Vision 2020 reaches landmark year
The 2020 landmark year of the Global Initiative for the Elimination of Avoidable Blindness opens with a positive balance. As stated in the latest World Report on Vision, “a strong platform of success on which to build future actions” is now in place thanks to the concerted efforts of the WHO, the International Agency for the Prevention of Blindness, and many nongovernmental and governmental partners.
“Vision 2020 is a work in progress, intrinsically a vision, a direction for globally coordinated efforts. Through Vision 2020, the overall awareness about eye care and the affordability and availability of interventions has been so augmented that most of the countries have significantly improved access to high-quality eye care,” Ivo Kocur, MD, MSc, MA, MBA, previous WHO Vision 2020 global coordinator and current CEO of the International Council of Ophthalmology, said.
Vision 2020: The Right to Sight was formally launched in 1999. At the time, advocacy was the first priority, and action was taken to sensitize local governments and health care planners to the need, availability and affordability of basic interventions for the major causes of preventable or treatable blindness, such as cataract, trachoma, vitamin A deficiency, glaucoma and diabetes. From 2003, four consecutive World Health Assembly (WHA) resolutions were adopted, two of which were accompanied by action plans that identified specific objectives and activities.
The 2014-2019 Universal Eye Health Global Action Plan was a major shift from disease control to the concept of health care system-integrated eye care. WHO member states were invited to develop and implement national eye health plans, and 16 regional workshops along with many national ones were organized to provide instructions on how to develop interventions.
Unprecedented progress, unmet needs
“Putting eye care on the agenda of the WHA every third year with a resolution and clear guidance on what to do next indicates strong political support and professional attention to eye care. Major improvement in eye care delivery has been witnessed around the world, including in low-income settings. Globally speaking, in terms of advocacy and planning, the progress has been unprecedented,” Kocur said.
The last two decades have also witnessed unprecedented scientific and technological advances. While the cost of imaging devices such as OCT might be prohibitive in low-income clinical settings, telemedicine projects and mobile-based applications have made them accessible through audio and video connectivity even in remote areas. Artificial intelligence is contributing to the detection and monitoring of eye disease, and significant progress has been made in the design and production of high-quality lens technology at a relatively low cost. As stated in the World Report on Vision, further noteworthy technological advances are expected during the coming decades.
On two points, the global initiative failed to fully achieve its goals, according to Kocur. One of them was generation of resources, which was “not as adequate as initially hoped.”
“But why?” Kocur asks. “Why, although vision is very precious to everyone, is eye care not obtaining more?’”
The second weak point was infrastructure development in local health care systems.
“We need dedicated professionals well placed in countries and supported in terms of finances and manpower to build processes and organize interventions. NGOs are helping with many of the projects, but a major global initiative requires a critical number of people who prepare and support the work of eye care specialists. Without this, it is hard to progress,” Kocur said.
Fostering stakeholders’ partnership in Latin America
For 13 years, Rainald Duerksen, MD, was the chairperson of the International Agency for the Prevention of Blindness (IAPB) in Latin America, as well as the founder of Fundación Visión in Paraguay and a practicing ophthalmologist. For Latin America, he said, Vision 2020 was instrumental in bringing together governments, the public and private sectors, and part of the corporate sector to discuss and effectively implement strategies toward the elimination of avoidable blindness.
“It helped us to speak one language. It brought us together around one issue: Blindness is preventable, it is a problem within our communities, and something can be done if we work together,” he said.
As a first step, national surveys were carried out, showing that cataract was still the cause of half the cases of blindness across the region.
“It came as a surprise to most of the scientific bodies because Latin America has plenty of ophthalmologists and there was a lot of cataract surgery done,” Duerksen said.
With the joint support of IAPB, other NGOs and the Pan-American Association of Ophthalmology, the London School of Hygiene and Tropical Medicine provided provision courses in which opinion leaders and young ophthalmologists were invited to promote responsibility, indicate solutions and design strategies. Governments realized the need for establishing national eye care units, and national blindness prevention committees were organized with the purpose of identifying needs and providing services.
“This movement throughout Latin America led to a strong increase in cataract surgeries and also monitoring quality. It started with cataract, but then it added diabetic retinopathy, uncorrected refractive errors for children, low vision services and ROP,” Duerksen said.
These interventions have resulted in a 60% reduction of blindness overall.
