Tanzania

Hakuna Matata and my identity crisis

Flying from Lusaka, Zambia to Dar es Salaam, Tanzania was an interesting ordeal. Leaving from Lusaka, we flew to Harare, Zimbabwe, Blantyre, Malawi, Lilongwe, Malawi, and finally to Dar. Basically, within 5 hours, I was in 4 African capitals (although technically Dar isn't the capital. It's Dodoma. But that hasn't really caught on). Maybe not a record, but definitely an interesting future fun fact.

Dar es Salaam means Abode of Peace in Arabic. It may once have deserved that designation, but today as the largest city in one of the largest countries in Africa, it most certainly is not peaceful, but rather chaotic. Rapid growth and poor (aka no) urban planning set the tone for my stay in the area. The city does not have a sterling reputation for safety, but I didn't really feel unsafe. This feeling was one that I had throughout my stay in East and Sub-Saharan Africa. Most of the countries I visited in the area had a pretty significant Indian presence. It was something that I was aware of, but really hadn't understood the scope of until I was there.

There were Indian temples in most every city I visited from Cape Town onwards. Dar actually had an entire Indian part of town where it seemed more people were speaking Hindi and Gujarati (a language spoken in one state of India) than Swahili or English. As such, throughout my time in the region, I could be treated as an Indian rather than an American. I rode the crowded minibuses, walked through town relatively unharassed by peddlers, and could often secure lower prices for services than other "Muzungus". Muzungu is a Swahili/Bantu word that draws from the legacy of Europeans that visited and colonized the region. Today, it more generally refers to tourists, particularly white people.

Undoubtedly, my upbringing and social norms are more Muzungu, but I often found it convenient to co-opt a more Indian identity. Rather than talking exclusively about what I did at home, I talked about experiences in India more because it afforded me more unfiltered access to the places and people I interacted with. At the same time, when I met with doctors and hospital officials, being an American trained biomedical engineer afforded me tremendous access that might otherwise not have been extended. The whole exercise revealed a previously unexplored layer to the Indian-American identity that I have struggled with to fully embrace.

Dar is much more glitzy than people think

I sat in an Uber for two hours the first day. Then I walked the next day. I saved an hour

I didn't see a road named for Trump for some reason

But enough free association. I called this section Hakuna Matata, not just as an ode to one of the best movies ever, Lion King, but also to recognize that it has very real meaning for a great many people in the world.

"It means no worries for the rest of your days. It's a problem-free philosophy."

Timon and Pumba are like real-life Zanzibar. This beautiful and historic island is a three hour ferry ride off the coast of Dar es Salaam and one of my favorite places I visited. The people of Zanzibar are overwhelmingly Muslim. Around 99%. It also has a rich history as a critical port for trade between East Africa and India, especially slaves and spices. The historic center of the area is called Stone Town, a UNESCO World Heritage Site. The area is characterized by extremely narrow alleys between buildings, big beautiful wooden doors, and the never-ending presence of men and women sitting outside and chatting along these narrow streets. The rich smell of Swahili, Arabic, Malay, and Indian cuisine can be found exuding from the various street food fixtures along the water front and the larger alleyways. It was a wonderfully relaxing time before heading back to the chaos of Dar.

Fun fact: the walls of Stone Town are actually more coral than stone, meaning they are breaking down due to acidifying rains

Muhammad made me that banana leaf tie and hat.

This tortoise is from the Seychelles, the second oldest living after Galapagos. Only 150 yrs old.  

It was also revealing. The family I stayed with through Airbnb was extremely open and shared the struggles of raising a child with intellectual deficits. There story was tragic, and perhaps more tragically, not the only such one I heard. Following multiple trips to the National hospital in Dar with differing and incorrect diagnoses, the family finally had to take their son to India where he was diagnosed with cerebral malaria. However, the swelling of his brain for extended periods had done irreversible damage, making him reliant on round the clock care from his parents. I came away in awe of their strength, and just in much in shock of the failure of the healthcare system, a feeling that I never truly was able to shake.

Surgery and Policy: A Deep Dive

My visit to Dar Es Salaam was primarily in order to meet with a contact provided by one of the team members in Macha. Safe Surgery 2020 is a public health initiative working in cooperation with Harvard School of Public Health. This was a different aspect of the project that I had less experience with, but surprisingly, one that I now find to be the most important.

