instead, “Tutaonana!”: we will see each other again!
9/29 Sat: Tarangire National Park: Overcast, 65 degrees, no wind. With some sadness, we packed into guide Norman’s safari Landcruiser at 8am and said goodbye to our home of one month. With us are doctors Rosie and Andrew from Canada who will safari with us today and then they head to hike Mt. Kilimanjaro.
We drove north in the direction of Arusha passing towns whose names we know from our patients, past Lake Manyara National Park, and past the Saturday market at Mto wa Mbu where there was an Ujamaa Village in the 1970s during President Nyerere’s flirtation with Socialism.
Ninety minutes out of Karatu, in the heart of very dry Maasai country, we turned right to Tarangire National Park that we reached at 10:15.
“Tarangire” is the name of the river that flows through the Park; in Kimaasai it means “never dry”.
We had a five-hour drive through Tarangire. Mostly we found scattered animals in the dry, dusty plain of acacias. The highlights were the massive baobab trees and the many elephants that cluster along the river.
We stopped at a pool to watch wildebeest, zebras and warthogs come down to drink. We descended to a dry river bed where a matriarch elephant used her tusks to dig a pool of water for a group of 18 elephants; we watched three babies playing in the mud. Further along the river bed were another 70 elephants, four eland, six elephants crossing the road, then a group of another seven elephants, a few waterbuck, and then eleven more elephants who passed by us on their way down to the river. Driving in that direction ourselves, we watched 60 more elephants in the river, three Cape buffaloes , and another 18 elephants a bit downstream. We saw vultures feasting on a Cape buffalo carcass in middle of the shallow river, seven giraffes near the water, and three female ostriches.
At 4, we left our friends to take a car four hours to Kilimanjaro Airport where we had a nice dinner at the Kia Lodge, and four hours sleep before heading to our flights to Nairobi and Lusaka. “Kwaheri, Tanzania!”
A European’s comment on African travel: "The only man I envy is the man who has not yet been to Africa - for he has so much to look forward to."
Next year: In July 2019, we plan to travel either to the mountains of Uganda or in Botswana and to the Victoria Falls in Zambia, followed by returning to FAME Medical in Karatu to work for the month of August. Please let us know if you would like advice on planning a trip to Tanzania’s game parks (and to drop by to see us), to Uganda, to Zambia or to Botswana.