Module 12: Poverty and Blindness

Introduction

It is approximated that 45 million people are blind in the world and that 87% of visually impaired people live in developing countries.(1) Thus, “poverty and blindness are believed to be intimately linked, with poverty predisposing to blindness, and blindness exacerbating poverty by limiting employment opportunities, or by incurring treatment cost.”(2) People who are poor are more likely to become blind due to lack of access and ability to pay for health services, an increased susceptibility to eye infections and diseases, and lack of awareness about eye health. For example, a study conducted in Pakistan found that the prevalence of total blindness was more than three times higher in poor clusters of the population than in affluent clusters. (3) In addition, “clear evidence shows that some blinding eye diseases are a direct consequence of poverty (for example, trachoma).” (4) However, it is important to realize that blindness may also cause people to become poor. For instance, a review on poverty and its consequences found that “although some individuals become disabled because of low income, a staggering 64% of those with disabilities were not in poverty prior to onset of the disability. Households affected by disability, and which were not initially impoverished, had three times the probability of entering into poverty within one year of onset of disability compared with unaffected households. Households affected by disability also had a lower probability of leaving poverty because of the increased costs and reduced earnings associated with disability.” (5) Thus, it is evident that disabilities such as blindness may not only be a result of living in poverty, but also may lead an individual or family to become impoverished. “Sadly, disability is both caused by poverty and causes poverty.”(6)

Economic Burden of Blindness

Blindness and poor vision have a tremendous impact on quality of life, particularly for those living in poverty. The blind are heavily affected economically, as ninety % of blind individuals cannot work.(7) Culturally, there are often negative stigmas associated with blindness, further alienating the afflicted from their communities. Social disadvantages are also significant.  Half of the blind people in impoverished countries report a loss of social standing and decision-making authority, and 80% of all women note a loss of authority within their families.(8)  Blind individuals are also less likely to engage in productive activities than others.  Since poverty among older people in Africa and Asia may be related to an inability to satisfy social and economic roles, the restrictive impact of visual impairment on productive and leisure activities may also contribute to poverty in these settings.(9)

Blindness exacerbates poverty and can lead to financial insecurity and social isolation even in affluent countries. “It is known that as a disability, blindness often leads to unemployment, which in turn leads to loss of income, higher levels of poverty and hunger and low standards of living. This then results in limited accessibility and affordability of health-care services and deprives those affected of educational and other opportunities. All of these together lead to early mortality and loss of economic productivity of a nation as a whole.” (10) In addition, blind individuals and the household members who care for them have reduced earning potential and undergo a loss of productivity.(11) Recent publications suggest that loss of economic productivity as a result of visual impairment is $8 billion a year in the United States and the global annual loss in gross domestic product from blindness and low vision in 2000 was estimated at between $19,223 million and $22,764 million.(12) Moreover, researchers Smith and Smith estimated that the annual worldwide productivity cost of blindness was $168 billion using 1993 data on prevalence rates, gross domestic products, and populations.(13) These authors assumed that all adults and children were productive and that all blind individuals were completely unproductive.  This projected cost could be decreased either by limiting the prevalence of blindness or by decreasing the impact of blindness on productivity through workplace accommodations.

The Impact of Blindness on Children and Family Members

While those who are blind have to deal with substantial debilitating consequences, blindness also impacts family and community members.  Because blindness imposes restrictions on the ability to move about and control self and environment, a high proportion (75%) of visually impaired people require assistance with everyday tasks.(14)

In developing countries, most blind adults need to be led by either sighted children or sighted adults.  When a child becomes the caretaker, that child is often unable to attend school, thus denying the child an opportunity to escape the poverty cycle.(15) When a sighted adult becomes the caregiver, he or she often needs to stop working. Thus, there are long-term repercussions for economics and education that extend beyond the blind individual.  In fact, the social fabric of a community is impacted on a practical level.

