Foresight prevents blindness / by Björn Thylefors

'' Foresight prevents blindness" This was the slogan chosen by WHO for World Health Day in 1976, when efforts were made around the world to raise public awareness about the problem of preventable blindness. This issue of World Health reviews the progress that has been made in the past decade [ wo of the commonest prob- lems encountered in develop- ing countries are poverty and ignorance, and both of these have a direct bearing on the burden of blindness. Poverty may sometimes be the reason for a fami- ly's not seeking early treatment for trachoma, or for an elderly person's not having a cataract operated on, but more often lack of information, awareness and motivation is the underlying reason. To this must be added the equally common problem of the physical and social remoteness of the avail- able health services from the rural poor in outlying areas, together with the general shortage of trained personnel and facilities for eye care in most developing countries. It is hardly surprising, therefore, that blindness rates in many of the least developed countries are often as much as 20 times higher than those found in developed countries, and that nine out of ten of today's more than 28 million blind people live in developing countries. And yet, a fair amount of pro- gress has been made over the last decade in the fight against "avoid- able" blindness in developing coun- tries, that is to say in dealing with blindness that can be prevented or cured relatively easily with locally available resources and technology. An example of such a cause of blindness is trachoma, which is gradually being brought under con- trol in an increasing number of countries. According to recent esti- mates, the number of people suffer- ing from this disease may have dropped from some 500 million to W oriLo HEALTH, May 1987 by Bjorn Thylefors about 360 million over a period of some three decades. Onchocerciasis has been the target of intense vector control ef- forts in West Africa for the last ten years, with very successful results. Furthermore, the availability of a promising new drug, ivermectin, for the treatment of onchocerciasis A primary eye care scheme can be set up relatively easily at the community level. Photo WHO/P. Larsen Left: Vitamin A deficiency blinded one of these Nepalese children ; early ac- tion could have saved her sight. Photo WHO/J. Schytte may in the near future dramatically improve possibilities for control of the disease and its blinding manifes- tations. More is being learned about the effects of vitamin A deficiency during childhood, which may in- clude increased mortality as well as the blindness it was already known to cause. As a result, intensified efforts are now being made in a number of countries to assess and control the problem of vitamin A deficiency, as a component of pro- jects aiming for increased child survival. The primary cause of blindness in the world as a whole-cataract-is still posing a serious problem in both developed and developing countries despite the increased ef- forts being made to corn~ to grips with this disorder. We now know that it causes half or more of all the blindness in developing countries and therefore that millions of pa- tients could have their sight re- stored by surgery. However, to pro- vide such surgical services on a large scale is already very difficult with the scanty trained personnel and facilities available in most de- veloping countries; and meanwhile the number of cases requiring cataract surgery is rapidly increas- ing the world over, owing to the close relationship between cataract and age. In developed countries, the es- calating cost of cataract surgery is becoming a matter for concern, par- ticularly as ever increasing use is being made of artificial intra-ocular lenses, which allow excellent resto- ration of vision following surgery, but at high cost. To cope with this problem, cataract surgery is now being performed on an out-patient basis in several countries, with en- couraging results. However, such experience is not directly applicable to the situation in developing coun- tries, where hospitalisation often has to be longer, mainly in order to ensure correct post-operative care but sometimes too because of 3 transport difficulties or for social reasons. Furthermore, the rapidly increas- ing proportion of elderly people in developing countries will add to the burden on the health administra- tions in many of the poorest coun- tries of the world. So, in the ab- sence of any known preventive measures against cataract, it is like- ly that this disorder will continue to be the main challenge to the pre- vention of blindness in coming years, and that, in general, coun- tries will have to make more re- sources available to deal with the growing backlog of unoperated cases. Perhaps one of the most signifi- cant developments in the field of blindness prevention over the last few years has been the concept of "primary eye care", that is, the inclusion of an eye-care component in a primary health care system. The idea of primary eye care, as one of the main ingredients of a primary health care approach to blindness prevention, has rapidly gained acceptance the world over. It is today recognised as a model for 4 eye care at the community level by many ophthalmologists, health ad- ministrators, voluntary agencies, and others. There is no universal blueprint for primary