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Need to prioritize eye health in India for 270,000 blind children, largest in the world

By Simi Mehta, Anshula Mehta, Arjun Kumar

Vision is not just critical to an individual’s growth and development but has direct implications for national and global development. It holds the potential to boost the global economy in a fair and equitable manner. It enables everyone to live their lives to the fullest, releasing their potential to learn, to work, and to lead fulfilled and productive lives. When the benefits of good vision remain without an iota of a doubt, the enormity of its implications on children becomes humongous.
This article discusses rationale and motivation with which eye health of the children must be prioritized. It then analyzes the issues and challenges in ensuring eye care to the children in India and how in the process, the nation’s commitment to the attainment of United Nations’ Sustainable Development Goals gets impacted. It also provides a glimpse of how the COVID-19 pandemic affected the eye health of the children.

Prioritizing Eye Health: Rationale and Motivation

Vision is the foundation of a child’s communication and learning skills and ability to become independent and a responsible citizen of the country. This implies that there should be a dedicated focus on vision for the children. Even SDG 4 of Quality Education is contingent upon the eye and overall health of children and learners of all ages.
According to VISION 2020/IAPB, it is estimated that around 91 million children and adolescents worldwide have a vision impairment but do not have access to the eye care services they need, which leads to them being 2-5 times less likely to be in formal education, especially in low- and middle-income countries. The COVID-19 pandemic-induced shifts in living standards and mode of education, have further increased the burden of children's eye care which risks the attainment of SDG 4 in a timely manner. Studies have shown how the provision of free spectacles to children is an inexpensive, simple intervention that can improve academic test scores and literacy skills, which in turn can improve future opportunities for decent work and paid employment.
A lack of access to eye care has a disproportionate impact on women and girls. This can have devastating consequences on girls’ education, increase dropouts, exacerbate poverty and the occurrence of child marriage, and negatively impact the participation of women in the workforce and the role of women in safeguarding the health and education of their own children (Steinmetz et al. 2021). The Vision Loss Expert Group (VLEG) and Global Burden of Disease study (GBD) 2020 model (VLEG/GBD 2020 model) estimates that women and girls are 12% more likely than their male counterparts to have vision ailments and experience additional barriers in accessing eye care services. Thus, this puts the SDG 5 of Gender Equality at risk of being pushed to the margins.

Eye Healthcare and Sustainable Development in India: Issues and Challenges

As per the Status of Child Eye Health Report by Orbis (2020), the economic burden of visual impairment in India accounted for roughly Rs 88,900 crore in 2020. The loss in income due to blindness in adults is estimated to be Rs 9,06,200 crore and Rs 3,31,100 crore for children, for 10 and 40 lost working years, respectively. This clearly indicates the consequent implications of unplanned expenditures on eye health thereby creating financial hardships for the people. This implies that the realization of SDG 1 of No Poverty remains a distant dream and monetary challenges may translate into becoming a roadblock to the attainment of SDG 2 of Zero Hunger as well.
The report highlights that there are approximately 270,000 blind children in India, the largest in any country across the world. Given that the books and mode of teaching remain dependent on visual aspects, the achievement of the Right to Education objective of providing affordable and quality education becomes difficult (SDG 4). While support in terms of Braille text, audio textbooks, special educators, among other tools are being undertaken, they are far from being ubiquitous. Further, the COVID-19 induced challenges translated into the online mode of teaching-learning, which further alienated a large section of the student population due to the inability to afford smartphones, tablets, and laptops/computers. This also had another dimension of visual impairments, eye strain, and sleep disturbance for a large number of students who found themselves struggling to learn in front of a digital screen. Additional health concerns include mental health problems ranging from difficulties in concentration, obsession to diagnosable mental illnesses such as anxiety, depression and attention-deficit hyperactivity disorder (Király et al., 2020; Meyer et al., 2020; Stavridou et al., 2021). Hence, the attainment of SDG 4 of Quality Education remains farfetched in India in the prevailing business- as- usual context.
It needs to pointed out here that India houses the world's highest number of malnourished children (Shenoy, 2017). A lot of this is related to improper diet and nutrition, where a balanced diet consisting of nutrient rich food, fruits and vegetables is largely out of the reach of children belonging to families that reel under chronic poverty. Hence, when we roll up our sleeves to focus on improving nutritional security in the country, we cannot compromise on the lives of the children. This is more so because considering that Vitamin-A deficiency is associated with childhood blindness, this becomes all the more urgent.
The table below demonstrates the State-wise targets undertaken and the consequent achievements for eye health improving tools during 2018-19. This covers screening for refractive errors and provision of free spectacles to school children.

