Identification & Diagnosis
I always consider what I am asking when I ask a Rwandan for an identification card. For seventy years, until the end of the war which brought the genocide against the Tutsi to a close, identification cards had been used to identify more than just the date of birth and the district from whence he or she came. It was used to define the person’s ethnicity as Hutu or Tutsi and therefore categorize them as “worthy” or “not worthy” for opportunities ranging from seats in the schoolroom, to job opportunities. The tides turned in favor of one ethnicity over another depending on who was in power and what foreign power held influence at the time. When tensions boiled over in the mid-1990’s, these identification cards served as a death sentence for those whose cards read “Tutsi”. Upon re-establishing order in the country over the years that followed, the categorization of a Rwandan citizen as “Hutu” or “Tutsi” was abolished, and the population was advised and encouraged to consider themselves one; as Rwandan only. That sense of unity is tangible throughout the country: a remarkable transition in such a comparatively short amount of time. As far as I can tell, no one even speaks of their “tribe affiliation” anymore. Still, I can’t help but wonder if there is a flash of remembrance of the foreboding that a request to see an identification card must has evoked. I can’t help but feel that I’m asking a very personal question when I ask to see that document, even though the ethnicity categorization has long since been removed.
Once we’ve identified the eligible family members, we inquire about spectacle use, known eye problems, awareness of ophthalmic services at the local health center, and symptoms of night blindness. Once their answers are received, we lay the rope down and test their vision. Anyone who does not pinhole to 6/18 gets dilated with tropicamide and examined in a dark room in their living space with a direct ophthalmoscope. For the local ophthalmologists, this is a fairly typical way to examine a patient. But for me, raised on the cutting edge technology of Wills Eye Hospital, this proves to be quite a challenge. I will note that, since I always knew I had an interest in global health and an intention to spend time in developing nations in an ophthalmic context, I did take care to become comfortable using a direct ophthalmoscope. Despite that special effort, I was surprised at just how much I had come to depend on the state-of-the-art resources at Wills. My mind reflexively craved further testing, and I was frustratingly hesitant to make definitive diagnoses with such little to go on. “The macular reflex looks blunted…I would kill for an OCT”. “Is this cataract, as seen with a direct ophthalmoscope from 3 feet away really enough to cause 3/60 vision (with a quick conversion in my head to 20/200, of course…)? What I wouldn’t do for just a glimpse at the slit lamp,” I think to myself. While we, at Wills, are privy to diagnoses that are not even on the radar for some other ophthalmologists–as they can only be diagnosed with advanced diagnostic testing–I do feel humbled at how this can blunt our skills as a clinician. I am looking forward to the clinical fortitude that will come by honing my exam skills in this limiting environment and the confidence that will build as I learn to rely less and less on ancillary testing. At graduation, just a few weeks ago, my classmates and I realized that we were “on our own” only in the most abstract sense. Now just weeks later, leading a team of eye care specialists in the heart of rural Africa I am coming to realize that, as they say, “the training wheels are off.”