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Blindness control in India: beyond anachronism
EYE DISEASES:
INDIA
Blindness control in India: beyond anachronism
data suggest that 25-40% of uring colonial rule in operations fail in many rural India, the administraareas. This unacceptably high tive systems used to implement public policy led to rate is due to poor-quality Lalit Dandona exploitation of the indigenous surgery and the inadequacy or majority population. Unfortunlack of thick spectacles needed ately, after the colonial rulers left half a century ago, these after operations done without an intraocular lens--a type of systems were not modified adequately to stimulate active surgery with poorer results, which still accounts for about participation of the majority in the nation's development: half of cataract operations in India (figure). undue control remained with legislators and bureaucrats. Responsible for these failings are the inadequate infrastructure and human resources for eye care in rural The generally poor health conditions in the inhabitants of rural India, who comprise three-quarters of India's India. These problems can themselves be attributed to the population, can be attributed largely complacency that has accompanied to these distorted systems, which are the "camp surgery" approach, in devoid of adequate acc6untability which a large number of patients with cataracts are gathered at checks, and have led to continued makeshift locations and operated on exploitation of the majority through en masse by visiting doctors. corruption. Consequently, they have thwarted real development for Reasonable-quality surgery and adequate postoperative care are common people. On the other hand, India produces many talented usually not possible in this setting. professionals. The challenge is to But with the hype associated with translate this talent into substantial the claims of large numbers of improvements in basic education surgeries done in such camps, the and health care, and consequently in "number game" has clouded the overall development. This backobjective of restoring vision. ground of inadequate action but What can be learnt from this reason for hope has to be kept in experience? And what can be done mind when analysing the blindness to reduce blindness in India? situation in India. The blindness-control policy in India is anachronistic in that it is too The National Programme for Control of Blindness in India was theoretical. It is not based on recent, launched in 1976, with the aim of reliable, population-based data, and reducing the prevalence of blindness g it does not address adequately the from 1-4% to 0.3% by the year 2000. g logistics needed at the community This intention was obviously good. level. Four inter-related issues need However, the logistics of how to This man is blind in one eye because of a to be addressed if blindness in India make this happen were not worked complication of cataract surgery, and in the is to be reduced substantially. One, out adequately, which was evident other because of inadequate spectacles current data on blindness and the from the estimated blindness rate of barriers to eye care perceived by the 1.5% around 1990. During the early 1990s, the World community must be taken into account while planning Bank agreed to give a large loan to the government of India blindness control; these data suggest that attempts at reducing cataract blindness are not working adequately, for a project to reduce cataract blindness during and that blindness due to refractive error, corneal disease, 1994-2001, the total budget for which was estimated at and glaucoma also need attention. Two, the training US$135 million. The assumption was that cataract was the programmes for ophthalmologists, optometrists, largest cause of blindness in India, and was easily treatable. ophthalmic technicians, and nurses need to be standardised The intention of this project with much more emphasis on quality, including regulation was, laudable. However, through accreditation. Three, effective attempts to establish recent evidence suggests that good-quality eye-care facilities in rural areas have to be the blindness rate in India made to motivate young professionals to work in these has increased further to areas, which would address the current problem of lack of 1.8% in 2000, implying that infrastructure and human resources in rural India. Four, the number of blind people the inefficient and overbearing participation of the in India has doubled to 18 government in the planning and implementation of eye care million over the past 25 in India should be reformed to allow more creative years. The story is one of approaches to take effect. Some experiments addressing the good intentions but failure to first three of these issues are underway in India, but unless realise them through the the fourth issue is also addressed, the widespread necessary logistics of eyeimplementation of such experiments will be hindered. care delivery at the comThere is hope for progress, however, since there are a fair munity level. number of bright young Indians out there. It is high time One particularly disturbthat this talent came together to jolt India's approach to ing aspect of this story is that blindness control, as well as general development in health although the number of and education, out of anachronism and into practically cataract surgeries in India effective alternatives which provide long-term solutions for has increased markedly to the development of the nation. 3"5 million in 2000, recent