Children's Eye Care: Heightened Need amidst the Pandemic

Children's eye care issues, their causes and treatment represent a specialty and niche area within the broader sector of ophthalmology. Nonetheless, it is an essential process to reduce the prevalence of avoidable blindness.
The factors primarily responsible for children's blindness and visual impairments have strong linkages with their social, environmental and economic backgrounds. With improvements in nutritional security and the rising usage of digital devices, children's eye care issues have substantially shifted. These causal changes have also necessitated modifications in national-level programs and their implementation. Further, these changes have revealed the importance of adopting complementary and integrated health care surveillance in the country.
Dandona et al. (1996) published a list of the causes of childhood blindness and strategies to reduce its prevalence. The authors identified a set of factors responsible for childhood blindness such as genetic/hereditary, intrauterine, and neonatal, and those related to infancy and childhood. Other miscellaneous factors included cataracts, glaucoma and retinoblastoma. To overcome childhood blindness, the authors suggested establishing an efficient human resource base such as a cadre to look after pediatric needs and developing a community-led preventive, curative and rehabilitative model.
As per studies conducted by Murthy G.V. et al. (2002) and Dandona R. et al. (2003), the prevalence of childhood blindness in India is 0.8/1000 in the 0-15 age year group. According to Saxena et al. (2015) the causes of visual impairment in children have changed since the beginning of the millennium. Due to better nutrition and improved immunization, eye conditions amenable to preventable factors such as trachoma and pediatric corneal infections have declined.
Visual impairment affects reading and invariably the learning opportunities for children. Childhood blindness can adversely impact national literacy rates. Further, if visual impairment continues to attract stigma, visually impaired individuals may suffer from psychological and mental health care problems, socially isolating themselves in the future.
Spending more time indoors and undertaking fewer outdoor activities are known risk factors that cause myopia. Excessive use of digital devices can cause dry eyes. Eyes are accustomed primarily to far-away vision. Hence, repeated usage of near-vision devices can impact children’s eyes and cause irritation and even blurred vision. The impact of digital devices goes beyond disrupting eye care. Blue light, emitted from digital devices, is known to disrupt the secretion of melatonin, a hormone that regulates sleep patterns.
During the COVID-19 pandemic induced lockdowns, and closure of physical mode of teaching in educational institutions, children were compelled to take online education classes. In this context several eye care practitioners warned about the possible side effects of digital devices on child eye care. Given these shifts in living standards and mode of education, the burden of children's eye care will only rise in the future. The country will face a grave threat in this niche yet important sub-sector of ophthalmology.
The mid-day meals scheme, which stipulates the provision of cooked meals for children till primary school, has been adversely impacted due to the shutdown of schools. The pandemic has doubly burdened children's access to nutrition. Lower nutrition levels can impact pediatric eye care, leading to a rise in cases attributed to preventable causes such as corneal scarring.
According to the Annual Report 2020-21 of the Ministry of Health and Family Welfare (MoHFW), in its efforts to implementing eye health improving tools, the average target of the activity of provision of number of free spectacles to school children suffering from refractive errors during 2021 was 11,00,000. The achievement during January to September 2020 was 4,05,387 and the projection for October 2020 to March 2021 was 3,45,000. So, the total 7,50,387 was essentially 32% less than the target. This was all the more needed and door-to-door implementation was necessary as the children were pushed indoors due to closure of schools and also of Anganwadi centers. The caveat of undertaking this under strict COVID-19 protocols should have been pursued.
The Rashtriya Bal Swasthya Karyakram (RBSK) programme of the National Health Mission, which evaluates a child’s health, includes screening for visual disorders. However, limitations of equipment and ophthalmologists allow only for a test for refractive error. The programme has been designed primarily to identify developmental delays (usually associated with a neurological deficit) in early childhood. It does not specifically identify visual impairment in children under 4-5 years of age. Identification of common visual defects such as amblyopia after the age of 7 or 8 years makes their rectification very difficult. Unlike hearing defects which need to be identified at, or soon after birth, visual defects are best identified just before a child starts school or formal education.
Most of the current child eye care models in India are focused on screenings and surgeries. They include school screening, consequent referral and community-based eye health programs. There is no nationwide data available on child eye health problems in India. Few studies have been undertaken to study pediatric eye health problems in the country, many emanating from South India. Since the majority of the people afflicted with visual impairment are over the age of 50 years, several policies of the government are tilting towards interventions in the adult population. Though the prevalence of childhood blindness in India is low, the lack of large-scale surveys and data may lead to unreliable information.

