Microsoft Word - zahid Hussain Awan 165 Review Article Blindness and Poverty Zahid Hussain Awan, P.S. Mahar, M. Saleh Memon Pak J Ophthalmol 2011, Vol. 27 No. 3 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . See end of article for authors affiliations …..……………………….. Correspondence to: Zahid Hussain Awan Isra Postgraduate Institute of Ophthalmology, Karachi Submission of paper August 2011 Acceptance for publication September’ 2011 …..……………………….. isual impairment or loss of vision is considered to be the most feared disability. This stems from the fact that since ancient times, the sense of sight is thought to be the most important sense. In addition to being a serious public health concern, it also has a great impact on the social and economic wellbeing of an individual. Blindness as a condition has fascinated man throughout history and continues to do so. In some cultures the blind is thought to be blessed with divine and psychic powers while in others blindness is considered a form of punishment for improper moral or social conduct. The negative perceptions about blindness result in social exclusion and rejection of the blind. The blind are left out of the decision making process and have limited opportunities for education and employment. This results in decreased self-esteem and a feeling of worthlessness. Limited social contacts accompanied by loss of employment and a drastic change in lifestyle leads to depression. Most of the world’s visually impaired population lives in the developing countries where basic health infrastructure is lacking or severely deficient and the health expenditure is insufficient in meeting the needs of its people. In addition, majority of people of developing countries are plagued by poverty and live below the poverty line. The situation in Pakistan is not different from rest of the developing world. The annual GDP allocated to health in Pakistan is 2%1 and 24%2 of its population lives below poverty line. Whereas it is a well-known fact that when any form of disability is found amongst the economically deprived, the disability itself, through social and economic exclusion, further entangles the disabled into the web of poverty. While it has been studied that the prevalence of blindness is higher in the economically impoverished, the economic and social implications of poverty, compounded by visual impairment, has not been studied. Visual Impairment As defined by the International statistical classification of diseases, injuries and causes of death, tenth revision (ICD-10)3, visual impairment encompasses both low vision and blindness (Table I). Low vision is defined as best corrected visual acuity worse than 6/18 and equal to or better than 3/60 in the better eye or visual impairment categories 1 and 2. A person with low vision is one who uses or is potentially able to use vision for the planning and/or execution of a task. V 166 Blindness is defined as the best corrected visual acuity4 in the better eye of less than 3/60 or visual impairment categories 3, 4 and 5 (Table 1). Visual Impairment – Magnitude of the problem There are around 314 million visually impaired people in the world5. This figure comprises of 153 million people with uncorrected refractive error and 161 million people with best corrected refractive error. Out of the 314 million visually impaired people worldwide, 45 million of them are blind – 37 million with best corrected refractive error and 8 million with uncorrected refractive error. Although more than 82% of all blind people are 50 years and older, blindness in children is a vital problem worldwide. There are 1.4 million blind children below 15 years of age and more than 12 million children between 5 to 15 years of age that are visually impaired because of uncorrected refractive errors. 87% of the world’s visually impaired live in developing countries. In the Eastern Mediterranean Region-D (EMR-D), to which Pakistan belongs, the prevalence of blindness in 2002 was 0.97% and prevalence of low vision was 2.9%. These prevalence figures do not take uncorrected refractive errors into account. In EMR-D, the prevalence of visually impaired from uncorrected refractive error is 1.19% (age group: 5->50 years) and the prevalence of blindness from uncorrected refractive error in adults >50 years is 0.95% in rural and 0.4% in urban areas6. In Pakistan, according to the Pakistan National Blindness and Visual Impairment survey7, the estimated number of blind individuals of all ages in the year 2003 was 1.25 million. The prevalence of blindness among individuals of all age groups was 0.9%. The age and gender standardized prevalence of blindness in adults 30 years and older was found to be 2.7%. The estimated numbers of blind individuals age 30 and above in the four provinces of Pakistan is shown in (Table 2). The prevalence of blindness in rural areas was more (3.8%) than prevalence in urban areas (2.5%). After adjustment for age difference, women were found to share a significantly greater burden of blindness and severe visual impairment. If the prevalence rate remains the same, the number of blind persons in Pakistan in the year 2020 will be 2.4 million8. Causes of Blindness Globally, the leading cause of blindness is cataract followed by uncorrected refractive error (Table 3). 