Individuals with blindness in the world with and without vision in2020.
Louis Pizzarello, Adenike Abiose, Timothy Ffytche, Rainaldo Duerksen, R. Thulasiraj, Hugh Taylor, Hannah Faal, Gullapali Rao, Ivo Kocur, Serge Resnikoff. VISION 2020: The Right to SightA Global Initiative to Eliminate Avoidable Blindness. Arch Ophthalmol. 2004;122(4):615–620. doi:10.1001/archopht.122.4.615
An estimated 45 million people around the world are blind.1 Mostof them have lost their sight to diseases that are treatable or preventable.Eighty percent of them live in the lesser-developed world in countries wherechronic economic deprivation is exacerbated by the added challenge of failingvision. Without intervention, the number of individuals with blindness mightreach 76 million by 2020 because of a number of factors, primarily the rapidaging of populations in most countries.2 Sinceeye disease is seen largely in older people, the projected doubling of theworld's population older than 50 years to 2 billion by 2020 has profound effectson the number of those with blindness and low vision.
In response to this global need, the World Health Organization (WHO),Geneva, Switzerland, with the International Agency for the Prevention of Blindness(IAPB), London, England, a partnership of eye care organizations, launchedthe VISION 2020: The Right to Sight initiative in 1999.3- 5 VISION2020 aims to eliminate avoidable blindness in the world by 2020 and targetsthe world's leading causes of avoidable visual impairment: cataract, trachoma,onchocerciasis, childhood blindness (including vitamin A deficiency), andrefractive error and low vision (Figure 1). In areas of the world where these focal diseases have been controlled,glaucoma and diabetic retinopathy are included among the targeted conditions.To achieve its goals, VISION 2020 requires the training of adequate numbersof eye care providers at all levels and the establishment of critical infrastructureand appropriate technology (Table 1).Just as importantly, VISION 2020 has provided the advocacy that is essentialto raise sufficient resources and commitment to attain the goals of the initiative.VISION 2020 is now 4 years into the process. This article summarizes the statusof VISION 2020 at this time and provides a description of what lies ahead.
The IAPB was established in 1975 by the International Council of Ophthalmologyand the World Blind Union. It links national programs for the prevention ofblindness, nongovernmental organizations (NGOs), educational institutions,individuals, and the founding organizations. In addition, IAPB has an officialrelationship with the WHO Program on Prevention of Blindness and Deafnessbased in Geneva, Switzerland, and with the blindness prevention coordinatorassigned to some WHO regional offices.
In each country, it is intended that a national blindness preventioncommittee oversees the VISION 2020 agenda. At this time, national committeeshave been developed in more than 100 countries. A critically important activityis the development of national plans of action. These plans reflect the prioritydiseases to be addressed and have been formulated with the input of the majorinterest groups including the government, ophthalmologists, public healthspecialists, NGOs, and others. Once a national plan has been adopted by thegovernment, a coordinated effort can then proceed. Allocation of availableresources should reflect the priorities established in the national plan,which will be updated on a 5-year basis.
In each of the 7 regions of IAPB, a chairman coordinates the activitiesof the VISION 2020 program in partnership with the WHO staff. The regionsvary widely in population, level of development, and targeted eye diseases(Table 2). Similar variation canalso be seen within a region. Despite this diversity, regional plans havebeen drafted through a series of regionwide workshops and 5-year plans ofaction have been developed, which are summarized in this section.
The Africa region comprises all the countries of sub-Saharan Africa.VISION 2020 was launched in 2000 in Bamako, Mali, and Pretoria, South Africa.The Africa regional plan was reviewed and adopted in Durban, South Africa,in April 2002. A West Africa Advocacy Forum took place in Abidjan, Cote d'Ivoire,in June 2002. Several regional planning workshops have taken place, and severalcountries are at various stages of development of national plans for blindnessprevention. In particular, 4 countries (Nigeria, Democratic Republic of Congo,South Africa, and Ethiopia), representing half of the regional population,have received special attention. Major constraints to program implementationare lack of manpower and monetary resources. However, success can be achieved,as has been demonstrated in a dramatic reduction in blindness rates followingthe implementation of a national blindness prevention program in the Gambia.6
Programs emphasize the major causes of blindness: cataract, trachoma,onchocerciasis, childhood blindness, and refractive error. Cataract programshave stressed outreach to underserved areas and development of additionalsurgical manpower. Several courses have been given to assist with the conversionfrom intracapsular to extracapsular surgery with intraocular lenses. Severalindividuals have attended management courses to enhance the productivity ofexisting programs. A team has been trained in financial sustainability ofcataract services.
Long-standing programs have targeted onchocerciasis (OnchocerciasisControl Program and the African Program for Onchocerciasis Control) and trachoma(Global Eradication of Trachoma by 2020), and they have been integrated intothe regional implementation plan.
