By Volunteer Neurologist, Dr. Michael Rubenstein
One of the unique aspects of our bi-annual Neurology Clinic is the team’s mobile clinic outreach that they provide for villages surrounding Karatu. Below are reflections on their experiences for their four outreach clinics last month:
RIFT VALLEY CHILDREN’S VILLAGE: Our outreach began in the village of Oldeani at Rift Valley Children’s Village (RVCV). India Howell (Mama India) founded the children’s village in 2004, and over the years, they have continued to grow such that she now has nearly 100 children that call this their home and call her Mama. She has partnered with the community to improve their schools by helping to fund certain programs and she has offered healthcare to the residents of the surrounding community, as they knew that a healthy community would only improve the chance of success for their children. It was on the backdrop of India creating her children’s village in Oldeani that Frank and Susan ultimately decided to locate FAME here in Karatu, allowing them to be in close proximity to India and her children.
After morning report, we all loaded up and began our drive towards the village of Oldeani along a lovely route through cultivated fields and eventually arriving at the coffee plantations surrounding the children’s village. Driving into the parking circle in front of the administrative offices, there is a huge gathering of patients sitting on benches and waiting to be seen. Our first thought is how we are possibly going to see all these patients in one day, but we were relieved to find that the attendees are not all neurology patients as RVCV’s nurse Gretchen was seeing patients today in their regular clinic. Still, there are quite a few patients for us to see so we make sure with our social worker, Kitashu, that the patients are going to be properly screened. Triage, though, it really tough. At FAME, it’s easy for us to send them over to the outpatient department. Here, they would have to see Gretchen and she was definitely going to be a bit overwhelmed today.
Many of the patients here we’ve seen before, some for as long as I’ve been coming. We see some of the children from RVCV with epilepsy or ADHD, but there are more patients from the community that are seen. We usually see a larger percentage of epilepsy patients here than at other clinics, but otherwise, there is the typical smattering of diagnoses. Several of the patients are new to the clinic and we’ve diagnosed them with chronic illnesses, such as epilepsy, and they will require continued medications going forward from the clinic at RVCV. We had planned to finish early, but somehow the time got away from us and clinic stretched to after five.
KAMBI YA SIMBA: Kambi ya Simba is a small village in the Mbulumbulu ward of the Karatu District and about 45 minutes from FAME. It is a totally self-contained clinic, meaning that we bring all of the medications we will prescribe to our neurology patients and all of the tools that we would need to provide our care.
The drive to Kambi ya Simba took us through extremely fertile farmlands past the Rhotia valley and on to the Mbulumbulu ward. Despite the dry season, there is quite a bit of green as we meander through the hills in this area that sits at the top of the escarpment of the Great Rift Valley and continues until the mountains of the Ngorongoro Highlands meet the drop off and the road ends.
As we arrived at Kambi ya Simba, it was evident that the new dispensary has continued to grow even in the last six months since I was here last. In addition to the large number of buildings that are here now, they have rebuilt the original dispensary that we had begun to work in and now there is a covered arcade connecting everything. There is even an area to drop patients off who are arriving by car or motorcycle. Amazingly, a large number of patients arrive at the clinic on the backs of the motorcycle taxis called piki-pikis. Watching a nearly paraplegic patient load onto one of these as one of two passengers, in addition to the driver, can be a bit nerve-wracking to the say the least.
At the clinic today we have a smattering of return and new patients who all have to be screened for neurological disorders. Our purpose here is not to supplant the government medical staff here providing care, but rather to work with them and provide specialty care that would not otherwise be available in most of Northern Tanzania. These clinics allowing us to practice in their community is not something that is merely a given, but rather a sign of trust that we respect.
Before lunch we had seen our general mix of patients, with headaches and epilepsy, along with a few arthralgias, and still had several patients to get to after lunch who had showed up through the morning. The last patient we saw, though, was perhaps the most complicated. He was a gentleman in his thirties who came to see us in a wheelchair because he was unable to walk due to lower extremity “pain.” It turns out that this gentleman has lost most of the use of his legs, with no effects in his upper extremities, about ten years prior and hadn’t been evaluated medically for this condition.
