India is home to nearly 1/4th of the world’s blind population, and it has the largest number of blind children. Over 75 per cent of all visual impairment can be prevented or treated. Millions would be able to see today if they had received treatment, surgery or just a pair of glasses – the kind of care that many of us take for granted. Blindness has profound human, social and economic consequences. Thus, access to eye care can open up a world of opportunities for individuals in need – education, gainful employment, independence, reduced inequality thereby helping in breaking the cycle of poverty. In an interaction with Rishi Raj Borah, Country Director, Orbis India, CSR Mandate finds out more about the work the organisation is doing in building India’s capacity for paediatric eye care and the emphasis it lays on training and skilling so quality eye-care can be accessible for all.
What is the current scenario of childhood blindness in India?
Childhood blindness refers to a group of diseases and conditions occurring in childhood or early adolescence, which, if left untreated, result in blindness or severe visual impairment that are likely to be untreatable later in life. The major causes of blindness in children vary widely from region to region, being largely determined by socioeconomic development, and the availability of primary health care and eye care services. In high-income countries, lesions of the optic nerve and higher visual pathways predominate as the cause of blindness, while corneal scarring from measles, Vitamin A deficiency, use of harmful traditional eye remedies, ophthalmia neonatorum, and rubella cataract are the major causes in low-income countries. Retinopathy of prematurity is an important cause in middle-income countries. Other significant causes in all countries are congenital abnormalities, such as cataract, glaucoma, and hereditary retinal dystrophies.
Refractive errors are the largest cause of moderate and severe visual impairment and this is on the rise. Reduced outdoor play and exposure to the sun are increasingly replaced by indoor activities and game for children. This increases the chances of children developing myopia.
India is the second-most populous country in the world and home to over 20 per cent of the world’s blind population. Unfortunately, India is also home to the largest number of blind children in any one country. There are 9.3 million visually-impaired and 270,000 blind children in India.
What are the challenges which exist in the country when it comes to eradicating childhood blindness?
Since children constitute only three per cent of the world’s blind population, childhood blindness has not been given its due importance as compared to other causes of blindness and visual impairment. However, if childhood blindness is measured in blind-person-years, it is second only to cataract blindness.
Additionally, the divide between the rich and poor continues to increase, leaving a significant portion of the population without access to basic healthcare services — most of whom live either in rural India or urban slums. To further compound the situation, a majority of ophthalmologists in India live and practice in urban areas. Lack of awareness about eye care in general, and childhood blindness in particular, continues to remain a barrier in preventing and treating childhood blindness.
Having the right people in the right place is the cornerstone of any successful public health programme. Keeping all of this in mind, in 2002, the India Childhood Blindness Initiative (ICBI) was launched by Orbis to help ensure that India’s children have access to quality eye care for generations to come.
What are the primary interventions which need to be done to improve the situation?
In 2000, there were only four comprehensive tertiary paediatric eye care centres in India. At that time, with a population of one billion, India needed 100 Children’s Eye Centers (CEC) as per the WHO guidelines of one centre per ten million population.
Building India’s capacity for paediatric eye care presented itself as a mammoth challenge. Examining children needs special skills and their treatment protocols require specific training, knowledge and equipment. This meant we had to build the infrastructure for service delivery including equipping the facilities and supporting community work, along with the development of all cadres of human resources required. Having the right people in the right place is the cornerstone of any successful public health programme. Keeping all of this in mind, in 2002, the India Childhood Blindness Initiative (ICBI) was launched by Orbis to help ensure that India’s children have access to quality eye care for generations to come.
With these, we have been able to do the following:
We pioneered the introduction of paediatric ophthalmology services in rural India and worked with communities to generate public awareness. We have also contributed to the development of paediatric ophthalmology as a distinct sub-speciality in the Indian ophthalmology landscape. We have been instrumental in creating and promoting the idea of a paediatric ophthalmology team consisting of a paediatric ophthalmologist, optometrist/orthoptist, paediatric anaesthetist, paediatric nurse and other support staff such as paediatric patient counsellors and outreach coordinators. This team goes beyond the boundaries of the CEC to work integrally with a network of community organisations and volunteers.
How and when did Orbis begin its sight-saving initiative in the country?
We began our sight-saving initiative in India through its Flying Eye Hospital (FEH). The FEH came to Hyderabad and New Delhi for its first-ever programme in the country in 1988. Following multiple Flying Eye Hospital training, India was identified as a priority country, and in 2000, we began our country programme in India and established an office in New Delhi. Soon, we identified childhood blindness and corneal blindness as priority areas in India and launched the India Childhood Blindness Initiative.
In India, the programmes focus on the prevention of blindness and treatment of eye diseases, especially among children. We launched the India Childhood Blindness Initiative (ICBI), our flagship programme in 2002, to help ensure that India’s children across geographies have access to quality eye care for generations to come. Till date, 33 Children’s Eye Centers (CEC) have been developed across 17 States of the country, and the good work is continuing at these child-friendly facilities.
We are fighting the problem of Refractive Error – the largest cause of moderate to severe visual impairment – through the REACH (Refractive Error Among Children) programme across 15 districts of India. We have also worked in the areas of eye banking, diabetic retinopathy and quality assurance.
Building on our work in Quality Assurance at eye hospitals, we have developed a Quality Resource Center which is now supporting eye care facilities across India and internationally.
As a Founder Member of Vision 2020: The Right to Sight India, we are actively involved in the activities of Vision 2020 – India.
