India finds itself in the enviable position of being on track to attain its goals related to the "Vision 2020: The Right to Sight" initiative, a World Health Organisation campaign to eradicate preventable blindness by the year 2020.
In 2001, the number of blind people in India was estimated to be 18.7 million. Current estimates suggest that 10 million are blind in India - a prevalence of 1%. India's goal is to reduce the prevalence of blindness to 0.3% by 2020. This may seem like a challenging target bearing in mind that India is home to a fifth of the world's blind children. However, the trend seems set to continue, with the figure projected to fall to 8 million by 2010. What is unclear is whether this decrease in blindness has occurred equally between males and females.
World Sight Day is taking place on 8th October, an international day of awareness, to focus attention on the global issue of avoidable blindness and visual impairment. The theme for this year is Gender and Eye Health – Equal Access to Sight, providing a timely reminder that although blindness rates have been falling worldwide, this reduction has not happened equally between the genders.
The evidence is startling: almost two-thirds of the blind population worldwide are women and girls, and in many settings, men have twice the access to eye care as women.
What are the reasons for this gender inequity? Women do have a longer life expectancy than men, and blindness is associated with increasing age. This might be a plausible explanation, but examining age-specific rates of blindness shows a female excess in most age groups. The overwhelming reason is likely to be related to unequal utilisation of eye care services by females.
Several studies conducted in India provide evidence of gender inequity, with females up to 50% more likely to be blind compared to their male counterparts. Cataract is the major cause of blindness in India (as in most countries), and females also fare worse when it comes to receiving cataract surgery. A study in south India found that women were 30% less likely to be operated on for cataract despite there being a greater proportion of women blind with cataract.
Girls are also susceptible to gender inequity receiving less surgical intervention compared to boys. Presbyopia relates to the need for near-sight spectacles as we get older, and is more likely to affect women, however men are more likely to own such spectacles. Presbyopia not only causes problems for the literate who develop difficulties with reading print, it also leads to functional impairment for near-vision tasks, which are often gender related, resulting in reduced quality of life.
The majority of India's blind are poor and live in rural areas, perhaps leading to the assumption that gender inequity in eye care is partly due to lack of investment in ophthalmic public services. In fact, the Aravind Eye Care System and LV Prasad Eye Institute, both in south India, have created sustainable and affordable high quality eye care delivery models that have been replicated globally. India was the first country worldwide to initiate a public health program for control of blindness with the National Programme for the Control of Blindness (NPCB) in 1976. Since then, considerable achievements have been made, particularly with the cataract surgical rate (CSR). This is a measure of cataract service delivery, reflecting the number of cataract operations performed per year, per million population. Ten years ago, the CSR in India was 1500, now it is around 4500. The CSR in much of sub-Saharan Africa averages 700, and China’s CSR is estimated at between 300-500.
Strategies to address inequity in cataract services may involve more tangential issues than simply finding out which women in a village would benefit from treatment. Transport to hospital may be a concern as some women may have little experience of travelling outside their environs and it may instil a sense of fear or perceived danger. Appropriate counselling is another method that may be effectively used to address gender inequity. Men are more likely to express need, while women are more likely to hide their needs. Some women report feeling 'shame' in being blind. Counselling can be used to engage husbands, men, and children of widows to reach out to women, and to seek those who have visual loss. Active counselling also helps to establish or strengthen links between the community and eye care service providers. These strategies may increase the uptake of surgery by women, but in the long-term more innovative approaches are needed.
The current five-year plan NPCB objectives include raising public awareness about prevention and treatment of eye disease. It suggests "there should be a convergence with various ongoing schemes for the development of women and children". More than any of the strategies within the entire plan, this is the most important objective to achieve in order to achieve equal access to eye care.
Addressing gender inequity in eye health involves more than enhancing the level of services, or increased effort by stakeholders. Eye health for women and girls must be seen within the context of comprehensive healthcare, and integrated with gender-responsive health care policies and programs. The gender gap also needs to be closed in other areas of development such as primary and secondary education – in south India literacy was the most important predictor for females receiving cataract surgery.
Comprehensive and accessible eye care will not occur in isolation. Eye care providers also need to embrace a shift from a curative approach to seeking interactions and partnerships outside of eye care. Local NGOs and organisations often have established grass roots and networks that may be of great value when linked to eye care efforts. For example, organisations related to child health may provide a platform for effective childhood cataract and refractive error screening. Partnering with industry may also be a possibility - if telecommunications companies can target rural outposts, could they not run eye health advocacy campaigns alongside?
Equal access to sight is attainable if eye health is integrated with general healthcare as well as the broader development agenda. Partnerships outside of eye care and indeed public health may be required. As links develop and new partnerships are forged, the tools available for advocacy are also expanded, and these broader coalitions may ultimately improve the current status of gender inequity in eye health so that all may see.
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Dr. Sophia Pathai is an ophthalmologist, with a specialist interest in ophthalmic public health and epidemiology. She is a Clinical Research Fellow at the International Centre for Eye Health, London School of Hygiene and Tropical Medicine.