eye care; the local setting determines the final range and type of activities needed. How- ever, the promotion and protection of eye health, together with on-the- spot treatment for the commonest eye diseases, are its cornerstones. Most of the measures needed for control of diseases such as trachoma and the xerophthalmia due to vit- amin A deficiency can be under- taken by a trained primary health care worker, who is also often the best educator for eye health in the community. For other common dis- orders, such as cataract or eye in- juries, the health worker should be capable of recognising cases and referring them for further examin- ation and treatment. Experience from a number of countries has shown that a primary eye care scheme can be set up relatively easily, as a start to action for eye health at the community level. There are, however, some obstacles, one of the commonest being lack of appropriate referral facilities. The local health worker is not supposed to act as a kind of mini-ophthalmologist, but to refer any cases that need further exam- ination or treatment. If those cases referred are not given appropriate and timely attention at higher levels of the health system, there is a danger that the local population will lose faith in their health worker and in the eye care he or she provides. This in turn leads to a short-circuit in the health system with immediate demand for special- ist care-a particularly common, and often avoidable, problem in ophthalmology and the prevention of blindness. If we consider the fact that in many developing countries there are more than a million people to every ophthalmologist, it becomes obvious that the few specialists av- ailable should really deal with only the most complex cases of eye dis- ease and devote their time rather to training and supervlSlng other levels of personnel who provide a more basic kind of eye care. This is W oRLD HEALTH, May 1987 "Foresight prevents blindness" Left: About 75 per cent of blindness in developing countries could be pre- vented, but sights like this are still all too frequent in many parts of the developing world. Right: In Guatemala, the National Committee for the Welfare of the Blind has opened several eye hospitals and clinics which offer much-needed eye care to the population. Photos WHO/J. Schytte and WHO/P. Almasy an area where much remains to be done, and there is increasing aware- ness amongst the ophthalmological profession of the need for new approaches to ensure optimum management of all cases in need of eye care. The development in many countries of new cadres of person- nel, such as ophthalmic assistants, reflects a recognition of the need for tasks relating to eye care and blindness prevention to be dele- gated by the specialists to auxiliary personnel. Another important development in connection with the prevention of blindness has been the establish- ment of national programmes in some 50 countries over the last decade. Many of these programmes were first started by non-govern- mental organizations concerned with blindness prevention, and some of them focused on a single disease, such as trachoma. The in- creasing recognition of the primary health care approach to blindness prevention, and the work of non- governmental organizations in that field, have resulted in an active and fruitful partnership between minis- W oRLD HEALTH, M ay 1987 tries of health and such organiz- ations in many countries. The set- ting-up of national committees for blindness prevention in a rapidly increasing number of countries is demonstrating the usefulness of this formula for bringing together re- sources and expertise from all avail- able sources and interested parties. The international non-govern- mental organizations working for the prevention of blindness have accumulated extremely valuable field and planning experience in developing countries, and have of- ten acquired excellent knowledge of local conditions through their numerous national groups and rep- resentatives. Together, moreover, they spend more than US $20 mil- lion a year on field projects for blindness prevention in a large number of countries. The WHO Pro- gramme for the Prevention of Blindness has developed close col- laboration with the international non-governmental organizations concerned, particularly through the International Agency for the Pre- vention of Blindness, which com- prises some ten member organiz- ations. These organizations have set up a consultative group of non- governmental organizations to the WHO Programme for the Prevention of Blindness to facilitate communi- cation and the development of joint programme activities and the chan- neling of support. Already such joint activities include the develop- ment of training and educational materials on eye care, and joint reviews of progress made in specific projects. Much remains to be done for the preve9tion of unnecessary blind- ness, in order to make the goal of Health for all by the year 2000 a reality. There is still room for optimism in this regard, even if greater efforts and more resources are needed in many countries. The first and most important steps to- wards preventing blindness have already been taken with the recog- nition that it is an avoidable obsta- cle to individual and collective well- being and development, and that much can be done about blinding diseases through primary health care and increased awareness and community involvement. • 5