In exploring the connection between medicine and technology, the aspects of Western medicine that have spread more quickly are those technologies that are easiest for users. Swallowing a white pill when you have a headache is relatively easy (In Guatemala, people preferred syrups rather than pills which they were unaccustomed to swallowing). An RDT can be reliably administered and interpreted by a rural health worker with minimal training. But what about surgery? Things ranging from C-Sections and hernia to cancerous tumor removal all require a trained individual and equipment, both of which are in short supply in lower and middle income countries (LMICs).

I had heard briefly of the challenges from Dr. Spurrier in Zambia, but here in Tanzania, I got to explore the challenge more fully than before. My contact was Desmond Jumban, a native of Cameroon, that had been working and living in the US for the past few years. He shared with me some of the shocking numbers that had led him to focus his efforts on surgery.

Around the world, almost 5 billion people (shiiiiit) lack access to safe surgery, despite it being one of the most effective treatments we have for a wide range of conditions. That is, at least one (usually most) of the following is lacking: trained surgeons, anesthesiologists, nurses, equipment, oxygen, and the ability to provide adequate and responsive peri-operative care.

Like many other countries in the region, inadequate human capital has led to reliance on task sharing. In some arenas, this has been hugely impactful and beneficial. Consider community health workers. Managing the HIV/AIDS epidemic or malaria in the region would be near impossible if the only people that provided healthcare and medication were trained doctors. It takes too long, costs too much, and is inefficient to rely on trained doctors to ensure that patients are doing relatively simple things, such as taking their antiretroviral medication. Rather, local workers and volunteers who are provided basic medical training are able to perform such tasks.

Perhaps more importantly, they are able to do at just as high a degree of success and efficacy as a doctor. In addition, there are some pragmatic reasons why CHWs are effective. Because they are often locals, CHWs are able to gain the trust of the community more quickly than a doctor, even if they are Tanzanian. There are dramatic differences in culture, customs, and language across the country, and you're far more likely to believe a community member than random doctor that might not even be from the country. Similarly, CHWs are less likely to move away and leave their community drained of precious human resources. Doctors, on the other hand, often leave for more Western countries, or at the very least for wealthier cities within the country leaving large swaths of the country as what can best be described as healthcare deserts.

The challenges are further exacerbated by the overall lack of quality healthcare providers. Focusing on just surgery, there are only 2 surgeons for every 100,000 people in LICs as compared to 9 in high income countries. When it comes to anesthesiologists, there are only about 20 anesthesiologists in all of Tanzania (that's 1 per 2.5 million!). As compared to the global recommendation of 20 surgeons, anesthesiologists, and obstetricians per 100,000, Tanzania has only 0.46.

This leads to the more dangerous facet of task sharing: its blurring with task shifting. Undoubtedly, there are benefits to task sharing. It allows for the creation of a more robust healthcare delivery apparatus than would otherwise be possible, where systemic needs can be more efficiently matched to the system's ability to address those needs. In the tiered systems of many African countries, CHWs and Community Health Officers (CHOs) at a local clinic or hospital serve as primary healthcare providers. They are usually found in rural communities, and can deal with basic injuries, run RDTs to test for potential cases of malaria, and are complemented by CHWs that may be engaged in grassroots education, point of care testing in the field and healthcare awareness efforts. For cases that cannot be handled, patients are subsequently referred to secondary, tertiary, and occasionally quaternary hospitals based on each level's ability to handle the case.

Tanzania's Healthcare system (similar to other's in the region)

The numbers speak for themselves, however. When there are not sufficient numbers of trained practitioners at the top of this pyramid, tasks are shifted down to individuals that may not have the skill or training to do so safely. However, in doing so, the credibility of CHOs, doctors, surgeons, and Western medicine is undermined at large. Doing so creates long term damage and sets back efforts by countless other individuals and organizations. The prime example of the tragic consequences of this limitation is found in obstetrics. 