85% of all visual impairment globally is avoidable9. In Pakistan, according to the Pakistan National Blindness and Impairment survey, the leading cause of blindness in adults more than 30 years of age is cataract (Table 4). While globally 39.1% of all blindness is attributable to cataract, in Pakistan the burden of blindness due to cataract is significantly larger at 51.5%.85.4% of blindness is avoidable in Pakistan. Individuals with moderate visual impairment (<6/18 to ≥6/60) had refractive error (43%) and cataract (42%) as the cause of their visual impairment. Economic Burden of Blindness Disability has often been associated with poverty and the people with disability are amongst the “poorest of the poor10.” Because of physical and social barriers, people with disability face loss of opportunity and are excluded because of institutional, environmental and attitudinal discrimination. There are several studies11,12 that indicate that people in the lowest socioeconomic group share a greater burden of blindness than those in the higher socioeconomic group. Some eye diseases, such as trachoma, are known to be a direct consequence of poverty. Blindness as a disability leads to unemployment resulting in loss of income, increased level of poverty, lower standard of living and decrease in affordability of health care services. This leads to a vicious cycle of poverty and blindness where majority of the people disabled by blindness are poor and their disability leads to a further decline in their economic productivity and quality of life (Fig. I). Blindness has a huge economic cost attached to it. The cost of blindness depends on the cause and duration of blindness as well as on the availability of family members and alternative sources of income. It also depends on number of economically productive individuals that are affected by blindness. The global economic productivity loss from unaccomodated blindness is projected to grow from $19 billion in the year 2000 to $ 50 billion in the year 2020. The global productivity loss from blindness and low vision combined is projected to grow from $ 42 billion in the year 2000 to $ 110 billion in the year 202013, 14. 167 Table I: Categories of Visual Impairment Visual acuity with possible correction 0. Category Worse than Equal to or better than 1. Mild or no visual impairment 6/18, 20/70 2. Moderate visual impairment 6/18, 20/70 6/60, 20/200 3. Severe visual impairment 6/60, 20/200 3/60, 20/400 4. Blindness 3/60, 20/400 1/60 or counts fingers at 1 meter 5/300 (20/1200) 5. Blindness No light perception 6. Undetermined or unspecified Source: International classification of disease-10 (2007) Table 2: Provincial distribution of estimated number of blind adults Province Estimated number of blind individuals Punjab 769,000 Sindh 200,000 NWFP 114,000 Baluchistan 52,000 Total 1,140,000 Source: Prevalence of blindness and visual impairment in Pakistan: The Pakistan National Blindness Visual Impairment survey (Jadoon et al, 2006) The economic burden of visual impairment can be considerably lessened with appropriate interventions. The two leading causes of blindness, cataract and uncorrected refractive error, can be easily treated by cost-effective interventions such as surgery and eyeglasses. A study in India in the year 199815 suggested that if 52% of blindness in India that is due to cataract is corrected with an investment of $0.15 billion; the saving in annual GNP would be $1.1 billion. It has also been reported that after cataract surgery people become economically productive again16. Another study estimates that if cataract surgery is provided to 95% of those who require surgery then 3.5 million disability adjusted life years (DALYs) would be averted17.The global provision of eyeglasses would result in a net economic gain even if up to $1000 were spent per person18. Table 3: Global Causes of blindness as a percentage of total blindness in the year 2004 Cataract 39.1% Uncorrected refractive error 18.2% Glaucoma 10.1% Age-related macular degeneration 7.1% Corneal opacity 4.2% Diabetic retinopathy 3.9% Childhood blindness 3.2% Trachoma 2.9% Onchocerciasis 0.7% Other 10.6% Source: Bulletin of World Health Organization 2008;86:63-70 Social and Psychological Effects of Blindness Blind people experience social exclusion and are left out of decision making process. They are also deprived of academic achievements and schooling. It is thought that the predominant negative perceptions about blindness are the cause of this social exclusion. Another factor that influences a blind person’s social status is the ability to contribute to household income. Visually disabled unemployed