As the 2015 deadline for the Millennium Development Goals approaches we take a look at how vision impairment features in these goals and initial efforts to build a post-2015 agenda.
There were great expectations about eradicating poverty and transforming global health and economic development when the Millennium Development Goals (MDGs) were established in 2000. While successes have been celebrated, many of these ambitious targets won’t be met by the 2015 deadline.
In recognition of this, the United Nations (UN) and Member States have re-asserted their commitment to target off-track MDGs and scale up proven interventions. In parallel with the intensified efforts to accelerate the achievement of the MDGs, they are determined to craft a strong post-2015 development agenda. This will build on the foundations laid by the MDGs, complete unfinished business and respond to new challenges.1,2
Given this period of reassessment and transition, it’s worth revisiting where vision impairment fits into this paradigm and what efforts are underway to ensure that post-2015, eye care issues feature on the
international development agenda.
Blind children are less likely to have a school education when compared to their non-vision impaired counterparts
MDGs and eye care
The MDGs are eight international development goals that were established after the UN’s Millennium Summit in 2000. All 189 Member States (of which Australia is one) of the UN agreed to achieve these goals by the year 2015.
The eight MDGs are:
1. Eradicate extreme poverty and hunger
2. Achieve universal primary education
3. Promote gender equality and empower women
4. Reduce child mortality
5. Improve maternal health
6. Combat HIV/AIDS, malaria and other diseases
7. Ensure environmental sustainability
8. Develop a global partnership for development.
The eight MDGs are ambitious and large goals. The International Agency for the Prevention of Blindness (IAPB), and others, stated that seven of the eight goals (all but ‘improve maternal health’) are adversely affected by vision impairment and that the attainment of the MDGs is linked to achieving the goals of Vision 2020.3,4 This then has implications for governments, eye care professionals and non-government organisations involved in eye care.
Link to poverty
We know that people with vision impairment are more likely to be poor and that the removal of cataracts alleviates poverty.5,6 In addition, there is a link between a country’s economic development status and the prevalence of blindness. Ho and Schwab found that more than 90 per cent of the world’s blind live in developing countries and that as per capita income increased, blindness decreased.7 From this, we may be able to hypothesise that as individuals earn more money, they then have the means to seek medical treatment. Conversely, as per capita income decreases, people have less money to spend on health.
Vision impairment is both a cause, and an outcome of poverty.5 Thus, MDG 1 – to eradicate extreme poverty and hunger – is inextricably linked to blindness and vision impairment.
Link to education
Blind children are less likely to have a school education when compared to
their non-vision impaired counterparts. A study in Malawi found that only 25 per cent of school-aged blind children were attending school.8
Children from poor families are more likely to be working (and not in school) and adults (particularly women) with higher schooling are more likely to keep their children in school.9 Children of adults with vision impairment are also likely to be kept home as carers for their parents.
Link to gender inequality
We know that the burden of vision impairment lies with women, with up to 65 per cent of those with a vision impairment being female. We also know that women access eye care services at a rate 50 per cent lower than men.10,11
In addition to this, women traditionally fulfil the role of caregiver. This means that a person who is blind (whether male or female) is likely to have a female caregiver. This limits a female’s ability to work and may also create psychological, medical and economic problems.12
It is evident that increasing gender equality and empowering women can have a flow on effect to the other MDGs. Improving MDGs can improve the schooling of the next generation of children, can reduce family sizes and child mortality and can decrease child labour.9 Likewise, improving access to eye care for women will contribute to MDG 3 (to promote gender equality and empower women) in many ways.
Link to child mortality
A strong correlation exists between maternal blindness and high neonatal mortality.13 Children of educated
mothers are more likely to survive past the age of five than children of mothers with no education. In addition to this, vitamin A deficiency is the leading cause of preventable blindness in children and significantly increases the risk of severe illness and death.14,15
Link to maternal health
While the IAPB did not identify maternal health as being significant in the eye care field, nearly 20 million pregnant women in the developing world have low vitamin A, with an estimated 6.2 million annual cases of maternal xerophthalmia.16 Yet this is not simply an eye condition. Night blind women are five times more likely to die from infections than those that are not, and are at significantly higher risk of dying for up to two years after pregnancy declaration (1.3 years post-partum) than those who do not have night blindness.17
Link to HIV/AIDS
Little research exists on the prevalence of HIV in vision-impaired people, or of people with a disability. However, evidence suggests that all risk factors associated with HIV are increased for individuals with a disability.18,19
What is well documented, is that the risk of HIV/AIDs is greater in vulnerable groups, including low-income earners, women and people with a lack of education.