Imagine (for many this is a reality) an individual with between 3 months-year of basic surgical training leading your wife's, sister's or mother's C-section in a primary level district facility. In addition to the lack of a clean working environment, the instruments and protocols employed may not prioritize infection control measures as possible due to lack of supplies or awareness of risks. The nurse anesthesist (forget having a trained anesthesiologist) will usually administer ketamine because it is cheap, can be administered without machines requiring oxygen or electricity, and therefore requires minimal training. However, due to the lack of formalized dosing and delivery protocol, underdosed patients may still move on the table while under the knife, leading to additional and unexpected surgical complications. Overdosed patients, on the other hand may never wake up (euphemism: dead). Assuming there are no complications during the procedure that an inadequately trained individual cannot handle, the mother is at risk for a variety of complications, including uncontrolled hemorrhaging, infection, and sepsis. Infections are so common that mothers are frequently put on a regimen of antibiotics post-parturition for a week.

No wonder they use ketamine. The prerequisites for anesthesia are usually lacking.

These systemic deficiencies highlight the global disparity in maternal mortality between high income and low/middle income countries. While the US does not have a stellar reputation with nearly 14 maternal death/100,000 births (Western Europe is between 3-8/100k), Tanzanian mother's die 400/100k births. In other words, a mother is 25 times more likely to die during the perinatal period as compared to a mother in the States. Mind you, I haven't even talked about infant mortality yet. 

This sad reality leads to the tragic calculus by mothers to forego the care of a (supposedly) trained professional in favor of traditional birth attendants (TBAs). TBAs are important members of the healthcare system, but they lack the training to address complications as well as are not equipped to deliver babies in cases where HIV transmission mother-to-child is possible. However, with maternal mortality so common, many choose to take the risk and, at the very least, be able to die at home rather than in a hospital. With Western medicine implicitly associated with the dark prospect of death that is promised under the guise of better care, you can hardly blame one for being resistant to change.

I am not painting a bleak picture to reinforce a stereotype, but rather to acknowledge the complicated nature of the problem. To understand the role of Safe Surgery, I had to temporarily put aside my engineering cap and don my policy wonk hat. Safe Surgery is invested in bringing relevant stakeholders to the table and craft a comprehensive policy that defines for the first time the requisite skills, roles, and limitations of those within the healthcare system tasked with the delivery of surgical, anesthetic, and obstetric services. They identify six facets that need to be successfully addressed to meet the surgical burden of Tanzania: (a) service delivery, (b) infrastructure, (c) workforce, (d) information management and technology, (e) finance and (f) governance.

With most doctors found almost exclusively in the large cities of Dar, Arusha, and Mwanza, the primary question is who is going to deliver medical services. Only 27% of dispensaries, 33% of health centers and 51% of hospitals which provided surgical care had the correct personnel and equipment to provide safe surgical services. In many cases, that effectively is a death sentence. Without the ability to diagnose cancer due to the lack of equipment and experienced personnel, there is no reason to refer a patient until it is too late.

Assume now that a health center realized that it was ill-equipped to handle a case and referred it to a hospital. There is then the issue of inefficient communication between these centers to properly hand off patient medical information. Getting the patient from one place to another is similarly difficult, with ambulances being scarce and poorly maintained at best and public transportation and roads being inadequate as well. There is also the challenge of overcrowding and resource constraints at frequently-referred hospitals with little to no horizontal referring of patients to private hospitals.

Infrastructure and IT and management are key components of this puzzle, and perhaps the most frustrating as a biomedical engineer trained in the West. In most cases, the technology to help patients exists. However, the road to go from here to there does not, both literally and metaphorically. Anesthesia machines that are specifically designed for the tough low resource environment exist, but they still require electricity and/or water. However, only 52% of hospitals have a reliable water source. Electricity is a fickle thing that comes and goes in most rural settings, and usually cannot meet the loads required by a hospital, meaning trade-offs have to be made.

Effectively managing patient information requires time investment and coordination among government entities that are more concerned with aggregating power than working together (a problem that certainly is not unique to the region, but far more consequential). Every hospital I visited, from Muhimbili National Hospital in Dar down to a rural clinic outside of Mwanza collected all information on paper, leaving it nearly impossible at worse and unbearably tedious at best to accurately collect information on patient outcomes, surgical procedures, and surgical facilities. Without this information, identifying critical gaps and accurately measuring progress cannot happen. Again, even if the value of collecting this information is recognized, there is insufficient human capital to manage such a system.

Governance and finance are expected, but no less frustrating, challenges. You can hardly blame countries in the region for being distrustful of European and American organizations meddling in state affairs. Putting aside that elephant in the room, there are multiple departments that need to cooperate. As you can guess, they usually don't. The Health and Education ministries have different priorities and visions of how to achieve goals. Surgery is not as popular a health topic as malaria and HIV/AIDS, so getting people to the table is contingent on convincing them that a problem exists.