Do share something about the Flying Eye Hospital? This sounds like a unique initiative. What was the outcome of the project?
Founded by the leaders of the medical and aviation industries in 1973, we started our work on a plane – a fully-equipped mobile teaching hospital. Back then, the expense of tuition and international travel prevented most doctors and nurses in developing countries from training overseas. Our founders and donors brought the school to the doctors by building a Flying Eye Hospital into the frame of a DC-8 aircraft. In 1982, this aircraft took to the air for the first time. The second-generation Flying Eye Hospital, the DC-10, took flight in 1994, and the latest third generation MD-10, in 2017. This plane is like no other. The Flying Eye Hospital is the world’s only ophthalmic teaching hospital on board an aircraft. It features a state-of-the-art, fully accredited eye hospital, complete with an operating room, patient care and laser room, pre- and post-operative care room, sterilisation/sub sterile room, observation room, classroom, administration room and audiovisual/IT room with 3D broadcast technology that can transmit live surgeries around the world.
This unique Flying Eye Hospital is flown by volunteer pilots from country to country, and an international volunteer medical team develops sight-saving skills among ophthalmic professionals through hands-on training and lectures. For over three decades, this plane has been raising awareness, creating positive change, and rallying supporters to join us in our quest to end avoidable blindness.
The first association between Orbis’s Flying Eye Hospital and India dates back to 1988 in Delhi and Hyderabad. Though the years, the Flying Eye Hospital has continued to be an important part of our journey, with our latest programme in Kolkata, in 2013. Through years of continuous efforts, we have been able to provide value-added training to doctors, bring access to quality eye care to patients in need, and create a positive impact upon health policies. The Flying Eye Hospital also helps develop strong and lasting connections to affect progressive change, wherever it goes.
Today, we train doctors, nurses, other cadres of eye health professionals, community outreach teams and medical technicians to save and restore sight and leave a lasting footprint everywhere we go.
What are the priority areas for Orbis in India?
Over the years, we have worked in the areas of corneal blindness and eye banking, childhood blindness, quality assurance, refractive error and diabetic retinopathy. As a founding member of Vision 2020: The Right to Sight INDIA, we are also actively involved in the activities of the World Health Organization’s Vision 2020 initiative.
Today, we train doctors, nurses, other cadres of eye health professionals, community outreach teams and medical technicians to save and restore sight and leave a lasting footprint everywhere we go. We treat patients with a variety of eye health conditions to preserve and restore sight. We expand access by supporting local hospitals and clinics with the infrastructure and systems to provide primary and tertiary care as well as build and improve public awareness around eye health. We stay connected through our digital telemedicine and tele-education platform, Cybersight, and other initiatives.
What has been the impact of the work Orbis is undertaking in different parts of India?
Since we began the India Childhood Blindness Initiative, together with our partners we have been able to conduct 12,479,389 screening on children by giving them access to the care they deserve, provided 1,443,237 treatments and performed over 101,622 on children giving them the gift of good sight. Besides, we have medically trained 118,638 doctors, nurses, other allied ophthalmic professionals as well as community workers, teachers etc. giving them the expertise they need to identify and deliver quality eye care.
What is your vision for the future in terms of the eye healthcare scenario in India? How can we build on India’s capacity, especially for child eye care?
Today there are 33 Children’s Eye Centers (CECs) that have been developed with Orbis’ support across 17 States in India, and the good work is continuing at these child-friendly facilities. This is the largest network of CECs in the world. Besides, some of these centres as well as continue to provide training and support to the eye care system in India and many neighbouring countries. Further, this model has been successfully replicated in Nepal and Bangladesh.
Besides, three of the existing tertiary level paediatric facilities in the country were developed as paediatric ophthalmology learning and training centres (POLTCs) by providing infrastructure as well as technical support. This included standardisation of the curricula for different cadres of eye health professionals for the CECs and community work.
POLTCs offer fellowships in paediatric ophthalmology, short/long-term training programmes and periodically conducted workshops/refresher training as well as Continuing Medical Education (CME). Conducting impactful research on child eye health is an integral part of a POLTC.
At every step of the journey, for nearly four decades, we have harnessed the latest in technology and innovation to take efforts to end avoidable blindness to an unprecedented scale around the globe. We invented its Flying Eye Hospital – a state-of-the-art teaching facility complete with an operating room, classroom and recovery room – to reach remote communities before the internet was born. An advanced audiovisual system allows local eye care teams in the plane’s classroom to watch surgeries happening in the operating room ‘live’ in 3D. Our simulation training programme uses the latest technology – like virtual reality, artificial eyes, and life-like mannequins – to safely build local eye care teams’ skills. Our telemedicine platform, Cybersight, uses the latest internet and mobile technologies to reach eye care teams worldwide, including in remote and conflict-affected areas, with training.
Training activities, including live lectures and surgeries, onboard the Flying Eye Hospital are broadcast via Cybersight to partner hospitals and classrooms around the globe. A new artificial intelligence (AI) tool on Cybersight examines digital photographs to identify common eye diseases in a mere eight seconds, allowing more doctors in low-resource countries to provide early detection for their patients.
Closer to home, the most recent example that I can think of is our school eye health programme. School is the first formal space for learning. Using this space to reach the vast cohort of school-aged children who constitute a particularly vulnerable group because of the high prevalence of refractive error is a common practice. There are several models of school eye health programmes currently operational across India. REACH – Refractive Error Among Children is a model aiming to address challenges in the school eye health space and build innovative, sustainable and scalable programmes.