Module 1: Why Eye Care Is Important

Low vision and blindness have dire effects on individuals, families, and communities. These effects range from a decrease in quality of life and increased mortality to large-scale economic consequences. Culturally, there is often a stigma associated with blindness, further alienating the afflicted from their communities.(1) Social disadvantages are also enormous: 50% of the blind in impoverished countries report a loss of social standing and decision-making authority, and 80% of blind women note a loss of authority within their families.(2) Fortunately, there is hope that we can reverse these devastating impacts, as long as the medical community continues to increase access to surgery and care.

Poverty and Blindness

The impact of blindness and poor vision on quality of life is particularly alarming for those living in poverty. Approximately 45 million people in the world are blind, and 87% of visually impaired people live in developing countries.(3) The economic consequences of blindness are staggering, as 90% of blind individuals cannot work.(4) Thus, “poverty and blindness are believed to be intimately linked, with poverty predisposing to blindness, and blindness exacerbating poverty by limiting employment opportunities, or by incurring treatment cost.”(5) Impoverished people are more likely to become blind due to lack of access to health services. They also tend to be more susceptible to eye infections and diseases, and lack awareness about eye health. One study conducted in Pakistan found that the prevalence of total blindness was more than three times higher in impoverished clusters of the population than in affluent clusters.(6) In addition, “clear evidence shows that some blinding eye diseases are a direct consequence of poverty (for example, trachoma).”(7) However, the converse is also true: blindness may also cause people to become poor. For instance, one study on the consequences of poverty reported:

“Although some individuals become disabled because of low income, a staggering 64 per cent of those with disabilities were not in poverty prior to onset of the disability. Households affected by disability, and which were not initially impoverished, had three times the probability of entering into poverty within one year of onset of disability compared with unaffected households. Households affected by disability also had a lower probability of leaving poverty because of the increased costs and reduced earnings associated with disability.”(8) 

Thus, it is evident that blindness may be a result of living in poverty and may also lead an individual or family into poverty.

The Social and Economic Effects of Blindness

Blindness also significantly affects family and community members. Because blindness restricts mobility, approximately 75% of visually impaired people require assistance with everyday tasks.(9) Consequently, blindness affects the community on a practical level, as children cannot attend school when they become caretakers for blind adults. Thus, countless children are denied the opportunity to receive a formal education, and perhaps escape the poverty cycle.(10) Often, when a sighted adult becomes the caretaker for a blind individual, he or she must stop working. This leads to long-term economic and educational repercussions that extend beyond the blind individual.

Furthermore, blind individuals and the household members who care for them struggle with reduced earning potential and a decrease in productivity.(11) Since poverty among older adults in Africa and Asia may be related to an inability to satisfy social and economic roles, the restrictive impact of visual impairment on productive and leisure activities may also contribute to poverty in these settings.(12) The economic impact of blindness on a family should not be underestimated:

“The physical and emotional toll impacts ... the social and economic fabric of the communities and everyone’s existence. Sudden blindness of one individual in a family can become the tipping point for survival when they are impoverished to begin with.”(13)

Cataracts, for example, have economic implications for families through reduced productivity of the visually impaired person as well as opportunity costs to household members who look after them.(14) Recent publications suggest that loss of economic productivity due to visual impairment amounts to $8 billion a year in the United States, while the global annual loss in gross domestic product from blindness and low vision in 2000 was between $19,223 million and $22,764 million.(15) Moreover, one research team using data from 1993 on prevalence rates, gross domestic products, and populations estimated that the annual worldwide productivity cost of blindness was $168 billion.(16) This projected cost could be substantially decreased by limiting the prevalence of blindness and by decreasing the impact of blindness on productivity through workplace accommodations.

The ramifications of one person’s blindness are felt by the community at large, particularly in community-oriented cultures such as those in the developing world. Ghanaian ophthalmologist Dr. Seth Wanye explains:

“When we talk about healthcare needs in the government sector, it is all about killer diseases. The government's attention is on these diseases that actually cause immediate death. It is assumed that eye diseases do not kill, resulting in resources being channeled to other areas of healthcare. However, I have a different opinion. If you have someone who is blind, then someone else will have to forgo his or her activities in order to take care of this person. Oftentimes, you have a child who is supposed to go to school, but he is instead guiding a blind man around the house and directing him wherever he wants to go. This child could have gone to school, studied, and become somebody in the future to help the family.