D
s25
The Lancet Perspectives • 356 • December
• 2000
INDIA
Blindness control in India: beyond anachronism
data suggest that 25-40% of uring colonial rule in operations fail in many rural India, the administraareas. This unacceptably high tive systems used to implement public policy led to rate is due to poor-quality Lalit Dandona exploitation of the indigenous surgery and the inadequacy or majority population. Unfortunlack of thick spectacles needed ately, after the colonial rulers left half a century ago, these after operations done without an intraocular lens--a type of systems were not modified adequately to stimulate active surgery with poorer results, which still accounts for about participation of the majority in the nation's development: half of cataract operations in India (figure). undue control remained with legislators and bureaucrats. Responsible for these failings are the inadequate infrastructure and human resources for eye care in rural The generally poor health conditions in the inhabitants of rural India, who comprise three-quarters of India's India. These problems can themselves be attributed to the population, can be attributed largely complacency that has accompanied to these distorted systems, which are the "camp surgery" approach, in devoid of adequate acc6untability which a large number of patients with cataracts are gathered at checks, and have led to continued makeshift locations and operated on exploitation of the majority through en masse by visiting doctors. corruption. Consequently, they have thwarted real development for Reasonable-quality surgery and adequate postoperative care are common people. On the other hand, India produces many talented usually not possible in this setting. professionals. The challenge is to But with the hype associated with translate this talent into substantial the claims of large numbers of improvements in basic education surgeries done in such camps, the and health care, and consequently in "number game" has clouded the overall development. This backobjective of restoring vision. ground of inadequate action but What can be learnt from this reason for hope has to be kept in experience? And what can be done mind when analysing the blindness to reduce blindness in India? situation in India. The blindness-control policy in India is anachronistic in that it is too The National Programme for Control of Blindness in India was theoretical. It is not based on recent, launched in 1976, with the aim of reliable, population-based data, and reducing the prevalence of blindness g it does not address adequately the from 1-4% to 0.3% by the year 2000. g logistics needed at the community This intention was obviously good. level. Four inter-related issues need However, the logistics of how to This man is blind in one eye because of a to be addressed if blindness in India make this happen were not worked complication of cataract surgery, and in the is to be reduced substantially. One, out adequately, which was evident other because of inadequate spectacles current data on blindness and the from the estimated blindness rate of barriers to eye care perceived by the 1.5% around 1990. During the early 1990s, the World community must be taken into account while planning Bank agreed to give a large loan to the government of India blindness control; these data suggest that attempts at reducing cataract blindness are not working adequately, for a project to reduce cataract blindness during and that blindness due to refractive error, corneal disease, 1994-2001, the total budget for which was estimated at and glaucoma also need attention. Two, the training US$135 million. The assumption was that cataract was the programmes for ophthalmologists, optometrists, largest cause of blindness in India, and was easily treatable. ophthalmic technicians, and nurses need to be standardised The intention of this project with much more emphasis on quality, including regulation was, laudable. However, through accreditation. Three, effective attempts to establish recent evidence suggests that good-quality eye-care facilities in rural areas have to be the blindness rate in India made to motivate young professionals to work in these has increased further to areas, which would address the current problem of lack of 1.8% in 2000, implying that infrastructure and human resources in rural India. Four, the number of blind people the inefficient and overbearing participation of the in India has doubled to 18 government in the planning and implementation of eye care million over the past 25 in India should be reformed to allow more creative years. The story is one of approaches to take effect. Some experiments addressing the good intentions but failure to first three of these issues are underway in India, but unless realise them through the the fourth issue is also addressed, the widespread necessary logistics of eyeimplementation of such experiments will be hindered. care delivery at the comThere is hope for progress, however, since there are a fair munity level. number of bright young Indians out there. It is high time One particularly disturbthat this talent came together to jolt India's approach to ing aspect of this story is that blindness control, as well as general development in health although the number of and education, out of anachronism and into practically cataract surgeries in India effective alternatives which provide long-term solutions for has increased markedly to the development of the nation. 3"5 million in 2000, recent
D
s25
The Lancet Perspectives • 356 • December
• 2000