I would also argue that the challenge of safe surgery is a much more local challenge. In other words, it is not as simple as securing a Gates Foundation grant to buy some mosquito nets that some white people can distribute on their spring break. Creating a safe environment for surgery is contingent on local development at large. The local hospital needs clean water and electricity. Patients in dire need of surgery must be able to get to the hospital on decent roads. Surgeons and doctors must be available, meaning that there must be experienced individuals that can teach them over a number of years. Logistics to ensure that surgical supplies and anesthesia are affordable and available must be considered. The list goes on. Organizations like Safe Surgery can beat the drum, but their success is contingent on state, regional, and local buy-in to a greater degree than other public health efforts. That also means local investment. In the case of Tanzania, that remains the biggest challenge going forward. The Chinese are glad to pitch in and build roads across the country as part of Xi Jinping's Belt and Road Initiative (aka 21st century economic imperialism). The National Hospital in Dar was actually built by by the South Koreans. Cuban anesthesiologists work in Dar because of the dire shortage. Healthcare expenditures by the Tanzanian government are extremely low because someone else is glad to foot the bill. The question is at what cost?

An interesting quirk to the situation in Tanzania is that the country actually has a huge problem with unemployed doctors! Almost 2,000 doctors are without work despite the dire need for health professionals across most of the country. Up until 15 years ago, most doctors in the country were trained outside the country in South Africa, Kenya, Uganda, or Europe. The ones that came back to Tanzania found themselves overwhelmed by the demand in the country. Then, the government invested in educating healthcare professionals and established 8 medical schools across the country. Come 2017, the country churns out nearly 1,000 doctors a year. The problem is that doctors are employed by the government, which doesn't have the money to pay that many doctors. At the same time, there is a dire shortage of doctors in more rural district level health centers. Creating incentives for doctors to work in more rural settings remains a significant challenge.

My elegant solution

Medical Equipment

In addition to spending my time meeting with doctors to talk about policy changes necessary to establish nationalized surgical protocols, I also explored the technical challenges faced in the region with regards to medical equipment. In more cases than not, that led to me trying to fix instruments in a challenging and humbling environment. When I visited Kilimanjaro Christian Medical Center (KCMC) in Moshi, I was struck by the state of affairs. There, I met their lead engineer. He was one of the few people that I met that I could describe as an engineer during my time in East Africa.

Tasked with the maintenance and management of equipment, he bluntly outlined the challenges he faced at work day in day out. An important aspect of this was medical donations. As a Christian-affiliated medical center, KCMC was significantly better off than other hospitals that I visited, as there was a Dutch team of doctors and engineers there delivering equipment.

The maintenance center.

This was an important takeaway message for me. The majority of equipment I saw at even the largest hospitals in the region were secondhand. In Mwanza, I found myself trying to fix a Siemens patient monitor that had had its last software update in 2002!! The device itself was older than me.

People feel good when they are helping all the poor people in Africa that don't have all of our wonderful gadgets and gizmos. Thinking that they are being altruistic, they send over their old medical equipment thinking that they are doing everyone a service. However, for the most part, this is done irresponsibly. From the day the device arrives until the day that the instrument ends up locked in some room collecting dust because it doesn't work, the process has numerous flaws.

Many of these problems are logistical. No organized system to log equipment when it arrive, track preventative maintenance schedules, or collect instruction manuals is in place. The typical procedure I encountered was a young secretary from intake comes and writes down the device serial number in a huge spiral notebook along with a brief description. The device is now "logged". The question then becomes what to do with the device. Where should the patient monitor go? Well, pediatrics has been complaining about how they don't have enough, but when the engineers walks through urology, a nurse complains how they don't have any that work (she cannot bother to have notified the maintenance department through the procedure in place). Fine. The monitor goes to urology. It turns out that the monitor that supposedly did not work actually works fine. The nurse just assumed it didn't work or did not know how to use it. That monitor gets carted off to peds. Did you follow that? If not, maybe you can go pull out the spiral notebook where the device history is logged...