We often see very young people who are blind, many times younger than the age of 40. They become blind during their productive years; they could have been working and helping to contribute towards building wealth in the country. Instead, the blindness results in a financial loss to the nation because these people are not able to contribute to building the nation. We have therefore been trying to advocate to policy makers so that they understand that even though eye diseases do not kill, they do result in financial losses to the nation. We must see this as an emergency issue.”(17)

Additionally, blindness leads to financial insecurity and social isolation even in affluent countries. According to a journal article from 2007:

“[I]t is known that as a disability, blindness 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 and affordability of health-care services and deprives those affected of educational and other opportunities. All of these together lead to early mortality and loss of economic productivity of a nation as a whole.”(18)

Increased Mortality

Although it is not typically recognized as a “killer disease,” blindness does lead to increased mortality. Because poverty and blindness are closely linked, the blind are faced with the well-documented mortality risks associated with living below the poverty line. As one study notes, “[t]o be poor sentences people to unfair, life-threatening challenges.”(19)

Shockingly, “the life expectancy of blind persons is one-third less than that of their sighted peers, and most of them die within 10 years of becoming blind."(20) The data are even more discouraging for children affected by blindness:

“Poverty and blindness is a tragic, even lethal, combination... a widely quoted but difficult to trace figure [estimates] that 50 to 60 per cent of children die within one to two years of becoming blind, largely from associated diseases, for example, measles, but also from neglect... the poor and blind in Africa have been found to live 15 to 20 years less than those who are only poor… a study in Tanzania showed [that] rates of mortality begin to increase when vision is worse than [20/20] and rise eight-fold in the group with worst vision.”(21)

The Impacts of Successful Treatment

The vast majority of visually impaired people throughout the developing world are suffering from preventable visual impairments. Eye infections that lead to blindness can usually be treated with antibiotic eye drops and ointments. Because such eye infections require immediate attention, eye care must always be accessible. For those already suffering from blindness, simple and lasting cures are often available. For many patients with cataracts and other visual impairments, corrective surgeries are among the most cost-effective and highly successful medical interventions.

“In 1993, the World Bank reported cataract surgery as one of the most cost-effective health interventions in terms of cost per DALY [disability-adjusted life-years].* Cataract extraction in the developing world is an extremely cost-effective intervention, costing as little as US $5 per DALY in Nepal and 57 International dollars in Southeast Asia. In developed countries, such as the United States and Canada, where mortality rates are low and the cost of cataract surgery is high, the cost rises to approximately 800 International dollars per DALY. The DALY methodology may actually underestimate the economic and quality of life impact of cataract, as it does not account for the financial and social support provided by relatives and community members to visually impaired individuals.”(22)

*Cost per DALY may be measured in US or International dollars. One International dollar is equivalent to the purchasing power of 1 US dollar within the United States at any one time, and allows a more accurate comparison of actual costs between countries.

Though blindness may temporarily trap individuals in poverty, health interventions have the potential to help the blind and their families improve their socioeconomic status. The intervention study conducted in Kenya, the Philippines, and Bangladesh that was discussed earlier demonstrated the impact of eye disease on socioeconomic status, and illustrated the way in which interventions increase income levels and status. In this study, poverty data was collected from adults over the age of 50 who were visually impaired due to cataract, and from matched controls with normal vision. Those who were visually impaired were offered free or subsidized cataract surgery, and data on the participants' poverty levels were collected one year later. Before the surgery, those with cataracts were poorer than the matched controls in terms of per capita expenditure, assets, and self-related wealth. However, after the surgery, the per capita expenditure had increased significantly among individuals who had been operated on in each of the three settings compared to the levels of the control groups. The largest per capita expenditure increases were found among those who were poorest at baseline, and received the surgery.(23) Moreover, individuals who were operated on spent 1-2 hours more on productive activities compared to their baseline levels before surgery. Time spent in “inactivity” in Kenya and Bangladesh among individuals who had surgery also decreased by approximately 2 hours, and the frequency of reported assistance with activities was more than halved in each setting among those who underwent cataract surgery.(24) Thus, the data “suggest that cataract blindness may cause poverty” and that interventions that reduce and eliminate blindness may help to increase productivity and alleviate poverty.(25)

One study conducted at Aravind Eye Hospital in Madurai, India also found that cataract surgery is an effective intervention and can help break the cycle of poverty that entraps the blind. The study found that 85% of males and 58% of females who had lost their jobs due to blindness regained those jobs following cataract surgery. In addition, some of those who did not return to work relieved other family members from household duties, enabling them to return to work. The results also illustrated that on average, individuals who regained vision through surgery generated 1,500% of the cost of surgery in increased economic productivity during the first year following surgery.(26) Thus, the success of cataract surgery initiatives shows that “ophthalmologic intervention in disadvantaged communities helps prevent further continuance in the destructive cycle of poverty.”(27) Moreover, “extrapolations on a global level indicate that a successful eye care programme could prevent more than 100 million cases of blindness between 2000 and 2010, and consequently save at least US$102 billion, which would otherwise be lost to reductions in productivity associated with blindness.”(28)

Thus, it is crucial that public health programs focus on preventing blindness, as eye care interventions can have incredible economic and social returns and can dramatically improve the quality of life of blind individuals and their families.