Both HIV/AIDS and blindness are linked to poverty. They are both the cause and the consequence of poverty.20,21 In addition to this, we know that HIV/AIDS can have ocular manifestations that have implications for how this is managed at all levels of a health system.
Link to environmental sustainability
Environmental sustainability has implications for blindness prevention. From a health perspective, climate change may have implications for ocular diseases such as pterygium and cataract.
Yet we can also think about issues such as resource sustainability. Climate change has the potential to impact transportation costs and food production. Those living in poverty will suffer most from any adverse impacts in these areas. Rising costs in food and transport may also drive those on the margins into poverty. People in abject poverty will prioritise food over eye and health care out of necessity. Knowing that blindness and vision impairment is both a consequence and a cause of poverty, we can hypothesise improving environmental sustainability is important to eye health.
Link to global partnerships for development
The global Vision 2020 initiative and Vision 2020 Australia’s Global Consortium represent examples of unique and effective responses to MDG 8, to develop a global partnership for development. The fostering of strong partnerships between health ministries, international and national organisations, professional organisations and civil society groups ensures the benefits of partnership are experienced at all levels, enabling expertise to be shared, and minimises program overlap and inefficiencies. Such partnerships in the eye care sector may help increase the availability of vital medications and technologies.
There are 14 ophthalmic preparations on the World Health Organization’s essential medicines list. In addition, this list contains drugs for diseases with ocular complications, including cardiac disease, vitamin A deficiency and diabetes. Ensuring access to these can reduce blindness and help to treat eye disease where it occurs.
New technologies can improve eye care, and reduce the burden of vision loss. New devices such as retinal imaging can help to detect and track eye disease. Adaptive technology, such as low cost CCTVs, can also help to reduce the burden that a loss of vision can impose.
The MDG goals are due to be achieved by 2015. Despite significant improvement in some areas, progress has been uneven within and across countries, meaning only three out of the eight MDG targets have been met ahead of the deadline.22
The future development framework – the post-2015 agenda – should build on lessons learned from efforts to meet the MDGs, go beyond these existing objectives and become a universal framework with poverty reduction and sustainable development at its core.22
Civil society and philanthropic organisations also have a vital role toplay in the post-2015 period and to
help shape the global agenda. Hence, they are being engaged to assist in monitoring and contributing to this post-2015 development agenda. Agencies such as AusAID, the Australian Council for International Development (ACFID) and the IAPB participated in this consultation process and are encouraging their members to engage further with the Australian Government and the international community.
The Vision 2020: The Right to Sight23 goals are due to be achieved by 2020, five years later. While they are also unlikely to be reached in full, the gap between the current situation and the ultimate goals should serve as a clarion call to ophthalmic professionals to step up their efforts to address these serious issues. This includes supporting ophthalmic NGOs, lobbying government and becoming involved where possible in programs to support developing communities.
The Vision 2020 objectives provide some guidance as to how this may be achieved:24
- Raise the profile, among the key audiences, of the causes of avoidable blindness and the solutions that will help to eliminate the problem
- Identify and secure the necessary resources around the world in order to provide an increased level of prevention and treatment programs
- Facilitate the planning, development and implementation of the three core Vision 2020 strategies by National Programs.
A special event summit of the UN General Assembly was held last September (2013), allowing the UN Secretary-General, Ban Ki-moon, to present his report on the MDGs and post-2015 agenda, A life of dignity for all: accelerating progress towards the Millennium Development Goals and advancing the United Nations development agenda beyond 2015.2 The recommendations were informed by extensive consultation with Member States, as well as the world’s youth, civil society and included the work of a high-level panel.
It is important that the global community does not lose sight of the commitments and progress it has made on the MDGs as they have been successful in creating a shared set of development priorities and their simplicity has been a powerful advocacy tool for citizens and civil society organisations.
Stephanie Looi is the Global Service Development Manager at the Brien Holden Vision Institute, Public Health Division. An optometrist with a Masters in Public Health, Stephanie is involved in advocating for, planning, implementing and evaluating sustainable eye health projects throughout the world.
Tricia Keys is Programs Manager for Asia Pacific at the Brien Holden Vision Institute, Public Health Division. Tricia is an optometrist with a Masters in Public Health and is currently doing further post-grad studies in program evaluation. As Programs Manager, Tricia is extensively involved in a management and leadership capacity across a range of Institute projects covering education, service development, research and advocacy throughout the Asia Pacific region.