That seems like a fixable problem, right? There are computers with Excel that could go a long way in improving this problem. A centralized list of equipment as it arrives is possible to create, and there are people that know how to do it. The engineer I talked to was all for it. However, his boss was not. This frustrated me to no end. As I made my way around, I was often pawned off to junior maintenance workers after meeting the senior brass. It turned out the younger staff was just as frustrated as I was. As a generation that had grown up and been able to learn in better technical programs, they were usually more tech savvy and creative than their superiors. However, they had one major problem: they were young. Talented individuals were limited by the bureaucracy and office politics. Promotions were almost always a matter of "experience" rather than talent or capability. Even an idea as simple as logging equipment by Excel was met by resistance because it was a challenge to his authority. Shifting away from paper logbooks to a system that a young tech savvy individual could manage suggested that his pencil-pushing job was irrelevant as it was currently performed. I know that I am being harsh, but I wasn't alone. As one engineer put it, "we just have to wait until they retire or die". Dark.

Then, there is the usual problem that the equipment that hospitals get is old, meaning that it comes with myriad other implicit challenges. Older equipment breaks more often, and is certainly not helped by the dusty conditions and frequent power cycling due to inconsistent electricity. When a device breaks (already broken devices are also given), fixing it is often not possible. That's because that biomedical technicians, let alone engineers, are few and far between. Most "engineers" are usually people that got a certificate at a university and learned basic theory about electronics. With no better alternative, they are the people most often tasked with fixing devices. Unsurprisingly, they are often out of their depth. For example, the idea of preventative maintenance often fell on deaf ears. Simple steps like clearing the filter weekly that could extend the lives of critical equipment were neglected.

This leads to a mistrust of the maintenance department, with doctors and nurses not calling engineers when there are problems with a device assuming that they will be unable to fix the problem. Maintenance workers become similarly jaded because they often do not have the ability to fix the problem even if they can diagnose it (which they often can), or they are called when a device fails completely rather than when they could have done something. That's because spare parts for 20 year old devices are usually not available, and if they are, they far exceed the financial resources of the hospital. While Muhimbili National Hospital has the luxury of refusing all medical donations and purchasing all equipment new, that simply is not possible for most hospitals as I saw firsthand at the second and third best hospitals in the country.

Among doctors and staff, this creates complacency and a lacking sense of ownership. If something breaks, no one cares because they will get another one for free thanks to some big-hearted donor. Many hospitals had minimal budgets for equipment because they had come to rely on this unsustainable cycle of dependence. Because the hospital never paid for it and the device is second-hand, staff treat the equipment with less respect. Some of it is lack of knowledge and training on how to use the equipment. Nurses, those that primarily watch patients at point of care, aggressively yank on delicate pulse ox cables. Leaks in air pressure cuffs are ignored, compromising the basic function of the device. While training sessions are held, many choose to not attend or are shy to ask questions if they do not understand. Even if people understand, there is significant turnover and no systemic way to ensure that new staff receive the same training.

Made in Africa?

Africa is a big place. With the world's most rapidly growing population and 800 million people that are quickly growing wealthier, it seems like the next "it" place for technology. In many ways, it is. When it comes to mobile banking, Silicon Valley is second to Nairobi, Kenya as a tech hub. Innovations that have grown out of necessity like mPesa as a mobile banking platform feel like the future. When it comes to healthcare, however, that change has been slow. Why doesn't Siemens market patient monitors in Africa? The simple answer is that it isn't worth it. Western medical device companies in general have very healthy profit margins. While there is a clear need in Africa for these devices, entering the market would require significant investments in PR, customer relations, and logistics infrastructure that companies have determine exceed the potential revenue that they could make.

Consider the case of HIV antiretroviral medicine. Back in the 1990s when the HIV/AIDS epidemic was rolling into high gear, medicines that could allow patients to live with HIV already existed. However, they cost $10,000/year, so only rich people like Magic Johnson could afford it. Screw poor Africa. It wasn't until 2005 when Indian pharma companies released a generic medicine that prices plummeted to $100/yr, making it possible to scale up ART treatment and manage the epidemic.

In most cases, India remains the pharmacy of the developing world, and increasingly, is entering the medical device market. Most of the new patient monitors and large scale medical equipment I saw were made in India.

