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An estimated 40 to 45 million people in the world are blind to the point that they cannot walk without assistance. The World Health Organization estimates that this number will double by the year 2020 unless decisive public health action is taken. In addition to the tragic human cost most persons in the developing world die within three or four years of becoming blind blindness costs the world more than $25 billion in lost productivity. Some 60% of the world's blind live in sub-Saharan Africa , China , and India . Up to 80% of global blindness is avoidable, either by prevention or surgery, such as cataract surgery. While the elimination of preventable blindness is theoretically achievable by these means, it requires a stupendous global effort. About 50% of blindness in the developing world is caused by cataract but to clear the backlog of blindness and to treat new cases would require some 32 million cataract operations every year for the indefinite future 20 million more operations a year than are performed today. "Vision 2020: The Right to Sight" addresses these formidable goals. Set up as a partnership between the WHO and the International Agency for the Prevention of Blindness (IAPB) in 1999, the Vision 2020 initiative aims to eliminate preventable blindness by the year 2020. From Practice to Politics Historically, eye care in the developing world has been driven by committed individuals or small groups, who set out for Africa or Asia on their holidays, with a suitcase full of begged and borrowed instruments. Such enterprises are noble, but inevitably make little headway against a global problem of such vast proportions. As Dr David Moran, medical adviser to the Fred Hollows Foundation, put it in an editorial in Clinical and Experimental Ophthalmology last year, "Cataract blindness will not be beaten by the meagre resources presently devoted to it, by hit-and-run' programmes, and certainly not by doctors alone. It is far too large a task. It needs a massive realignment of government priorities. It needs money and management on a large scale." Such a realignment of resources and priorities is promised by Vision 2020 but can it really make the kind of difference needed? The global objectives of the WHO are laudable, but its achievements have all too often been mired in politics and bureaucracy. Vision 2020 is different, Mike Whitlam CBE, Chief Executive Officer of the IAPB, told EuroTimes. Whitlam brings more than 20 years experience to the job, and was previously head of the Red Cross and of an international campaign to ban landmines. The IAPB is an umbrella organisation coordinating a task force of leading international NGOs and academic institutions like the International Federation of Ophthalmological Societies. "The partnership gives us a unique opportunity," says Whitlam. "We can leverage the WHO's connections to influence government policies at the highest level, and through the expertise of the NGOs on the ground we can avoid duplication and learn from past mistakes. This means we can help governments implement workable policies locally. We can make a real difference. We're now working directly with more than 80 governments worldwide." So what exactly have the IAPB been doing since the launch of Vision 2020 in 1999? "We've been laying the groundwork so far," said Mr Whitlam. "To mobilise governmental resources we have to raise awareness of blindness it's still perceived as a low priority in comparison with, for example, AIDS, but the fact is that improving eye care has very immediate returns. The World Bank described cataract surgery as one of the most highly cost-effective interventions that can be offered in the developing world'. We have to build on that. Just in terms of lost economic productivity, a recent study by Kevin Frick and Allen Foster showed that the Vision 2020 initiative has the potential to save at least $102 billion by 2020. But to achieve this we need major investment in infrastructure and community health, year-on-year, and for that we must raise awareness of the problem." The most important interim step, said Mr Whitlam, is to get governments to develop concrete action plans to tackle preventable blindness. Importantly, in May 2003, governments around the world voted unanimously in support of a resolution at the 56th World Health Assembly. The resolution urges governments to develop, implement and evaluate Vision 2020 National Prevention of Blindness Plans, with a view to implementing them by 2007. "This is not political posturing" Mr Whitlam told EuroTimes. "We have provided all world governments with a tool kit' on CD-ROM, which gives comprehensive guidance and local support along with contact information for local NGOs on the ground for governments and healthcare professionals at all stages of development. There's no excuse for saying we don't know what to do' it's all there in a clear and searchable format." The CD-ROM is in English at the moment but will be