His examination was myelopathic (meaning that he had a problem somewhere in his cord) as we surmised even before Lindsay, one of the U Penn residents, had first tapped on one of his reflexes. The process, though, had occurred gradually over several years and was purely motor-related as the predominance of his sensory examination was fully intact. Without a sensory level, though, we were unable to tell exactly what level in the spinal cord we were dealing with, but it was clearly thoracic in nature. Having purely motor-related findings is more the exception than the rule. There was little else we could come up with for this gentleman and, perhaps more importantly, nothing that we could do to make him better at this late date. Though we tried to explain to him what our thought processes were, in the end, the answer was the same, that very little could be done other than to make him more comfortable by using a medication such as baclofen for his spasticity which we prescribed.
We left Kambi ya Simba in the mid-afternoon to make our way slowly back to Karatu, once again traveling through the gorgeous countryside that we had traversed earlier in the day.
QARU: The drive to Qaru is less than 45 minutes and is on a main thoroughfare, albeit gravel, as there are very few paved roads other than the main highway traveling from Arusha to Karatu, as well as the road that travels east from Makuyuni towards Tarangire.
It is important to understand that the purpose of our neurology mobile clinics is perhaps less to provide care for patients who cannot reach FAME, but rather to bring the concept to them that neurological diseases can be treated effectively. The villages are not so remote that their residents are unable to get to a medical facility capable of providing treatment; rather their illnesses are often just accepted as part of their life. This can often be most impressive for patients with epilepsy where it is merely a matter of placing them on the right medication and they can be seizure free or at least nearly so. Epilepsy carries with it a huge social stigma, which results in severely limited access to adequate medical care in countries like Tanzania. The percentage of these patients who are treated is appallingly low – in the range of 10%. It can be so rewarding to see one of these patients who has never known a life without seizures become seizure free with a simple medication. Thankfully, many of the patients we see are young children with epilepsy and we are able to place them on the appropriate medications at a much earlier age.
At Qaru, the number of patients waiting for us was rather small – a common occurrence at the mobile clinics. We do advertise the clinics much the same way as we do for those we hold at FAME (where we are always packed), but since we’re at each village only one day, if that happens to be a day of planting or harvest or your cow has run away, then you may not be able to make it. There were several new patients with epilepsy and a few follow-ups, as well as our normal smattering of patients with complaints that we couldn’t necessarily attribute to an underlying neurological process.
UPPER KITETE: It was off to Upper Kitete for the day, a trip of less than two hours, but out to the far reaches of the Mbulumbulu area and the top of the escarpment where one can travel only a few kilometers further before running out of land. We took the same road we use to get to Kambi ya Simba and then continue beyond for an equal distance making it almost twice as far as the closer village.
We arrived at the Upper Kitete dispensary only to find a huge gathering of patients that were thankfully not all for us as it was also their well-baby visit day. After some negotiation with the clinical officer here, we eventually ended up using the two offices that we normally use (the nurse’s office, otherwise referred to as the bat cave for the distinct smell of guano coming from the opening in the ceiling, and the labor and delivery room that was not currently being used), along with the outside area that we normally use as our pharmacy, but would now serve as our third examination room. The pharmacy was bumped to the end of the outdoor walkway and we just moved all of our patients to the other side of the building to wait for us so as to maintain some sense of privacy.
We got through our patients, though, and had our lunch around midday with still a few stragglers to see afterwards. One of our later patients was a gentleman who was brought to us sitting in a chair (not a wheelchair). We were told that he had been unable to walk for well over 10 years. His examination was myelopathic, suggesting some sort of cord problem, and we felt he most likely had a cervical myelopathy as it had been gradual in onset. We discussed the possibility of an evaluation, but were realistic with him: We noted that it was very unlikely that we would find anything that would be treatable at this late stage and, therefore, it would not benefit him functionally. The family understood and we did treat him with some baclofen for his spasticity, which was the least that we could do for him. As with our patient at Kambi ya Simba who was also paraplegic, he was eventually helped onto the back of a motorcycle by his sons and began his trip home. Not long after, we also loaded up and headed home, finished with our mobile clinic outreach for this season.