“The physical and emotional toll impacts not just the individual and family but the social and economic fabric of communities and everyone’s existence. Sudden blindness of one individual in a family can become the tipping point for survival when they are impoverished to begin with.”(16),(17)

Cataract, for example, has economic implications through reduced productivity of the visually impaired person as well as opportunity costs to household members who look after them.(18) Estimates of the economic impact of cataract have been based on assumptions of likely productivity losses. Such findings support the wider impact of cataract beyond individual quality of life, through loss of productivity, with implications for the household economy.(19)  For example, a study on poverty and cataract in Bangladesh, Kenya, and the Philippines found that “cataract blindness may also have resulted in restrictions of productivity of other household members as almost half of cases in Bangladesh and a quarter of cases in Kenya and the Philippines reported receiving assistance from household members at baseline.”(20)

The Impact of Interventions

Though blindness may lead an individual to become trapped in poverty, health interventions have the potential to help many blind individuals and their families improve their socioeconomic status.  A multi-center intervention study conducted in Kenya, the Philippines and Bangladesh demonstrates the impact of eye disease on socioeconomic status and how interventions may help increase income levels and status. In the study, poverty data was collected from people over the age of 50 who were visually impaired due to cataract, and from matched controls with normal vision. Those who were visually impaired were offered free or subsidized cataract surgery, and data was collected again one year later on the participants’ poverty levels. Before the surgery, those with cataracts were poorer than the matched controls in terms of per capita expenditure, assets and self-related wealth. However, after the surgery, the per capita expenditure had increased significantly among operated cases in each of the three settings compared to the level of the controls. The largest per capita expenditure increases were found among the cases that were poorest at baseline and received the surgery.(21) Moreover, at follow-up, operated cases spent 1-2 hours more on productive activities compared to their baseline levels before surgery. Time spent in “inactivity” in Kenya and Bangladesh among operated cases also decreased by approximately 2 hours, and the frequency of reported assistance with activities was more than halved in each setting among those who underwent cataract surgery. (22) Thus, the data “suggest that cataract blindness may cause poverty” and that interventions that reduce and eliminate blindness may help to increase productivity and alleviate poverty.(23)

A study conducted at Aravind Eye Hospital in Madurai, India similarly found that cataract surgery is an effective intervention and can aid in breaking the cycle of poverty that many blind people are trapped in. The study found that 85% of males and 58% of the females who had lost their jobs as a result of blindness regained those jobs following cataract removal. In addition, some of those who did not return to work relieved other family members from household duties, enabling them in turn to return to work. The results also demonstrated that the average individual who regained vision through surgery generated 1,500% % of the cost of surgery in increased economic productivity during the first year following surgery.(24) Thus, the success of cataract surgery initiatives shows how “ophthalmologic intervention in disadvantaged communities helps prevent further continuance in the destructive cycle of poverty.” (25) Moreover, “extrapolations on a global level indicate that a successful eye care programme could prevent more than 100 million cases of blindness between 2000 and 2020, and consequently save at least US$102 billion, which would otherwise be lost to reductions in productivity associated with blindness.” (26)

Footnotes

(1) “Visual Impairment and Blindness.” WHO. (2009). Accessed on 4 January 2011.

(2) Kuper, H., et. al. “Does Cataract Surgery Alleviate Poverty? Evidence from a Multi-Centre Intervention Study Conducted in Keyna, the Philippines and Bangladesh.” PloS Medicine. 5.11 (2010). Accessed 3 January 2011.

(3) Gilbert, C., et. al. “Poverty and blindness in Pakistan: results from the Pakistan national blindness and visual impairment survey.” British Medical Journal. 336.29 (2008). Accessed on 3 January 2011.

(4) Ibid.

(5) Holden, B. “Blindness and poverty: a tragic combination.” Clinical and Experimental Optometry. 90.6 (2007): 401-403. Accesed on 4 January 2011.

(6) Ibid.

(7) “World Blindness Overview.” Himalayan Cataract Project. www.cureblindness.org. Accessed on 7 January 2009.

(8) Wagner-Lampl, A. and Oliver, G.W. “Folklore of Blindness.” Journal of Visual Impairment & Blindness. 88.3 (1994). Accessed on 8 January 2009.