Conclusions

Government of India must work in a target-based manner along with the state and local governments and must not tolerate any complacency from any functionary involved in the process. The much-acclaimed mid-day meal scheme for children at Anganwadi centers fix the hunger aspect, but hardly takes care of the nutrition. Besides, the quality of nutrient rich food- if at all provided, for example, eggs, have many a times been reported that they are of poor quality or rotten. The suppliers/traders of such items must be penalized and their services must be discontinued with immediate effect.
Screenings and eye checkups for children must be periodic (and not a one-off) for gathering sufficient and reliable data on the progress of their eye health. Digital records may be prepared and maintained, utilizing functionalities of the Ayushman Bharat Health Account (ABHA) as a repository of digital health records, for a technology-driven boost towards effectively addressing children’s eye health issues.

References:

  • Dandona, Lalit., Dandona, R., & John, R. K. 2001. Estimation of blindness in India from 2000 through 2020: Implications for the Blindness Control Policy. National Medical Journal of India, 14(1), 3267-334. https://pubmed.ncbi.nlm.nih.gov/11804362/
  • Király, O., Potenza, M. N., Stein, D. J., King, D. L., Hodgins, D. C., Saunders, J. B., et al. 2020. Preventing Problematic Internet Use During the COVID-19 Pandemic: Consensus Guidance. Compr. Psychiatry. 100, 152180. doi:10.1016/j.comppsych.2020.152180
  • Meyer, J., McDowell, C., Lansing, J., Brower, C., Lee, S., Tully, M., et al. 2020. Changes in Physical Activity and Sedentary Behavior in Response to COVID-19 and Their Associations with Mental Health in 3052 US Adults. Int. J. Environ. Res. Public Health. 17, 18. doi:10.3390/ijerph17186469
  • Murthy, G. V. S., John, N., Gupta, S. K., Vasisht, P. & Rao, G.V. 2008. Status of pediatric eye care in India. Indian Journal of Ophthalmology, 56(6), 481–488. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2612972/
  • Saxena, Rohit., Vashist, Praveen., Singh, Digvijay., & Tandon, Radhika. 2015. Preventing Childhood Blindness: Synergy between Ophthalmology and Community Medicine. Indian Journal of Community Medicine, 40(3), 149-151. https://www.ijcm.org.in/article.asp?issn=0970-0218;year=2015;volume=40;issue=3;spage=149;epage=151;aulast=Saxena
  • Shenoy, J. 2017. India has largest number of malnourished children in the world: Study. Times of India. November 1, 2019. https://timesofindia.indiatimes.com/india/india-has-largest-number-of-malnourished-children-in-the-world-study/articleshow/61405188.cms
  • Steinmetz, J., P. Briant, T. Vos. 2021. Staring Down Gender Disparities in Vision Loss. Think Global Health. February 19, 2021. Available at: https://www.thinkglobalhealth.org/article/staring-down-gender-disparities-vision-loss
  • Stavridou, A., Kapsali, E., Panagouli, E., Thirios, A., Polychronis, K., Bacopoulou, F., et al. 2021. Obesity in Children and Adolescents During COVID-19 Pandemic. Children 8 (2), 135.
  • Ministry of Health and Family Welfare, Government of India. 2021. India has crossed a key milestone in universal primary healthcare [Press Release, 21 March 2021]. New Delhi; 2021.

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