Active ophthalmology program in Paraguay
In 1999, Paraguay was the first country to conduct a Rapid Assessment of Cataract Surgical Services (RACSS), later called Rapid Assessment of Avoidable Blindness (RAAB), and one of the first to establish a national blindness prevention committee, the Comité Nacional Visión 2020 Paraguay, which set up priorities, raised funds and drafted a national eye health plan together with the ministry of health and Pan American Health Organization.
At the same time, the NGO sector provided support to government programs by setting up a novel “active ophthalmology” program.
“Passive means we are waiting for the patient to come, and with that strategy, we might cover about 10% to 30% of the national need in Paraguay, where 70% of the population does not have any form of health insurance. Active ophthalmology means that we are going to the communities. Volunteers, churches and now primary health care providers go house to house to identify people with treatable vison impairment,” Duerksen said.
This program was later adopted by the ministry of health as part of the national eye health plan. Thirty areas of the country are now covered on a monthly basis, and satellite hospitals have been opened in places that are far from the main hospital in the capital city, Asunción.
“When visually impaired persons are identified in their homes, we try to understand what are the barriers that they have toward the uptake of services, which may be transportation, fear, money or religious beliefs. We then start to tackle these barriers individually. If they need transportation, we organize a bus to bring these people to us. If they don’t have the money, we will finance surgeries. If they are fearful, we spend time with them and ask them to talk with another patient who had good results,” Duerksen said.
With this approach, over the years, the number of cataract surgeries has tripled in the country, from 600 to 700 per million per year to 2,000 to 2,500 per million per year, and the number is still growing. In addition, a survey found that blindness was reduced by 60% from 1999 to 2011.
Educating to socially oriented health care
Maintaining cooperation is key to the growth of socially oriented health care, but it is also a challenge in a globalized world where the tendency toward a materialistic approach to medicine is increasingly stronger, Duerksen said.
“For many of the younger generation, medicine is becoming a business and not a calling. We see that with some concern, and it has been part of our discussion within our mentoring and training programs. If there is anything that we can do, it is to select people, to make sure we have professionals who do understand that the community is responsible for its individuals and not just the government. If we have ophthalmologists who are serving only those who can pay the fee, which is one in 10, and don’t feel ethically responsible for the other nine, we cannot expect stable changes,” he said. “We need people who are prepared to personally do something to change the reality of the environment in which they practice ophthalmology.”
Similarly, industries should actively promote the use of low-tech alternatives rather than the expensive techniques and tools that can be afforded by no more than 5% to 10% of the population.
Manual small-incision cataract surgery (MSICS), for instance, is a low-cost technique that uses simple tools but is not promoted much.
“Phacoemulsification may be the gold standard in the USA, Europe, Australia and Japan, but it is unaffordable for 70% to 80% of our population,” Duerksen said.
Cataract surgery in Africa
With an average of two ophthalmologists per million population, six to ten times less than in high-income countries, Africa has insufficient human resources to fight blindness.
“Our cataract surgery rate is around 300 to 500 per million per year, while it is 10,000 in high-income countries. Since the incidence of cataract is about 2,000 per million per year, our current cataract surgical rate is not sufficient to eliminate cataract blindness in the Sub-Saharan Africa region,” Aaron Magava, MD, chair for the IAPB Africa region, said.
Funding is also insufficient because ministries of health do not prioritize eye care in their budgets.
“Resources are channeled toward the many conditions that cause mortality, such as HIV and malaria, and the money provided by NGOs is not in the least sufficient to cover the needs for services,” he said.
However, several local projects were developed within Vision 2020. In Zimbabwe, with the partnership of Christian Blind Mission (CBM), an eye care unit was built from scratch and equipped in Marondera, the provincial capital of Mashonaland East Province. There, Magava, with the occasional support of another surgeon and 19 trained nurses, performs about 1,000 cataract surgeries per year, and 5,000 pairs of spectacles are prescribed and provided. The ministry of health is actively involved, covers the salaries of personnel, takes care of the maintenance of the buildings, pays for some of the consumables and provides administrative staff.
“We reach patients in their homes and bring them to Marondera on a minibus or sometimes one of the smaller district hospitals that have OR facilities. What we find is blind patients, white cataracts, this week 60% of the people I operated on were blind in both eyes. We usually perform MSICS. It is amazing for the blind, and they are very happy to be independent again,” Magava said.
Using smartphones to detect and monitor glaucoma
Glaucoma is another major issue in Sub-Saharan Africa, and programs are currently in place for the detection and monitoring of the disease.