(9) Barrientos, A.,  Gorman, M. and Heslop, A. (2003) Old age poverty in developing countries: contributions and dependence in later life. World Develop. 31, pp. 557-570.

(10) Khanna, R., Raman, U., and Rao, G. “Blindness and poverty in India: the way forward.” Clinical and Experimental Optometry. 90.6 (2007): 406-414. Accessed on 4 January 2011.

(11) Kuper, H., et. al. “A Case-Control Study to Assess the Relationship between Poverty and Visual Impairment from Cataract in Kenya, the Philippines, and Bangladesh.” PloS Medicine. 5.12 (2008) Accessed on 3 January 2011.

(12) Gilbert, C., et. al. “Poverty and blindness in Pakistan: results from the Pakistan national blindness and visual impairment survey.” British Medical Journal. 336.29 (2008). Accessed on 3 January 2011.

(13) Smith, A. F. and Smith, J. G. The economic burden of global blindness: a price too high!. Br J Ophthalmol. 80 , (1996): 276-277.

(14) Javitt, J.,  Venkataswamy, G. and Sommer, A. Henkind, P. (ed) (1983) The economic and social aspect of restoring sight. ACTA: 24th International Congress of Ophthalmology pp. 1308-1312. JP Lippincott , New York.

(15) Wright, H., Turner, A., and Taylor, H. “Trachoma and poverty: unnecessary blindness further disadvantages the poorest people in the poorest countries.” Clinical and Experimental Optometry. 90.6 (2007): 422-428. Accessed on 4 January 2011.

(16) Javitt, J.,  Venkataswamy, G. and Sommer, A. Henkind, P. (ed) (1983) The economic and social aspect of restoring sight. ACTA: 24th International Congress of Ophthalmology pp. 1308-1312. JP Lippincott , New York.

(17) Shamanna, B. R.,  Dandona, L. and Rao, G. N. Economic burden of blindness in India. Indian J Ophthalmol. 46 , (1998): 169-172.

(18) Frick, K. D. and Foster, A. The magnitude and cost of global blindness: An increasing problem that can be alleviated. Am J Ophthalmol. 135. (2003): 471-476.

(19) Smith, A. F. and Smith, J. G. The economic burden of global blindness: a price too high!. Br J Ophthalmol. 80 , (1996): 276-277.

(20) Kuper, H., et. al. “Does Cataract Surgery Alleviate Poverty? Evidence from a Multi-Centre Intervention Study Conducted in Keyna, the Philippines and Bangladesh.” PloS Medicine. 5.11 (2010). Accessed 3 January 2011.

(21) Kuper, H., et. al. “Does Cataract Surgery Alleviate Poverty? Evidence from a Multi-Centre Intervention Study Conducted in Keyna, the Philippines and Bangladesh.” PloS Medicine. 5.11 (2010). Accessed 3 January 2011.

(22) Polack, S. “The impact of cataract surgery on health related quality of life and time use in Kenya, Bangladesh and the Philippines.” J Epidemiol Community Health. 63.69 (2009). Accessed on 3 January 2011.

(23) Kuper, H., et. al. “Does Cataract Surgery Alleviate Poverty? Evidence from a Multi-Centre Intervention Study Conducted in Keyna, the Philippines and Bangladesh.” PloS Medicine. 5.11 (2010). Accessed 3 January 2011.

(24) Jamison, D.T., et. al. “Impact of cataract surgery on individuals in India.” Disease Control Priorities in Developing Countries. (New York, Oxford University Press for the World Bank: 1993). Accessed on 3 January 2011.

(25) “Poverty and Human Development. Not a Stretch for Ophthalmology.” Arch Ophthalmol. 125.11 (2007). Accessed on 3 January 2011.

(26) Kuper, H., et. al. “A Case-Control Study to Assess the Relationship between Poverty and Visual Impairment from Cataract in Kenya, the Philippines, and Bangladesh.” PloS Medicine. 5.12 (2008) Accessed on 3 January 2011.