1. United Nations press release, 25/09/2013. World leaders renew commitment to anti-poverty targets, agree to adopt new development Goals at 2015 Summit. Accessed at: www.un.org/millenniumgoals/pdf/Press_release_Special_Event_FINAL.pdf
2. United Nations. Outcome document of the special event to follow up efforts made towards achieving the Millennium Development Goals, General Assembly, 1 Oct 2013 www.un.org/en/ga/search/view_doc.asp?symbol=A/68/L.4
3. IAPB. Blindness, Poverty and Development The Impact of Vision 2020 on the U.N. Millennium Development Goals: IAPB;n.d.
4. Faal H, Gilbert C. Convincing governments to act: Vision 2020 and the Millennium Development Goals. Community Eye Health Journal. 2007;20(64):62-64.
5. Kuper H, Polack S, Eusebio C, Mathenge W, Wadud Z, Foster A. A case-control study to assess the relationship between poverty and visual impairment from cataract in Kenya, the Philippines, and Bangladesh. PLoS medicine. 2008;5(12):e244.
6. Kuper H, Polack S, Mathenge W, Eusebio C, Wadud Z, Rashid M, et al. Does cataract surgery alleviate poverty? Evidence from a multi-centre intervention study conducted in Kenya, the Philippines and Bangladesh. PloS one. 2010;5(11):e15431.
7. Ho VH, Schwab IR. Social economic development in the prevention of global blindness. British Journal of Ophthalmology. 2001;85(6):653-7.
8. Kalua K, Patel D, Muhit M, Courtright P. Causes of blindness among children identified through village key informants in Malawi. Canadian Journal of Ophthalmology/Journal Canadien d’Ophtalmologie. 2008;43(4):425-7.
9. Ray R. Child labor, child schooling, and their interaction with adult labor: Empirical evidence for Peru and Pakistan. The World Bank Economic Review. 2000;14(2):347-67.
10. Abou-Gareeb I, Lewallen S, Bassett K, Courtright P. Gender and blindness: a meta-analysis of population-based prevalence surveys. Neuro-Ophthalmology. 2001;8(1):39-56.
11. Courtright P, Bassett K. Gender and blindness: eye disease and the use of eye care services. Community Eye Health. 2003;16(45):11.
12. Kipp W, Tindyebwa D, Rubaale T, Karamagi E, Bajenja E. Family caregivers in rural Uganda: the hidden reality. Health Care for Women International. 2007;28(10):856-71.
13. Rahman M, Huq S. Biodemographic and health seeking behavior factors influencing neonatal and postneonatal mortality in Bangladesh: evidence from DHS data. East African journal of public health. 2009;6(1).
14. Humphrey J, West Jr K, Sommer A. Vitamin A deficiency and attributable mortality among under-5-year-olds. Bulletin of the World Health Organization. 1992;70(2):225.
15. Sommer A, Katz J, Tarwotjo I. Increased risk of respiratory disease and diarrhea in children with preexisting mild vitamin A deficiency. The American journal of clinical nutrition. 1984;40(5):1090-5.
16. West KP. Extent of vitamin A deficiency among preschool children and women of reproductive age.
The Journal of nutrition. 2002;132(9):2857S-66S.
17. Christian P, West KP, Khatry SK, Kimbrough-Pradhan E, LeClerq SC, Katz J, et al. Night blindness during pregnancy and subsequent mortality among women in Nepal: effects of vitamin A and β-carotene supplementation. American journal of epidemiology. 2000;152(6):542-7.
18. Groce N. HIV/AIDS and disability: capturing hidden voices: the World Bank/Yale University global survey on HIV/AIDS and disability. 2004.
19. Groce NE. HIV/AIDS and Individuals with Disability. Health and Human Rights. 2005;8(2):215-24.
20. Lewallen S. HIV/AIDS: What is the impact on prevention of blindness programmes. Community
Eye Health. 2003;16(47):33-4.
21. Kestelyn PG, Cunningham Jr ET. HIV/AIDS and blindness. Bulletin of the World Health Organization. 2001;79(3):208-13.
22. United Nations Development Program. Post-2015 Development Agenda. www.undp.org/content/undp/en/home/mdgoverview/mdg_goals/post-2015-development-agenda/
23. World Health Organization. Vision 2020: The Right to Sight, 1999.
24. World Health Organization. What is Vision 2020? Prevention of Blindness and Visual Impairment