“We test the use of smartphones to take fundus photographs and send them to reading centers, and so we reach the people who are not coming to us, detecting the disease early and following it up over time,” Babar Qureshi, MD, global director of CBM and co-chair of the Eastern Mediterranean region for IAPB, said.
A study to be carried out at a university in Tanzania is evaluating whether this method could help lower the rate of glaucoma-related blindness. Should this be proven, the goal is to integrate it into public health management of glaucoma.
The true challenge, however, is lifelong management and treatment of glaucoma because the cost of medications is often too high, and adherence to treatment regimens poses additional challenges. For patients in Africa, surgery and laser are often better options, according to Qureshi.
“Africa has many programs related to eye care, and our goal is to integrate them into mainstream health care programs, convincing ministries of health to commit to practical action and financing. This is part of universal eye care coverage, which was the focus of the United Nations high-level meeting on universal health coverage last September,” Magava said.
Tissue donation awareness in Eastern Mediterranean region
Keratoconus is highly prevalent in the Eastern Mediterranean region, but religious and cultural barriers are still limiting the availability of donor tissue in some countries.
“The expertise for transplantation might be there, even the facilities to harvest the corneas, the technical knowhow and the banks might be there, but having to rely solely on imported corneas does not cover the need,” Qureshi said.
Jordan is an example of how advocacy and public awareness campaigns can successfully help to change the mindset of people. A coordinated series of actions, directed to religious leaders, policymakers and the communities, resulted in a consensual conclusion that access to corneal transplantation should be universal.
“Step by step, over the years, Jordan acknowledged that corneal disease leads to visual impairment and blindness, that there is a need for corneal transplantation, and that the only sustainable way of covering that need is by having local corneas,” Qureshi said.
In other countries, such as Afghanistan and Pakistan, as well as Africa, barriers still persist.
AI for DR screening in India
India, Bangladesh, Indonesia and Thailand have the highest rate of diabetes in the world. A pilot initiative, implemented by the Public Health Foundation of India and the ministry of health with the support of the Queen Elizabeth Diamond Jubilee Trust, was launched 5 years ago in 10 states of India to create a model of cost-effective screening and referral for diabetic retinopathy (DR).
“We are using fundus cameras with incorporated artificial intelligence to detect whether there is DR and the need to seek care from an ophthalmologist. However, this is only the beginning of the loop. We are still unable to count how many patients actually close the loop by going to the hospital,” Taraprasad Das, MD, FRCS, DSc, vice chair of the LV Prasad Eye Institute (LVPEI) and IAPB regional chair for the South East Asia region, said.
The LVPEI is equipped with a reading center receiving by cloud data transfer approximately 100 images per day from surrounding and remote areas. The images are analyzed by a technical system run by trained optometrists and supervised by ophthalmologists, and a diagnosis is formulated within 2 hours.
“One hundred images a day for 50 patients is a small drop in the ocean for diabetes in India, but we are setting a model that hopefully will be applied elsewhere. LVPEI operates in three states of southern India, and there are over 205 locations where patients can be examined (including primary care) and 24 locations where the patients can be medically and surgically treated (secondary and tertiary care). We place our primary and secondary eye care centers closer to people to reduce traveling costs. When patients come to us, in addition to clinical examination to confirm the diagnosis, we perform OCT at secondary level of care and also fluorescein angiography in tertiary level of care to decide on the treatment. We perform intravitreal injections, though when possible we consider laser first because it is cheaper and requires fewer number of visits to the hospital,” Das said.
AI has enormous potential for bridging resource gaps and offering affordable solutions, but there are still hurdles that prevent initiatives from scaling up to meet the region’s health challenges.
“Unmet needs in all these countries are the lack of human resources, as well as the huge lack of infrastructure and modern equipment — in the case of diabetes, the insufficient number of nonmydriatic fundus cameras and people who take care of the screening side,” Das said. – by Michela Cimberle
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- For more information:
- Taraprasad Das, MD, FRCS, DSc, can be reached at email: email@example.com.
- Rainald Duerksen, MD, can be reached at email: firstname.lastname@example.org.
- Ivo Kocur, MD, MSc, MA, MBA, can be reached at email: email@example.com.
- Aaron Magava, MD, can be reached at email: firstname.lastname@example.org.
- Babar Qureshi, MD, can be reached at email: email@example.com.
Disclosures: The sources in this article report no relevant financial disclosures.
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