India was the first country in the world to initiate a public funded program for the control of blindness as a national priority health problem with the World Bank-assisted Cataract Blindness Control Project. The program was launched in 1976 to prevent and reduce the prevalence of blindness in the country. It was extended and functioned as the Word Bank assisted Cataract Blindness Control Project until 2002.
This initiative spurred a series of other nation-wide efforts to decrease the prevalence of blindness in India. According to the National Blindness and Visually Impaired Survey in 2019, blindness has decreased from 1% to 0.36% since 2006 – when the last survey was conducted. However, in a country with 1.3 billion people, there is still a large margin for improvement.
What is visual impairment and blindness?
Visual impairment is when a person has sight loss that cannot be fully corrected using glasses or contact lenses. Blindness as defined by the National Programme for Control of Blindness (NPCB) under following headings:
- Inability of a person to count fingers from a distance of 3 meters
- Vision 6/60 or less with the best possible spectacle correction
- Diminution of field vision to 20 feet or less in better eye
To give some perspective, this is how normal vision may be impacted by various eye conditions or diseases.
The National Programme for Control of Blindness cites the major reasons for prevalence of blindness in India as:
- The overall increase in the size of the population
- The life expectancy for both males and females has steadily increased
- A major proportion of aged population in rural areas have poor access to eye care facilities
- Inadequate availability of trained health personnel.
- The poor nutritional status of mothers and young children predisposes the pre-school children to nutrition blindness.
- Adverse environmental conditions and domestic unhygienic conditions predispose to high infection rates
- Lack of community awareness and poor health seeking behavior
- The prevalence of myths and misconception about surgeries
The National Health Portal of India states that treatment depends on the cause of blindness. Blindness due to nutritional deficiency can be addressed by dietary changes. Visual impairment due to refractive error can be addressed by providing appropriate spectacles. Inflammatory and infectious causes of blindness can be treated with medication in the form of drops or pills. Cataract surgery, in most cases, restores sight by implanting a new lens in the eye after removal of the diseased natural lens.
Who is worst affected?
Rural and Urban Poor
According to a 2010 estimate, the number of people with glaucoma in India was 11 million and another 24 million were at risk of the disease. More than half of Indians reside in rural parts of the country.
Ophthalmic care is limited in rural areas due to several factors. Rural eye care facilities are inadequate, cost of treatment is often not affordable, and awareness about the eye diseases is low. Thus, a majority of the patients remain undiagnosed or untreated. The problem is intensified due to lack of simple and effective screening protocols to detect the visual impairment and eye diseases (IAPB).
Urban poor in India often face the same challenges. In addition to the hurdles to be diagnosed and treated with eye conditions, blindness in urban areas often leads to unemployment, which in turn leads to loss of income, higher levels of poverty and hunger and low standards of living. This then results in limited accessibility of educational and other opportunities. All of these together lead to early mortality and loss of economic productivity of a nation as a whole (Rohit Khanna MBBS DO MCEH).
As per Vision 2020 of The Right to Sight initiative, there are about 12,000 ophthalmologists in India for its 1.3 billion population, resulting in a ratio of one ophthalmologist for every one lakh people. In rural India, this ratio is even worse: one ophthalmologist for every 250,000. Their ratio of availability of qualified optometrists, approximately one for every 25,000 people, is also skewed.
In India, 320,000 children below the age of 16 were blind in 2008, which accounted for 1/5th of the world’s blind children (Murthy et al.) Corneal Scars (caused by Vitamin A Deficiency, Measles, or trauma) is the most common cause of childhood blindness. An estimated 39% of blindness in children is caused by Cataracts. Trachoma and Glaucoma are also prevalent causes.
Although the incidence of Vitamin A Deficiency in India has significantly declined, India still has the greatest number and percentage of VAD children in the world. Rural areas are particularly prone to this public health problem. VAD affects vision by inhibiting the production of the eye pigment responsible for low-light vision, therefore causing night-blindness, corneal deformities, and scarring.
According to a report in 2008, VAD is the most prevalent in North East India. VAD is the cause of blindness in 24% of blind schools in NE States in this study (Bhattacharjee et al).
“As a child grows older, it gets harder to correct the vision fully with spectacles,” said Shaurya Sharma, a resident ophthalmologist. If the brain is denied vision due to any cause for a prolonged period of time, its visual pathways don’t develop, leading to permanent visual loss.
In India’s settings, where cataract is responsible for most blindness, it is simply because women do not get to access services with the same frequency as men. For example, the cataract surgical coverage among women in India is nearly half that of men.
Barriers prevent both women and men from receiving surgery, but they are often more problematic for women. They include lack of awareness, distance of service providers and cost. Cataract is often viewed as an inevitable consequence of ageing. In a recent study in North East India, female patients reported accessibility as the primary barrier, due to poor road conditions and challenging terrains, while male patients reported misinformation and misconceptions, often due to poor surgical outcomes, as primary significant barriers.
Strategies to support girls and women to access care include screening events in remote communities, separate wards in eye hospitals, community mobilisation by women health workers, availability of women staff at the hospital, and more.
Genetic or Pre-existing Health Conditions
The most common type of glaucoma is hereditary. A family history of glaucoma increases an individual’s risk of developing the disease by 4 to 9 times, according to the Glaucoma Research Foundation.
Diabetic retinopathy affects over 30% of people with diabetes who are over the age of 40. The NIH also reports that glaucoma or diabetes are about twice that of someone without diabetes. Diabetic eye diseases are most common in the Urban Poor in India. Diagnosing and treating the diseases early after onset can reduce the risk of blindness by 95%.
How can we help?
We tend to know why children and adults do not access eye care services – poverty, inability to access services, uninformed about solutions to poor vision, the stigma involved, and the list goes on…
Knowing the “why” is the easy part. What we are all working towards is the “how.” How do we eliminate those barriers? How do we ensure eye care is everywhere?
Anyone who works in the health and development sector will tell you that there is not one, singular solution to achieving universal coverage. There isn’t a magical recipe that works for the entire population. It takes a myriad of services, skills, research, resources and professions to dissect each factor, and design systems and strategies to achieve schemes that work now and long into the future.
Our solution is working with partners to implement Hospital-Based Community Eye Health programmes that lead to avoidable blindness-free villages. There are hundreds of other organisations around the world who are implementing their successful solutions. We are inspired to see action because our citizens deserve it; we owe it to them to have eye care reach every village, town, district and city.
Is achieving eye care everywhere for everyone a big challenge? You bet it is. But it is NOT impossible. JS Trust encourages us all to find more ways to work with one another to achieve our common goal of eliminating avoidable blindness across India. To suggest a community in need or partner with us, contact us here. To sponsor a clinic, donate now.