As a first step toward addressing childhood blindness, 2 pediatric ophthalmologyteams have begun training and a WHO workshop to plan for eye care servicesfor children took place in June 2003. A program for training nonophthalmichealth care workers as refractionists is being sponsored by the InternationalCentre for Eyecare Education, Sydney, Australia, and will make refractiveservices available in rural locations.
To further strengthen ophthalmic manpower, the East Africa College ofOphthalmologists, Moshi, Tanzania, is developing. This will permit the poolingof training resources both to enhance existing educational opportunities forophthalmology resident physicians as well as increase the number of trainingplaces. Priority actions for the next 5 years include:
Completion of national VISION 2020 plans along with the mobilizationof necessary resources for immediate implementation of all completed plans.
Establishment of a regional database of available manpower, infrastructure,and other resources. At the same time, critically deficient areas will beidentified and a priority list of needs will be created.
Development of all cadres of middle-level manpower to serve communityneeds.
Development of collaborative regional training programs for ophthalmologiststo improve the quality of education and to increase the number of trainees.
Development of appropriate and sustainable mechanisms for supplyof equipment, drugs, and consumables.
Stretching from Morocco in the west to Pakistan in the east, this regionof 400 million people has a diversity of climates, populations, and eye diseases.Following the regional launch of VISION 2020 in Egypt, national launches tookplace in Tunisia, Saudi Arabia, Yemen, Sudan, and several other countries.National plans of action are being formulated in several countries.
Targeted diseases include cataract, trachoma, childhood blindness, andrefractive error. Many countries are part of the Global Eradication of Trachoma2020 initiative and some, like Morocco, have enjoyed significant success withthe SAFE strategy7 for trachoma control. Trainingfor improved cataract surgical care has taken place in many areas. Intraregionalcooperation has been strong, with teams from Tunisia visiting other nations.
The Europe region is defined as extending from Greenland to the easterntip of Siberia, containing 50 countries across 16 time zones with nearly 1billion inhabitants. VISION 2020 was launched in Geneva in 1999. Since thattime, a number of regional meetings have taken place and a regional implementationplan is being crafted.
Target diseases vary by geography: diabetic retinopathy, glaucoma, andlow vision services in Western Europe and cataract, childhood blindness, diabeticretinopathy, glaucoma, and low vision services in the eastern areas. Thereis no shortage of eye doctors, but in the eastern areas, the distances betweenmajor centers are vast, statistics on blindness are not available, preventionprograms are limited, and ophthalmic medications and equipment are difficultto obtain, as are textbooks and journals.
Activities in the early stages of VISION 2020 in Europe have been directedtoward the training of ophthalmologists in the eastern areas. Training coursesand short-term teaching visits have linked eye specialists in Western Europewith those in Eastern Europe. The VISION 2020 "triplet" is one example ofthese linkages, where a training center in the West develops a course in acenter in the East. Certain existing centers have received support to developeye care units from a number of NGOs including Christoffel Blindenmission,Bensheim, Germany; Orbis International, New York, NY; Lions International,Oak Brook, Ill; and Organization pour la Prevention de la Cecite, Paris, France.Future activities will include:
Strengthening data-gathering capacity to improve the quality ofstatistics on blindness in the region.
Improving local eye care services by creating more eye care units,training additional ophthalmologists and other eye care workers, and emphasizingthe adoption of blindness prevention programs in the various national plans.
Canada, the Caribbean, and the United States form the North Americaregion. The range of technical sophistication and health expenditure varieswidely within the region. With the exception of a few Caribbean countries,VISION 2020 targets the major causes of blindness, cataract, diabetic retinopathy,glaucoma, and refractive error and low vision.
Canada supports an excellent health care system with the highest oftechnological standards. There are some issues of access to care in certainrural areas, but in general, care is widely available. A National Coalitionfor Vision Health (Toronto, Ontario) has been created, which brings togetherNGOs, universities, health care providers, and consumers. The coalition isworking with the national government to develop a strategy to deal with theincreasing rates of blindness seen in an aging population.
In the Caribbean, a highly successful collaborating group has coordinatedactivities in the subregion and developed a 5-year strategic plan. Cataract,glaucoma, diabetic retinopathy, refraction and low vision, and children'sservices are the priorities for the program. Specific targets have been setfor each of these conditions as well as staffing standards for ophthalmologists,nurses, and assistants. New programs for diabetic-retinopathy screening arebeing established in Dominica, and school-based screening will be startingin Antigua and Jamaica. Sight Savers International of West Sussex, England,has been very supportive of these activities.
