Cataracts remain primary cause of preventable blindness

Nabi Bux is typical of most of those suffering from cataracts in Pakistan today. He has suffered from cataracts in both eyes for over four years and the father of four children with eight grandchildren may never see them again unless he takes action immediately. "I live in a rural area and have no money. That's why I haven't done anything about it," the 75-year-old former farmer from Dadu, a city in Pakistan's northern Sindh province, explained. Dr Zareen Mahdi, community ophthalmologist at Karachi's Prevention and Control of Blindness Cell is used to the problem. "We can treat this. However, if we don't do it soon, we won't be able to help him," she said from her office, citing poverty as the primary constraint to those seeking cataract treatment, cataract being the most common cause of blindness in Pakistan. Nabi needs to raise just over US $30 for the simple one hour operation, a paltry sum by Western standards but a small fortune for a man like him. For Halima Hussain, another cataract patient, the story is much the same. For two years she has suffered and has only a limited perception of light remaining in her left eye. Without treatment she is expected to develop glaucoma within two weeks. "My husband wouldn't let me come," the 50-year-old said with tears in her eyes. Although she lives within striking distance of the centre, the fact that her husband earns less than a dollar a day makes that journey impossible. According to Dr Asad Aslam Khan, professor of ophthalmology at the King Edward Medical College in Lahore and national coordinator for the World Health Organization's (WHO) Programme for Preventative Blindness in Pakistan, over 80 percent of all blindness is avoidable, with 90 percent of all blind people worldwide living in developing countries.

According to Dr Asad Aslam Khan, there are 4 million blind people in Pakistan today

"There are four million blind people in Pakistan, 1.5 million in the Punjab alone," Dr Khan said. "If proper measures are not taken, that figure will reach three million by the year 2020." With cataracts accounting for 66 percent of all blindness and glaucoma 12 percent in the nation of 150 million, the need to improve preventative care is undeniable, he stressed. In accounting for the prevalence of blindness in Pakistan, Khan cites a lack of human resources, coupled with a lack of training facilities for qualified ophthalmologists. While the World Health Organization (WHO) recommends a ratio of one ophthalmologist per 100,000 population, Pakistan has only one eighth of the required number, he explained. Compounding the problem further is a lack of the necessary infrastructure combined with little modern technology at the district level. Poorly maintained equipment and the absence of any referral chain along with a lack of motivation, advocacy, awareness or monitoring and evaluation, also play a part in the problem. Still another cause for the country's high prevalence is that there is no system for the prioritisation of need, whether it be sufferers from glaucoma, cataracts or diabetes-related blindness. "Intervention should be need-based after a situation analysis in each district," said Dr Khan. But resources remain scarce and a major proportion of eye care is still being provided by NGOs such as Sight Savers International (SSI), a UK-based group spearheading efforts to boost eye care in the country. "Presently, the number of cataract surgeries being performed is about 350,000 annually. This implies that while we are meeting the incidence, there is still a gap," Dr Haroon Awan, the NGO's country representative said from the capital, Islamabad. WHO recommends that the annual cataract surgical rate (CSR) should be about 3,000 per million population per year in 2005. Pakistan's current CSR is 2,333 per million population per year.

A young child suffering from cataracts

Yet the government, with support from SSI, the Fred Hollows Foundation and others, is making inroads into the issue of preventable blindness, particularly cataracts, by offering quality care for those who can't afford it through its centre in Karachi and a mobile outreach programme. "Last year, we had 45 eye camps and carried out 6,000 cataract operations successfully," Mahdi recalled. As a member of Pakistan's National Committee for the Prevention of Blindness, SSI has assisted in the upgrading of secondary-level district eye units in 16 districts of the country, including seven in the western tribal areas, four in the North West Frontier Province (NWFP), two in the Punjab and two in the southwestern province of Balochistan. "It [Sight Savers] has recently approved upgrading of one more district in the Punjab. Furthermore, it supports NGO partners who perform about 25 percent of all cataract surgery in the country," Awan explained. In a campaign entitled 'Seeing is Believing', run in partnership with the Standard Chartered Bank, Sight Savers has recently supported the training of ophthalmologists in small incision cataract surgery (SICS) at different provincial centres in Karachi and Lahore. "This form of surgery is known to improve the quality and outcome of surgery and shorten the rehabilitation period after surgery," Awan maintained. Seventy percent of the population lives in rural areas and at present, eye care services in the government sector are available generally only at teaching hospitals in major cities and at a district level. "Of the 120 districts in the country, eye care services have been upgraded in at least 50 percent of the eye units in the district headquarter hospitals," eye specialist Awan noted. "The government now has plans to upgrade the remaining district eye units and in fact take the eye care services up to the sub district level in the next five years."

Poverty prevented Halima Hussain from seeking treatment

But other difficulties remain for those needing care. These include a fear of surgery, traditional beliefs, access and distance from eye care facilities or the lack of an accompanying person to assist a patient after surgery, as well as a lack of confidence in government services - though this is changing. The cost of intraocular lenses (IOLs) also remains too high for a large segment of the population. Awan called on the government to redouble efforts to improve the situation, requesting the government to waive duties and taxes on IOLs used in cataract surgery, making them more available to the poor. He proposed extending eye care services, including cataract surgical services to the sub-district level and the creation of posts for both ophthalmologists and mid-level eye care personnel in sub-districts. Awan said that eye-care training should be provided to primary health care staff, particularly community health workers, to identify and refer persons with cataract and other causes of visual impairment. Finally he said that there needed to be monitoring of cataract surgical outcomes to ensure the quality of surgery is maintained.