Amarjit Singh writes: Way of seeing – The Indian Express


Some 35 years ago, Rajendra Prasad Yadav was studying in a primary school in a Bihar village. A bright lad, he had a deep yearning for education. But he could only see blurred images on the blackboard and, therefore, could not participate in the class fully. He did not know why this was happening and his teachers also did not understand his predicament. In their ignorance, they would often reprimand Rajendra, and send him to the back of the class as  punishment. Here, he would be at a further disadvantage for he would not be able to see the blackboard at all.
Rajendra’s is not an isolated case. Millions of our students suffer from visual impairment due to uncorrected refractive errors. Studies have shown the overall prevalence of refractive errors in children to be around 8.0 per cent. Among these, 61.02 per cent did not use spectacles. The population-based estimates of refractive errors in children in India indicate that around 33.4 million children in the country are in need of spectacles for vision correction.
Children often do not complain of defective vision as they may not even be aware of their problem. They may adjust to poor vision by strategies such as changing position in the classroom, moving objects closer, and tending to avoid tasks that require more visual concentration.
Refractive errors can be easily diagnosed, measured and corrected with spectacles or other refractive corrections to attain normal vision. They become a major cause of low vision and even blindness only if they are not corrected or the correction is inadequate. Uncorrected refractive errors have a profound effect on the overall development of a child, particularly on their educational and psychosocial development. According to ASER (2018), only half (50.3 per cent) of all students in Class 5 can read texts meant for Class II students. Only 40 per cent of Class 8 students in government schools can do simple division. Inter alia, impaired vision contributes to these poor outcomes. In later years, this manifests as lost educational and employment opportunities, foregone economic gains for individuals, families and societies, as well as a compromised quality of life.
Various factors are responsible for refractive errors remaining uncorrected: Lack of awareness and recognition; non-availability of and/or inability to afford refractive services for testing; insufficient provision of affordable corrective glasses; and cultural disincentives to compliance.
Rajendra was lucky. A local philanthropist saw his distress and got him a pair of spectacles. Once the refractive error was corrected, over a period of time, Rajendra became a distinguished scholar. After specialising in chest diseases, he monitored the TB programme in India, on behalf of WHO. Currently, he is Country Medical Officer at WHO (Philippines). All children, however, are not so fortunate.
In India, there are around 365 million children aged less than 15 years (29 per cent of the population). Ideally, every child should be screened for refractive errors. However, the large number of children as well as resource constraints precludes population-based screening for childhood refractive errors in India. Furthermore, the availability of eye care services in the country varies between and within regions.
Given these disparities, school-based vision screening services are considered cost effective in detecting correctable causes of decreased vision. In India, it is widely practised as part of the National Programme for Control of Blindness (NPCB). However, the coverage with traditional methods is meagre. For example, in Gujarat, one of the better performing states, close to 7.4 lakh children need refractive correction. Despite considerable expansion of the eye care infrastructure, the state is able to reach only around 96,000 children (13 per cent) and provide them with free spectacles.
So what can be done? Years ago, the Danish agency DANIDA piloted a unique eye care programme in five districts. Ophthalmologists and optometrists trained school teachers in basic eye care. The teachers selected were usually women, preferably science graduates, who understood the structure of the eye, and the key role of refractive correction and spectacles in dealing with the condition. Those wearing eyeglasses themselves were preferred as they could be an appropriate role model for the young girls. Their job was to screen the children and identify those who needed refractive error correction. At a prevalence rate of 8 per cent, a school with 500 children would have around 40 cases which would have to be examined by the optometrists. The preliminary examination by the teachers saved the precious time of the ophthalmologists and optometrists.
The children who were identified with refractive problems were given a slip, which they could take to the nearby optician contracted by the District Blindness Control Society and get the spectacles for free. In this manner DANIDA could cover the five pilot districts fully and provide spectacles to all children with refractive errors. While this may not be an optimal solution, it is much better than leaving out a majority of the children who need spectacles. We need to try out homegrown remedies, which can be operationalised on a scale.
Schools appear to be the best forum for implanting health education for children and for early detection of ocular morbidities. Well-trained teachers, appropriately backed by optometrists as well as ophthalmologists, could make a major difference to the malaise. Effective mechanisms can be put in place through the area district hospitals and medical colleges to make random checks to ensure capacity building and quality of the programme.
Concerted efforts from various stakeholders including health, education providers and parents are required to manage uncorrected refractive errors in children. It would be a pity if we allow the lack of a pair of spectacles to stymie the potential of millions of our children.
The writer, former health commissioner, Gujarat, is chairman, Gujarat RERA
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