translated into Spanish, French and Arabic shortly. The proof of the pudding will be in the eating. The approach of Vision 2020 is eminently workable, and makes the best use of existing resources, both at governmental level and on the ground. But whether the political will can be translated into the funding, training and infrastructure needed to eliminate preventable blindness on a global scale remains to be seen. The cost to implement Vision 2020 amounts to about $200 million a year. Altogether, the NGOs themselves are spending $100 million a year, leaving a substantial shortfall. Some of this money will come from the eye care industry. Companies such as Bausch and Lomb and Alcon have already pledged funding in support of Vision 2020. But the big money still comes from governments and organisations like the World Bank as well as big pharmaceutical companies. The philanthropy of Merck is still unsurpassed, with its donation of ivermectin (Mectizam) in 1987 to treat onchocerciasis (river blindness) for as many as need it, for as long as needed.' Since 1988, more than 700 million tablets have been donated, and are now reaching more than 30 million people in 33 endemic countries in Africa , Latin America and in Yemen , in collaboration with organisations like the Carter Center . More recently, other big pharmaceutical companies have entered into a similar spirit. In November 2003, Pfizer announced it would donate 135 million doses of its antibiotic azithromycin (Zithromax) over 5 years, for the treatment of trachoma an estimated commitment of $500 million. Despite the massive donations, Vision 2020 still faces huge difficulties in treating onchocerciasis and trachoma because of the logistical challenges posed by providing antibiotics and basic healthcare and sanitation to remote villages where so many of the diseases are rampant. Even if Vision 2020 overcomes that logistical hurdle, it still faces an even higher one in the form of the surgical treatment of cataracts. The goal of performing more cataract surgery cannot be met simply by distributing drugs and improving local sanitation; it requires the training of local practitioners. The problems here can only be solved by judicious decision-making on the ground the kind of decisions faced every day by organisations like the Himalayan Cataract Project in Nepal . Prospects Both the quality and the quantity of cataract surgery required to eliminate preventable blindness pose daunting challenges. A 2003 study by Lalit Dandona and colleagues at the Prasad Eye Institute in Hyderabad, India, estimated that the 3.5 million cataract surgeries in India each year will avert blindness in 0.32 million people. To eliminate cataract blindness in India would require an estimated 9 million good-quality cataract operations a year, rising to some 14 million by the year 2016. And cataract surgery in India is advanced in comparison with many places. How can this challenge be met on a global scale? Both Mike Whitlam and Geoff Tabin agree that the answer is not just training ophthalmologists, who may just migrate away from the problem areas, but in training nurses and ophthalmic assistants. They are essential in screening the right patients people who are not just blind with cataracts but because of cataracts and who can follow up and make sure that refractive errors are corrected. These people are less likely to migrate to the cities, because they have a central role in the community and a proud position in their local villages. "We need to train the nurses and ophthalmic assistants to recognise different eye conditions, not just cataracts but also other forms of blindness, especially major causes like trachoma and onchocerciasis, or vitamin A deficiency in childhood" said Dr Tabin. "With their central role in the community they are also best placed to distribute antibiotics and vitamin supplements to remote villages. Patients who would benefit from cataract surgery can be selected, and when there are enough in a local area they can call in an outreach program, who would come in from the cities to perform the surgery." These ideas require the training of ophthalmologists, nurses and assistants on a grand scale. Such programmes are already underway in Kathmandu , as well as large centres in India such as Arvind Eye Hospital and the Prasad Eye Institute. These centres train doctors, nurses and ophthalmic assistants from elsewhere in Asia , but also from Africa , where cataract surgery still lags behind. The challenge is daunting and does not take into consideration the likely rise in cases of glaucoma and AIDS-related blindness. But given the political will and the coordination of the IAPB and the WHO, Vision 2020 can succeed in eliminating preventable blindness by 2020, promises Allen Foster, Senior Vice President of the IAPB. "Vision 2020 will be achieved if people involved in eye care catch the vision' for themselves and decide to make it a reality for the people they serve."
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