It stands to reason, however, that devices could also be made cheaply in Africa. Labor is cheap, and shipping costs would be reduced. If the manufacturing is done locally, spare parts would be more readily available. Ironically, that isn't the case. When I chatted with the lead device engineer at the National Hospital, he lamented the red tape and logistical challenges that make it difficult to bring these manufacturing opportunities to more local settings. Political instability, innumerable police checks, corruption, nightmare border crossing, lack of skilled labor, unreliable utilities and transport infrastructure, and short-sighted policy decision undermine the region's ability to be a reliable hub. Locally grown medical device companies are few and far between because higher quality Indian devices tend to be cheaper despite being manufactured in a different continent. In the short to medium term, I don't see this changing.

Doc Talk

Talking with doctors themselves gave me further insight. In professions such as orthopedic surgery, secondhand doesn't really work. Instead, doctors have a grab bag of usually donated screws and plates. One surgeon in Mwanza told me that his surgical plan often comes down to opening up a patient, determining what screws and plate are needed, telling an assistant to run over and scramble through there inventory and see if he can find it, and if he can't, to close up the patient without doing the procedure. Parts are available irregularly and in unpredictable quantities, and they are rarely logged properly because it simply isn't possible with the limited hands they have available. In addition, parts that might be available in the morning unpredictably can be used by another surgeon. Again, because it isn't logged, there isn't much they can do.

These parts have to be bought new, and every surgeon I talked to knew that European and US made parts were of higher quality. However, because they can cost 3-5 times as much as Chinese or Indian made parts (usually Indian because Chinese were total crap), doctors were forced to buy subpar parts for their patients. Quite simply the sheer quantity of patients demanded that they do so.

Personal Reflections

If you actually read everything I just wrote, good for you. I hope you learned something. There were many days where I felt helpless. This repeated experience was not good for the spirit. Walking into the ER in the regional hospital in Mwanza, I was shocked to find every single monitor beeping in error. Nurses indifferently walked past the screeching alarm as patients lay there trying to rest amidst the alarms. This was the freaking ER, where the most critical patients were brought and where catching sudden fluctuation in vital signs was a matter of life and death, and they only had 6 functional monitors for 20 beds. No one cared to even turn off the alarms. When a cartridge on a blood gas analyzer needed to be changed, I was able to do so because I read the manual. The fact that no one had bothered to tell the maintenance worker because they didn't think he could was discouraging. The fact that he actually couldn't was even more discouraging.

Even at the National Hospital, this problem was ever-present. When the hospital got a new CT scanner, they had a problem and thought that the device was not working. After they flew in a Kenyan trained engineer, they found the problem. They hadn't flipped the on switch.

Death is never far away when at a hospital in Tanzania. In Zambia, I did not have this experience (probably because of where I was), but at every large hospital I went to in Tanzania, there was a casket shop outside the hospital. Walking past it as I came and went, I was constantly hit by the fact that many others that had come had left very differently than I had. For some messed up reason, it reminded me of an Indian movie about a wedding planning business. The lead actor quips (in Hindi), "Be it recession or inflation, weddings will happen and wedding planners will always be needed". Turns out that selling caskets outside of Tanzanian hospitals isn't all that different.

The hardest part of seeing the casket everyday was that a disproportionate number were a specific size. Two or three feet long wooden caskets. For babies. For children. Distraught families would march through the hospital compound streets carrying them. They are voices and images that have stayed with me.

It's older than me...

The Blood Gas Analyzer

One corner of one room of the Medical Device Graveyard

The Sunset on Lake Victoria made the end of my day less shitty

Kilimanjaro and Serengeti

Climbing Kili and visiting Serengeti reminded me of the great natural beauty and richness of Tanzania. Two unforgettable life experiences that I highly recommend. Challenge yourself and climb Kili in 5 days on Machame Route. On the 5th day, I went from 4600m up to 5900m and then all the way down from 1am to 3pm the next day. Longest but most rewarding day of hiking in my life.

Erastus, my guide. He's like 6'6 and a total boss

First sighting of the peak

Mt Meru, Tanzania

Safari to Serengeti, Ngorogoro, Lake Manyara, Maasai Village

This was an absolutely amazing experience. GO GO GO! I went right as the Wildebeest Migrations were beginning and the animals were returning from Masai Mara in Kenya. Every year, 20 million animals make this trip. That is an absolutely unfathomable number. GO GO GO!

Watching a giraffe run is so weird

Wildebeest as far as the eye can see

Driving through Serengeti is like the cornfields of the Midwest except it doesn't make me want to kill myself

Pumba is ugly

Ngorogoro Crater