The United States has developed the Healthy Vision 2010 program.8 Its 10 objectives cover the leading causes of visionloss in the country. Specific targets are being developed at this time foreach of the objectives, which include diabetic retinopathy, glaucoma, cataract,occupational eye injury, refractive error and low vision, vision rehabilitation,and childhood screening and treatment. Healthy Vision 2010 will be the strategicplan for blindness prevention for the next 10 years.
In the next 5 years, priorities will be:
Strengthening of the Coalition for Vision Health in Canada aswell as the creation of an effective VISION 2020/Canada committee linkingall the NGOs based in Canada.
Implementation of the strategic plan for the Caribbean foundedon a rights-based agenda for action, including the right to inclusion forthose with vision loss and the right to sight for all.
Successful implementation of the Health Vision 2010 program inthe United States.
Continued strengthening of intraregional communication and cooperation.
This region includes all of Central and South America with a populationof 400 million. VISION 2020 was launched in Natal, Brazil, in 2000. In July2001, a regional working group was established to implement VISION 2020 and,subsequently, links have been forged between IAPB and existing organizationsincluding the Pan American Health Organization, Washington, DC, and the PanAmerican Association of Ophthalmology, Arlington, Tex, both of whom have workedfor years in the area of blindness prevention. Five subregional groups havebeen established, and chairpeople have been appointed for each. National VISION2020 implementation plans have been developed for Colombia and Bolivia. Plansare in formulation in Paraguay, Mexico, Argentina, and Uruguay.
Target diseases include cataract, childhood blindness, refractive errorand low vision, and diabetic retinopathy. There are several limited foci ofonchocerciasis, which are being treated. Each year more than 150 ophthalmologistsand other health professionals take part in training courses organized bythe London School of Tropical Medicine, London, England; the InternationalCentre for Eye Health, London, England; and the IAPB. These courses encouragethe participants to develop community eye health projects, which are aimedat improving cataract surgical rates, detection and treatment of retinopathyof prematurity, and low vision and refractive services at the district level.In addition, the Pan American Health Organization has begun a rapid assessmentof cataract surgical services in a number of countries.
A protocol to detect and treat retinopathy of prematurity, the principalcause of childhood blindness in the region, was validated and approved bythe IAPB Childhood Blindness subcommittee. This protocol is now being implementedin a number of neonatal units in the main cities of the region. Bolivia hasincorporated the treatment of retinopathy of prematurity, as well as congenitalcataract, into maternal and child health insurance for the first time.
Financial support for all of these programs has come from ChristoffelBlindenmission; ONCE (a Spanish NGO), Madrid, Spain; and the Mirada SolidariaFoundation, Bilbao, Spain. During the next 5 years, the priorities will be:
Improving the training of ophthalmologists in blindness preventionprograms.
Developing national blindness prevention plans in all countriesin the region.
Improving the cataract surgical rate where needed.
Strengthening childhood blindness programs, in particular the recognitionand treatment of retinopathy of prematurity.
This region covers 11 countries—India, Nepal, Bangladesh, Indonesia,Timor Leste, Myanmar, Bhutan, Maldives, Sri Lanka, Thailand, and North Korea—witha combined population of 1.6 billion. Following the regional launch of VISION2020, an intercountry consultation convened in Jakarta, Indonesia, in February2000 by the WHO South-East Asia Regional Office. National plans of actionhave been developed in India and Nepal and have received budgetary allocationsfrom those governments. Several other countries are in the process of formulatingnational plans. In India, the Right to Sight India Forum is being establishedto bring together the international NGOs working there with the hundreds ofnational NGOs working in blindness prevention. This will improve cooperationand coordination, leading to improved synergy for eye care activities in India.
Target diseases are cataract, childhood blindness, refractive errorand low vision, diabetic retinopathy, corneal infections, and glaucoma. Akey strategy supporting all of these programs will be human resource development,in particular the development of midlevel ophthalmic personnel and trainingfor integration of primary eye care into primary health care. Management trainingis being carried out at the Lions Aravind Institute of Community Ophthalmology,Aravind Eye Hospital, Madurai, India, for heads of eye hospitals, programmanagers, hospital administrators, and midlevel ophthalmic personnel.
A regional workshop on childhood blindness was held in Bangladesh inJanuary 2003. With more than 150 participants, this gathering helped to sensitizeboth ophthalmologists and policy makers to the importance and the processof developing eye care services for children. A training course on pediatriceye surgery has been developed at the L.V. Prasad Eye Institute in Hyderabad,India. Teams consisting of ophthalmic surgeons, anesthetists, and midlevelpersonnel can then return to their own institution and set up pediatric eyecare facilities. Priorities for the next 5 years for the region include:
Implementation of national plans in all countries of the region.
Strengthening of pediatric eye care services in the region.
Development of midlevel eye care personnel in all countries.