Footnotes

(1) Wagner-Lampl, A. and Oliver, G.W. “Folklore of Blindness.” Journal of Visual Impairment & Blindness. 88.3 (1994).

(2) Ibid.

(3) World Health Organization. “Visual Impairment and Blindness.” (2009).

(4) Himalayan Cataract Project. “World Blindness Overview.”www.cureblindness.org.

(5) Kuper, H., et. al. “Does Cataract Surgery Alleviate Poverty? Evidence from a Multi-Centre Intervention Study Conducted in Kenya, the Philippines and Bangladesh.” PloS Medicine. 5.11 (2010).

(6) Gilbert, C., et. al. “Poverty and blindness in Pakistan: results from the Pakistan national blindness and visual impairment survey.” British Medical Journal. 336.29 (2008).

(7) Ibid.

(8) Holden, B. “Blindness and poverty: a tragic combination.” Clinical and Experimental Optometry. 90.6 (2007): 401-403.

(9) Javitt, J., Venkataswamy, G. and Sommer, A. Henkind, P. (ed) (1983) The economic and social aspect of restoring sight. ACTA: 24th International Congress of Ophthalmology pp. 1308-1312. JP Lippincott, New York.

(10) Wright, H., Turner, A., and Taylor, H. “Trachoma and poverty: unnecessary blindness further disadvantages the poorest people in the poorest countries.” Clinical and Experimental Optometry. 90.6 (2007): 422-428.

(11) Kuper, H., et. al. “Does Cataract Surgery Alleviate Poverty? Evidence from a Multi-Centre Intervention Study Conducted in Kenya, the Philippines and Bangladesh.” PloS Medicine. 5.11 (2010).

(12) Barrientos, A., Gorman, M. and Heslop, A. (2003) Old age poverty in developing countries: contributions and dependence in later life. World Develop. 31, pp. 557-570.

(13) Wagner-Lampl, A. and Oliver, G.W. “Folklore of Blindness.” Journal of Visual Impairment & Blindness. 88.3 (1994).

(14) Frick, K. D. and Foster, A. The magnitude and cost of global blindness: An increasing problem that can be alleviated. Am J Ophthalmol. 135. (2003): 471-476.

(15) Gilbert, C., et. al. “Poverty and blindness in Pakistan: results from the Pakistan national blindness and visual impairment survey.” British Medical Journal. 336.29 (2008).

(16) Smith, A. F. and Smith, J. G. The economic burden of global blindness: a price too high! British Journal of Ophthalmology. 80, (1996): 276-277.

(17) “What We Do: Best Practices.” Unite For Sight. www.uniteforsight.org.

(18) Khanna, R., Raman, U., and Rao, G. “Blindness and poverty in India: the way forward.” Clinical and Experimental Optometry. 90.6 (2007): 406-414.

(19) Holden, B. “Blindness and poverty: a tragic combination.” Clinical and Experimental Optometry. 90.6 (2007): 401-403.

(20) Harminder, S.D., Dalia, G.S., and Otri, A.M. “Are we doing too many cataract operations? Cataract surgery: A global perspective.” British Journal of Ophthalmology. 93 (2009): 1-2.

(21) Holden, B. “Blindness and poverty: a tragic combination.” Clinical and Experimental Optometry. 90.6 (2007): 401-403. Accessed 4 January 2011.

(22) Chang, M.A., Condon, N.G., Baker, S.K., Bloem, M.W., Savage, H. and Sommer, A. “The surgical management of cataract: barriers, best practices, and outcomes.” International Ophthalmology. 28.4 (2008): 247-260.

(23) Kuper, H., et. al. “Does Cataract Surgery Alleviate Poverty? Evidence from a Multi-Centre Intervention Study Conducted in Kenya, the Philippines and Bangladesh.” PloS Medicine. 5.11 (2010).

(24) Polack, S. “The impact of cataract surgery on health related quality of life and time use in Kenya, Bangladesh and the Philippines.” J Epidemiol Community Health. 63.69 (2009).

(25) Kuper, H., et. al. “Does Cataract Surgery Alleviate Poverty? Evidence from a Multi-Centre Intervention Study Conducted in Kenya, the Philippines and Bangladesh.” PloS Medicine. 5.11 (2010).

(26) Jamison, D.T., et. al. “Impact of cataract surgery on individuals in India.” Disease Control Priorities in Developing Countries. (New York, Oxford University Press for the World Bank: 1993).

(27) “Poverty and Human Development. Not a Stretch for Ophthalmology.” Arch Ophthalmol. 125.11 (2007).

(28) Kuper, H., et. al. “Does Cataract Surgery Alleviate Poverty? Evidence from a Multi-Centre Intervention Study Conducted in Kenya, the Philippines and Bangladesh.” PloS Medicine. 5.11 (2010).