persons face greater difficulty in being accepted in the local community. Additionally, lack of support from government and social institutions hinders provision of a conducive environment for people affected by blindness to become a productive part of the society. Family members of the visually impaired may undergo four reactions – denial, refusal, acceptance and overprotection. Overprotection is thought to be the most counterproductive as it reinforces the 168 patient’s physical and financial dependence on others19, 20. The families must accept the condition of their relative and provide a supportive role to promote and encourage the autonomy of their blind relative. Table 4: Causes of blindness in Pakistan as a percentage of total blindness Avoidable Causes Cataract 51.5% Corneal opacity 11.8% Uncorrected aphakia 8.6% Glaucoma 7.1% Posterior capsular opacification 3.6% Refractive error 2.7% Diabetic retinopathy 0.2% Total avoidable causes 85.4% Unavoidable Causes Phthisis/absent globe 2.7% Macular degeneration 2.1% Optic atrophy 0.9% Amblyopia 0.5% Other 8.4% Total unavoidable causes 14.6% Source: Causes of Blindness and Visual Impairment in Pakistan (Dineen et al, 2007) Blindness has great deal of emotional and psychological consequences. There are three types of responses to sight loss; acceptance, denial and depression/anxiety21. Acceptance is the best response to any disability and denial serves as a defense mechanism which may actually prove helpful in coming to terms with blindness. Depression as a physiological reaction may be encouraged and may even have a cathartic effect but it is also more likely to assume pathological characteristics22. In a study by Fitzgerald23, 90% of the studied cases, reported depressed mood accompanied by symptoms of depression including suicidal ideation. In another study24, depressive symptoms were more common in blind than in deaf persons. The duration and severity of depression depends on the patient’s socioeconomic status. Persons with moderate to high socioeconomic standings and young age maintain good social relations and avoid isolation. These characteristics are protective against the onset of psychopathology25. CONCLUSION Multiple studies reinforce the notion that any form of disability, including blindness, afflicts the poor. The economic cost of blindness results in further decline of the economic status of the individual, as well as, the entire family. The social discrimination of the blind alienates them from the society and results in depression and suicidal ideation. In order to reduce the economic costs associated with blindness and improve the quality of life, prevention is the best strategy. Awareness programs should be arranged for the general population regarding eye care and diseases in general and blindness in particular. In addition, the government should provide optimum health services and ensure access to healthcare. Health camps should be organized in all areas of the country where screening for eye diseases is also done. This way, through early diagnosis and intervention, blindness would be prevented. Investment should also be made by the government in social sector. Opportunities for education and support to the blind for attending school should be provided. Also, opportunities should be created for the blind to be included in the work force and they should be provided with training to live independently. The families of the blind should be provided social support, training and guidance so that they can take good care of the social and emotional needs of their blind family member as well as themselves. If above recommendations are implemented, we would be able to ensure that the blind are given access to basic human rights and live their lives with dignity and as productive members of their families and community. 169 Visual Impairment Poor health Lack of ability to assertrig hts Low level of develop ment Low self esteem Exclude d from formal and informa l Limite d social contac ts Low expect ation from comm unity Lack of employ ment opport unities and Limited access to basic health care Lowest priority for resource s, such as food Highest risk of illness, accident and impairment Source: Adapted from Yeo and Moore, 2003 Poverty Exclusion Limited access to education andemploym ent Limited access to land and shelter Poor sanitation Limited access to healthcare Insufficient or unhealthy food Excluded from Political and Legal process Forced to accept hazardous working conditions Unhygienic and overcrowded living conditions Malnutrition and poor health – physicallyweak Unable to assert rights Loss of Income Excluded from political and legal processes Fig. 1 Income generating opportunities reduced 170 Author’s affiliation Dr. Zahid Hussain Awan Community ophthalmologist Isra Postgraduate Institute of Ophthalmology Karachi Prof. P.S Mahar Isra Postgraduate Institute of Ophthalmology Karachi Dr. M. 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