This region, including China, is the most populous with 1.7 billionpeople. It stretches from Mongolia, across eastern Asia, to the island nationsof the Pacific. It spans the economies of highly industrialized nations tothe microstates of the South Pacific, with the attendant diversity of eyecare services. Following the regional launch of VISION 2020 in 1999, therehave been formal declarations of support for VISION 2020 in Australia, Cambodia,China, Cook Islands, Japan, Laos, Malaysia, New Zealand, Philippines, andVietnam. Korea and Mongolia plan declarations this year. De facto supportfor VISION 2020 exists in Fiji, Papua New Guinea, Singapore, Solomon Islands,Tonga, Tuvalu, Vanuatu, and Western Samoa. Together, these 20 countries representthe majority (20/26) of states in the Western Pacific region. VISION 2020workshops have been held in nearly every country, and national plans are invarying stages of formation in most nations.
Targeted diseases vary by country with cataract still a major causeof blindness in some nations, whereas diabetic retinopathy, glaucoma, andrefractive services and low vision are of major importance in others. Thereare a few countries with significant levels of trachoma, and they are involvedwith the Global Eradication of Trachoma by 2020 initiative. Emphasis has beenplaced on development of midlevel ophthalmic workers. The course developedat Korat, Thailand, for such workers has had a great deal of influence onprograms throughout the region.
The Western Pacific region has been fortunate to have the support ofa number of international NGOs including Christoffel Blindenmission; the FredHollows Foundation, Sydney, Australia; the International Centre for EyecareEducation; and Helen Keller International, New York, NY. Recently, the NGOsworking in Australia have formed VISION 2020/Australia to foster a collaborativeapproach to blindness prevention in the Pacific subregion.9 Thisis a model that has already been duplicated in other parts of the world. Prioritiesfor the coming years include:
Furthering of cooperation and coordination on the part of NGOsworking in the region.
Improvement in cataract surgical rates in those countries withsignificant cataract backlog.
Development of a cadre of midlevel eye health personnel to assistthe ophthalmologists with eye care programs.
Frick and Foster10 calculate that successfulcompletion of VISION 2020 will lead to the prevention of 429 million blindperson–years. (This is defined as 1 year of blindness for an individual.)This will have a dramatic effect on the lives of millions of people, thosewith blindness as well as their caregivers. Using conservative assumptions,they estimate that there would be $102 billion of economic gain if VISION2020 is successful. The costs of many of the interventions that form the VISION2020 initiative are relatively modest, particularly for public health interventions(such as the distribution of vitamin A capsules and ivermectin for onchocerciasis).11
Since its launch by Gro Brundtland, MD, director general of the WHOin 1999, VISION 2020 has received the endorsement of all of the supranationalophthalmic societies as well as many of the national organizations. Resourceshave come from sources as diverse as the state of Andra Pradesh in India,to the private sector of the pharmaceutical industry (Merck, Whitehouse Station,NJ, and Pfizer, New York, NY), to major foundations like the Bill and MelindaGates Foundation, Seattle, Wash; the Conrad N. Hilton Foundation, Reno, Nev;and the Edna McConnell Clark Foundation, New York, NY, and the work of manyNGOs. However, new sources of support will be needed to complete the missionof VISION 2020. Central to this success will be the commitment of individualophthalmologists on all continents. Those living in developing nations havegiven freely of their time to serve the poor in their midst. Brazil has seennational mobilization days, when thousands of ophthalmologists have workedvoluntarily to treat their countrymen. Examples like this are frequent. Butthere is also a role for ophthalmologists in the economically developed world.
VISION 2020 is a global initiative. Every nation has underserved peoplewho require assistance. Ophthalmologists, who are motivated to respond tothe call of VISION 2020, do not have to look far to see opportunities to beof assistance. They can become advocates with governments in their own countriesto increase support for blindness prevention programs. They can reach outto the underserved in their communities or can travel to areas that need theirhelp. Every ophthalmologist can take part in what will be the largest ophthalmicundertaking ever attempted.
Each year, the WHO World Health Assembly gathers to determine healthpolicy issues. Last year, at the 56th World Health Assembly, a resolutionwas adopted, which calls on all member states to commit themselves to VISION2020 by setting up national VISION 2020 plans by 2005.12 Further,member states are to establish national coordinating committees, which areto implement the national plans by 2007. The resolution also supports themobilization of resources to achieve a successful program. This is an extraordinaryshow of support for the program. It demonstrates the success that advocacyefforts have had to raise the visibility of blindness prevention. Now we mustdeliver on the challenge.
Corresponding author and reprints: Louis Pizzarello, MD, 137 HamptonRd, Southampton, NY 11968 (e-mail: email@example.com).
Submitted for publication July 1, 2003; final revision received December9, 2003; accepted December 30, 2003.
The authors have no relevant financial interest in this article.