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Light at the end of the tunnel

Recent surveys have shown that the blindness prevalence rate in India has decreased. Against this promising trend, B.S. PADMANABHAN reviews the programmes for blindness control.

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INDIA, with an estimated 12 million blind persons, has been striving to control blindness since Independence. Recently, it committed itself to the global initiative, "Vision 2020:The Right To Sight", launched by the World Health Organisation (WHO) in collaboration with the International Agency for Prevention of Blindness and other NGOs to eliminate avoidable blindness by 2020.

Based on the results of a survey conducted in 15 districts in 15 States from 1999 to 2002, it is estimated that the blindness prevalence rate — reported to be around 1.5 per cent in 1989 — has dropped to 1.1 per cent. Though far short of the national goal of reducing the prevalence rate to 0.3 per cent by 2000, this marginal reduction is significant in that it marks a reversal in the prevalence of blindness.

The latest trend should come as a morale booster for those active in blindness control activities. A study in Andhra Pradesh in 2000 had estimated a prevalence rate of 1.84 per cent, which implied that the blind population had actually increased to 18.7 million from 12 million estimated in 1989. The AP Eye Diseases Study was conducted jointly by the International Centre for Advancement of Rural Eye Care of the L.V. Prasad Eye Institute, the Centre for Social Services of Administrative Staff College and the Centre for Eye Research in University of Melbourne between October 1966 and February 2000. The authors of the study had reported in the National Medical Journal of India (Vol. 14 No. 6 2001) that if this trend continued the blind population would increase to 24.1 million in 2010 and 31.6 million by 2020.

Even at that time Dr. R. Pararajasegaram, Coordinator of Vision 2020 Initiative of WHO, had expressed reservations over the assumptions in the study in terms of the population studied being representative of the population of A.P. and application of the findings in that State to the rest of the country. In the National Medical Journal of India, he had observed that application of A.P. study findings to the rest of the country is fraught with some danger because of the known inequity in development in general, and in eye health care services in particular, within and between States.

In this context, the outcome of the survey conducted from 1999 to 2002 is significant. But this covered only those aged 50 and above and the results extrapolated to arrive at the estimate for the general population. On the other hand, the earlier estimate of 1.5 per cent was arrived at on the basis of a national survey conducted from 1986 to 1989 covering the population in all the age groups.

It was found that the prevalence of blindness and low vision was correlated with socio-demographic variables like gender, age, literacy, occupational status and place of usual residence. Females had a higher prevalence of both social and economic blindness, and low vision compared to males. The prevalence of low vision, economic blindness and social blindness increased with age. Those, who had studied beyond Std. 10 had the lowest prevalence of blindness and low vision compared to others. The urban population had a lower prevalence than the rural people.

Cataract accounted for 62.6 per cent of blindness, while uncorrected refractive errors accounted for 19.7 per cent. The other important causes were glaucoma (5.8 per cent), posterior segment pathology (4.7 per cent), surgical complications (1.2 per cent), corneal opacities (0.9 per cent) and other causes (5 per cent). Ten per cent of the people surveyed had undergone cataract surgery in one or both eyes and high rates of operated cataract surgery in one or both eyes and high rates of operated cataracts were found in Gujarat, Punjab, Tamil Nadu, Himachal Pradesh and Rajasthan. Fifty per cent of the cataract surgeries were done in private hospitals or NGO institutions, while 24 per cent were in government hospitals and 26 per cent in eye camps. The visual outcome of the surgeries showed that only 28.2 per cent of the individuals could be categorised as having near normal vision and 16.6 per cent were blind after surgery.

Since cataract continued to be the most common cause of blindness, increasing the number of cataract surgeries to clear the backlog and treat new cases had been the focus of the National Programme of Control of Blindness. India was the first country to seek a soft loan from International Development Agency of the World Bank for control of blindness. A special project was launched in 1994 to step up cataract operations in Andhra Pradesh, Madhya Pradesh, Maharashtra, Orissa, Rajasthan, Tamil Nadu and Uttar Pradesh. A review of this project has shown that 15.35 million cataract operations were performed against the Project target of 11 million.

While Orissa and Rajasthan could achieve only 73 per cent and 91 per cent of the target, the rest had achieved more than the target. Maharashtra topped with 220 per cent coverage of the target, followed by Andhra Pradesh with 182 per cent, Tamil Nadu with 162 per cent, Uttar Pradesh with 125 per cent and Madhya Pradesh with 108 per cent. To clear the backlog, 400 operations for every 1,00,000 population require to be performed. Only Tamil Nadu, Andhra Pradesh and Maharashtra have reached this level with 596, 491 and 489 operations respectively for every 1,00,000 population. There has been a drop in camp surgeries, indicating a shift towards institutional surgery.

One of the project's aims was to increase the proportion of cataract surgeries with intra ocular lens (IOL) implant. This has been achieved. Expansion of eye-care services to rural and remote areas and greater participation of NGOs in blindness control activities were welcome features. A cost-benefit analysis has shown the project to be highly cost-effective.

In order to sustain these activities, after the completion of the World Bank-aided Project, the Health Ministry has allocated Rs. 445 crore for the programme during the Tenth Plan (2002-07). Official sources feel that this should not only sustain the project in the States presently covered but also provide similar inputs in other under-served States.

Based on the project's performance and the outcome of the survey in 15 districts, the Health Ministry is not only confident that brighter days are ahead for the visually handicapped but also claims that India is in a position to take up a leadership role in guiding other developing countries to control blindness. This may sound a tall claim considering that the task of preventing and controlling blindness is gigantic. However, the trend is promising and political commitment is not lacking.

What is required is adequate financial allocation and implementation of the various programmes with the same zeal over the next two decades.

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